This is a lecture by Dr. Jim Holliman from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
crush syndrome comprises of compartment syndrome and crush injury. its effects , pathophysiology and management is discussed. it will be helpful for post graduate orthopaedic theory exam
Vascular Injuries and Principles of ManagementVascular Surgery Workshop 2018
Joel Arudchelvam,MBBS (Col), MD (Sur), MRCS (Eng),Consultant Vascular and Transplant Surgeon Teaching Hospital Anuradhapura.
Causes, Mechanism of injury, Arterial Level injuries, Signs of vessel injury -Hard signs,Soft sign, Principles of management
Principles of Management of the multiply injured patientCHRIS ALUMONA
The multiply injured or polytraumatised patient is at a greater risk of morbidity and mortality than patients with isolated injuries. This risk is greater than the sum of the risks of their individual injuries. A high index of suspicion is needed to recognise immediately life threatening injuries and promptly address them. The principles of management is captured with the ATLS protocol and every trauma surgeon should be conversant with this indispensable tool.
crush syndrome comprises of compartment syndrome and crush injury. its effects , pathophysiology and management is discussed. it will be helpful for post graduate orthopaedic theory exam
Vascular Injuries and Principles of ManagementVascular Surgery Workshop 2018
Joel Arudchelvam,MBBS (Col), MD (Sur), MRCS (Eng),Consultant Vascular and Transplant Surgeon Teaching Hospital Anuradhapura.
Causes, Mechanism of injury, Arterial Level injuries, Signs of vessel injury -Hard signs,Soft sign, Principles of management
Principles of Management of the multiply injured patientCHRIS ALUMONA
The multiply injured or polytraumatised patient is at a greater risk of morbidity and mortality than patients with isolated injuries. This risk is greater than the sum of the risks of their individual injuries. A high index of suspicion is needed to recognise immediately life threatening injuries and promptly address them. The principles of management is captured with the ATLS protocol and every trauma surgeon should be conversant with this indispensable tool.
Debridement is an important component of the wound bed preparation (WBP) management Model.
Cause of the wound and patient-centered concerns, debridement is a necessary step in local wound care.
Debridement is the removal of necrotic tissue, exudate, bacteria, and metabolic waste from a wound in order to improve or facilitate the healing process
* Fluid resuscitation is mandatory in shock from traumatic haemorrhage * Massive use of resuscitative fluids following injury is now being disputed * Adequate resuscitation is no longer judged by presence of normal vital signs * Normalcy of organ and tissue specific measured values are to be achieved * Search for a single endpoint that works for all trauma patients, is unrealistic * Resuscitate with appropriate fluid, in appropriate amount, at appropriate time
My seminar presentation slides. Please correct me if I've did something wrong in it. You can also leave any message thru my email, nurhanisahzainoren@gmail.com
Seminar presentation by 4th year medical student of Lincoln University College, supervised by HRPZ Orthopedic's specialist.
Reference were from reliable medical websites and also from texttbook; Apley and Solomon's Concise System of Orthopaedics and Trauma, 4th Ed.
This is a lecture presentation on applying external fixator on open fracture specially on tibia. This method is a classical method. Various new and dynamic fixators are there but the basics are the same.
Pinned in a car for two hours, trapped in a building collapse for 12, fallen on the floor for 24. Each of these patients may be experiencing different, but deadly aspects of crush injury, compartment syndrome, and rhabdomyolysis. Why are some victims okay under pressure, but die suddenly when rescued and what, if anything, can EMS do about it? Real-world case-studies bring this presentation to life as it answers these questions and more by bringing you evidence based best practices, protocols and resources that you can use to treat these high-pressure and high-profile patients.
For More Information See:
www.RomDuck.com
www.RescueDigest.com
Learning Objectives: Students will be able to:
- Identify crush injury, compartment syndrome and injuries consistent with rhabdo-myolysis.
- Utilize model pre-hospital protocols for advanced care for crush injury, compart-ment syndrome and rhabdomyolysis patients.
- Integrate with trauma systems of care to provide crush injury, compartment syn-drome and rhabdomyolysis patients with the best chance of outcome.
Debridement is an important component of the wound bed preparation (WBP) management Model.
Cause of the wound and patient-centered concerns, debridement is a necessary step in local wound care.
Debridement is the removal of necrotic tissue, exudate, bacteria, and metabolic waste from a wound in order to improve or facilitate the healing process
* Fluid resuscitation is mandatory in shock from traumatic haemorrhage * Massive use of resuscitative fluids following injury is now being disputed * Adequate resuscitation is no longer judged by presence of normal vital signs * Normalcy of organ and tissue specific measured values are to be achieved * Search for a single endpoint that works for all trauma patients, is unrealistic * Resuscitate with appropriate fluid, in appropriate amount, at appropriate time
My seminar presentation slides. Please correct me if I've did something wrong in it. You can also leave any message thru my email, nurhanisahzainoren@gmail.com
Seminar presentation by 4th year medical student of Lincoln University College, supervised by HRPZ Orthopedic's specialist.
Reference were from reliable medical websites and also from texttbook; Apley and Solomon's Concise System of Orthopaedics and Trauma, 4th Ed.
This is a lecture presentation on applying external fixator on open fracture specially on tibia. This method is a classical method. Various new and dynamic fixators are there but the basics are the same.
Pinned in a car for two hours, trapped in a building collapse for 12, fallen on the floor for 24. Each of these patients may be experiencing different, but deadly aspects of crush injury, compartment syndrome, and rhabdomyolysis. Why are some victims okay under pressure, but die suddenly when rescued and what, if anything, can EMS do about it? Real-world case-studies bring this presentation to life as it answers these questions and more by bringing you evidence based best practices, protocols and resources that you can use to treat these high-pressure and high-profile patients.
For More Information See:
www.RomDuck.com
www.RescueDigest.com
Learning Objectives: Students will be able to:
- Identify crush injury, compartment syndrome and injuries consistent with rhabdo-myolysis.
- Utilize model pre-hospital protocols for advanced care for crush injury, compart-ment syndrome and rhabdomyolysis patients.
- Integrate with trauma systems of care to provide crush injury, compartment syn-drome and rhabdomyolysis patients with the best chance of outcome.
Rhabdomyolysis is potentially life-threatening syndrome due to breakdown of skeletal muscle fibers
with leakage of muscle contents into the circulation, The outcome varies depending on the extent of kidney damage, To avoid this problem Keep yourself always hydrated well supplemented with electrolytes & carbohydrates. Avoid drugs, alcohol, excessive heat & over-exercising,
An overview of the management of Rhabdomyolysis, put together for the weekly Emergency Medicine registrar teaching session at Wollongong Hospital ED. Information in the presentation is from both the journals and medicine 2.0 (and in particular "FOAMed" -the free open access medical education network that aims to improve sharing of medical education resources through the web). Enjoy. @trainthetrainer
- Recorded videos of this lecture:
English Language version of this lecture is available at: https://youtu.be/0tIlVJEyNOk
Arabic Language version of this lecture is available at: https://youtu.be/2QT68lgSDCM
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
Disseminated intravascular coagulation (DIC) is a condition in which blood clots form throughout the body, blocking small blood vessels. Symptoms may include chest pain, shortness of breath, leg pain, problems speaking, or problems moving parts of the body.
A condition affecting the blood's ability to clot and stop bleeding.
In disseminated intravascular coagulation, abnormal clumps of thickened blood (clots) form inside blood vessels. These abnormal clots use up the blood's clotting factors, which can lead to massive bleeding in other places. Causes include inflammation, infection and cancer.
complete information about the fluid resuscitation in burn patients, types of care given to the patient in the hospital after burning accidents, fluid replacement therapy, medical management, nursing management.
Similar to GEMC- Crush Injury and Crush Syndrome- Resident Training (20)
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Jim Holliman, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Alterations in Body Temperature: The Adult Patient with a Fever- Reside...Open.Michigan
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Rapid Sequence Intubation & Emergency Airway Support in the Pediatric E...Open.Michigan
This is a lecture by Michele Nypaver, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Disorders of the Pleura, Mediastinum, and Chest Wall- Resident TrainingOpen.Michigan
This is a lecture by Andrew Barnosky, DO from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Dental Emergencies and Common Dental Blocks- Resident TrainingOpen.Michigan
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Arthritis and Arthrocentesis- Resident TrainingOpen.Michigan
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Bursitis, Tendonitis, Fibromyalgia, and RSD- Resident TrainingOpen.Michigan
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Right Upper Quadrant Ultrasound- Resident TrainingOpen.Michigan
This is a lecture by Jeff Holmes from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC: Nursing Process and Linkage between Theory and PracticeOpen.Michigan
This is a lecture by Jeremy Lapham from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
2014 gemc-nursing-lapham-general survey and patient care managementOpen.Michigan
This is a lecture by Dr. Jeremy Lapham from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Dr. Jessica Holly from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC: The Role of Radiography in the Initial Evaluation of C-Spine TraumaOpen.Michigan
This is a lecture by Dr. Stephen Hartsell from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Dr. Jim Holliman from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
Safalta Digital marketing institute in Noida, provide complete applications that encompass a huge range of virtual advertising and marketing additives, which includes search engine optimization, virtual communication advertising, pay-per-click on marketing, content material advertising, internet analytics, and greater. These university courses are designed for students who possess a comprehensive understanding of virtual marketing strategies and attributes.Safalta Digital Marketing Institute in Noida is a first choice for young individuals or students who are looking to start their careers in the field of digital advertising. The institute gives specialized courses designed and certification.
for beginners, providing thorough training in areas such as SEO, digital communication marketing, and PPC training in Noida. After finishing the program, students receive the certifications recognised by top different universitie, setting a strong foundation for a successful career in digital marketing.
Introduction to AI for Nonprofits with Tapp NetworkTechSoup
Dive into the world of AI! Experts Jon Hill and Tareq Monaur will guide you through AI's role in enhancing nonprofit websites and basic marketing strategies, making it easy to understand and apply.
Introduction to AI for Nonprofits with Tapp Network
GEMC- Crush Injury and Crush Syndrome- Resident Training
1. Project:
Ghana
Emergency
Medicine
Collabora4ve
Document
Title:
Crush
Injury
and
Crush
Syndrome
Author(s):
Jim
Holliman
(Uniformed
Services
University),
MD
2012
License:
Unless
otherwise
noted,
this
material
is
made
available
under
the
terms
of
the
Crea9ve
Commons
A;ribu9on
Share
Alike-‐3.0
License:
hIp://crea4vecommons.org/licenses/by-‐sa/3.0/
We
have
reviewed
this
material
in
accordance
with
U.S.
Copyright
Law
and
have
tried
to
maximize
your
ability
to
use,
share,
and
adapt
it.
These
lectures
have
been
modified
in
the
process
of
making
a
publicly
shareable
version.
The
cita4on
key
on
the
following
slide
provides
informa4on
about
how
you
may
share
and
adapt
this
material.
Copyright
holders
of
content
included
in
this
material
should
contact
open.michigan@umich.edu
with
any
ques4ons,
correc4ons,
or
clarifica4on
regarding
the
use
of
content.
For
more
informa4on
about
how
to
cite
these
materials
visit
hIp://open.umich.edu/privacy-‐and-‐terms-‐use.
Any
medical
informa9on
in
this
material
is
intended
to
inform
and
educate
and
is
not
a
tool
for
self-‐diagnosis
or
a
replacement
for
medical
evalua4on,
advice,
diagnosis
or
treatment
by
a
healthcare
professional.
Please
speak
to
your
physician
if
you
have
ques4ons
about
your
medical
condi4on.
Viewer
discre9on
is
advised:
Some
medical
content
is
graphic
and
may
not
be
suitable
for
all
viewers.
1
3. Crush Injury and
Crush Syndrome
Jim Holliman, M.D., F.A.C.E.P.
Program Manager
Afghanistan Healthcare Sector Reconstruction Project
Center for Disaster and Humanitarian Assistance Medicine
Professor of Military and Emergency Medicine
Uniformed Services University
Bethesda, Maryland, U.S.A.
3
5. Causes of Crush Syndrome
Ÿ Immobility
against firm surface for > one hour :
Ÿ Drug or alcohol intoxication
Ÿ Carbon monoxide poisoning
Ÿ Cerebrovascular accident
Ÿ Head trauma with coma
Ÿ Elderly with hip fracture
Ÿ Improper positioning of surgical patient
Ÿ Assault with beating
Ÿ Pneumatic Antishock Garment (PASG or MAST)
5
6. Causes of Mass Casualties with
Crush Syndrome
Ÿ Building
collapse
Ÿ Earthquakes
Ÿ Landslides
Ÿ Bombings
Ÿ Construction accidents
Ÿ Heavy snow on roof
Ÿ Mine
or trench collapse
6
7. Crush Syndrome
Official Definitions
Ÿ From
recent consensus meeting :
Ÿ "A crush injury is a direct injury resulting from crush. Crush
syndrome is the systemic manifestation of muscle cell damage
resulting from pressure or crushing."
Ÿ Better (mine) :
Ÿ Crush syndrome is the clinical condition caused by
compression of muscle with subsequent rhabdomyolysis
which can then cause the complications of electrolyte
disturbances, fluid sequestration, & myoglobinuria.
Ÿ Another :
Ÿ "A form of traumatic rhabdomyolysis that occurs after
prolonged continuous pressure & is characterized by systemic
involvement".
7
8. Historical Reports of Crush
Syndrome
Ÿ Old
Testament Book of Numbers
Ÿ Deaths from illness involving muscle pain & weakness
(rhabdomyolysis)
ƒ Due to eating quail which had consumed hemlock
seeds
Ÿ Larrey (Napoleon's army surgeon) in 1812 described limb
gangrene in carbon monoxide victims
Ÿ Bywaters & Beal in 1941 reported 5 patients from the
London Blitz who died of renal failure
Ÿ Later reports (both clinical & animal studies) by
Bywaters identified myoglobinuria as the cause for the
renal failure
8
9. Major Mass Casualty Events with
Reports of Crush Syndrome
Ÿ Earthquakes
:
Ÿ Tangshan, China 1976
Ÿ Armenia 1988
Ÿ Iran 1990 and 2003
Ÿ Northridge, California 1994
Ÿ Kobe, Japan 1995 ("Hanshin-Awaji")
Ÿ Turkey 1992 (Izmit, "Marmara" 1999)
Ÿ Terrorist bombings :
Ÿ Israel
Ÿ Lebanon
Ÿ Saudi Arabia
9
11. Incidence of Crush Syndrome in
Mass Casualty Events
Ÿ 10
to 60 % of survivors extricated from
collapsed buildings
Ÿ Up to half may develop renal failure
ƒ At least half of these require dialysis
Ÿ Typically about 20 % of injured are
hospitalized, and 5 to 20 % of these have crush
injury, and 0.5 to 1 % end up needing dialysis
Ÿ Incidence less in quakes where most
residences are adobe or one story (Central
America for example)
11
12. Pathophysiology of Crush
Syndrome
Ÿ Not
usually directly due to ischemia
Ÿ Main cause is stretch of the muscle sarcolemma
Ÿ Sarcolemma permeability increases
Ÿ Influx of sodium, water, & extracellular calcium into the
sarcoplasm
ƒ Results in cellular swelling, increased intracellular
calcium, disrupted cellular function & respiration,
decreased ATP production, & subsequent myocytic
death
Ÿ Muscle swelling can then cause early or even days delayed
compartment syndrome
12
13. Systemic Sequelae of Crush
Injury
Ÿ Result
from death of muscle cells and
leak of intracellular metabolites into the
systemic circulation ("reperfusion injury"
Ÿ Superoxide anions (free radicals) then
cause further membrane injury
Ÿ May
not manifest until just after
entrapped part of body is extricated
13
14. Metabolic Derangements from
Crush Syndrome
Ÿ Hypovolemia
(fluid sequestration in
damaged muscle)
Ÿ Hyperkalemia
Ÿ Hypocalcemia (due to calcium deposition
in muscle)
Ÿ Hyperphosphatemia
Ÿ Metabolic acidosis
Ÿ Myoglobinemia / myoglobinuria
14
15. Effects of Myoglobinuria in
Crush Syndrome
Ÿ Myoglobin
can precipitate (particularly
with hypovolemia and acidosis) and
directly obstruct renal tubular flow
Ÿ Myoglobin is also directly toxic to the
renal tubular cells
15
16. Renal Toxicity of Myoglobin
Ÿ Bywaters'
studies showed acid urine is
required for myoglobin to cause renal
injury
Ÿ At pH < 5.6, myoglobin dissociates into
its 2 components :
Ÿ Globin (shown nontoxic if infused)
Ÿ Ferrihemate (probably the toxic
component)
16
17. Other Clinical Syndromes with
Similar Effects as Crush Syndrome
Ÿ Tumor
lysis syndrome
Ÿ Heatstroke
Ÿ Exertional rhabdomyolysis
Ÿ High voltage (> 1000 volts) electrical
injury
17
18. Field Rescue Considerations for
Patients with Crush Syndrome
Ÿ Apply
facemask to protect from dust inhalation
Ÿ Oxygen (if no risk of fire at the scene)
Ÿ If building unstable, then equipment stabilization
may be needed before medical treatment can be
given
Ÿ Start IV normal saline early if possible
Ÿ Ventilate well near gas or diesel powered
generators to avoid CO poisoning
18
19. Hyperkalemia in Crush Syndrome
Ÿ Can
occur soon after extrication
Ÿ Can be quickly fatal
Ÿ May occur before manifestations of renal
failure
Ÿ May occur without obvious signs of
compartment syndrome
Ÿ May require emergent prehospital
treatment
19
20. Emergent Treatment of Hyperkalemia
from Crush Syndrome
Ÿ Normal
saline IV fluid bolus
Ÿ IV NaHCO3 50 to 100 meq
Ÿ Aerosolized albuterol (2.5 mg in 3 cc)
Ÿ Less effective or practical :
Ÿ IV dextrose (25 grams) & insulin (5 units IV)
Ÿ PO or PR kayexalate
Ÿ Note
that IV calcium is controversial (as it may just
worsen intramuscular hypercalcemia)
Ÿ Emergent hemodialysis may be needed
20
21. Main Treatment for Crush
Syndrome : IV Fluid Resuscitation
Ÿ Normal
saline (0.9 %) preferred
Ÿ (lactated Ringers contains 4 meq / liter of
potassium, & so may worsen
hyperkalemia, & also has calcium)
Ÿ If
started early, may prevent later
development of renal failure
Ÿ Best if IV fluids can be started even prior
to extrication
21
22. Recommended IV Fluid Infusion
Rates for Crush Syndrome
Ÿ 1
to 1.5 liters per hour for young adults
Ÿ 20 cc per kg per hour for children
Ÿ 10 cc per kg per hour for elderly
Ÿ Insert foley catheter as early as possible
Ÿ Target urine output should be > 50 cc per hour
for adults, and > 2 cc per kg per hour for
children
Ÿ Some references advocate 150 to 200 cc per
hour target in early phase
22
23. Use of IV Bicarbonate for Crush
Syndrome
Ÿ Goal
is to have alkaline urine (check with
pH paper)
Ÿ Can bolus supplement the normal saline
with 50 meq (1 amp) doses
Ÿ Up to 300 meq per 24 hours may be
needed
Ÿ Or
add 3 amps (150 meq) to one liter D5W
and infuse as first or second IV bolus
23
24. Use of Mannitol for Crush
Syndrome
Ÿ May
help eliminate myoglobin from the
kidney & prevent renal failure
Ÿ May be useful to initiate diuresis in a
patient who has adequate normal saline
on board but whose urine output is still <
2 cc per kg per hour, or if adequate urine
output is still not achieved 4 hours after
treatment started
24
25. Mannitol Dosage for Crush
Syndrome
Ÿ Mannitol
20 % solution 0.25 grams per kg IV
over 10 to 30 minutes
Ÿ Diuresis should start in 15 to 30 minutes
Ÿ If urine output thereafter drops again,
hypovolemia should be assumed, and only
after aggressive rehydration should a second
dose of mannitol be given
Ÿ Maximum
dose : 2 grams per kg per day (or
200 grams per day)
25
26. Contraindications to Mannitol
Ÿ Established
anuric renal failure
Ÿ Severe congestive heart failure
Ÿ These patients may require pressors
such as dopamine in order to tolerate the
fluid load required for treatment, or may
need early dialysis
26
27. Other Advantages of Mannitol
for Treating Crush Syndrome
Ÿ May
scavenge free radicals in muscle
thus limiting necrosis
Ÿ Positive inotropic effect on the heart
Ÿ Most important : may help decompress
compartment syndrome by mobilizing
fluid from damaged muscle (thereby
preventing need for fasciotomy)
27
28. Compartment Syndrome in
Crush Injury
Ÿ Normal
muscle compartment pressure is < 15 mm Hg
Ÿ Pressure > 30 mm Hg produces muscle ischemia, so fasciotomy
indicated if pressure is persistent above this
Ÿ Irreversible muscle damage occurs after 6 hours, & irreversible
nerve damage may occur after 4 hours of ischemia
Ÿ Patients with higher diastolic pressure can tolerate higher tissue
pressure without ischemia, so fasciotomy recommended when
compartment pressure approaches 20 mm Hg below diastolic
pressure
Ÿ However, if patient is hypotensive, they can have significant
ischemia at lower compartment pressures
28
29. When Should Fasciotomy be
Done for Crush Injury ?
Ÿ In
most reports of mass casualties from earthquakes, most of the
fasciotomies were done more than 12 hours after the time of
trauma
Ÿ Reviews of these cases showed high infection rates with
increased mortality and amputations, and poor long term
function
Ÿ Israeli experience has shown better results with not routinely
performing delayed fasciotomies
Ÿ So fasciotomy would be indicated if the victim can be extricated
and receive definitive medical care within 6 hours of injury, but not
later
Ÿ If initial compartment pressures are normal, and delayed
compartment syndrome develops, fasciotomy may be needed
29
30. Additional Treatments for Crush
Injury
Ÿ Don't
forget oxygen suplementation (even if the
patient is not hypoxemic, O2 may help ischemic
muscle)
Ÿ Don't forget pain medications
Ÿ Address tetanus immunization status
Ÿ Acetazolamide (250 mg PO tid) may help excrete
bicarbonate in the urine
Ÿ Furosemide may initiate diuresis but not favored
since it makes acid urine
30
31. Diagnostic Testing in Patients
with Crush Injury
Ÿ EKG
as early as possible to look for signs of hyperkalemia
Ÿ Handheld fingerstick blood analyzer may be useful in the field to
identify hyperkalemia early
Ÿ Routine labwork to obtain :
Ÿ CBC, platelets, type and screen, electrolyte panel, BUN,
creatinine, CPK, liver panel, urinalysis
Ÿ Optional labwork : ABG, myoglobin, PT, PTT
Ÿ Chest X-ray
Ÿ Other radiographs, computed tomography, etc. to evaluate for
other injuries
31
32. Monitoring the Crush Syndrome
Patient
Ÿ Urine
output and urine pH (hourly)
Ÿ Serial electrolytes (particularly potassium) : every
6 hours initially
Ÿ CPK, BUN, creatinine : every 8 to 12 hours
Ÿ ABG (if initially acidotic or on ventilator) : every 4
hours
Ÿ May need central IV line or Swan Ganz catheter for
patients with cardiac or pulmonary disease
Ÿ Compartment pressures : every 4 hours initially
32
33. Other Injuries in the Crush
Syndrome Patient
Ÿ High
incidence of associated injuries
Ÿ Extremity fractures and lacerations are most common
Ÿ With crush injury to trunk, can have internal abdominal
injuries in addition to abdominal wall muscle compression
injury
Ÿ May have "traumatic asphyxia" if chest compressed
Ÿ Dust inhalation common in concrete building collapse
Ÿ Fires common with earthquakes, so may have burns,
smoke inhalation, and CO poisoning
Ÿ Hypothermia or hyperthermia
33
34. Mortality Related to Crush
Syndrome
Ÿ In
earthquakes, most of on scene deaths
are due to direct head and trunk trauma
Ÿ Of those extricated, mortality reports
vary widely (zero to 60 %)
Ÿ Mortality increases with :
Ÿ Age > 50, prior chronic illness
Ÿ Duration of entrapment (almost no
survivors after 5 days)
34
36. Car crushed by 1989 Nimitz Freeway collapse ; one patient
rescued here on the fifth day later died from complications 36
Source
Undetermined
of crush syndrome
37. Prognosis Related to Crush
Syndrome
Ÿ Major
risk factors for renal failure :
Ÿ 2 or more limbs crushed
Ÿ Insufficient early IV fluid
Ÿ Delayed in presentation to hospital
Ÿ Children
at lesser risk to need dialysis
Ÿ 50 % or more may have severe long term limb
disability if fasciotomy done
Ÿ Patients often need long term physical
therapy and may need counseling
37
38. Disaster Planning Aspects
Related to Crush Syndrome
Ÿ Need
to have access to increased number of
hemodialysis machines
Ÿ The Renal Disaster Relief Task Force of the
International Society of Nephrology has been
organized to bring multiple machines to a
disaster region
Ÿ Prehospital personnel need to be supplied with
extra facemasks and respirators
Ÿ Prehospital personnel will need access to
large amounts of IV fluid and amps of
bicarbonate
38
39. Crush Syndrome
Lecture Summary
Ÿ Start
IV fluids prior to extrication if
possible
Ÿ Assess quickly for hyperkalemia and
associated injuries
Ÿ If extrication > 6 hours after injury, do not
perform fasciotomy for compartment
syndrome
Ÿ Perform careful monitoring after
admission to hospital
39