Crush Injury and Crush Syndrome

1. Crush Injury and Crush Syndrome Dr.S.Pezeshki Orthopedist Azad university of Tehran Medical Branch

2. History World War One: Meyer-Betz Syndrome Noted in extricated soldiers Triad of: muscle pain weakness brown urine

3. Bywaters’ Syndrome • Battle of Britain, May 1941 • Multiple subjects • Trapped for 3-4 hours • Then developed: • Shock • Swollen Extremities • Dark Urine • Survived  Renal Failure  Died of Uremia

4. Epidemiology Earthquakes Bombings Structural Collapse Road crush Trench Collapse “Down and Out”

5. Definition • compression of extremities or other parts of the body that causes muscle swelling and/or neurological disturbances in the affected areas of the body • Typically affected areas of the body include lower extremities (74%), upper extremities (10%), and trunk (9%).

6. Functional Definition Any injury that has: Involvement of Muscle Mass Prolonged Compression Usually 4-6 hours Compromised local circulation

7. Crush Epidemiology Earthquake Victims 3-20% of all victims Number of limbs affects risk 1 Limb  50% 2 Limbs 75% >3 Limbs  100%

8. Crush syndrome is localized crush injury with systemic manifestations. traumatic rhabdomyolysis (muscle breakdown) release of potentially toxic muscle cell components and electrolytes into the circulatory system. • approximately 50% of those with crush syndrome developing acute renal failure • 50% need dialysis

9. Clinical Presentation Sudden release of a crushed extremity may result in reperfusion syndrome ==acute hypovolemia and metabolic abnormalities ==lethal cardiac arrhythmias myoglobinuria==renal failure

10. Shock and ARF Arrhythmia

11. 372 crush syndrome 202 developed ARF 78 required Hemo- dialysis Aggressive Fluid Management Kobe, 1995

12. Myoglobinemia Limb Compression • Local Pressure • Local Tamponade • Muscle necrosis • Capillary necrosis • Edema SHOCK Muscle Ischemia Muscle Infarction Acidosis & Hyperkalemia ARF Cardiac Arrhythmia Extracellular Fluid Shifts

13. Myoglobinemia Limb Compression • Local Pressure • Local Tamponade • Muscle necrosis • Capillary necrosis • Edema SHOCK Muscle Ischemia Muscle Infarction Acidosis & Hyperkalemia ARF Cardiac Arrhythmia Extracellular Fluid Shifts

14. Myoglobin Brown urine pH Volume Status Acids Renal Effects? Myoglobin Gel Distal tubules Oliguric Renal Failure Electrolyte Abnormalities Within 3-7 days post-extrication Acute Renal Failure

15. Aggressive Hydration In situ IVF GOAL: UOP: 200-300cc (2cc/kg/hr) Alkalinization of Urine 1st: Bicarbonate 2nd: Acetazolamide GOAL: Urine pH b/w 6-7 Forced Diuresis Lasix Mannitol ARF Treatment

16. Myoglobinemia Limb Compression • Local Pressure • Local Tamponade • Muscle necrosis • Capillary necrosis • Edema Muscle Ischemia Muscle Infarction Acidosis & Hyperkalemia ARF SHOCK Cardiac Arrhythmia Extracellular Fluid Shifts

17. Shock • Hypovolemic Shock • >12 L can sequester in the area of crush injury • Study by Oda • Annals of EM, 1997 • Kobe, 1995 • Most commom cause of death (66%) in the 1st 4 days

18. Early Aggressive Resuscitation IVF Blood Products Other products? Close Monitoring Oral Rehydration Not so good… IV Access Peripheral Central Intraosseus Bolus Therapy 250cc aliquots Titrate to radial pulses and/or UOP Shock Treatment

19. Myoglobinemia Limb Compression • Local Pressure • Local Tamponade • Muscle necrosis • Capillary necrosis • Edema Muscle Ischemia Muscle Infarction Acidosis & Hyperkalemia ARF SHOCK Cardiac Arrhythmia Extracellular Fluid Shifts

20. Dysrhythmia • Hyperkalemia • Hypocalcemia • Acidosis

21. Mild (5.5-6.5 mEq/L) peaked T waves Moderate (6.5-7.5 mEq/L) prolonged PR interval decreased P wave amplitude depression or elevation of ST segment slight widening of QRS Severe (7.5-8.5 mEq/L) Widening of the QRS bundle branch intraventricular blocks Flat and Wide P waves AV Blocks ventricular ectopy Life-threatening (>8.5 mEq/L) loss of P waves High-grade AV blocks Ventricular dysrhythmias Widening of the QRS complex eventually forming a sinusoid pattern. Hyperkalemia

22. Now, what do you see? Peaked T wave

23. What K is this? • Widening of the QRS • bundle branch • intraventricular blocks • Flat and Wide P waves • AV Blocks • ventricular ectopy

24. Describe the ECG. • loss of P waves • High-grade AV blocks • Ventricular dysrhythmias • Widening of the QRS complex • eventually forming a sinusoid pattern.

25. Management • What are your management options?

26. Alkalinization Bicarbonate Acetazolamide Calcium Ca Gluconate Ca Chloride Beta-Agonists Albuterol, etc. Insulin/Glucose Potassium Binding Resins Kayexalate Surgery: compartment release Management

27. Signs Chvostek’s Trousseau’s Tetany Seizures Hypotension ECG Changes Bradycardia arrhythmias Long QT segment Hypocalcemia

28. Treatment? • Implications of Hyperphosphatemia? • Metastatic calicification • Rebound hypercalcemia • Treat only if symptomatic.

29. Acidosis • Myocardial Irritability • Precipitates Arrhythmia • May be refractory to treatment • Treatment already discussed

30. In Situ Management Prehospital setting: • Patient Access • IV Access • Administer intravenous fluids before releasing the crushed body part. (This step is especially important in cases of prolonged crush [>4 hours]; however, crush syndrome can occur in crush scenarios of <1 hour) • If this procedure is not possible, consider short-term use of a tourniquet on the affected limb until intravenous (IV) hydration can be initiated • IV Hydration • Bicarbonate • Mannitol • Extrication

31. Hypotension Initiate (or continue) IV hydration—up to 1.5 L/hour Renal Failure Prevent renal failure with appropriate hydration, using IV fluids and mannitol to maintain diuresis of at least 300 cc/hrTriage to hemodialysis as needed Post-Extrication Hospital setting:

32. Metabolic Abnormalities • Acidosis: Alkalinization of urine is critical; administer IV sodium bicarbonate until urine pH reaches 6.5 to prevent myoglobin and uric acid deposition in kidneys • Hyperkalemia /Hypocalcemia: • calcium gluconate 10% 10cc or calcium chloride 10% 5cc IV over 2 minutes • sodium bicarbonate 1 meq/kg IV slow push • regular insulin 5-10 U and D5O 1-2 ampules IV bolus • kayexalate 25-50g with sorbitol 20% 100mL PO or PR

33. Secondary Complications • Monitor casualties for compartment syndrome; monitor compartmental pressure if equipment is available; consider emergency fasciotomy for compartment syndrome • Treat open wounds with antibiotics and tetanus toxoid, and debridement of necrotic tissue • Apply ice to injured areas and monitor for the 5 P’s: pain, pallor, parasthesias, pain with passive movement, and pulselessness • Observe all crush casualties, even those who look well

34. Disposition • Patients with acute renal failure may require up to 60 days of dialysis treatment; unless sepsis is present, patients are likely to regain normal kidney function

35. Delayed Causes of Death • ARF • ARDS • Sepsis • Ischemic Organ Injury • DIC • Electrolyte Disturbances

36. Advances in Management In situ fluid resuscitation Israel, 1982 1/8 developed ARF Aggressive Fluid Resuscitation, post-extrication Japan, 1995

37. Advances in Management • Disaster Relief Task Force • Marmara, Turkey • Task Force: • Trained Personnel • Portable HD • 462 ARF (18% mortality)