Updated: 12/28/2021

Crush Syndrome

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  • Snapshot
    • A 60-year-old man presents to the emergency room after an earthquake. His right leg had been trapped under his truck for an hour. After he was extracted, he was rushed to the emergency room, where aggressive fluid hydration was started. There is no penetrating injury. On physical exam, there is a large ecchymosis and abrasion on the right thigh. The right thigh is severely tender to palpation and the muscles feel tense. Laboratory evaluation reveals hyperkalemia and significantly elevated creatine kinase. He is immediately started on intravenous fluids and calcium gluconate.
  • Introduction
    • Clinical definition
      • syndrome of shock, rhabdomyolysis, and acute renal failure after prolonged crush injury
  • Epidemiology
    • Risk factors
      • natural disasters
        • e.g., earthquakes
      • trauma
      • cave-ins
  • ETIOLOGY
    • Pathogenesis
      • ischemia causes breakdown of skeletal muscle and rhabdomyolysis, releasing myoglobin, phosphorous, and potassium from cells
      • reperfusion injury releases the products of muscle breakdown into the system
      • acute tubular necrosis is caused by myoglobin, a nephrotoxic metabolite
    • Associated conditions
      • rhabdomyolysis
  • Presentation
    • Symptoms
      • pain from the crushed body part
    • Physical exam
      • abrasions, erythema, and ecchymosis
      • monitor for compartment syndrome with 6 P’s
        • Pulselessness
        • Pallor
        • Pain
        • Paresthesias
        • Poikilothermia
        • Paralysis
  • Imaging
    • Radiography
      • indication
        • to assess for fractures and other damage
  • Studies
    • Labs
      • ↑ potassium
      • ↑ creatine
      • ↑ creatine kinase
      • ↑ phosphorous
    • Urine
      • myoglobinuria
    • Electrodiagnostic
      • monitor for electrolyte abnormalities that may cause cardiac arrhythmias
    • Making the diagnosis
      • based on clinical presentation and laboratory studies
  • Differential
    • Penetrating injury
      • distinguishing factor
        • object is seen penetrating a body part
  • Treatment
    • Management approach
      • management is based on the specific patient scenario
      • patients are often treated with aggressive fluid hydration to protect the kidneys
    • Medical
      • intravenous fluids
        • indications
          • prevent hypotension for all patients
          • maintain consistent urinary output
      • calcium gluconate
        • indication
          • iLn the case of hyperkalemia
      • sodium bicarbonate
        • indication
          • prevent myoglobin and uric acid deposition in kidneys
  • Complications
    • Compartment syndrome
    • Acute tubular necrosis
    • Hyperkalemia
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Questions (2)

(M2.OR.16.4690) A 25-year-old male is brought into the emergency department by emergency medical services. The patient has a history of bipolar disease complicated by polysubstance use. He was found down in his apartment at the bottom of a staircase lying on his left arm. He was last seen several hours earlier by his roommate. He is disoriented and unable to answer any questions, but is breathing on his own. His vitals are HR 55, T 96.5, RR 18, BP 110/75. You decide to obtain an EKG as shown in Figure 1. What is the next best step in the treatment of this patient?

QID: 107585
FIGURES:

Intubation

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Epinephrine

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Albuterol

25%

(1/4)

Insulin

0%

(0/4)

Calcium gluconate

75%

(3/4)

M 7 E

Select Answer to see Preferred Response

(M2.OR.15.4686) A 45-year-old male is brought into the emergency department by emergency medical services. The patient has a history of substance abuse and was found down in his apartment lying on his right arm. He was last seen 24 hours earlier by his mother who lives in the same building. He is disoriented and unable to answer any questions. His vitals are HR 48, T 97.6, RR 18, BP 100/75. You decide to obtain an EKG as shown in Figure 1. Which of the following is most likely the cause of this patient's EKG results?

QID: 107378
FIGURES:

Hypocalcemia

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Hypercalcemia

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Hyperkalemia

100%

(6/6)

Hypokalemia

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(0/6)

Hypomagnesemia

0%

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M 6 E

Select Answer to see Preferred Response

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