Calcium Treatment in Crush Injuries
Calcium is not routinely given for crush injuries, but may be indicated specifically for treating hypocalcemia that commonly develops in crush syndrome. 1
Pathophysiology of Crush Syndrome and Calcium Disturbances
Crush syndrome is a systemic manifestation of traumatic muscle injury that can lead to several life-threatening complications:
- Rhabdomyolysis (muscle breakdown)
- Acute kidney injury (AKI)
- Electrolyte abnormalities, including hypocalcemia
- Hyperkalemia
- Acidosis
When massive muscle damage occurs in crush injuries, calcium becomes sequestered in damaged tissues, leading to hypocalcemia. Additionally, large doses of bicarbonate (sometimes used in treatment) may decrease free calcium and worsen hypocalcemia associated with crush injury. 1
Treatment Algorithm for Crush Injuries
1. Initial Management
- Early aggressive fluid resuscitation with 0.9% saline (NOT calcium-containing fluids)
- Begin IV fluids at 1L/hour during extrication if possible
- Avoid potassium-containing fluids (like Lactated Ringer's or Hartmann's solution)
- Avoid starch-based fluids (increase risk of AKI)
2. Electrolyte Management
- Monitor ionized calcium levels
- Administer intravenous calcium ONLY when hypocalcemia is documented or strongly suspected 1
- Treat hyperkalemia aggressively (this is often a more urgent concern than hypocalcemia)
3. Laboratory Monitoring
- Electrolytes (especially potassium and calcium)
- Acid-base status
- Creatine kinase
- Blood urea nitrogen and creatinine
- Point-of-care testing if standard laboratory services unavailable 1
When Calcium IS Indicated in Crush Injuries
Calcium administration is specifically indicated in the following scenarios:
- Documented hypocalcemia
- As part of hyperkalemia management (calcium helps protect the heart from hyperkalemic effects)
- When using recombinant Factor VIIa for uncontrolled bleeding (adequate calcium levels are needed) 1
Important Cautions and Contraindications
Do NOT use calcium-containing fluids for initial resuscitation (Lactated Ringer's, Hartmann's solution) as they contain potassium which can worsen hyperkalemia 1
Avoid routine calcium administration without documented hypocalcemia
Monitor calcium levels throughout treatment, especially when:
- Using bicarbonate therapy (which can worsen hypocalcemia)
- Treating hyperkalemia
- Managing coagulopathy
Common Pitfalls to Avoid
- Focusing only on calcium without addressing the more urgent need for aggressive fluid resuscitation
- Using calcium-containing IV fluids for initial resuscitation
- Failing to monitor calcium levels when using bicarbonate therapy
- Overlooking hypocalcemia as a contributor to cardiac arrhythmias in crush syndrome patients
The management of crush injuries requires careful attention to multiple electrolyte abnormalities, with calcium management being just one component of comprehensive care. The primary focus should remain on aggressive fluid resuscitation to prevent AKI, while monitoring and correcting electrolyte abnormalities including hypocalcemia when present.