OBJECTIVES 4/27/13 I VE GOT A CRUSH ON YOU! CRUSH INJURIES IN EMS DON T BELIEVE THIS MAN.

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1 I VE GOT A CRUSH ON YOU! CRUSH INJURIES IN EMS DON T BELIEVE THIS MAN. OBJECTIVES Recognize the differences between Crush Injury and Crush Syndrome List at least 2 complications that occur with Crush Syndrome Understand the interventions performed when treating someone with Crush Syndrome and how they work. List the three most common areas of the body that are more susceptible to developing Crush Syndrome 1

2 INJURY Cell Disruption/ injury at the point of impact. Occurs < 1 hour SYNDROME Systemic effects when muscle is RELEASED from compression Occurs after cells have been under pressure >4 hours* Suspect Syndrome with lightening strikes CRUSHING MECHANISM OF INJURY Building and Structure Collapse Bomb Concussions MVAs and Farm Accidents Assault with blunt weapon AKA: COMPRESSION SYNDROME First described by Dr. Minami in

3 INVOLVED ANATOMY Upper Arms Upper Legs Thorax and Buttocks INSIDE A CELL Potassium ATP (Krebs Cycle Aaaah! ) Hydrogen (=>acid*) Lactate (=>acid*) Urea (=>acid*) Phosphate (=>acid*) *when deprived of oxygen MYOGLOBIN The building block of muscle Doesn t belong in the bloodstream gels up when it hits acidic urine 3

4 AT THE POINT OF IMPACT As the weight presses down As the weight increases As the weight stays pressed down MINUTES LATER.. Blood flow floods to the injured area Histamine is released ONCE THE WEIGHT IS LIFTED 4

5 SMILING DEATH In Prolonged entrapment, smiling death may occur.. In this situation, the trapped person is alert and conversing with rescuers; however, when the entrapped body part is freed, cardiac arrest is almost instantaneous. Emergency Care in the Streets: American Academy of Orthopaedic Surgeons ISCHEMIC REPERFUSION Phosphate vascular calcifications Acids => more cellular injury Potassium Na/K pump => cardiac arrest HYPERKALEMIA Usually the thing that kills after the weight has been lifted. 5

6 TREATMENT OPTIONS. TOURNIQUETS Place a tourniquet just proximal to the weight if possible SALINE At least 2 large bore IVs & SALINE! Initial Bolus 30 ml/kg Desired Urine Output: ml/hr 6

7 4/27/13 CALCIUM Calcium Chloride 1 gm IVP over minutes Stablizes the cell wall Always give FIRST when dealing with hyperkalemia SODIUM BICARBINATE 1 meq/kg bolus Followed by. 1 amp of bicarb in a 1000 ml bag of NS and infuse wide open IF the patient survives the initial release of the toxic by-products and makes it to the hospital They remain at GREAT risk for developing RENAL FAILURE with severe morbidity 7

8 RHABDOMYOLYSIS SKELETAL MUSCLE DEGRADATION Myoglobinemia Muscle fibers breakdown resulting in the dumping of myoglobin into the bloodstream. Myoglobinuria The myoglobin gets filtered out of the blood through the kidneys into the urine MYOGLOBINURIA TREATING RHABDOMYOLYSIS Aggressive Volume Resuscitation for traumatic rhabdomyolysis is imperative! Desired Urine Output: ml/hr 8

9 TREAT THE URINE! Normal myoglobin excretion through the kidneys is 5% Alkalinize the urine with bicarb and the excretion rate increases ALBUTEROL Drives the potassium into the cell mg is recommended for hyperkalemia LASIX Forces Diuresis Causes Renal Vasodilation mgs IVP Remember!: This stuff will acidify urine 9

10 OTHER TREATMENTS Mannitol Allopurinol Hemodialysis Hyperbaric Oxygenation OTHER CONSIDERATIONS. COMPARTMENT SYNDROME Seen with broken long bones, crush injuries, etc The fascia don t stretch to accommodate for swelling Blood Flow and Nerve Damage Occurs 10

11 COMPARTMENT SYNDROME Pressure builds up within the compartment and compresses nerves and vessels. Occurs several hours after initial time of injury. THE 5 P S OF COMPARTMENT SYNDROME Pain Paresthesia Pallor Pulselessness Paralysis Poikilothermia 11

12 HARNESS SYNDROME Seen with repelling, commercial window washers, parachuters, etc Leg straps which cross over the femoral veins and arteries compress the circulation. I VE FALLEN AND I CAN T GET UP! PASG OR MAST The use of PASG has been reported to cause compartment syndrome and crush injury syndrome Journal of Trauma 1984 Issue 24 Pages

13 TRUE STORY. A cattle farmer was found pinned under the rear wheel of his tractor. Estimated to have occurred in the early afternoon. It is now dusk. Alert and Oriented, complains of severe back pain and no sensation in his legs. FIRST RESPONDERS ARRIVE.. Appears to have Crush Injuries to pelvis and bilateral lower extremity injuries Patient still Alert and Oriented and complains only of lower back pain. ALS units en route urge responders NOT to extricate until they arrive. THE REST OF THE STORY Due to family s increasing anxiety and demands, Incident Command ordered the extrication (ALS not on scene yet..) 13

14 THE REST OF THE STORY Just as the tractor is lifted from the patient, his condition deteriorated rapidly. ALS arrived to find patient had arrested and never responded to resuscitative efforts.?questions? 14