Page 99 - Journal of Special Operations Medicine - Fall 2016

prolonged QRS interval, PVCs or runs of ventricu- o Treatment instructions: 15–30g suspended in 50–
lar tachycardia, conduction block (bundle branch, 100mL liquid. Oral or rectal. Onset of action: >2
fascicular) hours. Duration of action: 4–6 hours.
• If PVCs become more frequent, the patient develops • Bicarbonate: Although routinely recommended as
bradycardia, peripheral pulse strength decreases, or mainstay treatment to reduce kidney damage by rais-
potassium levels are >5.5mEq/L or rising, treat ur- ing the urine pH and diminishing intratubular pig-
gently for hyperkalemia. ment cast formation, and uric acid precipitation; to
• Insulin and 50% dextrose (D50); calcium gluconate; correct metabolic acidosis; and to reduce potassium
albuterol (see treatment instructions below) levels, there is no clear evidence that bicarbonate re-
duces kidney damage , and the effect of reducing po-
20
Consider teleconsultation or more urgent evacua- tassium is slow and unsustained. 21
tion to facility with laboratory and ECG monitoring, if
possible. Sodium polystyrene sulfonate removes potassium
• Use tourniquets to isolate limb(s) (see Tourniquets from the body. All other treatments temporarily lower po-
below) tassium by shifting it out of circulation and into the cells.
Continue to monitor and repeat treatment when needed.
Treatments for Cardiac Arrhythmias
Due to Hyperkalemia Tourniquets for Management of Crush
Treat if potassium level is >5.5mEq/L or there are car-
diac arrhythmias (see above). Note that a normal ECG Tourniquets may delay the life-threating complications
may occur in patients with hyperkalemia. of a reperfusion injury if immediate fluid resuscitation
or monitoring is not initially available. Consider tourni-
Goal: Restore normal ECG/prevent fatal cardiac quet placement for crush injury before extrication if the
complications length of entrapment exceeds 2 hours and crush injury
protocol cannot be initiated immediately. 22–24
Treatment for Hyperkalemia
• Best: calcium gluconate; insulin + D50; albuterol; so- Goal: Delay acute toxicity until after fluid resuscitation
dium polystyrene sulfonate and monitoring are available.
• Better: calcium gluconate; insulin + D50 • Best: Apply two tourniquets side by side and proxi-
• Minimum: any individual or combination of treat- mal to the injury immediately before extrication
ments, as available • Minimum: Apply two tourniquets side-by-side proxi-
• Calcium gluconate (calcium replacement): Increases mal to the injury immediately after extrication
serum calcium to overcome the effect of hyperkale- • Initiate crush injury protocol before loosening tour-
mia on cardiac function. Alternate: may use calcium niquet, and then only if the patient meets criteria for
18
chloride, which is more irritating when administered tourniquet conversion or removal given in the TCCC
via peripheral IV. guideline
o Treatment instructions: Administer 10 mL (10%)
calcium gluconate or calcium chloride IV over 2–3 A limb that is cool, insensate, tensely swollen, and
minutes. Onset of effect: immediate. Duration of pulseless is likely dead. Patient may develop shock and
action: 30–60 minutes. kidney damage, and may die. Consider fasciotomy. If no
• Insulin and glucose: Insulin is given to lower the se- improvement, place two tourniquets side by side and
rum potassium level by driving it back into the cells; proximal to the injury and do not remove. Amputation
glucose is given to prevent hypoglycemia. 18 anticipated.
o Treatment instructions: give 10 units of regular in-
sulin followed immediately by 50mL of D50. Onset Fasciotomy
of effect: 20 minutes. Duration of action: 4–6 hours.
• Albuterol: Lowers serum potassium level by driving Extremity compartment syndrome must be anticipated
it back into the cells; effect is additive with insulin. 19 with crush injury and reperfusion injury. 25–27
o Treatment instructions: Administer 12mL of alb-
uterol sulfate inhalation solution, 0.083% (2.5mg/ Goal: Decompress muscle, restore blood flow.
3mL) in nebulizer. Onset of effect: 30 minutes. Du- • Best: Perform fasciotomy (only if there are clinical
ration of action: 2 hours. signs of compartment syndrome). The earliest sign is
• Sodium polystyrene sulfonate (Kayexalate ; Concor- limb swelling with severe pain with or without pas-
®
dia Pharmaceuticals, http://concordiarx.com): Low- sive motion, persisting despite adequate analgesia,
ers serum potassium level by removing potassium followed by paresthesia, pallor, paralysis, poikilother-
from the gut. 18 mia, and pulselessness.

Management of Crush Syndrome Under Prolonged Field Care 81