Crush Injury and Crush Syndrome
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Questions and Answers

What is a common cause of crush syndrome?

  • Drowning
  • Carbon monoxide poisoning (correct)
  • Food poisoning
  • Carbon dioxide poisoning

    • What is the result of muscle cell damage in crush syndrome?

  • Rhabdomyolysis
  • Electrolyte disturbances
  • Myoglobinuria
  • All of the above (correct)

    • What is an example of a mass casualty incident that can lead to crush syndrome?

  • Car accident
  • Heart attack
  • Building collapse (correct)
  • Drowning

    • What is a definition of crush syndrome?

    <p>A clinical condition caused by compression of muscle with subsequent rhabdomyolysis</p> Signup and view all the answers

    What is a systemic manifestation of muscle cell damage in crush syndrome?

    <p>Electrolyte disturbances</p> Signup and view all the answers

    What is a common scenario that can lead to crush syndrome?

    <p>Immobilization against a firm surface for more than one hour</p> Signup and view all the answers

    What is the main cause of crush syndrome?

    <p>Stretch of the muscle sarcolemma</p> Signup and view all the answers

    What is the percentage of survivors extricated from collapsed buildings who develop renal failure?

    <p>Up to half</p> Signup and view all the answers

    What is the typical incidence of crush injury in hospitalized patients?

    <p>5-20%</p> Signup and view all the answers

    What is the effect of myoglobinuria on renal tubular flow?

    <p>It precipitates and directly obstructs renal tubular flow</p> Signup and view all the answers

    What is the effect of acid urine on myoglobin-induced renal injury?

    <p>It is required for myoglobin to cause renal injury</p> Signup and view all the answers

    What is the treatment for hyperkalemia in crush syndrome?

    <p>IV normal saline and IV NaHCO3</p> Signup and view all the answers

    What is the effect of compartment syndrome on muscle cells?

    <p>It causes muscle swelling and death</p> Signup and view all the answers

    What is the percentage of patients with crush injury who require dialysis?

    <p>Up to 20%</p> Signup and view all the answers

    What is the condition characterized by myoglobinuria and renal failure?

    <p>Crush syndrome</p> Signup and view all the answers

    What is the first aid rule for patients with crush syndrome?

    <p>Provide oxygen and start IV fluids</p> Signup and view all the answers

    What is the preferred IV fluid for resuscitation in crush syndrome?

    <p>Normal saline (0.9%)</p> Signup and view all the answers

    What is the recommended IV fluid infusion rate for elderly patients with crush syndrome?

    <p>10 cc per kg per hour</p> Signup and view all the answers

    What is the target urine output for adult patients with crush syndrome?

    <p>&gt; 50 cc per hour</p> Signup and view all the answers

    What is the goal of using IV bicarbonate in crush syndrome?

    <p>To achieve alkaline urine</p> Signup and view all the answers

    When should mannitol be initiated in crush syndrome?

    <p>When urine output is less than 2 cc per kg per hour</p> Signup and view all the answers

    What is the maximum dose of mannitol per day?

    <p>200 grams per day</p> Signup and view all the answers

    What is a contraindication to using mannitol in crush syndrome?

    <p>All of the above</p> Signup and view all the answers

    What is a potential benefit of mannitol in treating crush syndrome?

    <p>Scavenging free radicals in muscle</p> Signup and view all the answers

    When is fasciotomy indicated in crush injury?

    <p>When compartment pressure is &gt; 30 mm Hg</p> Signup and view all the answers

    What is the time limit for irreversible nerve damage in crush injury?

    <p>4 hours</p> Signup and view all the answers

    What is the common outcome of delayed fasciotomies in earthquake casualties?

    <p>High infection rates with increased mortality and amputations</p> Signup and view all the answers

    In what circumstances is fasciotomy indicated in earthquake casualties?

    <p>If the victim can be extricated and receive definitive medical care within 6 hours of injury</p> Signup and view all the answers

    What is a recommended adjunctive treatment for crush injury?

    <p>Acetazolamide to excrete bicarbonate in the urine</p> Signup and view all the answers

    What parameter should be monitored hourly in a crush syndrome patient?

    <p>Urine output and urine pH</p> Signup and view all the answers

    What is the primary purpose of obtaining an EKG in patients with crush injury?

    <p>To look for signs of hyperkalemia</p> Signup and view all the answers

    What is the role of a handheld fingerstick blood analyzer in the field?

    <p>To identify hyperkalemia early</p> Signup and view all the answers

    What is a common associated injury with crush syndrome?

    <p>Extremity fractures and lacerations</p> Signup and view all the answers

    What is included in the routine labwork for patients with crush injury?

    <p>CBC, platelets, type and screen, electrolyte panel, BUN, creatinine, CPK, liver panel, urinalysis</p> Signup and view all the answers

    What increases the mortality rate in crush syndrome patients?

    <p>Prior chronic illness</p> Signup and view all the answers

    What is a major risk factor for renal failure in crush syndrome patients?

    <p>All of the above</p> Signup and view all the answers

    What is a crucial aspect of disaster planning for crush syndrome?

    <p>All of the above</p> Signup and view all the answers

    When should fasciotomy not be performed in crush syndrome patients?

    <p>If extrication takes &gt; 6 hours</p> Signup and view all the answers

    What is a common complication in crush syndrome patients?

    <p>Severe long-term limb disability</p> Signup and view all the answers

    What is the importance of monitoring ABG in crush syndrome patients?

    <p>To monitor for acidosis</p> Signup and view all the answers

    What is a recommended intervention in crush syndrome patients?

    <p>Start IV fluids prior to extrication if possible</p> Signup and view all the answers

    What is the significance of assessing for hyperkalemia in crush syndrome patients?

    <p>It is a sign of muscle cell damage</p> Signup and view all the answers

    Study Notes

    Crush Syndrome

    • Caused by compression of muscle with subsequent rhabdomyolysis, leading to complications of electrolyte disturbances, fluid sequestration, and myoglobinuria.

    Causes of Crush Syndrome

    • Immobility against a firm surface for > 1 hour
    • Drug or alcohol intoxication
    • Carbon monoxide poisoning
    • Cerebrovascular accident
    • Head trauma with coma
    • Elderly with hip fracture
    • Improper positioning of surgical patient
    • Assault with beating
    • Pneumatic Antishock Garment (PASG or MAST)

    Causes of Mass Casualties with Crush Syndrome

    • Building collapse
    • Earthquakes
    • Landslides
    • Bombings
    • Construction accidents
    • Heavy snow on roof
    • Mine or trench collapse

    Historical Reports of Crush Syndrome

    • Old Testament Book of Numbers: deaths from illness involving muscle pain and weakness (rhabdomyolysis)
    • Larrey (Napoleon's army surgeon) in 1812: described limb gangrene in carbon monoxide victims
    • Bywaters and Beal in 1941: reported 5 patients from the London Blitz who died of renal failure
    • Later reports by Bywaters identified myoglobinuria as the cause of renal failure

    Major Mass Casualty Events with Reports of Crush Syndrome

    • Earthquakes: Tangshan, China (1976), Armenia (1988), Iran (1990 and 2003), Northridge, California (1994), Kobe, Japan (1995), Turkey (1992 and 1999)
    • Terrorist bombings: Lebanon, Saudi Arabia

    Incidence of Crush Syndrome in Mass Casualty Events

    • 10 to 60% of survivors extricated from collapsed buildings
    • Up to half may develop renal failure
    • At least half of these require dialysis
    • Incidence less in quakes where most residences are adobe or one story (e.g., Central America)

    Pathophysiology of Crush Syndrome

    • Not usually directly due to ischemia
    • Main cause is stretch of the muscle sarcolemma
    • Increased sarcolemma permeability
    • Influx of sodium, water, and extracellular calcium into the sarcoplasm
    • Results in cellular swelling, increased intracellular calcium, disrupted cellular function and respiration, decreased ATP production, and subsequent myocytic death

    Systemic Sequelae of Crush Injury

    • Result from death of muscle cells and leak of intracellular metabolites into the systemic circulation ("reperfusion injury")
    • Superoxide anions (free radicals) cause further membrane injury
    • May not manifest until just after the entrapped part of the body is extricated

    Metabolic Derangements from Crush Syndrome

    • Hypovolemia (fluid sequestration in damaged muscle)
    • Hyperkalemia
    • Hypocalcemia (due to calcium deposition in muscle)
    • Hyperphosphatemia
    • Metabolic acidosis
    • Myoglobinemia/myoglobinuria

    Effects of Myoglobinuria in Crush Syndrome

    • Myoglobin can precipitate (particularly with hypovolemia and acidosis) and directly obstruct renal tubular flow
    • Myoglobin is also directly toxic to the renal tubular cells

    Renal Toxicity of Myoglobin

    • Bywaters' studies showed acid urine is required for myoglobin to cause renal injury
    • At pH < 5.6, myoglobin dissociates into its 2 components: globin (nontoxic) and ferrihemate (probably the toxic component)

    Other Clinical Syndromes with Similar Effects as Crush Syndrome

    • Tumor lysis syndrome
    • Heatstroke
    • Exertional rhabdomyolysis
    • High voltage (> 1000 volts) electrical injury

    Field Rescue Considerations for Patients with Crush Syndrome

    • Apply facemask to protect from dust inhalation
    • Oxygen (if no risk of fire at the scene)
    • If building unstable, then equipment stabilization may be needed before medical treatment can be given
    • Start IV normal saline early if possible
    • Ventilate well near gas or diesel powered generators to avoid CO poisoning

    Hyperkalemia in Crush Syndrome

    • Can occur soon after extrication
    • Can be quickly fatal
    • May occur before manifestations of renal failure
    • May occur without obvious signs of compartment syndrome
    • May require emergent prehospital treatment

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    Crush Syndrome: L-16 Lecture Notes PDF

    Description

    Learn about the causes, pathophysiology, treatment, and management of Crush Injury and Crush Syndrome. This lecture outline covers the essential topics related to this medical condition.

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