MED-NERD

Management and Treatment of Crush syndrome:

The Management of crush syndrome includes the following steps:

-Rescue

-Resuscitation

-Recognition of the syndrome and treatment

-Rehabilitation

1-Rescue:

Is done by a professional rescue team to transport patients to healthcare facilities. Potassium binders like oral polystyrene sulfonate sometimes may be given to patients before transportation to avoid renal damage.

2-Resuscitation:

The syndrome may be insidious in patients looking well. Treatment should start with aggressive fluid therapy as most patients are in shock.

3-Recognition of crush syndrome and treatment:

The treatment process represents cooperation of surgeons, physicians, radiologists, biochemists and other healthcare workers.

4-Rehabilitation:

Rehabilitation involves physical as well as psychiatric consultation.

Treatment of crush syndrome:

Initial management >> Advanced trauma life support(ABCDE):

-Airway >> check the patency of the airway

-Breathing >> check breathing

-Circulation >> check the heart beating

-Disability >> check consciousness

-Exposure >> look for injuries (assessment of mechanism of injuries and potential injuries) or bleeding

-Intravenous (IV) hydration through Isotonic saline administration with monitoring until transport to hospital. The main line of treatment is fluid therapy. Fluid therapy is started as early as possible within the first 6 hours even before the victim is extricated. Some studies report more than 25 litres of saline administrated to patients in one day, but there are variations in the quantity of fluids should be given to patients.

Hospital management:

-Physical examination and ABCDE assessment

-Assessment of response to initial management and the need for operation

-Continue IV hydration

-Blood product transfusions

-Urine output monitoring

-Correction of electrolyte disturbance

-Correction of metabolic disturbances such as alkalinization of urine in acidosis. For metabolic acidosis, bicarbonate and lactate or even oral citrate are administrated to correct metabolic acidosis. Insulin glucose drip is given to reduce the elevated levels of serum potassium. Monitoring of Blood pressure (BP), Central Venous Pressure (CVP), pulmonary function and urine output is essential.

-Diuresis:

Maintaining effective kidney function is the major concern in management of crush syndrome. Urine output should be at least 300 ml/hr (equals at least 12 lit of fluid/day). The fluid trapped inside the damaged muscles and tissue may reach up to 4 litres. Mannitol diuresis can be used to prevent renal failure. Dopamine also can be used as it increases the renal blood flow and helps to achieve a steady blood pressure.

-Dialysis (including Haemodialysis):

Factors indicating dialysis include fluid overload, anuria, bicarbonate levels, serum creatinine levels, and Blood Urea Nitrogen(BUN). Another important indicator for dialysis is potassium level above 7 meq/1. Dialysis is performed at least 2 or 3 times daily and may continue up to 15 days. In high risk patients with hyperkalaemia, prophylactic dialysis may be used.

-Hyperbaric oxygen:

Hyperbaric oxygen means oxygen provided at high pressures. The usual dose is nearly 2.5 atmospheres for 1.5 hours twice daily for a one week duration. The oxygen levels increases in plasma. The use of hyperbaric oxygen can improve tissue viability. It can reduce tissue oedema. It can promote fibroblast proliferation and therefore improves wound healing. Moreover, hyperbaric oxygen can reduce the growth if anaerobic bacteria in the necrosed muscles.

-Analgesia

-Wound care

-Proper antibiotics (multiple broad spectrum non nephrotoxic antibiotics)

-Immunization against Tetanus, toxoid

-Surgery:

Debridement of all necrosed muscles followed by primary or secondary suturing (Laparotomy and thoracotomy). Fasciotomy is performed in compartment syndrome. Early fasciotomy is preferred. Most cases after 8-10 hours of crush require amputation.

-Management of fractures by fixation and management of internal organ injury

-Complications such as muscle contracture require good rehabilitation therapy.