Synopsis
Manage crushing trauma as multisystem injury, coordinate safe early release without prophylactic tourniquet delay, recognise evolving muscle necrosis, treat hyperkalaemia immediately, individualise fluid and renal support, and identify compartment or unsalvageable-limb surgery.
- Release the crushing force as early as safely possible; do not use a tourniquet merely to delay reperfusion, although one may be loosely pre-positioned for rapid use if catastrophic bleeding begins.
- Establish monitoring and IV or IO access during prolonged extrication when practicable, but do not delay release solely to deliver a predetermined fluid volume.
- Use blood products for haemorrhagic shock and individualised warmed isotonic crystalloid for hydration and rhabdomyolysis risk, reassessing pressure, lungs and urine rather than chasing a universal urine target.
Key red flags
Bradycardia, broad QRS, absent P waves, sine-wave change, ventricular arrhythmia or cardiac arrest around crush release is hyperkalaemia until urgently assessed and treated.
Investigation priorities
Detect potassium cardiotoxicity before or during biochemical confirmation.
Management branches
A person remains compressed by debris, machinery or body position.
- Ensure scene safety, perform accessible ABCDE care, give analgesia and control catastrophic bleeding while planning earliest safe release.
- Establish ECG and IV or IO access when feasible and consider loosely positioning a tourniquet only for possible catastrophic haemorrhage.
Key medicines
Calcium for severe hyperkalaemia with ECG changesGive 10 mL of 10% calcium chloride intravenously over 5 minutes; if calcium chloride is unavailable, give 30 mL of 10% calcium gluconate intravenously over 10 minutes, then reassess the ECG and repeat through the resuscitation algorithm if toxicity persists.
Insulin-glucose for moderate or severe hyperkalaemiaGive 10 units soluble insulin with 25 g glucose intravenously for potassium 6.0–6.4 mmol/L or above 6.5 mmol/L; if pre-treatment glucose is below 7 mmol/L, follow with 10% glucose at 50 mL/hour for 5 hours.