What are the symptoms and treatment of a crush injury?

From the Guidelines

Crush injuries require immediate removal of the crushing force, assessment of airway, breathing, and circulation, and control of bleeding, with severe cases necessitating emergency services and potential surgical intervention for complications like compartment syndrome and rhabdomyolysis. The management of crush injuries involves several key steps to prevent morbidity, mortality, and improve quality of life.

• Immediate management includes removing the crushing force, assessing airway, breathing, and circulation, and controlling bleeding, as stated in the guidelines for the acute care of severe limb trauma patients 1.
• For severe cases, calling emergency services immediately is crucial, and clean and dress open wounds, immobilize the injured area, and elevate it if possible to reduce swelling.
• Pain management typically involves acetaminophen or NSAIDs for mild cases, while severe injuries may require prescription pain medications.
• Monitoring for complications like compartment syndrome (characterized by severe pain, pallor, paresthesia, paralysis, and pulselessness) is essential, which requires immediate surgical intervention through fasciotomy, as discussed in the study on disaster nephrology: crush injury and beyond 1.
• Rhabdomyolysis is another serious complication where damaged muscle releases myoglobin into the bloodstream, potentially causing kidney failure, and treatment includes aggressive IV fluid administration (normal saline at 1-2 L/hour initially, then adjusted based on urine output), with a target urine output of 200-300 mL/hour, as recommended in the study on fluid resuscitation controversies 1.
• Sodium bicarbonate may be administered to alkalinize the urine, but its benefits are still debated, and current evidence does not suggest benefit from active alkalinization over active fluid resuscitation, as mentioned in the study on fluid resuscitation controversies 1.
• Crush injuries can lead to systemic effects including hyperkalemia, metabolic acidosis, and acute kidney injury, requiring close monitoring of electrolytes and kidney function, and recovery depends on injury severity and may involve physical therapy to restore function and prevent contractures. The importance of early fluid resuscitation in crush injury victims cannot be overstated, and an algorithm for fluid resuscitation provides guidance for the clinician to adequately restore intravascular fluid volume while avoiding hypervolemia, pulmonary edema, and the subsequent need for emergency dialysis, as discussed in the study on the importance of early fluid resuscitation in crush injury victims 1.

From the Research

Definition and Causes of Crush Injury

• Crush injury is a type of injury caused by direct physical trauma and compression of the human body, most commonly involving the lower extremities 2.
• It can result from various incidents such as motor vehicle accidents, natural disasters, and building collapses 3, 2.
• Crush injury can lead to severe medical issues, including asphyxia, severe orthopedic injury, compartment syndrome, hypotension, and organ injury 2.

Systemic Manifestation and Complications

• Crush syndrome is the systemic manifestation of severe, traumatic muscle injury, which can lead to metabolic derangement and acute kidney injury 4.
• Complications of crush injury and syndrome include cardiac failure, kidney dysfunction, shock, systemic inflammation, and sepsis 5.
• Other potential complications include hyperkalemia, metabolic acidosis, and disseminated intravascular coagulation 5.

Diagnosis and Treatment

• Early, aggressive resuscitation is recommended in prehospital settings, ideally even before extrication, to reduce the complications of crush syndrome 4, 5.
• Treatment includes fluid resuscitation, management of compartment syndrome, and prevention of hyperkalemia and acute renal failure 2, 4, 6.
• Serum CK levels can be used to screen patients with crush injuries to determine injury severity, and forced mannitol-alkaline diuresis may be instituted for prophylaxis against hyperkalemia and acute renal failure 6.

Importance of Prehospital and Emergency Care

• Prehospital providers and emergency clinicians play a crucial role in the evaluation and treatment of patients with crush injury and syndrome 2, 5.
• Immediate treatment is essential in reducing the mortality of disaster-situation crush syndrome, and ongoing research is needed to advance diagnostic and therapeutic modalities 5.