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