What is the treatment for a crush injury?

Treatment for Crush Injury

Early intensive fluid resuscitation is the cornerstone of crush injury management, starting as soon as the victim is located and extrication efforts are underway, to prevent acute kidney injury and crush syndrome. 1, 2, 3

Initial Management

• Begin intravenous fluid resuscitation immediately with an initial rate of 1000 ml/h of 0.9% saline, to be tapered by at least 50% after 2 hours 2, 3
• Insert intravenous cannulae as soon as victim is located; if a suitable vein cannot be located and a lower limb is accessible, use an intra-osseous needle for fluid infusion 1
• Avoid potassium-containing balanced salt fluids (such as Lactated Ringer's solution) as potassium levels may increase markedly even with intact renal function 2, 3
• Avoid starch-based fluids as they are associated with increased rates of acute kidney injury and bleeding 2, 3
• Insert a bladder catheter to monitor urine output unless there is evidence of urethral injury 1, 3

Fluid Management Considerations

• Individualize fluid administration based on:
  • Scale of disaster: in mass disasters, restrict fluids to 3-6 L/day if close monitoring is impossible 1, 3
  • Environmental conditions: less fluid needed in low ambient temperatures 1
  • Time spent under rubble: more fluid needed for victims with delayed rescue, but a more conservative approach is needed if rescue takes several days as many will have established AKI 1
  • Length of extrication procedure: adjust fluid administration accordingly 1

Assessment for Compartment Syndrome

• Assess for signs of compartment syndrome using the "6 Ps": pain, paresthesia, paresis, pain with stretch, pink color, and pulselessness 2, 3
• Remove any tight-fitting dressings and avoid limb elevation if compartment syndrome is suspected 2, 3
• Consider fasciotomy if intracompartmental pressures are elevated; however, fasciotomy should be performed judiciously as it can lead to infection 3, 4

Wound Care

• Thoroughly irrigate superficial wounds and abrasions with large volumes of warm or room temperature potable water 2
• Apply cold therapy (crushed or cubed ice with water) to reduce pain, swelling, and edema, limiting application to 20-minute intervals 2, 3
• Cover wounds with antibiotic ointment and clean occlusive dressing 2
• Leave blisters intact and loosely cover with sterile dressing 2

Monitoring and Laboratory Assessment

• Monitor electrolytes, acid-base status, lactate, creatine kinase, blood urea nitrogen, and creatinine levels to detect complications such as hyperkalemia 3, 5
• Watch for dark urine (indicating myoglobinuria), decreased urine output, and signs of kidney dysfunction 2, 5
• Be alert for signs of infection: increasing pain, redness, warmth, swelling, or purulent drainage 2, 6

Management of Complications

• Consider renal replacement therapy (dialysis) in cases with life-threatening complications such as acidosis, hyperkalemia, or fluid overload 3, 6
• Treat hyperkalemia aggressively to prevent life-threatening arrhythmias 7, 5
• Provide vigorous antibiotic therapy when infection is evident, as infection is a main cause of morbidity and mortality 6, 4
• Consider alkalinization of urine and forced diuresis to prevent acute renal failure 7, 5

Common Pitfalls and Caveats

• Failure to recognize crush injury early can miss the narrow time window when intensive fluid resuscitation may prevent acute kidney injury 1, 3
• Inappropriate use of mannitol has little extra benefit compared to crystalloid fluid resuscitation alone and is potentially nephrotoxic 3, 5
• Delayed fasciotomy when indicated significantly reduces its benefits 3, 4
• Conservative local treatment of crush injury often has better outcomes than operative treatment, with fasciotomy being avoided unless absolutely necessary 4

Special Considerations

• In mass casualty situations, triage decisions should not exclude crush victims from treatment due to lack of dialysis availability, as intensive fluid management can restore renal function in some patients 1
• High caloric, high protein nutrition is important for recovery 6
• Consider hyperbaric oxygen therapy to enhance wound healing, though evidence is limited 2, 5