Crush injury can be categorised into 3 areas, which are;
- Crush Injury: Tissue injury as a result of prolonged compressive forces applied to an area of the body, most commonly limbs.
- Compartment Syndrome: Increased pressure within a muscle, due to the non-elastic nature of the fascia, leading to reduced circulation distal to the injury. If left untreated this can result in tissue ischaemia and necrosis.
- Crush Syndrome: The systemic manifestation of crush injury, as a result of tissue destruction. This results in the destruction of myocytes release of myoglobin, potassium and uric acid upon reperfusion. This can further deteriorate into rhabdomyolysis leading to hypovolaemia, hyperkalaemia, metabolic acidosis and acute kidney failure, resulting in death.
Mechanism or pattern of injury suggesting crush injury, with prolonged entrapment.
Signs of crush injury include;
- Hypovolaemia
- Compartment syndrome
Reperfusion injuries are common;
- Shock
- Hyperkalaemia
- Dysrhythmias
ECG Signs of Hyperkalaemia;
- Tall tented T-waves
- Absent p-waves
- Widened QRS
- Sine Wave
- If entrapment is prolonged consider USAR Physician deployment.
- Patients with diabetes and bleeding disorders are at increased risk of reperfusion injury.
- Do not delay transport time if patient is no longer trapped.
- Fluid bolus should be started prior to release of compressive forces or immediately after if unable to do so.
- Adequate fluid resuscitation in crush syndrome should be performed as a preference over permissive hypotension.
- Tourniquets on trapped limbs have shown no benefit
- Primary Survey with c-spine consideration
- Be aware of Trauma Management Principles
- Manage catastrophic bleeding (with haemorrhage control as required)
- Airway management/ventilatory support (as required)
- Oxygen therapy as per protocol
- Perform remainder of vital sign survey
- Secondary / CNS Survey
- Administer pain relief
- Consider applying cardiac monitor if trained and authorised
- Monitor patient persistently, recording full observations every 10 minutes (or 5 minutes if time critical)
- Transport Priority 1 if patient time critical, pre-notifying receiving facility
- Apply cardiac monitoring
- Manage and prevent hypotension with IV crystalloid solution as per protocol
- Administer pain relief
- Consider ondansetron
- Consider advanced airway management as required
- Metropolitan crews should consider Major Trauma Bypass as per guideline
- Monitor patient persistently, recording full observations every 5 minutes
- Transport Priority 1 immediately post extrication, pre-notifying receiving facility
- Manage hypotension:
- Consider intravenous crystalloid solutions
- Consider metaraminol
- Manage hyperkalaemia:
- Consider calcium gluconate
- Consider sodium bicarbonate
- Consider continuous nebulised salbutamol
- Consider use of insulin/glucose
- Consider packed red cells
- Hypovolaemia
- Hyperkalaemia
- Metabolic Acidosis
- Acute Kidney Injury
- Cardiac Dysrhythmias
- Clinical deterioration
- Death
| Settings | |
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| Extended Care: | |
| Colour assist: | |
Gibney, R. T. N., Sever, M. S. and Vanholder, R. V. (2014). Disaster Nephrology: crush injury and beyond. Kidney International, 85(5), pp. 1049-1057. doi: 10.1038/ki.2013.392
Queensland Ambulance Service (2015). Clinical Practice Guidelines: Trauma/Crush Injury. Retrieved from: https://www.ambulance.qld.gov.au/docs/clinical/cpg/CPG_Crush%20injury.pdf
Genthon, A. and Wilcox, S. R. (2014). Crush Syndrome: A Case Report and Review of the Literature. The Journal of Emergency Medicine, 46(2), pp 313-319. doi: 10.1016/j.jemermed.2013.08.052
Australian Capital Territory Ambulance Service (2016). Clinical management Guideline: Crush Syndrome. Retrieved from: http://cdn.esa.act.gov.au/wp-content/uploads/CMG-30-CRUSH-SYNDROME-June -2016.pdf
Walters, T., Powell, D., Penny, A., Stewart, I., Chung, K., Keenan, S. and Shackelford, S. (2016). Management of Crush Syndrome Under Prolonged Field Care. Journal of Special Operations Medicine.
Sever, M. S. and Vanholder, R. (2011). Management of Crush Syndrome Casualties after Disaster. Rambam Maimonides Medical Journal, 2(2). doi: 10.5041RMMJ.10039
Sahjian, M. and Frakes, M. (2007). Crush Injuries: Pathophysiology and Current Treatment. Advanced Emergency Nursing Journal, 29(2), pp. 145-150
Palmer, B. F. and Clegg, D. J. (2017). Diagnosis and Treatment of Hyperkalaemia. Cleveland Clinic Journal of Medicine, 84(12), pp. 934-942. doi: 10.3949/ccjm.84a.17056
Queensland Ambulance Service (2018). Drug Therapy Protocols: Calcium Gluconate 10%. Retrieved from: https://www.ambulance.qld.gov.au/docs/clinical/dtprotocols/DTP_Calcium%20gluconate.pdf
Queensland Ambulance Service (2016). Drug Therapy Protocols: Sodium Bicarbonate 8.4%. Retrieved from: https://www.ambulance.qld.gov.au/docs/clinical/dtprotocols/DTP-Sodium-bicarbonate.pdf
Australian Capital Territory Ambulance Service (2016). Clinical management Guideline: Hyperkalaemia. Retrieved from: http://cdn.esa.act.gov.au/wp-content/uploads/CMG-27-HYPERKALAEMIA-June- 2016-top.pdf
Australian Capital Territory Ambulance Service (2017). Clinical management Guideline: Calcium Chloride. Retrieved from: http://cdn.esa.act.gov.au/wp-content/uploads/CALCIUM-CHLORIDE-Nov- 2017-left-justified.pdf
Sever, M. S. and Vanholder, R. (2012). Management of Crush Victims in Mass Disasters. Clinical Journal of the American Society of Nephrology. doi: 10.2215/CJN.07340712
Kidney Health Australia. (2017). Pre-Budget Submission Federal Budget. Retrieved from: https://kidney.org.au/cms_uploads/docs/kha-pre-budget-submission-2016-2017.pdf
Queensland Ambulance Service (2016). Clinical Practice Guidelines: Medical/Hyperkalaemia. Retrieved from: https://www.ambulance.qld.gov.au/docs/clinical/cpg/CPG_Hyperkalaemia.pdf
North Carolina EMS. (2012) Treatment Protocol: Crush Syndrome Trauma. Retrieved from: https://www.ncems.org/nccepstandards/protocols/88CrushSyndrome.pdf
Abuelo, J. G. (2018). Treatment of Severe Hyperkalaemia: Confronting 4 Fallacies. Kidney International Reports, 3(1), pp 47-55. doi: 10.1016/j.ekir.2017.10.001
Guthrie, K. (2018, June 29th). Hyperkalaemia. Retrieved from: https://lifeinthefastlane.com/hyperkalemia/
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