Crush Injury 

Assessment

Pediatric Pearls: Signs & Symptoms: Differential: 
□ Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg

□ Back pain without trauma is concerning in the pediatric patient 		□ Compartment Syndrome 
□ Pain on passive stretch 
□ Paresthesia 
□ Paralysis  
□ Pallor 
□ Pulselessness 
□ Hypoperfusion 
□ Hypotension 
□ Altered Mental Status		□ Skin irritant exposure 
□ Dust concentrations in airway 
□ Hypo/Hyperthermia 
□ Hyperkalemia 
□ Dehydration 
□ Additional trauma

Clinical Management Options

EMT-B
• Oxygen target SpO2 92% – 96%  
• Treatment in a confined space should be performed only by appropriately trained personnel. 
• Air quality monitoring should be conducted and documented prior to entry into confined space. • Continuous air quality monitoring must be maintained once contact is made with victim and when any rescuer is in a confined space. Document air quality measurement at patient location on PCR. 
• Remove rings, bracelets, and other constricting items 
• N95 mask PRN for dust environment 
• If amputation is being considered, contact WUEMS for physician response.
Paramedic
• Vascular access x 2 
• Bolus Isotonic Crystalloid 20cc/kg for max of 1 liter followed by a continuous drip. 
• Continuous ETCO2 and ECG monitoring once practical. 
• If goes into cardiac arrest, then treat for hyperkalemia with both Calcium Chloride and Sodium Bicarbonate in conjunction with cardiac arrest guidelines. 
• Consider a sodium bicarbonate drip if prolonged extrication
• Add 1 amp bicarb to a 250cc bag of D10. Infuse of 1 hour. Check glucose every 30 minutes if the patient is diabetic or the history is unknown. 
• If MAP > 65 and no respiratory failure, then Fentanyl for pain and Ketamine for refractory pain 
• If MAP < 65 and/or respiratory failure, then Ketamine for pain 
• Push Calcium Chloride and Sodium Bicarbonate immediately prior to released. Start nebulized Albuterol prior to release of the patient. 
• Consider Dissociation with Ketamine prior to removal from entrapment 
Consult Online Medical Control as Needed

Pearls

  • Refer to drug formulary charts for all medication dosing for both adults and pediatric patients. 
  • Hydration should begin prior to extrication whenever possible. Large volume resuscitation prior to removal of the crush object and extrication is critical to preventing secondary renal failure and death. 
  • Crush injury is usually seen with compression of 4-6 hours but may occur in as little as 20 min. 
  • If possible, monitor patient for signs of compartment syndrome. 
  • Crush injury victims can 3rd space > 12L in the first 48 hours. 
  • Elderly patients should be monitored closely for volume overload but do NOT withhold fluids unless clinical signs/symptoms of volume overload. 
  • The larger the mass crushed (i.e., more limbs) the greater the likelihood of severe rhabdomyolysis and renal failure, which has high risk for hyperkalemia.
  • Crush injury may cause profound electrolyte disturbances resulting in dysrhythmias. Monitor as soon as practically possible. 
  • Do not overlook treatment of additional injuries, airway compromise, hypothermia/ hyperthermia. 
  • ETCO2 if multiple doses of Narcotic Medication administered or if the patient is altered.