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ISR/PFC Crush Injury Clinical Practice Guideline

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ISR/PFC Crush Injury Clinical Practice Guideline All articles published in the Journal of Special Operations Medicine are protected by United States copyright law and may not be reproduced, distributed, transmitted, displayed, or otherwise published without the prior written permission of Breakaway Media, LLC. Contact [email protected]. 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 injury, burns) 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, traumatic brain injury). 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 reperfusion injury that leads to is intended to be used after Tactical Combat Ca- traumatic rhabdomyolysis. Reperfusion results in the Tsualty Care (TCCC) Guidelines when evacuation release of muscle cell components, including myoglobin 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 kidney damage. TCCC. This Clinical Practice Guideline (CPG) is meant Hyperkalemia 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 hypocalcemia, contributing to cardiac guidance for how to manage the various aspects of crush arrhythmias. 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 compartment syndrome, and severe tion that can occur as a result of entrapment of the ex- limb trauma involving blunt trauma 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 arrhythmia, and Telemedicine: Management of crush syndrome is death. complex. Establish telemedicine consult as soon as possible. 79 All articles published in the Journal of Special Operations Medicine are protected by United States copyright law and may not be reproduced, distributed, transmitted, displayed, or otherwise published without the prior written permission of Breakaway Media, LLC. Contact [email protected]. Fluid Resuscitation 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 crush injury 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 o 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. o Increasing the fluid rate • Best: IV crystalloids o 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 o 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 o 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 hypotension, • 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), 80 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2016 All articles published in the Journal of Special Operations Medicine are protected by United States copyright law and may not be reproduced, distributed, transmitted, displayed, or otherwise published without the prior written permission of Breakaway Media, LLC. Contact [email protected]. prolonged QRS interval, PVCs or runs of ventricu- o 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 • Insulin and 50% dextrose (D50); calcium gluconate;
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