J R Army Med Corps 2003; 149: 255-259 J R Army Med Corps: first published as 10.1136/jramc-149-04-02 on 1 December 2003. Downloaded from ORIGINAL PAPERS Consensus Statement On The Early Management Of Crush Injury And Prevention Of Crush Syndrome I Greaves, K Porter, JE Smith ABSTRACT cause the syndrome is incompatible with life Crush Syndrome remains rare in due to the inherent internal organ damage, European practice. It is however comm- but there are a few reported cases of such on in areas of civil disorder and where instances (3). the normal structures of society have Crush syndrome bears many similarities given way to civil war or natural to, but is distinct from, the syndrome caused disaster. Western Doctors are becoming by heat illness. increasingly involved in such situations and there is no reason to believe that Definition instances due to more conventional Following a search of the literature, it was felt causes, such as collapse in the elderly or that a definition of crush injury and crush road traffic accidents will cease. For all syndrome was required. these reasons it is important that clini- Consensus view cians who deal infrequently with crush “A crush injury is a direct injury resulting from syndrome have access to appropriate crush. Crush syndrome is the systemic guidelines. This consensus report seeks manifestation of muscle cell damage resulting to provide such advice. from pressure or crushing”. The severity of the condition is related to Key Words: Crush Syndrome, Renal Failure, the magnitude and duration of the com- Natural Disasters. pressing force, and the bulk of muscle aff- ected. The definition is not, however, dep- Introduction endent on the duration of the force applied. Crush injuries and crush syndrome were first Examples of this relationship are firstly a described in the English Language literature patient whose legs are run over by the wheels by Bywaters and Beall in 1941 (1), after of a truck. In this case the force is large, but the duration is very short. At the other several patients who had been trapped under http://militaryhealth.bmj.com/ rubble of buildings bombed in the Blitz extreme, there is the elderly patient who has subsequently died of acute renal failure. It suffered a stroke, falls, and lies in the same has been described in numerous settings position for hours, sustaining a crush injury since, most commonly after natural disasters to the areas of the body on which they are such as earthquakes, in war, and after lying. In this case, the force is relatively small, buildings have collapsed as a result of ex- but crush syndrome may develop as a result Lt Col I Greaves plosion. Crush syndrome is also seen foll- of the prolonged period of pressure. Similar RAMC owing industrial incidents such as mining cases to this are described as a result of drug overdose (4). Visiting Professor of accidents and road traffic accidents. How- Emergency Medicine ever, crush syndrome is not confined to Education Centre, traumatic aetiologies, and has also been Pathogenesis and clinical on September 27, 2021 by guest. Protected copyright. The James Cook described following periods of crush by features University Hospital, patients’ own body weight, after stroke or The typical clinical features of crush syn- Marton Road, intoxication (2). drome are predominantly a result of Middlesbrough, Most commonly in traumatic crush, the traumatic rhabdomyolysis and subsequent TS4 3BW legs are affected, and less frequently the release of muscle cell contents. The mech- arms. Many authors believe that crush injury K Porter anism behind this in crush syndrome is the of the head and torso significant enough to leakiness of the sarcolemmal membrane Consultant Trauma This paper reports the findings of a consensus meeting on Crush Injury and Crush Syndrome held in Surgeon, University Birmingham on 31 May 2001, and co-ordinated by the Faculty of Pre-Hospital Care of the Royal Hospital, Birmingham College of Surgeons of Edinburgh. Surg Lt Cdr JE Smith MBBS MSc MRCP RN Organisations represented The Voluntary Aid Societies The Royal College of Physicians Specialist Registrar in Emergency Medicine The Ambulance Service Association The Royal College of Surgeons of Edinburgh Defence Medical The British Association for Immediate Care The Intensive Care Society Services, British Association for Emergency Medicine The Royal College of Nursing Derriford MDHU, Faculty of Accident and Emergency Medicine The Military Plymouth, PL6 8DH. The Royal College of Anaesthetists The Faculty of Pre-hospital Care 256 Consensus Statement On Crush Injury J R Army Med Corps: first published as 10.1136/jramc-149-04-02 on 1 December 2003. Downloaded from caused by pressure or stretching. As the Airway, Breathing and Circulation is the next sarcolemmal membrane is stretched, sod- priority. Attention must be given in trauma to ium, calcium and water leak into the the possibility of spinal injury and full spinal sarcoplasm, trapping extracellular fluid precautions should be maintained. Admin- inside the muscle cells. In addition to the istration of high flow oxygen by mask should influx of these elements into the cell, the cell be a priority in treatment, as should the releases potassium and other toxic arrest of any obvious external haemorrhage substances such as myoglobin, phosphate and the splinting of limb injuries.The patient and urate into the circulation (5). should be exposed as necessary to assess and The end result of these events is shock manage injuries. In a hostile environment, or (discussed below), hyperkalaemia (which where there is a risk of hypothermia, may precipitate cardiac arrest), hypocalc- exposure should be as limited as possible. aemia, metabolic acidosis, compartment Assessment of distal neurovascular status is syndrome (due to compartment swelling), essential if exposure is to be kept to a and acute renal failure (ARF). The ARF is minimum. due to a combination of hypovolaemia with The patient should be released as quickly subsequent renal vasoconstriction, metabolic as possible, irrespective of the length of time acidosis and the insult of nephrotoxic trapped. substances such as myoglobin, urate and phosphate. Fluid resuscitation Once the initial primary survey has been Shock performed, intravenous access should be Haemodynamic instability secondary to obtained. If limb crush injury has occurred, crush syndrome is multi-factorial. Firstly, and there is a likelihood of the patient many patients have other injuries, such as developing crush syndrome, the following fractures of the pelvis or lower limbs, fluid guidelines should be followed. In the sufficient in themselves to cause hypovol- presence of life-threatening thoraco- aemia. The sequestration of fluid into the abdominal injury, fluid resuscitation should affected muscle compartments has already be performed according to the Faculty’s been described, resulting in fluid shift from previously published guidelines (8). the intravascular to the intracellular comp- artments. This may cause hypovolaemia, as Consensus view the intravascular volume is depleted. Elec- An initial fluid bolus of 2 litres of crystalloid trolyte imbalances such as hyperkalaemia, should be given intravenously.This should be hypocalcaemia and a metabolic acidosis will followed by 1-1.5 litres per hour.The fluid of have a negatively inotropic effect, and there is choice is normal saline, warmed if possible, also evidence that there is direct myocardial as this is established as the fluid carried by http://militaryhealth.bmj.com/ depression from other factors released when the majority of pre-hospital vehicles in the muscle cells are damaged (6). United Kingdom. Hartmann’s solution contains potassium and has a theoretical Approach to treatment disadvantage of exacerbating hyperkalaemia. Treatment of the crushed patient can be If possible, fluid should be started prior to divided into two phases. The initial pre- extrication, however, gaining intravenous hospital phase may, depending on the access and the administration of fluid should mechanism of injury, involve a prolonged not delay extrication and transport to a extrication period.The second phase comm- definitive care facility. Early catheterisation ences on reaching a definitive medical care should be considered, especially if there is a facility. In the case of prolonged on-scene prolonged extrication or evacuation phase. on September 27, 2021 by guest. Protected copyright. time, or delay in transfer due to geographical Once the patient reaches hospital, 5% reasons, some of the second phase guidelines dextrose should be alternated with normal may be employed in the pre-hospital saline to reduce the potential sodium load. environment. Analgesia Consensus view Consensus view Safety is the first priority when approaching The use of medical teams including an accident scene, and this is particularly paramedics, nurses and doctors should be relevant to situations where patients may considered at an early stage, and appropriate have suffered crush injuries, as there may be analgesia should be given. This may involve danger from falling debris or risk of further the use of Entonox® initially, but most building collapse. patients will require intravenous analgesia Once the scene has been declared safe, in such as an opiate, titrated against response. cases of mass casualties, a triage system (such The use of ketamine, with or without the as the triage sieve – Major Incident Medical concomitant use of a benzodiazepine, is also Management & Support (MIMMS) (7)) an effective means of relieving pain, and may should be used to prioritise casualties and aid extrication. assess the need for further treatment. For First responders may give oral analgesia in each individual casualty, an assessment of the absence of senior clinical support. I Greaves, K Porter, JE Smith 257 J R Army Med Corps: first published as 10.1136/jramc-149-04-02 on 1 December 2003. Downloaded from Triage use of a solute alkaline diuresis is accepted to Consensus view be protective against the development of Patients with crush injuries should be taken acute renal failure (11,12).