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Updated: Dec 28 2021

Crush Syndrome

  • 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
    • 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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