Crush syndrome: Difference between revisions
| (23 intermediate revisions by 5 users not shown) | |||
| Line 1: | Line 1: | ||
==Background== | ==Background== | ||
* | *Also known as traumatic rhabdomylosis | ||
===Criteria=== | |||
#Involvement of muscle mass | |||
#Prolonged compression of 4-6 hours but possible in <1 hr | |||
#Compromised local circulation | |||
===Pathophysiology=== | ===Pathophysiology=== | ||
* | *Hypovolemic [[shock]] | ||
**Third spacing of fluids | **Third spacing of fluids | ||
*Metabolic acidosis | *[[Metabolic acidosis]] | ||
**[[Hyperkalemia]] | **[[Hyperkalemia]] | ||
**Hyperphosphatemia | **[[Hyperphosphatemia]] | ||
**[[Hypocalcemia]] | **[[Hypocalcemia]] | ||
**[[Rhabdo]] and [[Renal Failure]] | **[[Rhabdo]] and [[Renal Failure]] | ||
==Clinical Features== | |||
*Skin trauma or local signs of compression over a muscle mass | |||
**Erythema, ecchymosis, bullae, abrasion | |||
*Tense muscle mass | |||
==Differential Diagnosis== | |||
{{Extremity trauma DDX}} | |||
==Evaluation== | |||
===Work Up=== | |||
*CBC | |||
*Chem 10 | |||
*CK | |||
*Urine dip and UA | |||
*Strict I&Os | |||
*[[ECG]] | |||
*Imaging as indicated by injury | |||
*Compartment pressure monitoring for suspected [[Compartment syndrome]] | |||
===Results=== | |||
One or more of these should be found in the right clinical setting | |||
*Myoglobinuria and/or hematuria | |||
*Peak CK (typically >10,000) | |||
*Oliguria (<400ml/24hrs) | |||
*Elevated BUN (>40) | |||
*Elevated creatinine (>2.0) | |||
*Elevated uric acid (>8) | |||
*[[Hyperkalemia]] (>6) | |||
*Hyperphosphotemia (>8) | |||
*Hypocalcemia (<8) | |||
==Management== | ==Management== | ||
===Prehospital | ===Prehospital Protocol for Entrapment Lasting >4hrs or Suspicion of [[Hyperkalemia]]=== | ||
''Should begin BEFORE extrication'' | |||
*Cardiac monitoring | |||
*Hydration (~NS 1.5 L/hr) | |||
*Pain control | |||
* | *[[Albuterol]] neb | ||
* | *[[Calcium chloride]] | ||
**1 gram slow IV push over 60 sec | |||
* | *[[Sodium bicarbonate]] | ||
**Flush IV with NS (prevent precipitation), then | |||
**1mEq/kg added to 1L of normal saline, run IV wide open just prior to extrication | |||
*Release compression | |||
**In the field, use of [[tourniquet]] before extrication is controversial | |||
===ED Management=== | |||
*ATLS | |||
*Aggressive IVF | |||
*Treat [[Hyperkalemia]] with typical management | |||
===Extended Management=== | |||
*250ml IV bolus q15min until UOP is 2ml/kg/hr | |||
*[[Lasix]] or [[Mannitol]] for forced diuresis | |||
*[[Acetazolamide]] for pH >7.5 | |||
==Disposition== | |||
*ICU | |||
*Intermediate Care or Floor for minor cases | |||
==See Also== | ==See Also== | ||
| Line 32: | Line 81: | ||
*[[Disseminated Intravascular Coagulation (DIC)]] | *[[Disseminated Intravascular Coagulation (DIC)]] | ||
==References== | |||
<references/> | |||
[[Category: EMS]] | [[Category: EMS]] | ||
[[Category: Trauma]] | [[Category: Trauma]] | ||
Latest revision as of 03:10, 8 May 2021
Background
- Also known as traumatic rhabdomylosis
Criteria
- Involvement of muscle mass
- Prolonged compression of 4-6 hours but possible in <1 hr
- Compromised local circulation
Pathophysiology
- Hypovolemic shock
- Third spacing of fluids
- Metabolic acidosis
Clinical Features
- Skin trauma or local signs of compression over a muscle mass
- Erythema, ecchymosis, bullae, abrasion
- Tense muscle mass
Differential Diagnosis
Extremity trauma
- Compartment syndrome
- Contusion
- Crush syndrome
- Degloving injury
- Fracture
- Laceration
- Myositis ossificans
- Open joint injury
- Peripheral nerve injury
- Rhabdomyolysis
- Tendon injury
- Vascular injury
Evaluation
Work Up
- CBC
- Chem 10
- CK
- Urine dip and UA
- Strict I&Os
- ECG
- Imaging as indicated by injury
- Compartment pressure monitoring for suspected Compartment syndrome
Results
One or more of these should be found in the right clinical setting
- Myoglobinuria and/or hematuria
- Peak CK (typically >10,000)
- Oliguria (<400ml/24hrs)
- Elevated BUN (>40)
- Elevated creatinine (>2.0)
- Elevated uric acid (>8)
- Hyperkalemia (>6)
- Hyperphosphotemia (>8)
- Hypocalcemia (<8)
Management
Prehospital Protocol for Entrapment Lasting >4hrs or Suspicion of Hyperkalemia
Should begin BEFORE extrication
- Cardiac monitoring
- Hydration (~NS 1.5 L/hr)
- Pain control
- Albuterol neb
- Calcium chloride
- 1 gram slow IV push over 60 sec
- Sodium bicarbonate
- Flush IV with NS (prevent precipitation), then
- 1mEq/kg added to 1L of normal saline, run IV wide open just prior to extrication
- Release compression
- In the field, use of tourniquet before extrication is controversial
ED Management
- ATLS
- Aggressive IVF
- Treat Hyperkalemia with typical management
Extended Management
- 250ml IV bolus q15min until UOP is 2ml/kg/hr
- Lasix or Mannitol for forced diuresis
- Acetazolamide for pH >7.5
Disposition
- ICU
- Intermediate Care or Floor for minor cases