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An Ongoing Series

Management of Crush Syndrome Under Prolonged Field Care

Thomas Walters, PhD; Douglas Powell, MD; Andrew Penny, NREMT-P; Ian Stewart, MD; Kevin Chung, MD; Sean Keenan, MD; Stacy Shackelford, MD

Introduction to the Prolonged Field Care beyond the initial evaluation and treatment of casual- Prehospital Clinical Practice Guideline Series ties in a PFC operational environment. This and fu- ture CPGs are aimed at serious clinical problems seen Sean Keenan, MD less frequently (e.g., crush , ) or where fur- ther advanced practice recommendations are required THIS FIRST CLINICAL PRACTICE GUIDELINE (CPG) (e.g., pain and sedation recommendations beyond was produced through a collaboration of the SOMA TCCC recommendations, ). Prolonged Field Care Working Group (PFCWG) and the Joint Trauma System (JTS) at the U.S. Army Insti- We hope that this collaboration of experienced op- tute of Surgical Research (USAISR) in San Antonio. Of erational practitioners and true subject matter ex- note, this effort is the result from requests for informa- perts, operating under the guidance set forth in past tion and guidance through the PFC website (PFCare.org) JTS CPG editorial standards, will bring practical and and from the Joint Special Operations Medical Training applicable clinical recommendations to the advanced Center instructors located at Fort Bragg, North Carolina. practice first responders and Role 1 providers in the field. For feedback or additional input, please visit We are excited to introduce the first prehospital (pre- PFCare.org. surgical) CPG specifically aimed at providing ­guidance

his Role 1, prolonged field care (PFC) guideline Crush syndrome is a that leads to is intended to be used after Tactical Combat Ca- traumatic . Reperfusion results in the Tsualty Care (TCCC) Guidelines when evacuation release of muscle cell components, including to higher level of care is not immediately possible. A and potassium, that can be lethal. Myoglobin release provider of PFC must first and foremost be an expert in results in rhabdomyolysis, with risk of damage. TCCC. This Clinical Practice Guideline (CPG) is meant can cause kidney damage and cardiac ar- to provide medical professionals who encounter crush rhythmias. Calcium is taken up by injured muscle cells syndrome in austere environments with evidence-based and this can cause , contributing to cardiac guidance for how to manage the various aspects of crush . The risks are increased with large areas of injury care and monitoring. Recommendations follow a tissue crushed (one or both lower extremities) and the “minimum,” “better,” “best” format that provides al- length of time the casualty is pinned prior to extrication. ternate or improvised methods when optimal hospital The primary treatment is aggressive fluid administration. options are unavailable. Reperfusion after prolonged tourniquet application (>2 Crush syndrome is a life and limb-threatening condi- hours), extremity , and severe tion that can occur as a result of entrapment of the ex- limb trauma involving can also result in tremities accompanied by extensive damage of a large rhabdomyolysis by the same mechanisms as crush syn- muscle mass. It can develop following as little as 1 hour drome, and the treatment is the same. of entrapment. Effective medical care is required to re- duce the risk of kidney damage, cardiac , and Telemedicine: Management of crush syndrome is death. complex. Establish telemedicine consult as soon as possible.

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Fluid Urine Output8,9 Goal: UOP of 100–200mL/h. The fluid rate should be adjusted to maintain this level of UOP. The principles of hypotensive resuscitation accord- • Best: place Foley catheter. ing to TCCC DO NOT apply in the setting of extremity • Minimum: capture urine in premade or improvised requiring extrication. However: graduated cylinder (e.g., Nalgene® bottle [Thermo Fisher Scientific, nalgene.com]). In the setting of a crush injury associated with • Maintain goal UOP until myoglobin can be moni- noncompressible hemorrhage, aggressive fluid resusci- tored and normalized. tation may result in increased hemorrhage. Balancing oo If UOP is below goal at IV fluid rate of 1L/h for the risk of uncontrolled hemorrhage against the risk of >2 hours, kidneys may be damaged and unable to cardiotoxic levels of potassium should ideally be guided respond to fluid resuscitation. Consider: by expert medical advice (in-person or telemedicine). Teleconsultation, if available Fluids1–5 • Decreasing the fluid rate to reduce risks of volume Goal: Correct hypovolemia to prevent myoglobin in- overload (e.g., pulmonary edema) jury to the kidneys and dilute toxic concentrations of • Hemorrhage or third spacing may cause hypovole- potassium to reduce risk of kidney damage and lethal mia. Consider: arrhythmias. oo Increasing the fluid rate • Best: IV crystalloids oo Start intravenous (IV) or intraosseous (IO) admin- Urine Myoglobin10–13 istration IMMEDIATELY (before extrication). Rate Goal: Monitor for worsening condition and volume: initial bolus, 2L; initial rate: 1L/h, ad- • Best: laboratory monitoring of urine myoglobin just to urine output (UOP) goal of >100–200mL/h • Better: urine dipstick monitoring of erythrocyte/he- (see below) moglobin (Ery/Hb)10 • Better: oral intake of electrolyte solution • Urine dipstick Ery/Hb will be positive in patients with oo Sufficient volume replacement may require “coached” myoglobinuria. drinking on a schedule.6 • Minimum: monitor urine color. Darker urine (red, • Minimum: rectal infusion of electrolyte solution brown, or black), either consistently or worsening oo Rectal infusion of up to 500mL/h can be supple- over time, is associated with increasing myoglobin- mented with oral hydration.6,7 uria and increased risk of kidney damage.

Life-threatening hyponatremia can result from Hyperkalemia and Cardiac Arrhythmias large-volume administration of plain water. If using oral Release of potassium from tissue damage and kidney or rectal fluids because of unavailability of IV fluids or damage can result in hyperkalemia (5.5mEq/L), re- access, they must be in the form of a premixed or impro- sulting in life-threating cardiac arrhythmias or heart vised electrolyte solution to reduce this risk.6 failure14–17

Examples of mixed or improvised electrolyte solutions Goal: Monitor for life-threatening hyperkalemia include the following: • Best: laboratory monitoring of potassium levels, 12- lead electrocardiogram (ECG), cardiac monitor (e.g., ZOLL® [ZOLL Medical Corp, www.zoll.com]; Tempus • World Health Organization (WHO) oral rehydration Pro™ [Remote Diagnostic Technologies, http://www salts (ORS): preferred .rdtltd.com]) • Pedialyte® (Abbott Laboratories, https://pedialyte.com) • Better: laboratory monitoring of potassium levels, • Per 1L water: 8 tsp sugar, 0.5 tsp salt, 0.5 tsp baking soda cardiac monitor (e.g. ZOLL®, Tempus Pro™) • Per quart Gatorade® (Stokely-Van Camp Inc, www • Minimum: close monitoring of vital signs and circula- .gatorade.com): 0.25 tsp salt, 0.25 tsp baking soda tory examination • Frequency: every 15 minutes for initial 1–2 hours Monitoring • Decrease frequency to every 30 minutes, then hourly Goal: maintain high UOP, detect cardiotoxicity, ade­ if stable or if urine is clearing quate oxygenation and ventilation, avoid , • Monitor for premature ventricular contractions (PVCs; trend response to resuscitation. Document blood pres- skipped beats), bradycardia, decreased peripheral pulse sure (BP), heart rate (HR), fluid input, urine output strength, hypotension (UOP), mental status, pain, pulse oximetry, and tem- • Specific ECG signs: sinus bradycardia (primary sign); perature on a flowsheet. peaked T waves, lengthening PR interval (early signs),

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prolonged QRS interval, PVCs or runs of ventricu- oo Treatment instructions: 15–30g suspended in 50– lar tachycardia, conduction block (bundle branch, 100mL liquid. Oral or rectal. Onset of action: >2 fascicular) hours. Duration of action: 4–6 hours. • If PVCs become more frequent, the patient develops • Bicarbonate: Although routinely recommended as bradycardia, peripheral pulse strength decreases, or mainstay treatment to reduce kidney damage by rais- potassium levels are >5.5mEq/L or rising, treat ur- ing the urine pH and diminishing intratubular pig- gently for hyperkalemia. ment cast formation, and uric acid precipitation; to • and 50% dextrose (D50); ; correct metabolic ; and to reduce potassium albuterol (see treatment instructions below) levels, there is no clear evidence that bicarbonate re- duces kidney damage20, and the effect of reducing po- Consider teleconsultation or more urgent evacua- tassium is slow and unsustained.21 tion to facility with laboratory and ECG monitoring, if possible. Sodium removes potassium • Use tourniquets to isolate limb(s) (see Tourniquets from the body. All other treatments temporarily lower po- ­below) tassium by shifting it out of circulation and into the cells. Continue to monitor and repeat treatment when needed. Treatments for Cardiac Arrhythmias Due to Hyperkalemia Tourniquets for Management of Crush Treat if potassium level is >5.5mEq/L or there are car- diac arrhythmias (see above). Note that a normal ECG Tourniquets may delay the life-threating complications may occur in patients with hyperkalemia. of a reperfusion injury if immediate fluid resuscitation or monitoring is not initially available. Consider tourni- Goal: Restore normal ECG/prevent fatal cardiac quet placement for crush injury before extrication if the complications length of entrapment exceeds 2 hours and crush injury protocol cannot be initiated immediately.22–24 Treatment for Hyperkalemia • Best: calcium gluconate; insulin + D50; albuterol; so- Goal: Delay acute toxicity until after fluid resuscitation dium polystyrene sulfonate and monitoring are available. • Better: calcium gluconate; insulin + D50 • Best: Apply two tourniquets side by side and proxi- • Minimum: any individual or combination of treat- mal to the injury immediately before extrication ments, as available • Minimum: Apply two tourniquets side-by-side proxi- • Calcium gluconate (calcium replacement): Increases mal to the injury immediately after extrication serum calcium to overcome the effect of hyperkale- • Initiate crush injury protocol before loosening tour- mia on cardiac function.18 Alternate: may use calcium niquet, and then only if the patient meets criteria for chloride, which is more irritating when administered tourniquet conversion or removal given in the TCCC via peripheral IV. guideline oo Treatment instructions: Administer 10 mL (10%) calcium gluconate or IV over 2–3 A limb that is cool, insensate, tensely swollen, and minutes. Onset of effect: immediate. Duration of pulseless is likely dead. Patient may develop and action: 30–60 minutes. kidney damage, and may die. Consider fasciotomy. If no • Insulin and : Insulin is given to lower the se- improvement, place two tourniquets side by side and rum potassium level by driving it back into the cells; proximal to the injury and do not remove. glucose is given to prevent hypoglycemia.18 anticipated. oo Treatment instructions: give 10 units of regular in- sulin followed immediately by 50mL of D50. Onset Fasciotomy of effect: 20 minutes. Duration of action: 4–6 hours. • Albuterol: Lowers serum potassium level by driving Extremity compartment syndrome must be anticipated it back into the cells; effect is additive with insulin.19 with crush injury and reperfusion injury.25–27 oo Treatment instructions: Administer 12mL of alb- uterol sulfate inhalation solution, 0.083% (2.5mg/ Goal: Decompress muscle, restore blood flow. 3mL) in nebulizer. Onset of effect: 30 minutes. Du- • Best: Perform fasciotomy (only if there are clinical ration of action: 2 hours. signs of compartment syndrome). The earliest sign is • Sodium polystyrene sulfonate (Kayexalate®; Concor- limb swelling with severe pain with or without pas- dia Pharmaceuticals, http://concordiarx.com): Low- sive motion, persisting despite adequate analgesia, ers serum potassium level by removing potassium followed by , , , poikilother- from the gut.18 mia, and pulselessness.

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1 hour Phase 4 2 hours Continue Continue Continue. Continue. Goal UOP Goal UOP Every 1 hour Every 1 hour Record every Refer to Pain/ sedation CPG Every 6 hours 100–200mL/h 100–200mL/h 100–200mL/h Titrate to UOP Titrate Every 4–6 hours Every 4–6 hours Every 4–6 hours Record UOP every Prolonged Field Care Consider If no fasciotomy. improvement, place two tourniquets side by and proximal to the Amputation injury. anticipated

N/A Monitor; repeat as required Monitor; repeat as required Check Check Check 1 hour Phase 3 Continue Continue Continue. Continue. Goal UOP Goal UOP Per TCCC 15 minutes Immediately Record every 100–200mL/h 100–200mL/h 100–200mL/h Titrate to UOP Titrate Every 15 minutes Every 15 minutes Record UOP every Following Extrication Fasciotomy: only if qualified medical personnel or teleconsultation available Cool limb (evaporative or environmental cooling, no ice/snow) Ensure wounds cleaned and dressed, hygiene of wounds and patient optimized to the extent possible given environment. — — N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Phase 2 minutes Continue Continue Continue Continue Per TCCC Extrication Continue 1L/h Record every 15 Every 15 minutes Every 15 minutes If the patient meets criteria for tourniquet conversion or removal, and fluids are available, initiate crush injury protocol before loosening tourniquet. — — N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Initiate Initiate Phase 1 Continue Continue Per TCCC 15 minutes Entrapment Record every continue 1L/h Initial bolus: 2L, Every 15 minutes Every 15 minutes If entrapment time >2 hours, consider tourniquet. Place two tourniquets side by side and proximal to the injury Ertapenem, 1g IV/day (1g, 10mL or sterile water) Cefazolin, 2g IV every 6 to 8 hours; clindamycin (300–450mg by mouth three times daily or 600mg IV every 8 hours); or moxifloxacin (400mg/day; by mouth) IV or IO crystalloids Oral electrolyte solution Rectal electrolyte solution Clinical assessment • 6 Ps* • Rigid compartment If adequate fluids are unavailable, or arrhythmia cannot be managed during entrapment and extrication See above 10mg (4 vials) in nebulizer 15–30g suspended in 50– 100mL liquid, oral or rectal 10mL IV over 10 minutes 10 units IV push + 50mL D50 A limb that is cool, insensate, tensely swollen, and pulseless is likely dead. Patient may develop shock and kidney damage, and may die. 10 units IV push + 50mL D50 10mL IV over 2–3 minutes Portable monitor with ECG Monitor pulse and mental status Portable monitor with ECG Check intermittent vital signs Check intermittent vital signs Monitor pulse and mental status Place Foley catheter Laboratory monitoring Laboratory monitoring of potassium levels Close monitoring of vitals and circulatory examination Capture urine in premade or improvised graduated cylinder Dark urine (red, brown, or even black) 12-lead ECG Assess urine color (red, brown, or even black) Laboratory monitoring of potassium levels 3–5 lead ECG paresthesia, pallor, paralysis, poikilothermia, pulselessness *6 Ps: Pain persisting despite adequate analgesia is most important symptom, followed by paresthesia, pallor, Best Best Best Best Best Best Best Best Best Better Better Better Better Better Better Minimum Minimum Minimum Minimum Minimum Minimum Minimum Minimum Monitoring and Management Considerations Over Time Management of Injured Extremity Extremity compartment syndrome Any individual or combination of above, as available Tourniquet (for crush management) Albuterol (2.5mg/3mL vial) Sodium polystyrene sulfonate (Kayexalate) Calcium gluconate 10% Alternate: calcium chloride 10% Insulin (regular) and D50 Tourniquet (for irreversible injury) Insulin (regular) and D50 Pain Fluids for Hyperkalemia (>5.5mEq/L) or Cardiac Arrhythmia Treatments Calcium gluconate (10%) Telemedicine: consult on management Telemedicine: Monitoring: 15-minute to hourly vital signs, examination, urine output documented on flowsheet signs Vital Infection control UOP Urine myoglobinuria Potassium and cardiac arrhythmia N/A, not applicable; UOP, urine output. N/A, not applicable; UOP, Appendix B

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1 hour Phase 4 2 hours Continue Continue Continue. Continue. Goal UOP Goal UOP Every 1 hour Every 1 hour Record every Refer to Pain/ sedation CPG Every 6 hours 100–200mL/h 100–200mL/h 100–200mL/h Titrate to UOP Titrate Every 4–6 hours Every 4–6 hours Every 4–6 hours Record UOP every Prolonged Field Care Consider If no fasciotomy. improvement, place two tourniquets side by and proximal to the Amputation injury. anticipated

N/A Monitor; repeat as required Monitor; repeat as required Check Check Check 1 hour Phase 3 Continue Continue Continue. Continue. Goal UOP Goal UOP Per TCCC 15 minutes Immediately Record every 100–200mL/h 100–200mL/h 100–200mL/h Titrate to UOP Titrate Every 15 minutes Every 15 minutes Record UOP every Following Extrication Fasciotomy: only if qualified medical personnel or teleconsultation available Cool limb (evaporative or environmental cooling, no ice/snow) Ensure wounds cleaned and dressed, hygiene of wounds and patient optimized to the extent possible given environment. — — N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Phase 2 minutes Continue Continue Continue Continue Per TCCC Extrication Continue 1L/h Record every 15 Every 15 minutes Every 15 minutes If the patient meets criteria for tourniquet conversion or removal, and fluids are available, initiate crush injury protocol before loosening tourniquet. — — N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Initiate Initiate Phase 1 Continue Continue Per TCCC 15 minutes Entrapment Record every continue 1L/h Initial bolus: 2L, Every 15 minutes Every 15 minutes If entrapment time >2 hours, consider tourniquet. Place two tourniquets side by side and proximal to the injury Ertapenem, 1g IV/day (1g, 10mL saline or sterile water) Cefazolin, 2g IV every 6 to 8 hours; clindamycin (300–450mg by mouth three times daily or 600mg IV every 8 hours); or moxifloxacin (400mg/day; by mouth) IV or IO crystalloids Oral electrolyte solution Rectal electrolyte solution Clinical assessment • 6 Ps* • Rigid compartment If adequate fluids are unavailable, or arrhythmia cannot be managed during entrapment and extrication 10mg (4 vials) in nebulizer 15–30g suspended in 50– 100mL liquid, oral or rectal 10 units IV push + 50mL D50 10mL IV over 2–3 minutes Portable monitor with ECG See above 10 units IV push + 50mL D50 A limb that is cool, insensate, tensely swollen, and pulseless is likely dead. Patient may develop shock and kidney damage, and may die. 10mL IV over 10 minutes Close monitoring of vitals and circulatory examination Check intermittent vital signs Monitor pulse and mental status Place Foley catheter Laboratory monitoring Laboratory monitoring of potassium levels Monitor pulse and mental status Portable monitor with ECG Check intermittent vital signs Capture urine in premade or improvised graduated cylinder Dark urine (red, brown, or even black) 12-lead ECG Assess urine color (red, brown, or even black) Laboratory monitoring of potassium levels 3–5 lead ECG paresthesia, pallor, paralysis, poikilothermia, pulselessness *6 Ps: Pain persisting despite adequate analgesia is most important symptom, followed by paresthesia, pallor, Best Best Best Best Best Best Best Best Best Better Better Better Better Better Better Minimum Minimum Minimum Minimum Minimum Minimum Minimum Minimum Monitoring and Management Considerations Over Time Albuterol (2.5mg/3mL vial) Sodium polystyrene sulfonate (Kayexalate) Calcium gluconate 10% Insulin (regular) and D50 Management of Injured Extremity Extremity compartment syndrome Any individual or combination of above, as available Tourniquet (for crush management) Insulin (regular) and D50 Tourniquet (for irreversible injury) Fluids for Hyperkalemia (>5.5mEq/L) or Cardiac Arrhythmia Treatments Calcium gluconate (10%) Alternate: calcium chloride 10% Telemedicine: consult on management Telemedicine: Monitoring: 15-minute to hourly vital signs, examination, urine output documented on flowsheet signs Vital Pain UOP Urine myoglobinuria Potassium and cardiac arrhythmia Infection control Antibiotics N/A, not applicable; UOP, urine output. N/A, not applicable; UOP, Appendix B

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Appendix A Fluid and equipment planning considerations Only if qualified medical personnel or teleconsul- Best: tation (ideally with real-time video capability) available. • Fluids: IV fluid to provide 1L/h for 24 to 48 hours oo Then only if wound care available. (depending on evacuation availability) oo Regional anesthesia with nerve block or IV seda- tion required. • Equipment: ECG, laboratory tests for serum potas- • Minimum: Cool limb to reduce extremity edema sium and urine myoglobin, Foley catheter with grad- (evaporative or environmental cooling only, do not uated collection system, tourniquets pack limb in ice or snow because of risk of further • Medications: hyperkalemia*: calcium gluconate (5 x tissue damage). 10mL vial or Bristojet), insulin: 1 vial Humulin R • Pain management: Refer to TCCC Guidelines for an- (500 units; Lilly USA, www.humulin.com), D50 algesia on the battlefield.28 (120mL), albuterol (24 vials), Kayexalate (360g; Concordia Pharmaceuticals, http://concordiarx.com) Infection • Pain: refer to Analgesia, Sedation Clinical Practice Guidelines (CPG) For infection due to associated wounds and not crush • Antibiotics: ertapenem injury itself, follow the Joint Theater Trauma System • Monitoring: Continuous monitoring with portable ­Infection Control Guidelines: “Prevent Infection in monitor; 15-minute to hourly vital signs, examina- 29 Combat-Related for Extremity Wounds.” tion, urine output documented on flowsheet

Goal: Prevent infection. Communications: real-time video telemedicine • Best: Ertapenem, 1 gm IV/day (1g, 10 ml saline or consultation sterile water) • Better: Cefazolin, 2g IV every 6 to 8 hours; clindamy- Better: cin (300–450 mg by mouth three times daily or 600 • Fluids: IV fluid to provide 1L/h for 24 to 48 hours mg IV every 8 hours); or moxifloxacin (400 mg/day; • Equipment: Dipstick urine tests to monitor urine, IV or by mouth) graduated container to monitor urine output, • Minimum: Ensure wounds are cleaned and dressed, tourniquets and hygiene of wounds and patient optimized to the • Medications: hyperkalemia: calcium gluconate (5 x extent possible given environment. 10mL vial or Bristojet), insulin: 1 vial Humulin R (500 units), D50 (120mL) Two appendices accompany this article: Appendix A • Pain medications presents a summary of fluid and equipment planning • Antibiotics considerations; Appendix B comprises three tables pre- • Monitoring: 15-minute to hourly vital signs, exami- senting monitoring and management considerations nation, urine output documented on flowsheet relative to time. Communications: telephone, possibly e-mail tele- References medicine consultation 1. Brochard L, Abroug F, Brenner M, et al. An official ATS/ERS/ Minimum: ESICM/SCCM/SRLF Statement: prevention and management • Fluids: IV fluid for initial bolus resuscitation (2L), of acute renal failure in the ICU patient: an international con- then oral or rectal fluid resuscitation with commer- sensus conference in intensive care medicine. Am J Respir Crit Care Med. 2010;181:1128–1155. cial or improvised electrolyte solution 2. Greaves I, Porter K, Smith JE, et al. Consensus statement on • Equipment: Guaduated container to monitor urine the early management of crush injury and prevention of crush output, tourniquets syndrome. J R Army Med Corps. 2003;149:255–259. • Medications: hyperkalemia: calcium gluconate (5 x 3. Greaves I, Porter KM. Consensus statement on crush injury and crush syndrome. Accid Emerg Nurs. 2004;12:47–52. 10mL vial or Bristojet) 4. Gunal AI, Celiker H, Dogukan A, et al. Early and vigorous • Pain medications fluid resuscitation prevents acute renal failure in the crush vic- • Antibiotics tims of catastrophic earthquakes. J Am Soc Nephrol. 2004;15: • Monitoring: 15-minute to hourly vital signs, exami- 1862–1867. 5. Sever MS, Vanholder R. Management of crush victims in mass nation, urine output documented on flowsheet or disasters: highlights from recently published recommendations. other written format Clin J Am Soc Nephrol. 2013;8:328–335. 6. Michell MW, Oliveira HM, Kinsky MP, et al. Enteral resuscita- Communications: telemedicine by telephone tion of shock using World Health Organization oral rehy- dration solution: a potential solution for mass casualty care. J *Calculated quantities based on treating one patient for 48 hours. Burn Care Res. 2006;27:819–825.

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7. Foex BA, Dark P, Rees Davies R. Fluid replacement via the 27. Michaelson M, Taitelman U, Bursztein S. Management of rectum for treatment of hypovolaemic shock in an animal crush syndrome. Resuscitation. 1984;12:141–146. model. Emerg Med J. 2007;24:3–4. 28. US Army Institute of Surgical Research. Tactical Combat Ca- 8. Li W, Qian J, Liu X, et al. Management of severe crush injury sualty Care Guidelines. 2014. http://www.usaisr.amedd.army. in a front-line tent ICU after 2008 Wenchuan earthquake in mil/pdfs/TCCC_Guidelines_140602.pdf China: an experience with 32 cases. Crit Care. 2009;13:R178. 29. US Army Institute of Surgical Research. Guidelines to prevent 9. Huang KC, Lee TS, Lin YM, et al. Clinical features and out- infection in combat-related injuries. Joint Theater Trauma come of crush syndrome caused by the Chi-Chi earthquake. J System Clinical Practice Guideline. 2012. http://www.usaisr. Formo Med Assoc. 2002;101:249–256. amedd.army.mil/cpgs/Infection_Control_2_Apr_12.pdf. 10. Alavi-Moghaddam M, Safari S, Najafi I, et al. Accuracy of urine dipstick in the detection of patients at risk for crush-in- duced rhabdomyolysis and . Eur J Emerg Med. 2012;19:329–332. 11. Better OS. The crush syndrome revisited (1940-1990). Neph- Dr Walters is a research physiologist and a member of the ron. 1990;55:97–103. Extremity Trauma and Regenerative Medicine Task Area at 12. Better OS, Abassi ZA. Early fluid resuscitation in patients the US Army Institute of Surgical Research (USAISR), where with rhabdomyolysis. Nat Rev Nephrol. 2011;7:416–422. he conducts human and animal research focused on limb sal- 13. Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhab- vage following combat-related muscle trauma. domyolysis. Crit Care Clin. 2004;20:171–192. E-mail: [email protected]. 14. Huerta-Alardin AL, Varon J, Marik PE. Bench-to-bedside re- view: rhabdomyolysis—an overview for clinicians. Cri Care. MAJ Powell is an intensive care physician currently serving 2005;9:158–169. as the 4th Battalion 3rd Special Forces Group (Airborne) sur- 15. Nespoli A, Corso V, Mattarel D, et al. The management of shock and local injury in traumatic rhabdomyolysis. Minerva geon and a staff intensivist at Womack Army Medical Center. Anestesiol. 1999;65:256–262. E-mail: [email protected]. 16. Polderman KH. Acute renal failure and rhabdomyolysis. Int J Artif Organs. 2004;27:1030–1033. SFC Penny, NREMT-P is a senior medic and instructor at 17. Zimmerman JL, Shen MC. Rhabdomyolysis. Chest. 2013;144: the Special Operations Combat Medic Course, U.S. Army 1058–1065. John F. Kennedy Special Warfare Center and School. 18. Weisberg LS. Management of severe hyperkalemia. Crit Care E-mail: [email protected] Med. 2008;36:3246–3251. 19. McCullough PA, Beaver TM, Bennett-Guerrero E, et al. LTC(P) Chung is a board-certified internist and intensivist Acute and chronic cardiovascular effects of hyperkalemia: and currently the critical care consultant to the Army Surgeon new insights into prevention and clinical management. Rev Cardiovasc Med. 2014;15:11–23. General. He has spent the last 11 years at the US Army Insti- 20. Scharman EJ, Troutman WG. Prevention of kidney injury fol- tute of Surgical Research in various capacities. He is an SME lowing rhabdomyolysis: a systematic review. Ann Pharmaco- for burns, critical care, and organ failure. ther. 2013;47:90–105. E-mail: [email protected]. 21. Parham WA, Mehdirad AA, Biermann KM, et al. Hyperkale- mia revisited. Tex Heart Inst J. 2006;33:40–47. COL Keenan is a board-certified phy- 22. Porter K, Greaves I. Crush injury and crush syndrome: a con- sician and is currently serving as command surgeon, Special sensus statement. Emerg Nurse. 2003;11:26–30. Operations Command, Europe. He has previously served as 23. Schwartz DS, Weisner Z, Badar J. Immediate lower extrem- battalion surgeon in both 1st and 3rd SFG(A) and as group ity tourniquet application to delay onset of reperfusion injury surgeon, 10th SFG(A). He is the coordinator for the SOMA after prolonged crush injury. Prehosp Emerg Care. 2015;19: 544–547. Prolonged Field Care Working Group. 24. Centers for Disease Control and Prevention. Crush injury E-mail: [email protected]. and crush syndrome. http://www.acep.org/MobileArticle. aspx?id=46079&parentid=740 COL Shackelford, MC, USAF, is a trauma surgeon, cur- 25. Chen X, Zhong H, Fu P, et al. Infections in crush syndrome: rently serving as the chief of performance improvement, Joint a retrospective observational study after the Wenchuan earth- Trauma System, San Antonio, Texas. She is a member of the quake. Emerg Med J. 2011;28:14–17. Committee on TCCC and has previously deployed as the di- 26. Guner SI, Oncu MR. Evaluation of crush syndrome patients rector of the Joint Theater Trauma System. with extremity injuries in the 2011 Van Earthquake in Tur- E-mail: [email protected]. key. J Clin Nurs. 2014;23:243–249.

Management of Crush Syndrome Under Prolonged Field Care 85