Page 106 - PJ MED OPS Handbook 8th Ed

Crush Syndrome Protocol

Definition:
Massive, prolonged crush injury resulting in profound muscle and soft tissue damage places the pa-
tient at significantly increased risk for developing circulatory and renal complications due to release
of potassium, acid and protein from the injured tissue.
SPECIAL CONSIDERATIONS:
1. Be aware of development of crush syndrome starting early post injury.
2. Employ the protocol if not immediately extricating a patient.
3. These medications are not part of the standard ATP aid bag and require development of
a separate crush injury kit.
SPECIAL INSTRUCTIONS:
1. The principles of hypotensive resuscitation according to TCCC DO NOT apply in the setting
of extremity crush injury requiring extrication.
2. In the setting of a crush injury associated with non-compressible (thoracic, abdominal,
pelvic) hemorrhage, aggressive NS fluid resuscitation may result in increased hemorrhage
and blood should be used – use your best judgment.
3. With extremity 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 or cardiac arrest due to hyperkalemia
immediately following extrication.

Management:
Phase 1: IMMEDIATE (while attempting extrication)
1. Perform MARCH PAWS (see page 17)
2. Monitor O2 sat with pulse ox and administer high flow oxygen if SpO2 <90%.
3. Give initial bolus of 1–2L of NS PRIOR to attempts at extrication and continue at 1.5L/hr. Can
place 2 lines if able. Adjust to urine output (UOP) goal of >100–200mL/hr if able.
a. If IV/IO crystalloids are not available, consider oral intake of electrolyte solution such as
water/rehydration salts, Pedialyte or a sports drink.
4. Ringer’s lactate is not recommended due to the potassium content, but can be used for first 2
liters if nothing else available.
5. Maintain urine output at greater than or equal to 200mL/hr. If possible, insert Foley catheter.
6. Monitor mental status.
7. Follow Pain Management Protocol (TMEP).
8. For open wounds give antibiotics – ertapenem (lnvanz) 1g IV.
9. Utilize cardiac/EKG monitoring during extrication and evacuation.

104 n Pararescue Medical Operations Handbook / 8th Edition