I Ve Got a Crush on You: Crush Injuries in EMS Janet Taylor, RN NREMT-B
I’ve Got a Crush on You: Crush Injuries in EMS Janet Taylor, RN NREMT-B
Depending on the source, there are a couple of different versions on how Crush Injury and Syndrome was discovered.
Also referred to as ______or ______Syndrome
It was first described by Dr. Minami in 1923 when he noticed WW1 soldiers were dying days later of non-lethal bombings that they had walked away from earlier. He noted these findings and the syndrome was officially given a name in 1941.
There are two different parts of Crush that we will talk about but this presentation focuses on Syndrome rather than Injury. But to understand I want to give you a comparison so you understand.
INJURY
Cell disruption at the time and point of impact
Occurs over the course of less than 1 hour
Focal in nature
SYNDROME
Systemic effects when muscle is RELEASED from compression.
Occurs after cells have been under pressure ______*
*Exceptions to this rule include lightening strikes, elderly, poor circulation or high blast injuries.
Different ways people can be exposed to a Crushing Mechanism
Building and Structure Collapse
Bomb Concussions
MVA’s and farm accidents
Assault with blunt weapon
Lack of spontaneous movement
Determining Factors that affect how quickly Crush Syndrome can occur are
The WEIGHT or pressure of the object
The TIME underneath of object
The PATIENT’s pre-disposed conditions*
ANATOMY involved.
*pre-disposed conditions include poor circulation, ______, and malnutrition.
The anatomy that is most likely to develop into Crush Syndrome are
______, ______, ______and ______.
This is due to the amount of muscle mass versus surface area. A hand doesn’t have near as much muscle mass as a portion of your thigh with the same amount of surface area.
Inside a Cell are many different things that are necessary for life. If given an ideal situation, nothing goes wrong. But deprive these things of oxygen and you get a bunch of nasty by-products
Potassium is in high concentrations INSIDE the cell.
ATP =>______
Hydrogen =>______
Lactate =>______
Urea =>______
Phosphate =>______
Myoglobin is a building block of ______
It doesn’t belong in the bloodstream. But when it hits acidic urine (when the kidneys are filtering the blood) it turns into a gel that sets up like plaster in the kidneys and clogs them up.
In very slow motion, we are going to review what happens at a cellular level when a weight is applied to the body.
As the weight begins to press down, ______is displaced and cells get squished.
As the weight increases, cells are squished open, dumping out ______& ______.
As the weight stays pressed down, blood flow to the area is halted and oxygen is deprived to the tissues. ______develops in the process.
Minutes later: blood flow continues to flow to the area, creating hypovolemia. ______continues to be released. Two side effects of histamine are ______and ______
______. So even more hypotension results and more fluid is being lost.
Once the weight if lifted a phenomenon generally occurs called, “______”
The weight is lifted and all of the fluid that was displaced is shifted around, the acids that were stewing in the sludge that was under that weight is re-introduced back into the circulation and ______which was forced out of the cell hits the heart and causes cardiac arrest.
______is actually what causes the Smiling Death.
______causes vascular calcifications
______cause more cellular injury (as if they hadn’t had enough, right?)
______Na/K pump => cardiac arrest from hyperkalemia
It is ______that usually kills the patient after that weight has been lifted.
Tourniquets placed proximal to the weight before the weight is lifted will slow the dumping of toxins back into the bloodstream and give you a few extra minutes to administer treatments.
______!! At least two large bore IV’s and NEVER USE LACTATED RINGERS.
Intial bolus, 30/kg followed by 1000 mL/Hr. Desired Urine output is ______-______mL/Hr.
______1 gm IVP over 10-15 minutes will stabilize the cell wall. It should be the FIRST medication given when faced with a Crush Syndrome.
______1 mEq/kg bolus followed by 1 amp in a 1,000 mL bag of NS wide open.
This will alkalinize the urine and activates the ATP pump to drive potassium back into the cell where it belongs.
Even if the patient survives the initial release of the weight and the bolus of acids and toxins that flood the bloodstream, they remain at great risk for developing ______with severe morbidity in the next days to weeks after a Crushing mechanism of injury.
______is literally translated as “Skeletal Muscle Degradation” When the weight or pressure (from lightening strikes or bomb concussions) hits the muscle, it begins to break down. Remember myoglobin? The building block of MUSCLE? When muscle breaks down, the myoglobin enters the bloodstream (where it doesn’t belong) and circulates through until it gets to the kidneys (where it doesn’t belong)
______myoglobin in the blood
______myoglobin in the urine
Urine with myoglobin in it looks like strong tea or cola. It can be charted as “tea colored urine” or “cola colored urine” when trying to describe it.
Luckily, the treatment for Rhabdomyolysis is the same for Crush Syndrome: Aggressive Fluid Resuscitation.
We also treat the urine on someone has Rhabdo:
Administration of ______will alkalinize the urine. Remember all of the acids that are dumped from muscle destruction and hypoxia? Well when the kidneys do excrete myoglobin (which they aren’t designed to do) their efficiency rate is about 5%. When you alkalinize the urine with sodium bicarbonate in the IV, the excretion rate increases to 85%!
______is another medication we can give for the side effects rather than what it was intended to do. A side effect of this medication is that in high doses, it drives potassium into the cell. In this case, that is EXACTLY what we want it to do! ______is the recommended dose.
______forces diuresis in the kidneys. It dilates the kidneys which gives the myoglobin a little more legroom to be excreted. But remember, this stuff is acidic.
Other Treatments that you may see being done for these patients once you drop them off at the ED
______
______
______
______
Other things to think about when dealing with Crush Syndrome or Rhabdo……..
______CAN be unhealthy (yes I said it). “Strenuous” is the key word here…..
______is seen with long bone fx, crush injuries, burns and tight bandages. ______and ______surgery are other potential factors.
______Syndrome can occur up to ______hours after the initial time of injury.
5 Ps’ of Compartment Syndrome (ha ha! I tricked you, there are actually 6 but not everyone is aware of the 6th one….)
______, ______, ______, ______, ______, ______.
Having a patient who has only ONE of the “Ps’” = ______correct diagnosis. BUT if your patient has THREE of any of the “Ps’” your chances of having a correct diagnosis is ______!! Know your “Ps’”!
The only treatment for this is ______.
Chronic Exertional Compartment Syndrome is different from regular Compartment syndrome because it’s ______and it is focal. People often mistake them for Shin Splints. Signs and Symptoms include
Pain beginning soon after exercising
Gets worse if you continue to exercise
Stops after rest
Can affect the ______, ______, and ______.
How to prevents Chronic Exertional Compartment Syndrome…..
______
______
______
______
Harness Syndrome is seen with repelling, commercial window washers, parachuters, etc. Anyone who wears a harness which has leg straps over the femoral veins and arteries when cinched down.
Don’t forget about the little old people who are lying on a cold tile or concrete floor for several hours or overnight. These folks, even though they aren’t crushed, will develop muscle breakdown due to having their own weight compressing the muscles that are in contact with the hard surface.
Factors include
______
______
______
______
______
Lack of Spontaneous Movement conditions include
______
______
______
______
PASG or MAST pants
“The use of PASG has been reported to cause compartment syndrome and crush injury syndrome” (that is all I am going to say about that)