Crush Injury Designation of Condition: Entrapped and Crushed Under a Heavy Load for > 30 Minutes Either Extremity Or Body

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Crush Injury Designation of Condition: Entrapped and crushed under a heavy load for > 30 minutes either extremity or body. Often seen in building or trench collapse, industrial accident or pinned or heavy equipment. It is important to consider possible vascular and orthopeadic injuries as well as metabolic derangements due to tissue ischemia. ABC’s with focus on ability to keep airway patent EXPOSE PATIENT Vital signs Pulse Oximetry procedure Capnography procedure B Oxygen supplementation >90% Assist ventilations as necessary with BVM Spinal precautions as indicated Cardiac monitor Control external hemorrhage and splint/stabilize orthopedic injuries IV/IO NS (two large bore preferred) Entrapped < 2 hours: Normal Saline infusion Adult: 1 liter/hour Pediatric: 10 ml/kg per hour I Entrapped > 2 hours: Normal Saline bolus Adult: 2 liters Pediatric: 20 ml/kg Pain management with MCEP contact Consider need for advanced airway including cricothyrotomy as indicated Pain management as per guideline Serial 12 lead ECG Immediately Prior to Extrication from Entrapment: P Sodium Bicarbonate: 50 meq Peds: 1 meq/kg Monitor closely for ECG changes consistent with hyperkalemia and treat per hyperkalemia guideline Given the unique nature of crush/confined space injuries with entrapment, patient’s will often suffer from severe anxiety. Consider calling EMS Consortium MCEP for benzodiazepines order for anxiolysis D There is a significant risk of airway compromise with this combination of benzodiazepines and narcotics; monitor airway and ETCO2 waveform and O2 as needed If the patient is in a position in which you cannot adequately manage the airway, do not give this combination of medications. ***KEY POINT*** A patient with a crush injury may initially present with very few signs and symptoms Therefore, maintain a high index of suspicion for any patient with a compressive mechanism of injury A fatal medical complication of crush syndrome is hyperkalemia. Suspect hyperkalemia if T-waves become peaked, QRS becomes prolonged (greater than 0.12 seconds), absent P wave, or prolonged QTc Evaluation for fractures and potential compartment syndrome development (neurovascular status of injured extremity).

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Crush Injuries Pathophysiology and Current Treatment Michael Sahjian, RN, BSN, CFRN, CCRN, NREMT-P; Michael Frakes, APRN, CCNS, CCRN, CFRN, NREMT-P
LWW/AENJ LWWJ331-02 April 23, 2007 13:50 Char Count= 0 Advanced Emergency Nursing Journal Vol. 29, No. 2, pp. 145–150 Copyright c 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins Crush Injuries Pathophysiology and Current Treatment Michael Sahjian, RN, BSN, CFRN, CCRN, NREMT-P; Michael Frakes, APRN, CCNS, CCRN, CFRN, NREMT-P Abstract Crush syndrome, or traumatic rhabdomyolysis, is an uncommon traumatic injury that can lead to mismanagement or delayed treatment. Although rhabdomyolysis can result from many causes, this article reviews the risk factors, symptoms, and best practice treatments to optimize patient outcomes, as they relate to crush injuries. Key words: crush syndrome, traumatic rhabdomyolysis RUSH SYNDROME, also known as ology, pathophysiology, diagnosis, and early traumatic rhabdomyolysis, was first re- management of crush syndrome. Cported in 1910 by German authors who described symptoms including muscle EPIDEMIOLOGY pain, weakness, and brown-colored urine in soldiers rescued after being buried in struc- Crush injuries may result in permanent dis- tural debris (Gonzalez, 2005). Crush syn- ability or death; therefore, early recognition drome was not well defined until the 1940s and aggressive treatment are necessary to when nephrologists Bywaters and Beal pro- improve outcomes. There are many known vided descriptions of victims trapped by mechanisms inducing rhabdomyolysis includ- their extremities during the London Blitz ing crush injuries, electrocution, burns, com- who presented with shock, swollen extrem- partment syndrome, and any other pathology ities, tea-colored urine, and subsequent re- that results in muscle damage. Victims of nat- nal failure (Better & Stein, 1990; Fernan- ural disasters, including earthquakes, are re- dez, Hung, Bruno, Galea, & Chiang, 2005; ported as having up to a 20% incidence of Gonzalez, 2005; Malinoski, Slater, & Mullins, crush injuries, as do 40% of those surviving to 2004).
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