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CRUSH INJURIES

CRUSH INJURIES Crush Injury Compression of body parts causing localized muscle and nerve damage. Frequent injury seen in both natural (earthquakes, tornadoes, etc.) and man-made (bombings, industrial accidents, etc.) disasters. ©2010 Trauma and Disaster Institute Crush Injuries

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CRUSH INJURIES

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  1. CRUSH INJURIES Crush Injuries

  2. Crush Injury • Compression of body parts causing localized muscle and nerve damage. • Frequent injury seen in both natural (earthquakes, tornadoes, etc.) and man-made (bombings, industrial accidents, etc.) disasters. ©2010 Trauma and Disaster Institute Crush Injuries

  3. Incidence • Lower extremities = 74% • Upper Extremities = 10% • Trunk = 9% Crush injury with amputation, El Salvador earthquake (1987) Crush Injuries

  4. Crush Syndrome • “Crush syndrome” first recorded in bombing of London during WWII. • 5 people who were crushed presented in shock with swollen extremities and dark urine. • All later died from renal failure. Crush Injuries

  5. Crush Syndrome • Localized crush injury with systemic manifestations • Systemic effects caused by traumatic rhabdomyolysis (muscle breakdown) and the release of toxic muscle cell components and electrolytes into the circulatory system Crush Injuries

  6. Crush injury of pelvis with secondary crush syndrome Crush Syndrome Common in Earthquakes Crush Injuries

  7. Earthquakes • Incidence of crush injury is 2-15% (historical data). • ~ 50% develop acute renal failure. • ~ 50% of those with acute renal failure need dialysis. • > 50% of casualties require fasciotomies. Crush Injuries

  8. Components of Crush Syndrome • Local tissue injury • Organ dysfunction • Metabolic abnormalities Crush Injuries

  9. Crush Injuries

  10. Metabolic Abnormalities • Acidosis (low blood pH levels) • Hyperkalemia (high potassium levels) • Hypocalcemia (low calcium levels) Crush Injuries

  11. Definitive Management of Crush Syndrome Crush Injuries

  12. Key Principles: • ADEQUATE FLUID RESUSCITATION is critical in treating victims of crush injury. • Ideal resuscitation fluid: Normal Saline Crush Injuries

  13. Secondary Treatment Modalities • Bicarbonate • Mannitol (no proven benefits but no significant deleterious effects) Crush Injuries

  14. Goals of Fluid Therapy: • Prevent tubular precipitation of myoglobin • Decrease risk of hyperkalemia • Correct acidemia Crush Injuries

  15. Prehospital Considerations in the Management of Victims with Crush Injuries Crush Injuries

  16. TREATMENT ALERT! • Pretreat casualties with prolonged crush (> 4 hrs), as well as those with abnormal neurological or vascular exams • 1-2 liters Normal Saline BEFORE releasing crush object whenever possible! Crush Injuries

  17. TREATMENT ALERT! • If not possible to pretreat, consider applying tourniquet to crushed limbs and maintain until IV fluid administration is initiated. Combat Application Tourniquet (CAT) Crush Injuries

  18. Key Principle: • Risk of acute deterioration and death with sudden release of pressure on the involved extremity (REPERFUSION SYNDROME). Crush Injuries

  19. Reperfusion Syndrome • Acute hypovolemia • Metabolic abnormalities Crush Injuries

  20. TREATMENT ALERT! • Metabolic abnormalities • Acidosis: IV sodium bicarbonate to prevent myoglobin deposits in kidneys • Hyperkalemia: Calcium, sodium bicarbonate, insulin/D5W • Hypocalcemia: Calcium Crush Injuries

  21. TREATMENT ALERT! • Delays of hydration for longer than 12 hours increase the incidence of renal failure. Crush Injuries

  22. Late Treatment: Dialysis Crush Injuries

  23. Compartment Syndrome • Following traumatic injury, the muscles within a compartment can swell, causing irreversible damage to nerves, vascular structures, and muscles. • Compartment syndrome is a medical emergency. Crush Injuries

  24. Compartment Syndrome • Consider the possibility of a compartment syndrome in all patients with significant crush injury. • Compartment syndrome reported with trapping times less than 1 hour. • Fracture not mandatory for compartment syndrome to develop. Crush Injuries

  25. RISK ALERT! • Peripheral pulses may be present in the early stages of limb ischemia. Crush Injuries

  26. Field Observation… • The cardinal symptom of compartment syndrome is pain out of proportion to apparent injuries. Crush Injuries

  27. Upper Extremity Compartment Syndrome • Forearm and hand are at highest risk. Crush Injuries

  28. Lower Extremity Compartment Syndrome • Anterior and lateral compartments of the lower leg (calf) are at highest risk. Crush Injuries

  29. Fasciotomy • The decision to undertake fasciotomy should be made based on a high index of suspicion of a compartment syndrome in patients with complex extremity injuries. • Err on the side of early fasciotomy. Crush Injuries

  30. Lower Extremity Fasciotomies Crush Injuries

  31. Early Mortality in Crush Syndrome • Hypovolemia • Hyperkalemia Crush Injuries

  32. Late Mortality in Crush Syndrome • Sepsis • Multiple Organ Failure Crush Injuries

  33. Factors Impacting Mortality and Morbidity: • Severity of the crush injury • Timing of treatment • Initial treatment provided to the victim Crush Injuries

  34. Questions… Crush Injuries

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