102-106_crush injury

J R Army Med Corps 2004; 150: 102-106
Consensus Statement On The Early Management Of Crush
Injury And Prevention Of Crush Syndrome
ABSTRACT
Many authors believe that crush injury of the Syndrome
head and torso significant enough to cause European practice. It is however comm-
the syndrome is incompatible with life due to on in areas of civil disorder and where
the inherent internal organ damage, but there the normal structures of society have
are a few reported cases of such instances (3).
given way to civil war or natural
Crush syndrome bears many similarities to, disaster. Western Doctors are becoming
but is distinct from, the syndrome caused by increasingly involved in such situations
and there is no reason to believe that
instances due to more conventional
Definition
causes, such as collapse in the elderly or
Following a search of the literature, it was felt road traffic accidents will cease. For all
that a definition of crush injury and crush these reasons it is important that clini-
cians who deal infrequently with crush
syndrome have access to appropriate
“A crush injury is a direct injury resulting from guidelines. This consensus report seeks
to provide such advice.
manifestation of muscle cell damage resultingfrom pressure or crushing”. Key Words: Crush Syndrome, Renal Failure,
The severity of the condition is related to the magnitude and duration of the com-pressing force, and the bulk of muscle aff- Introduction
ected. The definition is not, however, dep- Crush injuries and crush syndrome were first endent on the duration of the force applied.
described in the English Language literature Examples of this relationship are firstly a patient whose legs are run over by the wheels several patients who had been trapped under of a truck. In this case the force is large, but subsequently died of acute renal failure. It has extreme, there is the elderly patient who has been described in numerous settings since, suffered a stroke, falls, and lies in the same most commonly after natural disasters such position for hours, sustaining a crush injury as earthquakes, in war, and after buildings to the areas of the body on which they are have collapsed as a result of explosion. Crush lying. In this case, the force is relatively small, syndrome is also seen following industrial but crush syndrome may develop as a result incidents such as mining accidents and road of the prolonged period of pressure. Similar traffic accidents. However, crush syndrome is cases to this are described as a result of drug not confined to traumatic aetiologies, and has crush by patients’ own body weight, after Pathogenesis and clinical
features
The typical clinical features of crush syn- legs are affected, and less frequently the arms.
This paper reports the findings of a consensus meeting on Crush Injury and Crush Syndrome held in Birmingham on 31 May 2001, and co-ordinated by the Faculty of Pre-Hospital Care of the Royal Organisations represented
The Royal College of Surgeons of Edinburgh The British Association for Immediate Care British Association for Emergency Medicine Faculty of Accident and Emergency Medicine The Royal College of Anaesthetists release of muscle cell contents. The mech- should be used to prioritise casualties and anism behind this in crush syndrome is the assess the need for further treatment. For each individual casualty, an assessment of Airway, Breathing and Circulation is the next priority. Attention must be given in trauma to the possibility of spinal injury and full spinal 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 arrest of any obvious external haemorrhage and the splinting of limb injuries.The patient should be exposed as necessary to assess and manage injuries. In a hostile environment, or may precipitate cardiac arrest), hypocalc- exposure should be as limited as possible.
Assessment of distal neurovascular status is and acute renal failure (ARF). The ARF is 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 substances such as myoglobin, urate andphosphate.
Fluid resuscitation
Once the initial primary survey has been
obtained. If limb crush injury has occurred, crush syndrome is multi-factorial. Firstly, many patients have other injuries, such as fluid guidelines should be followed. In the sufficient in themselves to cause hypovol- aemia. The sequestration of fluid into the abdominal injury, fluid resuscitation should 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 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 depression from other factors released when the majority of pre-hospital vehicles in the United Kingdom. Hartmann’s solutioncontains potassium and has a theoretical Approach to treatment
disadvantage of exacerbating hyperkalaemia.
If possible, fluid should be started prior to divided into two phases. The initial pre- extrication, however, gaining intravenous access and the administration of fluid should 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.
time, or delay in transfer due to geographical reasons, some of the second phase guidelines dextrose should be alternated with normal saline to reduce the potential sodium load.
Analgesia
Safety is the first priority when approaching an accident scene, and this is particularly 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 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 as the triage sieve – Major Incident Medical concomitant use of a benzodiazepine, is also Consensus Statement On Crush Injury an effective means of relieving pain, and may The development of acute renal failure in these patients significantly decreases the First responders may give oral analgesia in chances of survival (10). Every effort must the absence of senior clinical support.
occurrence. Alkalinisation of urine and the use of a solute alkaline diuresis is accepted to Patients with crush injuries should be taken to a hospital with an intensive care facilityand the equipment and expertise necessary measured, and kept above 6.5 by adding50mmol aliquots of bicarbonate (50mls Tourniquets
The use of tourniquets has a theoretical role intravenous fluid regime. Solute diuresis is in the management of these patients. If the affected by administering mannitol at a dose release into the circulation of the contents of of 1-2g/kg over the first four hours as a 20% possibly with the use of a tourniquet, it may given to maintain a urine output of at least 8 be of benefit. However, there is currently no requirements are high, usually of the order of12 litres per day, due to the sequestration of fluid in muscle tissue. Fluid should be given The use of tourniquets should be reserved at approximately 500 mls/hour, but regular for otherwise uncontrollable life threatening review of clinical parameters such as central moment to support the use of tourniquets in dictate exact amounts of fluid given.
following extrication, or in the prevention of 200g, and it should not be given to patients washing of the products of rhabdomyolysis Children
Amputation
Another theoretically advantageous measure There is very little evidence in the literature is amputation of a crushed limb to prevent to guide the treatment of children suffering from crush injuries. In young children thedifference in body proportions, namely the reduced contribution to the total percentage There is no evidence to support the use of literature suggest that even severely crushed Paediatric Life Support (APLS) (13) of an limbs can recover to full function. If the limb is literally hanging on by a thread, or if the patient’s survival is in danger due toentrapment by a limb, amputation should be The elderly and patients with co-
morbidity
Consensus viewIn the elderly, and those with pre-existing Immediate in-hospital care
medical conditions such as cardiac failure, Patients should be assessed following normal requirements and given with caution. Close monitoring of the clinical state of the patient, guidelines (9). Baseline blood tests should and regular review of fluid requirements is be taken.These will include full blood count, urea and electrolytes, creatinine kinase,amylase, liver function tests, clotting screen Compartment syndrome
and group and save (cross match if deemed catheterised and hourly urine measurements uptake of fluid into damaged muscle tissue capillary perfusion pressure at about 30 -40mm The use of solute-alkaline
diuresis
syndrome is fasciotomy (4), but there is now tourniquet placement versus no tourniquet evidence that initial treatment with mannitol in delayed intravenous fluid administration was suggested as a further research option.
and avoid the need for surgery (5,12).
Are there any further deleterious effects due to the increased ischaemia times involved in In patients with compartment syndrome due to crush injury, in the absence of neuro- Could cooling the limb be used in order to slow cellular respiration and consequently therapy should be instigated, but a specialist Hyperbaric oxygen therapy
as a potential shortfall in their use. There is a There is theoretical and limited experimental requirement to perform a literature search evidence that hyperbaric oxygen therapy may into tourniquet usage, in particular regarding improve wound healing and reduce the need for multiple surgical procedures in crush determine the effectiveness of certain types of tourniquet and the leakage rates of drugs, leaking into the systemic circulation.
nitric oxide synthase inhibitors may also havea role in preventing excessive vasodilatation Fluid administration
Types of fluid currently used for admini- increase in third space fluid losses (15).
stration include: normal saline, Hartmann's,Dextran or starches.
amount of fluid to be giving? Should we be Logistically hyperbaric oxygen treatment has limited application. Patients with no sig- intake or acidity of urine as a guide to fluid nificant co-morbidity, and who can be man- secondary to massive fluid administration aged in a hyperbaric chamber where the fac- and may be detrimental. At what stage do we ility is available, may be treated with hyper- need to worry about this? What effect does baric oxygen therapy. It is recommended that treatment options are discussed with thelocal hyperbaric unit. This is not recomm- Prognostic indicators
ended as first line treatment. Patients should, Creatinine kinase, myoglobinaemia and amy- however, receive high flow oxygen, unless there is a specific contra-indication.
indicators, although it is not clear that theycan predict outcome at an early enough stage Further management
to allow effective intervention. The use of microalbuminuria as a prognostic indicator In many cases, intensive care support will be required for the complications of crushsyndrome. If the patient becomes oligo- or Hyperbaric oxygen therapy
anuric, it is likely that they will require Use of the Institute of Naval Medicine was suggested in order to evaluate the merits ofthis treatment modality. In view of the Multiple casualties
scarcity of this resource around the country it did not meet with a great deal of support.
In the civilian environment in the UnitedKingdom, there will be a huge strain on Bicarbonate administration
intensive care facilities if there are multiple Early administration of bicarbonate intra- crushed casualties. A policy should be drawn venously is thought to decrease metabolic acidosis and promote alkalisation of urine which decreases the precipitation of myo- national level should an incident occur.
globin in the renal tubules. Administration of Further information is available in Better’s bicarbonate immediately post-extrication, in anticipated metabolic acidosis, was dis-cussed. Has this been shown to be beneficial? Areas identified for future
research
would be the appropriate and safe doses to Use of tourniquets
use? Is there a role for the combined use of Is there a role for the tourniquet post or pre acetazolamide in order to prevent metabolic extrication of the crush injury casualty? The use of an animal model of crush injury was Consensus Statement On Crush Injury Mannitol and compartment syndrome
There is anecdotal evidence in the literature syndrome following unconsciousness: need for
urgent orthopaedic referral. BMJ 1994; 309: 857-
that due to the high complication rate in Better OS. Rescue and salvage of casualties syndrome in crushed patients, they are best suffering from the crush sydrome after mass managed with mannitol alone. It is suggested disasters. Mil Med 1999; 164: 366-9.
that there is a noticeable difference in dia- Rawlins M, Gullichsen E, Kuttila K, Peltola O,Niinikoski J. Central hemodynamic changes in meter and symptoms of the lower leg within experimental muscle crush injury in pigs. Eur Surg 40 minutes of administration of IV mannitol Res 1999; 31: 9-18.
Major Incident Medical Management & Support refractory cases. The use of an animal model (MIMMS) 2002. BMJ Bookshops, London.
Resuscitation in Pre-Hospital Trauma Care: A due to the anatomical differences from hum- Consensus View. J.R. Coll. Surg. Edinb. 47; 2; 451-
as models for humans, such as pigs, sheep Advanced Trauma Life Support for Doctors.
American College of Surgeons 1997 Chicago.
and dogs do not have fascial compartments.
10. Ward MM. Factors predictive of acute renal failure Primates share similarities but, ethically, in rhabdomyolysis. Arch Intern Med 1988; 148:
would be more difficult to justify. Further information on existing animal experiment- 11. Better OS. The crush syndrome revisited (1940- ation relating to compartment syndrome is 12. Better OS, Zinman C, Reis ND et al. Hypertonic tamponade in model compartment syndrome in
the dog. Nephron 1991; 58: 344-6.
13. Advanced Paediatric Life Support 2nd Edition Journal of the Royal Army Medical Corps Vol 14. Bouachour G, Cronier P, Gouello JP, Toulemonde JL, Talha A, Alquier P. Hyperbaric Oxygen therapyin the management of crush injuries; a randomized References
double-blind placebo-controlled clinical trial. J 1. Bywaters EGL, Beall D. Crush injuries with Trauma 1996; 41(2): 333-9.
impairment of renal function. BMJ 1941; 1: 427.
15. Rubinstein I, Abassi Z, Coleman R, Milman F, Michaelson M. Crush injury and crush syndrome.
Winaver J, Better OS. Involvement of nitric oxide World J Surg 1992; 16: 899-903.
system in experimental muscle crush injury. J Clin
Invest 1998; 101(6): 1325-33.
Hiraide A, Ohnishi M, Tanaka H et al. Abdominal
and lower extremity crush syndrome. Injury 1997;
28(9-10): 685-6.

Source: http://www.fphc.co.uk/downloads/crush%20injury.pdf