Crush syndrome medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Medical Therapy
Due to the risk of crush syndrome, current recommendation to lay first-aiders (in the UK) is to not release victims of crush injury who have been trapped for more than 15 minutes. Treatment consists of not releasing the tourniquet and fluid overloading the patient with added Dextran 4000 iu and slow release of pressure. If pressure is released during first aid then fluid is restricted and an input-output chart for the patient is maintained, and proteins are decreased in the diet.
The Australian Resuscitation Council recommended in March 2001 that first-aiders in Australia, where safe to do so, release the crushing pressure as soon as possible, avoid using a tourniquet and continually monitor the vital signs of the patient.[1] St John Ambulance Australia First Responders are trained in the same manner.
Field management
As mentioned, permissive hypotension is unwise. Especially if the crushing weight is on the patient more than 4 hours, but often if it persists more than one hour, careful fluid overload is wise, as well as the administration of intravenous sodium bicarbonate. The San Francisco emergency services protocol calls for a basic adult dose of a 2 L bolus of normal saline followed by 500 ml/hr, limited for "pediatric patients and patients with history of cardiac or renal dysfunction." [2]
If the patient cannot be fluid loaded, this may be an indication for a tourniquet to be applied.
Initial hospital management
The clinician must protect the patient against hypotension, renal failure, acidosis, hyperkalemia and hypokalemia. Admission to a intensive care unit, preferably one experienced in trauma medicine, may be appropriate; even well-seeming patients need observation. Treat open wounds as surgically appropriate, with debridement, antibiotics and tetanus toxoid; apply ice to injured areas.
Intravenous hydration of up to 1.5 L/hour should continue to prevent hypotension. A urinary output of at least 300 ml/hour should be maintained with IV fluids and mannitol, and hemodialysis considered if this amount of diuresis is not achieved. Use intravenous sodium bicarbonate to keep the urine pH at 6.5 or greater, to prevent myoglobin and uric acid deposition in kidneys.
To prevent hyperkalemia/hypocalcemia, consider the following adult doses:
- calcium gluconate 10% 10ml or calcium chloride 10% 5ml IV over 2 minutes
- sodium bicarbonate 1 meq/kg IV slow push
- regular insulin 5-10 U
- 50% glucose 1-2 ampules IV bolus
- kayexalate 25-50g with sorbitol 20% 100mL by mouth or rectum.
Even so, cardiac arrythmias may develop; electrocardiographic monitoring is advised, and specific treatment begun promptly.
References
- ↑ "Emergency Management of a Crushed Victim" (PDF). Australian Resuscitation Council. March 2001. Retrieved 20 July 2011.
- ↑ Crush Syndrome (PDF), San Francisco Emergency Medical Services Agency, 1 July 2002, Protocol: #P-101