Page 47 - JSOM Summer 2022

cough with pink frothy sputum, and cyanosis, because pul- output, administering oxygen and auscultating accurately in
monary edema could be caused by the large volume of fluid the immediate phase is technically difficult. These represent
required to treat fulminant rhabdomyolysis. A better practice optimal management and are only recommended if they are
would be lung auscultation with a stethoscope to assess for also tactically sound.
“wet” sounds and use of a pulse oximeter to monitor for im-
paired gas exchange. Post-extrication best practice is a chest Once the IV bolus is initiated, consider pain management, fol-
radiograph to assess the extent of pulmonary edema present. lowing established pain management protocols. Also, if time
and tactical situation permit, 1g of ertapenem should be ad-
Medics should at a minimum be evaluating any extremities dis- ministered IV over 30 minutes as a prophylactic measure. 5-7
tal to the injury site for the “5 Ps” that can identify compart-
ment syndrome: pain out of proportion to injury with passive If available during the immediate phase, cardiac monitoring
movement, palpably tense muscle compartments, paresthesias should be utilized to look for any signs of hyperkalemia. Sinus
or sensory deficits, pulselessness, and paralysis. It is important bradycardia will be the primary indicator of this, followed by
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to note that paralysis and paresthesias could also be due to peaked T waves or the presence of PVCs. Also, administration
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neural trauma. It is also important to understand that many of mannitol at 1–2g/kg at a rate of 5g/h can be considered if
of these signs occur late. Special attention should be given to available and the patient’s urine output has already been estab-
the finding of pain out of proportion on passive movement of lished. It should be noted that mannitol causes large volume
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the injured extremity and a high index of suspicion for com- diuresis and can precipitate when stored in temperature ex-
partment syndrome should be maintained when managing any tremes and requires a specific filter on the IV set. In addition,
crush injury, especially to the distal extremities. Compartment the use of mannitol in patients with possible ongoing internal
syndrome most often occurs in the lower legs, followed by the hemorrhage or identified hemorrhage from other sources may
forearms. Compartment syndrome can occur in the proximal exacerbate shock in a fashion that is difficult to recover from.
extremities but is much less common. While not all signs may As such, mannitol should be used thoughtfully, and this ad-
be present, monitoring for compartment syndrome develop- junct is not often carried by those providing POI or prehospi-
ment is imperative. Best practice would be utilizing a compart- tal care in austere and resource-limited environments.
ment pressure monitor to determine the presence and severity
of compartment syndrome, but this tool has significant limita- The extrication phase begins immediately before lifting the ob-
tions and is not recommended for use in theatre. 2 ject that is crushing the patient. If an extremity is pinned, this
is the time to apply and tighten tourniquets to prevent the po-
Additional diagnostics for remote laboratory capability could tassium and myoglobin release into the blood stream. Sodium
be used to assess blood gases, electrolytes, metabolites, and co- bicarbonate at a dose of 1mEq/kg should be given IV prior to
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™
agulation factors if available. While an iSTAT (https://www extrication. If a patient is going to experience a dysrhythmia
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.pointofcare.abbott/) or equivalent will unlikely be carried by or cardiac arrest, it may be immediately after extrication. If
a SOF medic on mission, in some countries the hospital system there is any evidence of dysrhythmia or arrest, calcium should
may have the same or a similar tool that can be borrowed be administered to the patient. A medic can give either 10mL
or bartered for if necessary. Small lactate monitors are easy of 10% calcium gluconate or 5mL of calcium chloride 5% IV
to carry and use, but only evaluate lactate, making it a hard over 2 minutes, although in this case, calcium gluconate is pre-
bargain to add to an already full truck bag or prolonged field ferred because it is less irritating to the vessel in a peripheral
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care (PFC) kit. IV. It is important to not administer either calcium product in
a solution containing sodium bicarbonate due to the creation
of calcium carbonate, a salt. A medic can also give albuterol to
Management of Crush Patients
the patient showing signs of hyperkalemia, by either metered
Management of patients who have experienced a prolonged dose inhaler or nebulizer. This will drive the free-floating po-
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crush injury focuses on preventing or readily addressing the tassium back into the cells and out of circulation. 7
associated complications discussed above. This patient man-
agement can be broken up into three phases: immediate, extri- The final phase is evacuation. If the patient is still presenting
cation, and evacuation. with signs of hyperkalemia after administration of all med-
ication above, one more ampule of sodium bicarbonate can
The immediate phase begins when the medic arrives to the pa- be administered. It is important to evacuate the patient to a
5,6
tient. Upon approaching a patient that has a crush injury, first higher echelon of care in the “urgent” MEDEVAC category,
conduct a standard MARCHE assessment and address any as this patient is going to require more advanced monitoring
immediate, life-threatening injuries. Next, obtain intravenous than a medic on the ground will be able to provide, including
(IV) access and begin an initial bolus of 1–2L of normal saline. cardiac and laboratory monitoring.
Do not use lactated Ringer’s due to the high potassium content
in this crystalloid, which may exacerbate hyperkalemia the pa- The medic should pay close attention to the limb that was
tient may experience during and after extrication. The goal for crushed, constantly assessing for evidence of a compartment
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the urine output should be equal to or greater than 1–2mL/kg/h syndrome. If compartment syndrome develops in a crushed ex-
during the extrication process, with an infusion rate of ap- tremity, a fasciotomy should be performed as soon as possible
5,6
proximately 1.5L/h after the initial bolus. During this time, to reduce the risk of loss of limb in the patient. Performing
5,6
the medic should be monitoring oxygenation (Spo ) and ad- a fasciotomy outside of a forward surgical capability is con-
2
5,6
ministering supplemental oxygen, if available. The medic troversial. On the one hand, it is undoubtedly the definitive
should also auscultate the patient’s lungs to ensure they are treatment for compartment syndrome. However, the skin and
not getting “wet” due to excessive crystalloid infusion caus- fascial incisions required are necessarily long and the medic
ing pulmonary edema. We acknowledge that monitoring urine will have to manage bleeding using all available hemostatic
Austere Crush Injury Management | 45