SALT LAKE CITY — Crush syndrome assessment and treatment were the focus of a lively presentation by Bryan Bledsoe, DO, FACEP, FAAEM, at the EMS Today conference. Bledsoe, who is a prolific EMS author and a popular conference presenter, began his presentation by defining crush syndrome as a series of metabolic changes caused by injury of the skeletal muscles of such severity to cause a disruption of cellular integrity and release of contents into the circulatory system. Common causes of crush syndrome include entrapment secondary to structural collapse, construction accidents or trench collapse.
Crush syndrome is just one type of crush injury, which is any injury caused as a result of direct physical crushing of the muscles due to something heavy. Other types of crush injury include:
- Acute compartment syndrome: Which occurs when the tissue pressure within a closed muscle compartment exceeds the perfusion pressure resulting in muscle and nerve ischemia.
- Compression syndrome: Indirect muscle injury due to a slow simple, compression of a group of muscles leading to ischemic damage and thus causing crush substances to enter the blood.
- Traumatic asphyxia: Pressure applied to the chest prevents respirations and produces a sudden increase in venous pressure. It is most commonly secondary to entrapment and high-velocity collisions.
Suspension trauma, which is not a type of crush injury, was also discussed. Suspension trauma is the development of pre-syncopal symptoms and loss of consciousness when the body is held motionless in a vertical position for a period of time.
Memorable quotes on crush syndrome
Bledsoe's presentation was peppered with anecdotes from his work as a Las Vegas emergency physician and the challenges to EMS dogma for which he is well known. Here are a few of his most memorable quotes on crush syndrome.
"Crush injury causes more risk for acute kidney injury than IV contrast."
"Eighty percent of crush syndrome patients die. Of the 20 percent who survive, half of them develop compartment syndrome."
"Absence of (the patient) making urine is a very bad diagnostic finding."
"Is suspension trauma really an injury" No it's a phenomenon. Suspension trauma is the natural physiological response to being motionless in a vertical position."
"Crush syndrome is something you are going to encounter. And you can make a difference to the patient."
Top takeaways on crush syndrome
Bledsoe broadly described the phenomenon of crush syndrome, including assessment and treatment. He also described assessments and treatments for types of crush injury, such as compartment syndrome and traumatic asphyxia. These top takeaways focus on crush syndrome.
1. Rescue from entrapment can make a patient worse
Many crush syndrome patients get worse after extrication from entrapment. Reperfusion of ischemic tissues spreads cellular toxins into the circulatory system.
2. Assessment of crush syndrome
The primary cause of crush syndrome is injury to sarcolemma, which is the fiber covering muscles. This leads to water entry into muscle cells, increased pressure in the muscle compartment and disruption in cellular function. Cellular death releases myoglobin into circulatory system, which eventually leads to kidney injury.
Local assessment findings for crush syndrome include pain out of proportion, swelling, bruising and weakness. Worrisome systemic findings are tea-colored urine, fever, malaise, nausea and vomiting, confusion, agitation, delirium and anuria, which is the inability to produce urine.
Hospital diagnosis of crush syndrome includes elevated CK and lactic acid, grossly swollen, hard, cold, insensitive, necrotic muscle tissues, arrhythmias from the complications of electrolyte imbalances and shock.
3. EMS crush syndrome protocol
The focus of prehospital providers is to assure ABCs and deliver supportive care. In addition, initiate aggressive IV fluid administration, while the patient is still entrapped, at 1500 mL/hour. Rapid extrication, pain management and EKG are also important EMS treatment components.
Paramedic level care, especially for long crush syndrome patients with long transport times, includes attempting to alkalize the patient's urine by administering sodium bicarbonate. A patient pH of > 6.5 helps protect kidney function.
Learn more about crush syndrome
Here are additional articles to learn more about crush and suspension injuries.
- 4 things EMS providers must know about crush syndrome
- Standing Orders: Tips for treating USAR crush injuries
- Why crush injury is important to treat early
- Exclusive: Field amputation difference between life and death
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