What is the management of crush injury?

Management of Crush Injury

Immediate aggressive fluid resuscitation with 0.9% normal saline at 1000 ml/hour is the cornerstone of crush injury management and should be initiated as soon as the victim is located, ideally before extrication, to prevent acute kidney injury and death from hyperkalemia. 1

Pre-Hospital and Field Management

Immediate Fluid Resuscitation (Before and During Extrication)

• Start IV fluids immediately upon locating the victim, even while still trapped under rubble 1
• Insert IV cannula in an accessible limb; if no vein is available, use an intra-osseous needle in a lower limb 1, 2
• Infuse 0.9% normal saline at 1000 ml/hour initially 1, 3
• If extrication takes longer than 2 hours, reduce infusion rate by at least 50% (to ≥500 ml/hour) 1
• Never use potassium-containing fluids (Lactated Ringer's, Hartmann's solution, Plasmalyte A) as potassium levels surge dramatically after reperfusion, even with normal kidney function 1, 2, 3
• Avoid starch-based colloids due to increased risk of acute kidney injury and bleeding 1, 3

Critical Timing Window

• Fluid resuscitation is most effective when initiated within 6 hours of injury to prevent progression to acute renal failure 3
• Many victims die from crush-related acute kidney injury and hyperkalemia when this narrow window is missed 1

Hospital Management

Continued Aggressive Fluid Therapy

• Administer 3-6 liters of 0.9% normal saline in the first 24 hours based on clinical response 1, 3
• Target urine output of 200-300 ml/hour until myoglobinuria clears 3
• Insert bladder catheter to monitor urine output (unless urethral injury suspected) 1
• Adjust fluid volumes based on:
  • Volume status and signs of fluid overload 1
  • Patient age (elderly and children more prone to overload) 1
  • Body mass (lower mass requires less fluid) 1
  • Environmental temperature (less fluid needed in cold conditions) 1

Immediate Laboratory Monitoring

• Creatine kinase (CK): Levels >5,000 IU/L confirm rhabdomyolysis; >75,000 IU/L indicates >80% risk of acute kidney injury 3
• Complete metabolic panel for electrolytes, especially potassium 1, 3
• Acid-base status and lactate 1
• Blood urea nitrogen and creatinine 1
• Use point-of-care devices (iStat) if laboratory infrastructure is unavailable, but maintain device temperature between 16-30°C 1

Local Wound Management

• Treatment should be conservative; avoid fasciotomy 4
• If fasciotomy is absolutely necessary, follow immediately with radical debridement of injured muscle to prevent infection 4
• Conservative local treatment has much superior outcomes compared to operative treatment 4
• Thoroughly irrigate superficial wounds with large volumes of warm or room temperature potable water until no foreign matter remains 2, 5
• Cover wounds with antibiotic ointment/cream and clean occlusive dressing 2, 5
• Leave blisters intact and cover loosely with sterile dressing 2, 5

Cold Therapy for Mild Injuries

• Apply ice with water for 20-minute intervals with a thin towel barrier between ice and skin 2, 5
• This reduces pain, swelling, and edema 2

Critical Monitoring for Complications

Compartment Syndrome Assessment

• Assess using the "6 Ps": pain, paresthesia, paresis, pain with passive stretch, pink color, pulselessness 2, 5
• Remove tight-fitting dressings and avoid limb elevation if compartment syndrome suspected 2, 5
• Severe pain, especially with passive muscle stretching, is the earliest and most sensitive sign 2, 5

Hyperkalemia Monitoring

• Life-threatening hyperkalemia is more frequent in crush-related acute kidney injury than other causes 1
• May necessitate earlier and more frequent dialysis 1

Signs Requiring Immediate Medical Attention

• Dark urine (myoglobinuria) or decreased urine output 2, 5
• Signs of compartment syndrome 2, 5
• Increasing pain, redness, warmth, swelling, or purulent drainage (infection) 2, 5
• Difficulty breathing 2
• Injuries to face, neck, hands, or genitals 2

Dialysis Considerations

• Initiate renal replacement therapy for life-threatening acidosis, hyperkalemia, or fluid overload 1
• Earlier dialysis initiation may improve survival in trauma-associated acute kidney injury 1
• In mass disasters, dialysis resources must be rationed among severely injured patients 1

Controversial Interventions to Avoid

Mannitol

• Do not use mannitol before adequate volume resuscitation as it can worsen renal injury in hypovolemic patients 3
• Studies show little extra benefit compared to crystalloid resuscitation alone 1
• Potentially nephrotoxic and requires close monitoring often impossible in disasters 1

Bicarbonate

• Current evidence does not support active alkalinization over aggressive fluid resuscitation alone 1
• Large bicarbonate doses may decrease free calcium and worsen hypocalcemia associated with crush injury 1

Common Pitfalls

• Triaging crush victims away from active treatment due to lack of dialysis availability—intensive fluid management can restore renal function and avoid dialysis need entirely 1
• Failure to recognize crush injury early, missing the critical 6-hour window for fluid resuscitation 1, 3
• Using potassium-containing fluids, which can cause fatal hyperkalemia 1, 2, 3
• Performing unnecessary fasciotomy, which increases infection risk and worsens outcomes 4