H02: Crush Injuries
Updated:
Reviewed:
Introduction
Crush injuries result from the entrapment of body parts by compressive forces, resulting in physical trauma and ischemia to tissues. These injuries are most commonly discussed in the context of collapsed structures, though crush injuries can occur even from a patient’s own body weight.
If significant muscle mass is involved, crush syndrome can develop following the release of the compression; this is a potentially life-threatening, systemic condition. The major factors that lead to the development of crush syndrome include the degree of compressive force, the amount of muscle mass involved, and the duration of the compression.
The onset of crush syndrome occurs following the reperfusion of the injured muscle upon release. This may have both acute and delayed-onset clinical effects. The three main acute concerns are electrolyte imbalances, which may result in cardiac dysrhythmias (predominantly hyperkalemia), hypovolemia, and metabolic acidosis, all of which can cause shock. The delayed-onset effects include renal failure, acute respiratory distress syndrome, coagulopathies, and severe sepsis.
Delayed medical care or inappropriate rescue management, such as the uncontrolled and rapid removal of the compressive force prior to intervention, may result in rapid clinical deterioration and death of the patient.
Essentials
- Pre-treatment of crush injury prior to release of forces is essential. Failure to treat can result in death.
- On advice of CliniCall, begin aggressive fluid management (see PCP interventions below).
- Electrolyte and dysrhythmia management should be undertaken as per license level.
- Provide analgesia as appropriate.
Additional Treatment Information
- Paramedics and EMRs/FRs should consider the possibility of other concurrent injuries beyond the crush, particularly hypothermia and other potential causes of shock.
- Crush injuries that occur in industrial settings, or in the context of a structural collapse or other disasters, can come with significant hazards for rescuers. Scene safety is paramount – consider the risks of confined spaces, carbon monoxide, hypoxic environments, or toxic atmospheres.
- Additional out-of-hospital resources should be sought early.
Referral Information
All patients with crush injuries should be conveyed to the closest appropriate trauma receiving hospital as per local trauma destination guidelines or clinical pathway.
General Information
- Triage according to the Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma decision tool, including Physiological Criteria, Anatomical Criteria, Mechanism of Injury Criteria, and Special Considerations
Interventions
First Responder (FR) Interventions
- Provide supplemental oxygen as required
- Consider hypothermia; protect patient from environment; consider thermal protection, insulation from cold surfaces, and warming blankets as available/appropriate
- Consider application of a tourniquet proximal to the injury site on the extremity, prior to release of the crush force
Emergency Medical Responder (EMR) & All License Levels Interventions
- Provide supplemental oxygen to maintain SpO2 ≥ 94%
- Coordinate lift with treatments
- CliniCall consultation recommended prior to tourniquet application and to discuss care planning options.
- Consider waiting until higher licensed paramedic is on scene; prepare for cardiac arrest on release of weight
- Manage pain
Primary Care Paramedic (PCP) Interventions
- Obtain vascular access where possible
- Consider administering normal saline 2 L immediately prior to release of crush force
- CliniCall consultation recommended prior to fluid administration and to discuss care planning options.
- Consider continuous salbutamol therapy
- CliniCall consultation required prior to salbutamol administration and to discuss care planning options.
Advanced Care Paramedic (ACP) Interventions
- Obtain vascular access where possible
- Correct electrolyte disturbances
- Calcium chloride
- Sodium bicarbonate
- CliniCall consultation required prior to administration of sodium bicarbonate.
- Caution: sodium bicarbonate and calcium chloride cannot be administered at the same time through the same IV/IO line
Critical Care Paramedic (CCP) Interventions
- Induce paralysis and facilitate ventilation if required; use rocuronium for paralysis – succinylcholine is contraindicated in crush syndrome
- Intravenous dextrose and insulin (IFT to tertiary care on advice of ETP/EPOS)
- Mannitol 20%: may be considered once ongoing urinary production and output has been verified (IFT to tertiary care on advice of ETP/EPOS; mannitol is contraindicated in anuric states
- Kayexelate – sodium polystyrene sulfonate (when practical and if prolonged ITF transfer to tertiary care is expected on advice of ETP/EPOS)
Evidence Based Practice
Supportive
Neutral
Against
Supportive
Neutral
Against
References
- International Search And Rescue Advisory Group. The Medical Management of the Entrapped Patient with Crush Syndrome. 2012. [Link]
Practice Updates
- 2022-09-28: changed salbutamol to requiring consultation prior to administration