Crush syndrome

[firefighter523]

2 part question.... Crush syndrome patients, has anyone ever gotten orders for lasix with bicarb for these patients, to diarese these toxins along with the alkinization? (Keeping in mind to keep the fluid running wide for hypovolemia)

Tricyclic antidepressants, Barbituate od's, Same question applies. I know bicarb is the treatment for these emergencies, but would lasix help the problem faster.

[bandaidpatrol]

If you have a patient with crush syndrome, you should try and avoid a bolus of fluids. By all means gain IV access, and run fluid for shock and hypovolemia, but do not run it wide. Set up a large bore IV, titrate to BP, Bicarb, CaCl & Lasix IV. Insulin IV could also be used, but you probably won't see that pre-hospital. Leave the patient in a sitting position, if you have to tube them, just don't lay them down. Combitube them if you have to.

I'd go on, but the chances of renal failure happening in the rig is unlikely, the rest is up to the ER.

[Ridryder 911]

This was discussed on Firehouse forum. One of the responses (from Croaker) I thought was very interesting. More detailed than I usually see in EMS for "crushing injuries".. I believe he is from Idaho. Here is copy of the protocol.

http://forums.firehouse.com/showthread.php?t=77821

PROTOCOL TITLE: Crush Injuries

REVISED:

GENERAL COMMENTS: This protocol covers isolated extremity crush injury with entrapment. Extrication of the victim from the means of entrapment should not be performed until medical care can be provided.

BLS SPECIFIC CARE: See General Trauma Care Protocol T-1

- Assess for the “Six P’s:

- Place (but do not tighten) tourniquet on the entrapped extremity. If this is not possible, have the tourniquet standing by.

 Tighten only if precipitous hemorrhage occurs.

 May use tourniquet as prophylaxis on Medical Control or ALS instruction.

- Be prepared for significant bleeding and sudden cardiac arrest when patient is freed, especially in prolonged incidents.

ILS SPECIFIC CARE: See General Trauma Care Protocol T-1

Prior to being freed from object:

- IV access (to a max of three attempts) with TWO LARGE BORE LINES.

 IV: 200-500 cc crystalloid solution. Repeat PRN.

 If the patient has been entrapped for more than 1 hour, fluid therapy 20 ml/kg rapid IV bolus (1 to 2 liters) using normal saline PRIOR TO RELEASE FROM ENTRAPMENT.

 Use with caution in patients with Hx of CHF.

After being freed from object: Fluid therapy 5 ml/kg/hr (300 to 500 ml/hr). Increase as needed for hypotension.

ALS SPECIFIC CARE: See General Trauma Care Protocol T-1

- Place a tourniquet, consider its use as prophylaxis .

- Strongly consider sedation and pain management.

For Crush Injuries with active entrapment greater than 1 hour:

- Sodium Bicarbinate.

 IV: 1 meq/kg IV (minimum 50 meq for adults) given IMMEDIATELY PRIOR TO RELEASE FROM ENTRAPMENT.

 OPTIONAL INFUSION: 50-100 meq/1000 cc, run at 150 cc/hr, titrated for effect.

- Calcium Chloride (for crush injuries with hyperkalemia changes on EKG)

 IV (Slow): 2-4 mg/kg

 DO NOT GIVE IN SAME LINE AS BICARB INFUSION.

PHYSICIAN PEARLS:

Victims entrapped and crushed due to heavy objects, (e.g. fallen debris from a structural collapse) present a unique challenge. These crushing objects place prolonged and continuous pressure on the extremities resulting in skeletal muscle death (rhabdomyolysis) with release of its cellular contents (myoglobin) into the plasma.

These adverse effects are known as Acute Crush Syndrome. After the skeletal muscle injury occurs and the crushing object is removed, the accumulated cellular toxins (myoglobin) and electrolytes (potassium) are released into circulation and may cause lethal cardiac arrhythmias, acute renal failure and sudden death. The systemic effects of Acute Crush Syndrome only occur after the object is removed and the injured extremity is re-perfused. Removal of the object causes a massive fluid shift into the injured muscle, resulting in acute hypovolemia and hypotension.

Large volumes of NS (avoid LR) must be given to the patient intravenously both before and after the patient is released. The addition of a buffering agent, such as sodium bicarbonate, to the IV solution can help prevent the myoglobin deposition in the renal tubules and may counteract hyperkalemia as well.

A tourniquet may slow the spread of toxins from the injured extremity, and result in improved outcomes as well as preventing catastrophic blood loss.

- Sodium bicarbonate should not be used in crush injuries of short duration (less than 30 minutes). Its use is indicated when evidence of distal ischemia is present. These signs are commonly known as the six “Ps.”

 Pain

 Pallor

 Pulselessness

 Paralysis

 Paresthesia

 Poikilothermia (cool to touch)

- Trauma patients are very susceptible to heat losses and preservation of body heat is paramount.

- While ACEMS typically uses normal saline exclusively, in MCI’s multiple IV fluid types may be available. It is important to note that Lactated Ringers should be avoided as it contains potassium and lactate

From what I read it is a very good general protocol.

R/R 911

[RaceMedic]

i have seen these protocols before... except this is the first time i have heard of lasix... most Doc's here would rather see manitol used for the kidney function and an amp of D50 along with the insulin to prevent hypoglycima. but here there is a difference between crush injury and crush syndrome. and of course the treatments are going to be different. .... but thats what i have for now.

[Ridryder 911]

Sorry, I don't see any difference in injury and syndrome if you are really talking about traumatic rhabdomyolysis. Also the D50W is used to treat the K+, not the hypoglycemia, when you are adminstering the Insulin, Ca+, etc.. the cellular shifts causing hyperkalemia.

R/R 911

[RaceMedic]

.... i should have been more clear i guess ... i understand what your saying Rid and thank you for pointing it out... and the D50 is for the insulin. Insulin drives K+ into the cells not the D50 ... albuterol does this as well. They D 50 is for hypoglycimia caused by the administeration of insulin in to a normally non diabetic PT. ... I will find the paper work and post if needed.. just went over this with the doc's.

Ohh and as far as the syndrome VS. injury..... i was refering to an earlier post what someone had refered to the injury as apposed to the syndrome... maybe i mis read... have done before. but otherwise ... yes i agree there is little to no difference..

I concede on the injury part ... i have know idea where that came from .... forget i mentioned injury

LMAO

Race

[Doczilla]

The bicarb and lasix are geared more toward preventing/treating a spike in the potassium level in the blood when you have profound tissue ischemia/injury and release of potassium from the extracellular space. The lasix helps the kidneys offload the excess potassium if they are still functioning. The insulin and D50 are also intended to lower the serum potassium level as detailed in Rid's post. We still alkalinize the urine (through a bicarb drip) for rhabdomyolysis to try to prevent renal failure (assuming relatively normal electrolytes), but the evidence doesn't really support a benefit.

Rhabdomyolysis can induce acute renal failure, but the immediate life-threat is from hyperkalemia, which is what the prehospital protocol is treating. The renal failure, if it's going to occur, will happen no matter what we do.

I see no reason to avoid large volumes of IV fluid. Profound swelling and third-spacing of fluid is common in these types of injuries, which can rapidly lead to hypovolemia. This is independent of vascular pressure, so the mantra of withholding fluid in incontrolled traumatic bleeding goes out the window. Large volumes of IVF may also help prevent renal failure in the patient with less severe rhabdo.

For part 2.... Giving bicarb kicks the TCA off the binding sites in the heart, reducing cardiotoxicity and enhancing elimination. Alkalinization of the urine will also enhance elimination of barbiturates, though I haven't heard that it reduces toxicity in the immediate setting the way that bicarb does for TCA OD.

'zilla

[akroeze]

So as a BLS service, would this be something to consider having a medical director attend the scene since we have no ALS back up?

[Ridryder 911]

Great post Doczilla .Akroeze you might want to consider an ALS rendezvous, or support (unsure of your local EMS community) if such an event does occur. I have seen very few protocols as this (reason I posted) the main point is to know the physiology, and why we are treating it. Even without protocol, if you can contact local medical control and do some consultations of the case.

Be safe,

R/R 911

[akroeze]

Nearest ALS is >1hr away other than a chopper which is ~30mins...

Let's just say that ALS (ACPs) are almost impossible around here.

So assuming that there is no hope of ALS, I would figure it would atleast be reasonable to contact a base hospital physician before removing to get direction?