Page 27 - 2026 SMOG

CRUSH SYNDROME
History History (Complications)
• Entrapped extremity (as little as 1hr) • Hyperkalemia
• Erythema, ecchymosis, abrasion • Hypocalcemia
• Swelling, tense muscle compartment • Compartment syndrome
• Rhabdomyolysis
• Arrhythmia
• Hypotension
Treatment
• Prior to extraction
˚ Consider tourniquet placement for crush injuries if the length of entrapment exceeds 2 hours
and the crush injury protocol cannot be initiated immediately.
˚ Apply two tourniquets side by side and proximal to the site of entrapment immediately prior
to extraction.
• Initiate crush injury protocol before extrication if possible and before loosening tourniquets
(if tourniquet conversion is indicated)
• IV/IO Protocol
˚ Initiate aggressive fluid administration of IV/IO crystalloids 2L initial bolus, followed by
an infusion rate: 1L/hr. Adjust to urine output (UOP) goal of >100–200mL/hr (via Foley or
improvised graduated cylinder)
• Monitor for life-threatening hyperkalemia (PVC’s, bradycardia, peaked T-waves, decreased
peripheral pulse strength, hypotension)
˚ If PVCs become more frequent, the patient develops bradycardia, peripheral pulse strength
decreases, or potassium levels are >5.5mEq/L or rising, treat urgently for hyperkalemia
■ Calcium: administer 10mL (10%) Calcium Gluconate or Calcium Chloride IV over
2–3min
■ Insulin and Glucose: administer 10 units of regular insulin followed immediately by
50mL of D50; titrate prn
■ Albuterol: administer 12mL of albuterol sulfate inhalation solution, 0.083% (2.5mg/3mL)
in a nebulizer
• If no signs of hyperkalemia develop, continue fluid administration and continuously monitor.
Notes, Cautions, Warnings
• Crush syndrome can occur in as little as 1 hour of entrapment.
• Tourniquets may mitigate life-threatening complications in situations where fluid resuscitation
and treatment cannot be immediately initiated.
• Aggressive fluid resuscitation for crush injury in the setting of noncompressible hemorrhage
may increase hemorrhage. Balance the risk of uncontrolled hemorrhage against the cardiotoxic
effects of hyperkalemia.
Reference: CPG ID #58 (Crush Syndrome – Prolonged Field Care)

2026 Standard Medical Operating Guidelines (SMOG) • 19