MATERI STUDY GUIDE BLOK EMERGENCY 2016

  

MATERI STUDY GUIDE

BLOK EMERGENCY

2016

  

LECTURE 13 :

Trauma and Non Trauma Conditions

which Potentially Disabling and Life

  

Threatening

  

I Ketut Suyasa, IGN Wien Aryana

  

LECTURE 13 :

Principle of Trauma Trauma Principles Jorge Fernandez, MD Neil Rifenbark, MD Key Points

• Assess all trauma patients with a rapid primary survey followed by a more comprehensive

  secondary evaluation.
• Address all emergent l ife threats in a stepwise manner during the primary survey before progressing to the next stage.
• Treat hemodynamically unstable patients as hemorrhagic shock until proven otherwise.

• Initiate aggressive volume resuscitation in all unstable patients while concurrently searching

  for active sources of hemorrhage.

  INTRODUCTION Trauma is currently the fourth leading cause of death in the United States across all age

groups and the leading cause of death in patients under the age of 44 years. It is responsible for

more deaths in patients under the age of 19 years than all other causes combined.

Approximately 40% of all emergency department (ED) visits are for trauma-related complaints,

and the annual costs exceed $400 billion. Adding to these costs, permanent disability is actually

3 times more likely than death in this cohort.

  Trauma is broadly classified by mechanism into blunt and penetrating varieties, with the

former more than twice as common as the latter. Regardless of mechanism, victims of

significant trauma present with a wide range of complex problems, and their proper care

necessitates a multidisciplinary approach, including emergency physicians, trawna surgeons,

and the appropriate subspecialties. Most trawna care delivery systems follow the Advanced

Trawna Life Support guidelines developed and maintained by the American College of

Surgeons.

  The mortality rates for trawnatic injuries typically follow a trimodal distribution. Certain

injury patterns including major vascular injuries and high cervical cord disruption with

secondary apnea result in near immediate death. The second cohort of injuries, including

conditions such as pnewnothorax and pericardia! tamponade, typically evolve over a duration

of minutes to hours and are generally responsive to aggressive emergent intervention.

Septicemia and multisystem organ failure account for the third peak of fatalities and typically

occur weeks to months after injury.

  CLINICAL PRESENTATION History Attempt to identify the severity of mechanism, as this will predict the patterns of injury.

For example, determine the approximate speed of a motor vehicle collision (MVC) and whether

or not the patient was restrained. Emergency medical service personnel can be an invaluable

resource, especially in amnestic and nonverbal patients. In assault patients, inquire if they can

recall exactly what they were struck with and the nwnber of times. Ask if there was any loss of

consciousness, as this may portend to a significant head injury. For penetrating trawna, ask

  

about the number of shots heard and how many times the patient felt himself or herself get

shot.

  Obtain a brief medical history using the AMPLE mnemonic. Ask about any known drug

allergies, current medication use,past medical history, last oral intake, and the immediate

events leading up to the injury. Keep in mind that regardless of past history, elderly patients

have less physiologic reserve and are prone to higher rates of morbidity and mortality. In

females of childbearing age, always ask about the last menstrual period and assume that they

are pregnant until proven otherwise. Pregnant patients are at higher risk for domestic violence

and warrant unique considerations such as placental abruption, uterine rupture, the supine

hypotensive syndrome, and fetal distress or demise. Even apparently minor injuries including

falls and low-speed motor vehicle accidents can induce preterm labor or placental abruption.

  Always ask about any evolving symptoms and identify the exact locations of pain, as this

will guide your physical exam. Patients with altered mental status should be treated as having a

traumatic brain injury until proven otherwise. Shortness of breath may indicate an underlying

pneumothorax ( PTX) , pulmonary contusion, or pericardia! tamponade. Chest pain may

indicate an underlying fracture of the ribs or sternum, hemothorax (HTX) , or traumatic aortic

injury (TAl) . Assume that patients with abdominal pain, hematemesis, or rectal bleeding have

an intra-abdominal visceral injury until proven otherwise. Patients complaining of hematuria

should be considered at a high risk for injury to the genitourinary (GU) tract. Neurologic

complaints including weakness and paresthesias may indicate an underlying spinal cord injury

or vascular dissection.

  Physical Examination The physical exam in major trauma patients is very systematic and can be divided into primary and secondary surveys.

  Primary Survey The primary survey is a very brief and focused exam meant to identify and address

emergent life threats. It should proceed in a stepwise approach outlined by the ABCDE

mnemonic. Always treat any encountered abnormalities before proceeding to the next step in

the survey. If a patient decompensates at any point during his or her clinical course, return to

the beginning of the primary survey and reassess. Assume an unstable cervical spine injury in all

major t rauma victims until proven otherwise and immediately immobilize on presentation.

  Assess the airway for patency. Signs of potential airway compromise include pooling

pharyngeal secretions, intraoral foreign bodies, stridulous or gurgling respirations, obvious

oropharyngeal burns, significant midface, mandibular, and laryngeal fractures, and expanding

neck hematomas.

  Evaluate the patient's breathing and ventilation. Expose the chest and look for any signs

of asymmetrical orparadoxical chest wall movement, obvious deformities or open wounds,

tracheal deviation, and jugular venous distention. Auscultate the chest to confirm strong

symmetric bilateral breath sounds. The goal is to identify the presence of emergent life threats

including tension PTX, massive HTX, open PTX ( sucking chest wound), and flail c hest.

  Rapidly assess the patient's circulation by evaluating for signs of altered mental status. A

depressed level of consciousness should be considered hypovolemic shock until proven

  

otherwise. Other findings concerning for hemorrhagic shock include pale, cool, and mottled

extremities and thready peripheral pulses. Auscultate the heart to detect distant heart tones

suggestive of an underlying pericardia! effusion. Identify all sources of active bleeding and

control with the application of direct pressure.

  Perform a rapid neurologic exam, noting any evidence of disability or deficits. Document

the patient's level of consciousness; note the size, symmetry, and reactivity of the pupils; and

assess for any focal numbness or weakness. Perform a rectal exam to ensure adequate rectal

tone and determine the patient's Glasgow Coma Scale (GCS ) .

  

Completely expose the patient t o ensure that all potential life threats have been accounted for.

Carefully log-roll the patient to examine the back and rule out any occult penetrating injuries.

Once complete, immediately cover the patient with warm blankets to prevent the development

of hypothermia.

  Secondary Survey The secondary survey is a complete head- to-toe examination that should be performed

once the patient has been stabi lized. Examine the scalp, noting any lacerations, c ontusions,

and deformities. Check the visual a cuity, visual fields, extraocular movements, and pupil size

and reactivity. Assess the globe for penetrating injuries, lacerations, or proptosis. Examine the

mid-face, looking for evidence of fracture, lacerations, epistaxis, or septal hematomas. Look for

signs of basilar skull fracture such as hemotympanum, periorbital (raccoon eyes) or

retroauricular ecchymoses (Battle sign) , and cerebrospinal fluid (CSF) rhinorrhea or otorrhea.

CSF rhinorrhea can be detected with the use of a bedside "halo-test." Check for dental injuries

or evidence of mandibular fracture, including point tenderness, malocclusion, and sublingual

hematomas.

  Inspect the neck, noting any signs of obvious tracheal deviation, laryngeal fracture,

subcutaneous emphysema, or expanding hematoma. Carefully palpate the cervical spine to

detect any point tenderness or bony step-offs. Re-inspect the chest, noting any signs of

contusions, asymmetry, paradoxical movement, or penetrating injury. Palpate the ribs and

sternum, checking for point tenderness, soft tissue crepitus, and bony deformity. Repeat

auscultation of the lungs and heart and document any abnormalities. Inspect the abdomen for

any signs of distention, contusions, or penetrating injury. Palpate all 4 quadrants to elicit any

tenderness, guarding, or rebound. Carefully assess the pelvis for signs of an unstable fracture by

gently compressing the iliac crests.

  Inspect the perineum for lacerations, contusions, and hematomas. Perform vaginal and

rectal examinations to assess for gross blood or mucosal trauma. Note the rectal tone and

check the prostate for signs of displacement. Findings consistent with urethral injury include

scrotal hematomas, blood at the urethral meatus, and a high-riding prostate.

  Look for any signs of blunt or penetrating trauma to the extremities. Document any

open wounds, point tenderness, or obvious deformities. Range all joints, looking for abnormal

movement. Palpate all muscle compartments to detect any signs of developing tension. Roll the

patient and palpate the entire spine, noting any point tenderness or bony step-offs.

  Assess the pulses in all 4 extremities. In penetrating trauma, the "hard" signs of arterial

injury include absent distal pulses, pulsatile bleeding, expanding hematomas, and the presence

of bruits or thrills. The "soft" signs of arterial injury include diminished distal pulses, visible

  

hematomas, corresponding peripheral nerve deficits, or delayed capillary refill. Patients with

soft signs for arterial injury require the measurement of the arterial pressure index (API ) . The

API can be calculated by dividing the systolic pressure of the affected extremity by the systolic

pressure of the contralateral unaffected limb. An API <0.9 is considered abnormal and

suggestive of arterial injury.

  Finally, perform a comprehensive motor and sensory examination, reevaluate the pupils and mental status, and recalculate the GCS.

  DIAGNOSTIC STUDIES Laboratory Check a STAT bedside capillary blood glucose level in all patients with an abnormal

mental status as hypoglycemia can mimic a traumatic brain injury. Check a complete blood

count to assess an initial hematocrit and follow serially to assess for occult hemorrhage and

responsiveness to therapy. If available, obtain a bedside serum base deficit and lactate level

and follow serially to gauge responsiveness to therapy. Send a type and screen on all trauma

patients and crossmatch blood as necessary for patients likely to require transfusions or

operative intervention. Obtain a urinalysis to rule out gross hematuria, a bedside urine

pregnancy test in all female patients of childbearing age, and a urine toxicology screen in

patients with an abnormal level of consciousness. Check coagulation studies in all patients with

a clotting disorder (eg, patients on warfarin ) .

  Imaging Portable plain radiography is readily available a t most institutions for the rapid bedside

evaluation of trauma patients. Plain films are useful for diagnosing bony fractures including

unstable pelvic and spinal injuries; determining the trajectory of penetrating projectiles;

identifying HTX, PTX, or an abnormal mediastinum; and detecting the presence of

intraperitoneal free air. Bedside ultrasonography provides a quick, highly sensitive, noninvasive,

and readily repeatable modality to detect occult hemorrhage. Perform a FAST exam to look for

signs of pericardial tamponade, PTX/HTX, and intraperitoneal bleeding.

  Computed tomography ( CT) imaging has revolutionized the care of trauma patients.

That said, this modality does expose the patient to increased health care costs, potential

contrast reactions, and harmful ionizing radiation, so every effort should be made to limit its

use to patients whose condition truly warrants it. Furthermore, CT imaging should be pursued

only in patients who are stable enough to safely leave the resuscitation area for an extended

period of time. CT imaging of the head has become invaluable for the evaluation and treatment

of patients with traumatic brain injury. CT imaging of the chest is now the preferred modal ity

to evaluate patients with potential intrathoracic vascular emergencies ( eg, TAl) and evolving

pulmonary contusions. CT of the abdomen and pelvis can simultaneously detect solid viscus

injury (eg, liver and spleen) and intraperitoneal hemorrhage and determine the severity of

pelvic injuries. Finally, CT angiography has rapidly become the preferred means to exclude

vascular injuries in patients whose c ondition warrants some form of radiographic imaging (eg,

patients with "soft signs" for arterial injury) .

  Magnetic resonance imaging is useful for the evaluation of patients with potential spinal

cord injury and to further delineate the severity of traumatic brain injury. That said, its use

  

should be limited only to stable patients who can afford prolonged excursions outside of a

resuscitation arena.

  PROCEDURES The coordinated resuscitation of a critically ill trauma patient may require a multitude of

simultaneous interventions. The following procedures are described in detail in the

corresponding chapters: central line placement and volume resuscitation, needle thoracostomy

and chest tube insertion, emergent airway management, pericardiocentesis and ED

thoracotomy, and diagnostic peritoneal lavage.

  Perform a retrograde urethrogram and cystogram in all patients with suspected urethral

and bladder injuries. Indications include straddle injuries, pelvic fractures, scrotal hematomas,

high-riding prostates, and blood at the urethral meatus. A urethrogram is performed by

injecting intravenous ( IV) dye into the urethral meatus while simultaneously capturing a pelvic

radiograph to detect any signs of urethral disruption (ie, contrast extravasation ) . Avoid the

insertion o f a Foley catheter into any patient with a demonstrated urethral injury without GU

consultation. For patients with an intact urethra, insert a catheter and distend the bladder with

up to 300 mL of diluted IV contrast while simultaneously capturing a pelvic radiograph

(cystogram) to detect any evidence of bladder rupture.

MEDICAL DECISION MAKING

  Obtain a complete set of vital signs and note any abnormalities. Hemodynamic

instability in the setting of trauma is hemorrhagic shock until proven otherwise. Initiate

aggressive volume resuscitation in said patients. Perform a n immediate primary survey and

address any emergent life threats including airway obstruction, tension or open PTX, massive

HTX, and pericardia! tamponade. Use your laboratory and imaging studies as necessary to

determine the presence and severity of injury. Following patient stabilization, perform a comprehensive secondary survey and treat all encountered injuries. Treatment Evaluation and treatment should coincide during the primary survey. All life-threatening

conditions must be stabilized before further evaluation. Secure the airway in any patient with

signs of impending compromise.

  Patients with a GCS ฀8 require endotracheal intubation to guard against obstruction

and/or aspiration. Examine the thoracic wall to identify any open PTX and cover with a 3 -sided

occlusive dressing to restore normal respiratory mechanics. Perform immediate needle

thoracos to my in all patients with signs of tension PTX, and place a chest tube in all patients

with evidence of traumatic PTX or HTX.

  Patients with evidence of impaired circulation require large-bore IV access and

aggressive volume resuscitation (Lactated Ringer's or normal saline) . Attempt to determine the

class of hypovolemic shock to guide fluid resuscitation and identify the need for packed red

blood cell transfusion. Concurrently attempt to identify the source of hemorrhage to determine

the need for surgical intervention. Unstable patients with either clinical evidence ( hypotension,

distant heart sounds, j ugular venous distention) or ultrasonographic confirmation of

pericardia! tamponade require emergent pericardiocentesis.

  Provide sufficient analgesia to ensure patient comfort and facilitate further evaluation.

  

Small boluses of IV fentanyl are ideal because of its short duration of activity and minimal

hemodynamic side effects. Ketarnine can be used both as an analgesic and sedative agent in

lower than normal "subdissociative" doses without concern for respiratory or cardiovascular

depression. Ondansetron can be given to reduce nausea and vomiting, and haloperidol may be

necessary to sedate agitated patients.

  DISPOSITION Admission The majority of blunt trauma victims require admission for observation to rule out

occult injuries not detected on either the primary and secondary surveys or CT imaging.

Hemodynamically unstable patients with positive focused assessment with sonography for

trauma (FAST) or CT imaging typically require operative intervention. Victims of penetrating

trauma generally require admission and operative intervention when the implements clearly

violate significant body cavities or injure vital anatomical structures.

  Discharge Blunt trauma patients with minor injuries who remain hemodynamically stable on serial

assessments can be safely discharged. Penetrating trauma patients may be discharged provided

that the path of the implement clearly does not violate any significant body cavities nor

approach any vital anatomical structures. Always ensure that the patient is able to ambulate

and tolerate oral intake before discharge.

  Reference

Fernandez J, Rifenbark N. Clinical Emergency Medicine. Chapter 84. Trauma Principle. New York,

NY: McGraw Hill Education, 2014.

  

LECTURE 13 :

Potentially Life Threatening Extremity

Injury

  ABSTRACT Crush Syndrome remains rare in European practice. It is however comm- on in areas of civil disorder and where the normal structures of society have given way to civil war or natural disaster. Western Doctors are becoming increasingly involved in such situations and there is no reason to believe that instances due to more conventional causes, such as collapse in the elderly or road traffic accidents will cease. For all these reasons it is important that clini- cians who deal infrequently with crush syndrome have access to appropriate guidelines. This consensus report seeks to provide such advice.

  The severity of the condition is related to the magnitude and duration of the com- pressing force, and the bulk of muscle aff- ected. The definition is not, however, dep- endent on the duration of the force applied.

  I Greaves, K Porter, JE Smith This paper reports the findings of a consensus meeting on Crush Injury and Crush Syndrome held in Birmingham on 31 May 2001, and co-ordinated by the Faculty of Pre-Hospital Care of the Royal College of Surgeons of Edinburgh. The Voluntary Aid Societies The Ambulance Service Association

  J R Army Med Corps 2003; 149: 255-259 Consensus Statement On The Early Management Of Crush

Injury And Prevention Of Crush Syndrome

  Lt Col I Greaves RAMC Visiting Professor of Emergency Medicine Education Centre, The James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW K Porter Consultant Trauma Surgeon, University Hospital, Birmingham Surg Lt Cdr JE Smith MBBS MSc MRCP RN Specialist Registrar in

  The typical clinical features of crush syn- drome are predominantly a result of traumatic rhabdomyolysis and subsequent release of muscle cell contents. The mech- anism behind this in crush syndrome is the leakiness of the sarcolemmal membrane

  Pathogenesis and clinical features

  Examples of this relationship are firstly a patient whose legs are run over by the wheels of a truck. In this case the force is large, but the duration is very short. At the other extreme, there is the elderly patient who has suffered a stroke, falls, and lies in the same position for hours, sustaining a crush injury to the areas of the body on which they are lying. In this case, the force is relatively small, but crush syndrome may develop as a result of the prolonged period of pressure. Similar cases to this are described as a result of drug overdose (4).

  Consensus view “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”.

  Key Words: Crush Syndrome, Renal Failure, Natural Disasters.

  Following a search of the literature, it was felt that a definition of crush injury and crush syndrome was required.

  Definition

  Crush syndrome bears many similarities to, but is distinct from, the syndrome caused by heat illness.

  Most commonly in traumatic crush, the legs are affected, and less frequently the arms. Many authors believe that crush injury of the head and torso significant enough to cause the syndrome is incompatible with life due to the inherent internal organ damage, but there are a few reported cases of such instances (3).

  Crush injuries and crush syndrome were first described in the English Language literature by Bywaters and Beall in 1941 (1), after several patients who had been trapped under rubble of buildings bombed in the Blitz subsequently died of acute renal failure. It has been described in numerous settings since, most commonly after natural disasters such as earthquakes, in war, and after buildings have collapsed as a result of ex- plosion. Crush syndrome is also seen foll- owing industrial incidents such as mining accidents and road traffic accidents. How- ever, crush syndrome is not confined to traumatic aetiologies, and has also been described following periods of crush by patients’ own body weight, after stroke or intoxication (2).

  Introduction

  The Royal College of Physicians The Royal College of Surgeons of Edinburgh Organisations represented ORIGINAL PAPERS caused by pressure or stretching. As the sarcolemmal membrane is stretched, sod- ium, calcium and water leak into the sarcoplasm, trapping extracellular fluid inside the muscle cells. In addition to the influx of these elements into the cell, the cell releases potassium and other toxic substances such as myoglobin, phosphate and urate into the circulation (5).

  The end result of these events is shock (discussed below), hyperkalaemia (which may precipitate cardiac arrest), hypocalc- aemia, metabolic acidosis, compartment syndrome (due to compartment swelling), and acute renal failure (ARF). The ARF is due to a combination of hypovolaemia with subsequent renal vasoconstriction, metabolic acidosis and the insult of nephrotoxic substances such as myoglobin, urate and phosphate.

  Fluid resuscitation

  The use of medical teams including paramedics, nurses and doctors should be considered at an early stage, and appropriate analgesia should be given. This may involve the use of Entonox ^® initially, but most patients will require intravenous analgesia such as an opiate, titrated against response. The use of ketamine, with or without the concomitant use of a benzodiazepine, is also

  Analgesia Consensus view

  Once the patient reaches hospital, 5% dextrose should be alternated with normal saline to reduce the potential sodium load.

  An initial fluid bolus of 2 litres of crystalloid should be given intravenously.This should be followed by 1-1.5 litres per hour.The fluid of choice is normal saline, warmed if possible, as this is established as the fluid carried by the majority of pre-hospital vehicles in the United Kingdom. Hartmann’s solution contains potassium and has a theoretical disadvantage of exacerbating hyperkalaemia. If possible, fluid should be started prior to extrication, however, gaining intravenous access and the administration of fluid should not delay extrication and transport to a definitive care facility. Early catheterisation should be considered, especially if there is a prolonged extrication or evacuation phase.

  Consensus view

  Once the initial primary survey has been performed, intravenous access should be obtained. If limb crush injury has occurred, and there is a likelihood of the patient developing crush syndrome, the following fluid guidelines should be followed. In the presence of life-threatening thoraco- abdominal injury, fluid resuscitation should be performed according to the Faculty’s previously published guidelines (8).

  The patient should be released as quickly as possible, irrespective of the length of time trapped.

  Shock

  Airway, Breathing and Circulation is the next priority. Attention must be given in trauma to the possibility of spinal injury and full spinal precautions should be maintained. Admin- istration of high flow oxygen by mask should be a priority in treatment, as should the arrest of any obvious external haemorrhage and the splinting of limb injuries.The patient should be exposed as necessary to assess and manage injuries. In a hostile environment, or where there is a risk of hypothermia, exposure should be as limited as possible. Assessment of distal neurovascular status is essential if exposure is to be kept to a minimum.

  Once the scene has been declared safe, in cases of mass casualties, a triage system (such as the triage sieve – Major Incident Medical

  Safety is the first priority when approaching an accident scene, and this is particularly relevant to situations where patients may have suffered crush injuries, as there may be danger from falling debris or risk of further building collapse.

  Consensus view

  Treatment of the crushed patient can be divided into two phases. The initial pre- hospital phase may, depending on the mechanism of injury, involve a prolonged extrication period. The second phase comm- ences on reaching a definitive medical care facility. In the case of prolonged on-scene time, or delay in transfer due to geographical reasons, some of the second phase guidelines may be employed in the pre-hospital environment.

  Approach to treatment

  Haemodynamic instability secondary to crush syndrome is multi-factorial. Firstly, many patients have other injuries, such as fractures of the pelvis or lower limbs, sufficient in themselves to cause hypovol- aemia. The sequestration of fluid into the affected muscle compartments has already been described, resulting in fluid shift from the intravascular to the intracellular comp- artments. This may cause hypovolaemia, as the intravascular volume is depleted. Elec- trolyte imbalances such as hyperkalaemia, hypocalcaemia and a metabolic acidosis will have a negatively inotropic effect, and there is also evidence that there is direct myocardial depression from other factors released when muscle cells are damaged (6).

  256 Consensus Statement On Crush Injury

  Triage Consensus view

  The development of acute renal failure in use of a solute alkaline diuresis is accepted to be protective against the development of acute renal failure (11,12).

  The traditional treatment of compartment

  The development of compartment syndrome in crush injury is due to the uptake of fluid into damaged muscle tissue contained within the restricted compart- ment. Once compartment pressure exceeds capillary perfusion pressure at about 30 - 40mm Hg, the tissue inside the compartment becomes ischaemic, and compartment syndrome develops.

  Compartment syndrome

  In the elderly, and those with pre-existing medical conditions such as cardiac failure, fluid replacement must be tailored to requirements and given with caution. Close monitoring of the clinical state of the patient, and regular review of fluid requirements is essential in these patients.

  The elderly and patients with co- morbidity Consensus view

  There is very little evidence in the literature to guide the treatment of children suffering from crush injuries. In young children the difference in body proportions, namely the reduced contribution to the total percentage made by the limbs, may influence the incidence of crush syndrome. The fluid resuscitation guidelines from Advanced Paediatric Life Support (APLS) (13) of an initial bolus of 20mls per kg should be followed in these patients.

  Children Consensus view

  The maximum daily dose of mannitol is 200g, and it should not be given to patients who are in established anuria.

  It is recommended that urine pH is measured, and kept above 6.5 by adding 50mmol aliquots of bicarbonate (50mls 8.4% sodium bicarbonate) to the intravenous fluid regime. Solute diuresis is affected by administering mannitol at a dose of 1-2g/kg over the first four hours as a 20% solution, and further mannitol should be given to maintain a urine output of at least 8 litres per day (300mls per hour). Fluid requirements are high, usually of the order of 12 litres per day, due to the sequestration of fluid in muscle tissue. Fluid should be given at approximately 500 mls/hour, but regular review of clinical parameters such as central venous pressure and urine output should dictate exact amounts of fluid given.

  Consensus view

  The use of solute-alkaline diuresis

  Patients with crush injuries should be taken to a hospital with an intensive care facility and the equipment and expertise necessary to provide renal support therapy such as haemofiltration or dialysis.

  Patients should be assessed following normal Advanced Trauma Life Support (ATLS) guidelines (9). Baseline blood tests should be taken.These will include full blood count, urea and electrolytes, creatinine kinase, amylase, liver function tests, clotting screen and group and save (cross match if deemed appropriate). The patient should be catheterised and hourly urine measurements commenced. Central venous pressure and invasive arterial monitoring should be considered.

  Immediate in-hospital care Consensus view

  There is no evidence to support the use of amputation as a prophylactic measure to prevent crush syndrome. Reports from the literature suggest that even severely crushed limbs can recover to full function. If the limb is literally hanging on by a thread, or if the patient’s survival is in danger due to entrapment by a limb, amputation should be considered and appropriate expert advice sought.

  Consensus view

  Another theoretically advantageous measure is amputation of a crushed limb to prevent crush syndrome.

  Amputation

  The use of tourniquets should be reserved for otherwise uncontrollable life threatening haemorrhage. There is no evidence at the moment to support the use of tourniquets in the prevention of reperfusion injury following extrication, or in the prevention of washing of the products of rhabdomyolysis into the circulation.

  Consensus view

  The use of tourniquets has a theoretical role in the management of these patients. If the release into the circulation of the contents of crushed muscle cells can be avoided, possibly with the use of a tourniquet, it may be of benefit. However, there is currently no available evidence to support this.

  Tourniquets

  I Greaves, K Porter, JE Smith 257

  Consensus view

  Could cooling the limb be used in order to slow cellular respiration and consequently decrease oedema, compartment syndrome and improve limb viability?

  Mannitol and compartment syndrome 258

  Early administration of bicarbonate intra- venously is thought to decrease metabolic acidosis and promote alkalisation of urine which decreases the precipitation of myo- globin in the renal tubules. Administration of bicarbonate immediately post-extrication, in anticipated metabolic acidosis, was dis- cussed. Has this been shown to be beneficial? Are there any detrimental features? What would be the appropriate and safe doses to use? Is there a role for the combined use of acetazolamide in order to prevent metabolic alkalosis following bicarbonate admini- stration?

  Bicarbonate administration

  Use of the Institute of Naval Medicine was suggested in order to evaluate the merits of this treatment modality. In view of the scarcity of this resource around the country it did not meet with a great deal of support.

  Hyperbaric oxygen therapy

  Creatinine kinase, myoglobinaemia and amy- lase have been suggested as prognostic indicators, although it is not clear that they can predict outcome at an early enough stage to allow effective intervention. The use of microalbuminuria as a prognostic indicator of crush syndrome was suggested.

  Prognostic indicators

  Types of fluid currently used for admini- stration include: normal saline, Hartmann's, Dextran or starches. What is the correct amount of fluid to be giving? Should we be looking at urine output, absolute volume intake or acidity of urine as a guide to fluid administration? Oedema occurring is secondary to massive fluid administration and may be detrimental. At what stage do we need to worry about this? What effect does this have on compartment syndrome?

  Fluid administration

  Tourniquet effectiveness was highlighted as a potential shortfall in their use. There is a requirement to perform a literature search into tourniquet usage, in particular regarding their use in Biers blocks, in order to determine the effectiveness of certain types of tourniquet and the leakage rates of drugs, past the tourniquet. This may assist in establishing the likelihood of potassium leaking into the systemic circulation.

  Is there a role for the tourniquet post or pre extrication of the crush injury casualty? The use of an animal model of crush injury was suggested, to assess the suitability of tourniquet administration. Comparison of to the increased ischaemia times involved in application of a tourniquet?

  In patients with compartment syndrome due to crush injury, in the absence of neuro- vascular compromise, a trial of mannitol therapy should be instigated, but a specialist opinion should be sought early.

  Areas identified for future research Use of tourniquets

  Further information is available in Better’s review of 1999 (5).

  In the civilian environment in the United Kingdom, there will be a huge strain on intensive care facilities if there are multiple crushed casualties. A policy should be drawn up to prepare for the dispersal of these casualties on both a National and Inter- national level should an incident occur.

  Multiple casualties Consensus view

  In many cases, intensive care support will be required for the complications of crush syndrome. If the patient becomes oligo- or anuric, it is likely that they will require haemofiltration or dialysis.

  Further management Consensus view

  Logistically hyperbaric oxygen treatment has limited application. Patients with no sig- nificant co-morbidity, and who can be man- aged in a hyperbaric chamber where the fac- ility is available, may be treated with hyper- baric oxygen therapy. It is recommended that treatment options are discussed with the local hyperbaric unit. This is not recomm- ended as first line treatment. Patients should, however, receive high flow oxygen, unless there is a specific contra-indication.

  Consensus view

  High concentrations of O ² cause systemic vasoconstriction but continue to deliver adequate O ² delivery. In a similar fashion, nitric oxide synthase inhibitors may also have a role in preventing excessive vasodilatation in the crushed muscle and the consequent increase in third space fluid losses (15).

  There is theoretical and limited experimental evidence that hyperbaric oxygen therapy may improve wound healing and reduce the need for multiple surgical procedures in crush injury (14).

  Hyperbaric oxygen therapy

  Consensus Statement On Crush Injury managed with mannitol alone. It is suggested that there is a noticeable difference in dia- meter and symptoms of the lower leg within 40 minutes of administration of IV mannitol (5). Fasciotomy should be reserved for refractory cases. The use of an animal model of a compartment syndrome is questioned due to the anatomical differences from hum- ans. Many animals that are commonly used as models for humans, such as pigs, sheep and dogs do not have fascial compartments. Primates share similarities but, ethically, would be more difficult to justify. Further information on existing animal experiment- ation relating to compartment syndrome is required prior to planning any further projects.

  References

  9. Advanced Trauma Life Support for Doctors.

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Consensus Statement On The Early Management Of Crush Injury And Prevention Of Crush Syndrome

  I Greaves, K Porter and JE Smith J R Army Med Corps 2003 149: 255-259 doi: 10.1136/jramc-149-04-02

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Consensus Statement On The Early Management Of

Crush Injury And Prevention Of Crush Syndrome

  I Greaves, K Porter, JE Smith * Abstract Crush Syndrome remains rare in European practice. It is however common in areas of civil disorder and

where the normal structures of society have given way to civil war or natural disaster. Western Doctors are