Emergency Preparedness

and Response

Background

Crush injury and crush syndrome may result from structural collapse during an earthquake. Crush injury is defined as compression of extremities or

other parts of the body that causes muscle swelling and/or neurological disturbances in the affected areas of the body. Typically affected areas of the

body include lower extremities, upper extremities, and trunk. Crush syndrome is localized crush injury with systemic manifestations. These systemic

effects are caused by a traumatic rhabdomyolysis (muscle breakdown) and the release of potentially toxic muscle cell components and electrolytes

into the circulatory system. Crush syndrome can cause local tissue injury, organ dysfunction, and metabolic abnormalities, including acidosis,

hyperkalemia, and hypocalcemia.

Previous experience with earthquakes that caused major structural damage has demonstrated that the incidence of crush syndrome is 2-15% with

approximately 50% of those with crush syndrome developing acute renal failure and over 50% needing fasciotomy. Of those with renal failure, 50%

need dialysis.

Clinical Presentation

Sudden release of a crushed extremity may result in reperfusion syndrome—acute hypovolemia and metabolic abnormalities. This condition may

cause lethal cardiac arrhythmias. Further, the sudden release of toxins from necrotic muscle into the circulatory system leads to myoglobinuria, which

causes renal failure if untreated.

Hypotension

Massive third spacing occurs, requiring considerable fluid replacement in the first 24 hours; Patients may sequester (third space) more

than 12 L of fluid in the crushed area over a 48-hour period

Third spacing may lead to secondary complications such as compartment syndrome, which is swelling within a closed anatomical space;

compartment syndrome often requires fasciotomy

Hypotension may also contribute to renal failure

Renal Failure

Rhabdomyolysis releases myoglobin, potassium, phosphorous, and creatinine into the circulation

Myoglobinuria may result in renal tubular necrosis if untreated

Release of electrolytes from ischemic muscles causes metabolic abnormalities

Metabolic Abnormalities

Calcium flows into muscle cells through leaky membranes, causing systemic hypocalcemia

Potassium is released from ischemic muscle into systemic circulation, causing hyperkalemia

Lactic acid is released from ischemic muscle into systemic circulation, causing metabolic acidosis

Imbalance of potassium and calcium may cause life-threatening cardiac arrhythmias, including cardiac arrest; metabolic acidosis may

exacerbate this situation

Secondary Complications

Compartment syndrome may occur, which will further worsen vascular compromise

Initial Management: Prehospital Setting

Administer intravenous fluids before releasing the crushed body part. (This step is especially important in cases of prolonged crush [more

than 4 hours]; however, crush syndrome can occur in crush scenarios of less than 1 hour) 

If this procedure is not possible, consider short-term use of a tourniquet on the affected limb until intravenous (IV) hydration can be

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Prevention 1600 Clifton Rd.

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initiated

Initial Management: Hospital Setting

Hypotension

Initiate (or continue) IV hydration—up to 1.5 L/hour

Renal Failure

Prevent renal failure with appropriate hydration, using IV fluids and mannitol to maintain diuresis of at least 300 cc/hr

Triage to hemodialysis as needed

Metabolic Abnormalities

Acidosis: Alkalinization of urine is critical; administer IV sodium bicarbonate until urine pH reaches 6.5 to prevent myoglobin and uric

acid deposition in kidneys

Hyperkalemia/Hypocalcemia: Consider administering the following (adult doses): calcium gluconate 10% 10cc or calcium chloride 10%

5cc IV over 2 minutes; sodium bicarbonate 1 meq/kg IV slow push; regular insulin 5-10 U and D5O 1-2 ampules IV bolus; kayexalate

25-50g with sorbitol 20% 100mL PO or PR

Cardiac Arrhythmias: Monitor for cardiac arrhythmias and cardiac arrest, and treat accordingly

Secondary Complications

Monitor casualties for compartment syndrome; monitor compartmental pressure if equipment is available; consider emergency

fasciotomy for compartment syndrome

Treat open wounds with antibiotics, tetanus toxoid, and debridement of necrotic tissue

Apply ice to injured areas and monitor for the 5 P’s: pain, pallor, parasthesias, pain with passive movement, and pulselessness

Observe all crush casualties, even those who look well

Delays in hydration of greater than 12 hours may increase the incidence of renal failure; delayed manifestations of renal failure can occur

Disposition

Patients with acute renal failure may require up to 60 days of dialysis treatment; unless sepsis is present, patients are likely to regain normal kidney

function.

Page last updated January 14, 2010

Content source: National Center for Environmental Health (NCEH) (http://www.cdc.gov/nceh/) /Agency for Toxic Substances and Disease

Registry (ATSDR) (http://www.atsdr.cdc.gov/) , National Center for Injury Prevention and Control, Division of Injury Response

(http://www.cdc.gov/injuryresponse/index.html)

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