Crush injury and rhabdomyolysis — Rapid

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.
Obtain an early venous or arterial blood gas, ECG, potassium, bicarbonate, calcium, phosphate, CK, creatinine and urinalysis, then repeat because initial values may be normal.
A urine dipstick positive for blood with few or no red cells supports myoglobinuria; dark urine increases suspicion but its absence does not exclude muscle breakdown.
For moderate or severe hyperkalaemia, give 10 units soluble insulin with 25 g glucose intravenously; add nebulised salbutamol 10–20 mg and monitor glucose closely.
For severe hyperkalaemia with ECG change, give 10 mL of 10% calcium chloride IV over 5 minutes, or 30 mL of 10% calcium gluconate over 10 minutes if chloride is unavailable.
Do not use routine bicarbonate, mannitol, loop diuretics, prophylactic hyperkalaemia drugs or preventative fasciotomy; involve renal and critical care early for refractory potassium, acidosis, overload or oliguria.

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.

Oliguria, dark brown urine, rapidly rising potassium, acidosis, CK or creatinine after muscle injury predicts crush syndrome and possible renal replacement therapy.

Disproportionate pain, passive-stretch pain, tense swelling or progressive neurological change suggests acute compartment syndrome and requires immediate surgical assessment; preventative fasciotomy without evidence is not supported.

Catastrophic haemorrhage, unstable pelvic or torso injury, hypothermia, blast injury, burns and entrapment-related trauma can kill before rhabdomyolysis and must remain within the primary survey.

Investigation priorities

First-line ECGFirst stepFirst line

Detect potassium cardiotoxicity before or during biochemical confirmation.

Management branches

EntrappedPrepare but do not delay release

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.
Use individualised warmed fluid according to trauma physiology and do not require a fixed volume before extrication.
Record release time, reassess immediately for collapse, bleeding, dysvascularity and compartment findings and transfer to definitive care.

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.Calcium does not lower potassium; use a secure line, avoid extravasation, separate calcium from bicarbonate by different lines or flushing and do not wait for CK results when ECG toxicity is present.

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.Check glucose repeatedly for at least 6 hours and treat hypoglycaemia promptly; effect is temporary, so repeat potassium and ECG and involve renal care for rebound or refractory elevation.

Open full textbook →Answer 2 questions