Notes – Crush Injury/Rhabdomyolysis

Crush Injury/Rhabdomyolysis

Patient Safety Considerations

  1. Scene safety for both rescuers and patients is of paramount importance.

Notes/Educational Pearls

  1. Causes of mortality in untreated crush syndrome:
    1. Immediate
      1. Severe head injury
      2. Traumatic asphyxia
      3. Torso injury with damage to intrathoracic or intra-abdominal organs
    2.  Early
      1. Hyperkalemia (potassium is released from injured muscle cells)
      2. Hypovolemia/shock
    3.  Late
      1. Renal failure (from release of toxins from injured muscle cells)
      2. Coagulopathy and hemorrhage
      3. Sepsis

Key Considerations

  1. Rapid extrication and evacuation to a definitive care facility (trauma center preferred)
  2. A patient with a crush injury may initially present with very few signs and symptoms Therefore, maintain a high index of suspicion for any patient with a compressive mechanism of injury
  3. A fatal medical complication of crush syndrome is hyperkalemia. Suspect hyperkalemia if T-waves become peaked, QRS becomes prolonged (greater than 0.12 seconds), absent P wave, or prolonged QTc
  4. Continue fluid resuscitation through extrication and transfer to hospital

Pertinent Assessment Findings

  1. Mental status/GCS
  2. Evaluation for fractures and potential compartment syndrome development (neurovascular status of injured extremity)
  3. Examination of spine
  4. Evidence of additional trauma, potentially masked by with other painful injuries

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914089 – Injury-Crush Syndrome

Key Documentation Elements

  • Time of tourniquet application, if applied
  • Neurovascular status of any crushed extremity
  • EKG findings consistent with hyperkalemia
  • Amount of IV fluid administered

Performance Measures

  • Initiation of fluid resuscitation prior to extrication
  • EKG/monitor to monitor for dysrhythmias or changes related to hyperkalemia
  • Treatment of hyperkalemia if evidence is noted on EKG

References

  1. Better OS. The crush syndrome revisited (1940-1990). Nephron. 1990;55:97-103.
  2. Jagodzinski N, Weerasinghe C, Porter K. Crush injuries and crush syndrome – a review. Trauma. 2010;12:69–88.
  3. Sever MS, Vanholder R, Lameire N. Management of crush-related injuries after disasters. N Engl J Med. 2006;354(10):1052-63.
  4. Smith J, Greaves I. Crush injury and crush syndrome: a review. J Trauma. 2003;54(5):S226-30.