Page 80 - 2025 Ranger Medic Handbook

Crush Syndrome Management
Crush Syndrome Management Considerations
DEFINITION: Massive, prolonged crush injury resulting in profound muscle and soft tissue damage places the patient at
significantly increased risk for developing circulatory and renal complications.
1. The principles of hypotensive resuscitation according to TCCC DO NOT apply in the setting of extremity crush injury
SECTION 2 2. In the setting of a crush injury associated with noncompressible (thoracic, abdominal, pelvic) hemorrhage, aggressive
requiring extrication.
fluid resuscitation may result in increased hemorrhage.
3. With extremity crush injuries, tourniquets should NOT be applied during Phase 1 unless there is hemorrhage that is
not controllable by other means.
4. Be aware of development of cardiac dysrhythmias due to hyperkalemia immediately following extrication.
5. BE AWARE OF DEVELOPMENT OF CRUSH SYNDROME STARTING AS EARLY AS 4 HOURS POST INJURY.
THESE MEDICATIONS ARE NOT PART OF THE STANDARD AID BAG AND REQUIRE DEVELOPMENT OF A SEPA-
RATE CRUSH INJURY KIT.

Phase 1: Immediate Management (while attempting to extricate)
The following management measures are to be initiated if time from initial crush to extrication exceeds 4 hours, while still
trying to extricate the patient, and complete prior to extrication when crush has been > 4 hours:
1. Maintain patent airway and adequate ventilation.
2. Monitor O 2 sat with pulse oximetry and administer high-flow oxygen if indicated.
3. Give initial bolus of 1–2L of crystalloid solution PRIOR to attempts at extrication and continue at 1.5L/hr. In a patient
making urine, physiologic isotonic fluids (plasmalyte or Ringer's lactate) are the fluid of choice to prevent worsening
acidosis and worsen hyperkalemia.
4. Maintain urine output at greater than or equal to 1–2mL/kg/hr and monitor urine output volume. Place a foley when-
ever possible to monitor for accurate urine output.
5. Assess and reassess mental status.
6. Follow Pain Management Protocol
7. Treat with prophylactic antibiotics: ertapenem 1g IV if time and tactical situation allow.
Utilize cardiac monitoring if available to monitor for signs of hyperkalemia. Treat suspected emergent hyperkalemia
accordingly. Cardiac arrest should be treated per standard ACLS protocol with addressing early hyperkalemia as likely
cause with calcium, sodium bicarbonate, insulin with glucose (if available), and albuterol treatments.
Phase 2: Immediately Prior To Extrication
The following management measures are to be attempted immediately after extricating the patient:
1. Cardiac dysrhythmias or arrest are likely immediately following extrication.
2. CPR should be initiated if cardiac arrest develops following extrication IAW ACLS Protocol. DO NOT follow the TCCC
guidelines on cardiac arrest.
3. If extrication is > 4 hours OR in the presence of dysrhythmias, administer 1 amp of calcium chloride or 3 amps of
calcium gluconate slow IV push. Calcium should not be given in bicarbonate-containing solutions due to precipitation
of calcium carbonate.
4. If arrhythmia occurs, calcium should be given repeatedly until arrhythmia resolves. Once arrhythmia has resolved, the
patient should be treated with high dose albuterol, sodium bicarbonate, and insulin with glucose to shift potassium
intracellularly.
5. TQ use in the Crush protocol is based on situation and time: TQ’s should be placed on crushed limbs for extended
crush times combined with the lack of drugs to perform proper ACLS.
Following extrication, once the patient is stabilized, be prepared to treat recurrent dysrhythmias or hyperkalemia. Moni-
tor urine color for myoglobin. Darker urine (red, brown, or black), either consistently or worsening over time, is associ-
ated with increasing myoglobinuria and increased risk of kidney damage. Consider increasing IV fluids to goals at or
above urine output goals of 100–200mL/hr. The fluid rate should be adjusted to maintain this level of UOP. Monitor for
compartment syndrome of the crushed extremity with evidence of pain out of proportion, paresthesia, pallor, paresis,
pulselessness, and poikilothermia.
Phase 3: Evacuate
Urgent: Evacuate to a surgical facility. If compartment syndrome develops, likelihood of loss of limb increases with time
to fasciotomy by a trained medical provider.

66 SECTION 2 PRIMARY TRAUMA PROTOCOLS