26/05/2017
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Crush syndrome

Crush syndrome

Crush & Trauma Injuries Crush syndrome is a medical condition characterized by major shock and renal failure after a crushing injury to skeletal muscle.

Start III  Transatlantic Race 2015

Start III
Transatlantic Race 2015

When a muscle is crushed it sends a flood of myoglobin into your bloodstream. Myoglobin is a protein that helps move oxygen in your muscles. Ordinarily, any myoglobin that ends up in your bloodstream becomes bound to other proteins, making it too large to fit into your kidney’s filtration system (tubules).

In a crush injury, however, so much myoglobin enters your blood that there’s not enough protein to bind with it, which means myglobin ends up blocking your kidney’s tubules.

The problem is made worse by lack of water, which worsens the build up on your kidneys. The end result is often kidney failure. STAT reported:

“ … [That one-two punch on the kidneys throws the body’s chemistry completely out of whack. The kidneys can no longer filter out acid, and so the blood becomes highly acidic and potassium pours out of cells into the veins. The kidneys can’t filter that out either, and too much potassium throws off the electrical currents that keep the heart beating regularly.”

The likelihood of developing acute crush syndrome is directly related to the compression time, therefore victims should be released as quickly as possible, irrespective of how long they have been trapped.

Crush injuries may result from a variety of situations, vehicle entrapment, falling debris, industrial accident or by prolonged pressure to a part of the body due to their own body weight in an immobile victim.

516542-racing-yacht-clyde-challenger-being-rescued-by-crew-of-hms-dragonCases occur commonly in yachting, particularly as the yachts and loads get bigger. We are seeing more and more of these injuries; the loads crew are playing with are ridiculous. Most recently I saw a crew member be lifted off the deck 15m high by his leg, caught in the jib sheet during a tack. This guy was so lucky, it was really serious, he spent the week with his feet up, lucky to have his leg, and no doubt stuck in the downward spiral of a post accident traumatic state. As you all know many haven’t fared so well. If you have not seen a crush injury, you have had a very fortunate life in yachting.

Victims of crushing damage present some of the greatest challenges in field medicine, and is one of the situations in yachting where a trained yacht medic is needed in the field. The most drastic response to crushing under massive objects may be field amputation. Even if it is possible to extricate the patient without amputation, appropriate first response care is vital. As always it is important to prevent shock, treat hypotension and administer IV or IO fluids for prehospital care, fluid loading is the main requirement in crush syndrome.

Due to the risk of crush syndrome, current recommendations have changed over the years.

Treatment consisted of using a tourniquet, if required, and overloading the patient with IV or IO fluids and slow release of the crush pressure.

These days the Australian Resuscitation Council, leading the way in terms of crush injury management, recommends that first-aiders in Australia, where safe to do so, release the crushing pressure as soon as possible, avoid using a tourniquet and continually monitor the vital signs of the patient (blood pressure, pulse, breaths per minute, temperature, blood sugar, urine and circulation).

MANAGEMENT

  • Ensure the scene is safe, and that there is no risk of injuryto the rescuer or bystanders.
  • Call an ambulance, local emergency services or your 24/7 Medical SOS Support.
  • If it is safe and physically possible, all crushingforces should be removed from the victim as soon as possible.
  • A victim with a crushinjurymay not complain of pain, and there may be no external signs of injury. All victims who have been subjected to a crush injury, including their own body weight, should be taken to hospital for immediate investigation.
  • Keep the victim warm, treat any bleeding.
  • Continue to monitor the victim’s condition. If the victim becomes unresponsive and is not breathing normally, follow the Resuscitation Basic Life Support protocols.
  • DO NOT leave the victim
  • DO NOT use a tourniquet for the first aid management of a crushinjury.

CrashCrushing force applied to the head, neck, chest or abdomen can cause death from breathing failure or heart failure so must be removed promptly. Always prioritize the Airway.

The Victoria’s, Australia’s emergency services protocol calls for a basic adult dose of a 2 litre bolts of normal saline followed by 500 ml/h IV fluids. This is contrary indicated in victims with cardiac or kidney problems and children. If the patient cannot be fluid loaded, this may be an indication for a tourniquet to be applied.

Admission to an intensive care unit preferably one experienced in trauma medicine may be appropriate; even well-seeming patients need observation. Treat open wounds as surgically appropriate, with debridement, antibiotics and tetanus immunization; apply ice to injured areas.

Intravenous hydration of up to 1.5 L/hour should continue to prevent hypotension. A urinary output of at least 300 ml/hour should be maintained with IV fluids.

I’ve spoken to remote medics who use bicarbonate of soda under the tongue to keep the urine pH at 6.5 or greater, to prevent myoglobin and uric acid deposition in kidneys.

Dunstan_MOB_DSCF1880What does baking soda have to do with crush syndrome? It’s often given to survivors as a remedy to help reduce acidity in the blood and dissolve myoglobin. A solution containing baking soda may be given to victims even before they’ve been extricated from the rubble.

Dr. Mark Pearlmutter, chair of emergency medicine for Steward Health Care Network in the Boston area, told STAT:

“People who are now on the scene can start treating patients while they are still trapped. They may have an arm that they have access to, and can start giving the patient fluid, and they can proactively give bicarbonate.”

As noted by The Journal of Emergency Medicine, “Early, aggressive resuscitation in the prehospital setting, before extrication if possible, is recommended to reduce the complications of crush syndrome.”

In addition to baking soda, intravenous saline solution is often given to prevent dehydration and help dilute myoglobin buildup.

One study reviewed nine patients with crush syndrome due to a building collapse who were given a solution of mannitol (a sugar alcohol) and bicarbonate upon hospital admission. Only two of them developed acute kidney failure, none of them had permanent kidney damage and all survived.

Other data regarding the use of baking soda in crush syndrome is mixed. For instance, research published in The Journal of Trauma found no difference in rates of kidney failure, need for dialysis or mortality in crush-syndrome patients given bicarbonate-mannitol solutions compared to those who were not.

October 14, 2014. Leg 1 onboard Team Vestas Wind: Tony Rae shows his rib injury after 4 days at sea. Team Vestas Wind on the Volvo Ocean Race.

October 14, 2014. Leg 1 onboard Team Vestas Wind: Tony Rae shows his rib injury after 4 days at sea. Team Vestas Wind on the Volvo Ocean Race.

Another study, a systematic review published in Emergency Medical Journal, found no high-quality evidence to support the use of bicarbonate infusions over saline alone.

Despite the mixed data, researchers writing in the Journal of Emergency Medicine suggest the use of baking soda in crush syndrome may help — and probably won’t hurt — and should continue until research proves otherwise. They noted:

“Regardless [of the mixed data], many authors continue to recommend this protocol. It is likely reasonable to provide bicarbonate and mannitol to patients with traumatic rhabdomyolysis, unless the patient has a contraindication.  This resuscitation should continue until the clinical and biochemical evidence of myoglobinuria resolves.”

Stay safe & keep hydrated on the race track and don’t forget to watch your feet, and the guest’s next to you.

Amanda Hewson, RN & Superyacht Medic, Medical Support Offshore

 

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