Difference between revisions of "Crush syndrome"

(Pathophysiology)
(Extended Management)
 
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==Background==
 
==Background==
*>4-6 hours to develop
+
Also known as traumatic rhabdomylosis
**Rare cases with severe compression can develop <1 hr
+
===Criteria===
*Starts after blood flow is restored
+
#Involvement of muscle mass
 +
#Prolonged compression of 4-6 hours but possible in <1 hr
 +
#Compromised local circulation
  
 
===Pathophysiology===
 
===Pathophysiology===
*Cardiovascular shock
+
*Hypovolemic [[shock]]
 
**Third spacing of fluids
 
**Third spacing of fluids
*Metabolic acidosis
+
*[[Metabolic acidosis]]
 
**[[Hyperkalemia]]
 
**[[Hyperkalemia]]
**Hyperphosphatemia
+
**[[Hyperphosphatemia]]
 
**[[Hypocalcemia]]
 
**[[Hypocalcemia]]
 
**[[Rhabdo]] and [[Renal Failure]]
 
**[[Rhabdo]] and [[Renal Failure]]
 +
 +
==Clinical Features==
 +
*Skin trauma or local signs of compression over a muscle mass
 +
**Erythema, ecchymosis, bullae, abrasion
 +
*Tense muscle mass
 +
 +
==Differential Diagnosis==
 +
{{Extremity trauma DDX}}
 +
 +
==Evaluation==
 +
===Work Up===
 +
*CBC
 +
*Chem 10
 +
*CK
 +
*Urine dip and UA
 +
*Strict I&Os
 +
*[[ECG]]
 +
*Imaging as indicated by injury
 +
*Compartment pressure monitoring for suspected [[Compartment syndrome]]
 +
 +
===Results===
 +
One or more of these should be found in the right clinical setting
 +
*Myoglobinuria and/or hematuria
 +
*Peak CK (typically >10,000)
 +
*Oliguria (<400ml/24hrs)
 +
*Elevated BUN (>40)
 +
*Elevated creatinine (>2.0)
 +
*Elevated uric acid (>8)
 +
*[[Hyperkalemia]] (>6)
 +
*Hyperphosphotemia (>8)
 +
*Hypocalcemia (<8)
  
 
==Management==
 
==Management==
===Prehospital Proticol for Entrapment Lasting >4hrs or Suspicion of Hyperkalemia===
+
===Prehospital Protocol for Entrapment Lasting >4hrs or Suspicion of [[Hyperkalemia]]===
*Should begin BEFORE extrication
+
''Should begin BEFORE extrication''
**Cardiac monitoring
+
*Cardiac monitoring
**Hydration (~NS 1.5 L/hr)
+
*Hydration (~NS 1.5 L/hr)
**Pain control
+
*Pain control
**Albuterol neb
+
*[[Albuterol]] neb
**Calcium Chloride
+
*[[Calcium chloride]]
***1 gram slow IV push over 60 sec
+
**1 gram slow IV push over 60 sec
**Sodium Bicarbonate
+
*[[Sodium bicarbonate]]
***Flush IV with NS (prevent precipitation), then
+
**Flush IV with NS (prevent precipitation), then
***1mEq/kg added to 1L of normal saline, run IV wide open just prior to extrication
+
**1mEq/kg added to 1L of normal saline, run IV wide open just prior to extrication
**Release compression
+
*Release compression
 +
**In the field, use of [[tourniquet]] before extrication is controversial
 +
 
 +
===ED Management===
 +
*ATLS
 +
*Aggressive IVF
 +
*Treat [[Hyperkalemia]] with typical management
 +
 
 +
===Extended Management===
 +
*250ml IV bolus q15min until UOP is 2ml/kg/hr
 +
*[[Lasix]] or [[Mannitol]] for forced diuresis
 +
*[[Acetazolamide]] for pH >7.5
 +
 
 +
==Disposition==
 +
*ICU
 +
*Intermediate Care or Floor for minor cases
  
 
==See Also==
 
==See Also==
*[[Compartment Syndrome]]
+
*[[Compartment syndrome]]
 
*[[Rhabdomyolysis]]
 
*[[Rhabdomyolysis]]
 
*[[Disseminated Intravascular Coagulation (DIC)]]
 
*[[Disseminated Intravascular Coagulation (DIC)]]
  
 +
==References==
 +
<references/>
 
[[Category: EMS]]
 
[[Category: EMS]]
 
[[Category: Trauma]]
 
[[Category: Trauma]]

Latest revision as of 01:33, 2 September 2019

Background

Also known as traumatic rhabdomylosis

Criteria

  1. Involvement of muscle mass
  2. Prolonged compression of 4-6 hours but possible in <1 hr
  3. Compromised local circulation

Pathophysiology

Clinical Features

  • Skin trauma or local signs of compression over a muscle mass
    • Erythema, ecchymosis, bullae, abrasion
  • Tense muscle mass

Differential Diagnosis

Extremity trauma

Evaluation

Work Up

  • CBC
  • Chem 10
  • CK
  • Urine dip and UA
  • Strict I&Os
  • ECG
  • Imaging as indicated by injury
  • Compartment pressure monitoring for suspected Compartment syndrome

Results

One or more of these should be found in the right clinical setting

  • Myoglobinuria and/or hematuria
  • Peak CK (typically >10,000)
  • Oliguria (<400ml/24hrs)
  • Elevated BUN (>40)
  • Elevated creatinine (>2.0)
  • Elevated uric acid (>8)
  • Hyperkalemia (>6)
  • Hyperphosphotemia (>8)
  • Hypocalcemia (<8)

Management

Prehospital Protocol for Entrapment Lasting >4hrs or Suspicion of Hyperkalemia

Should begin BEFORE extrication

  • Cardiac monitoring
  • Hydration (~NS 1.5 L/hr)
  • Pain control
  • Albuterol neb
  • Calcium chloride
    • 1 gram slow IV push over 60 sec
  • Sodium bicarbonate
    • Flush IV with NS (prevent precipitation), then
    • 1mEq/kg added to 1L of normal saline, run IV wide open just prior to extrication
  • Release compression
    • In the field, use of tourniquet before extrication is controversial

ED Management

  • ATLS
  • Aggressive IVF
  • Treat Hyperkalemia with typical management

Extended Management

Disposition

  • ICU
  • Intermediate Care or Floor for minor cases

See Also

References