Crush; Roadside to Resus
Highlights
- The Effects of Compartment Syndrome After a Crush Injury
Key takeaways:
(* When a crushing force is released, toxic substances and fluid shift can occur., * Hypovolemic shock can be a result of these events., * Compartment syndrome can also occur if fluid shifts occur into muscle masses.)
Transcript:
Speaker 1
So at the moment everything's sort of not too bad other than the situation the patient finds themselves in. But when the crushing force is released and we start to get reperfusion of that crushed area two things happen. Firstly we get toxic substances getting washed into the systemic circulation and secondly there can be a pretty significant fluid shift with even more water being drawn into the intracellular spaces resulting in decreased intravascular fluid which can then obviously lead to hypovolemic shock particularly if this is on the background of dehydration. And actually this is the leading cause of early death after crush injury the hypovolemic shock. But to add insult to injury if these large fluid shifts occur into muscle masses that are confined within facial planes then we start to get compartment syndrome. (Time 0:06:26)
New highlights added March 6, 2023 at 11:07 PM
- Hypovolemic Shock in Trapped Patients
Key takeaways:
(* Shock is a common complication in patients who have been trapped under rubble., * Shock can be caused by the concurrent injuries the patient has sustained., * Shock can be treated with fluids and electrolytes.)
Transcript:
Speaker 2
So this is caused by the concurrent injuries that the patient has got so the broken pelvis, the liver laceration that is definitely not going to help these patients out and they need that fixing in the same way as they would do normally but specifics across you know that fluid shift from the intravascular to the intracellular space and both of these together so the concurrent injury and that fluid shift will cause hypovolemia due to the reduction in that intravascular volume. So first up these patients can be shocked okay but then well then you've also got electrolyte disturbances namely the hypokalemia, the hypokalcemia and the metabolic acidosis all of which will have a negative inotropic effect and this is going to need you to have either a point of care gas analyzer followed by formal lab samples or whatever you've got but I guess the ECG pre-hospital might give you some clues along with the mechanism, the duration of entrapment etc for you to work off. So yeah first in our list of clinical factors for these patients that we're going to pick up on is probably going to be shock or the rapid development of shock shortly after release. Now depending on the time that the patient has spent trap there will be a host of other (Time 0:11:44)
- Compartment Syndrome in a Crush Injury
Key takeaways:
(* An acute kidney injury can develop in patients with oliguria or anuria., * Compartment syndrome is a potential complication of an acute kidney injury., * It is important to recognize and treat compartment syndrome in patients with a crush injury.)
Transcript:
Speaker 2
Nice I mean urinalysis reagents was not my specialized subject and remains not my specialized subject so that's good a little bit of random knowledge to throw at your trainees any day. So finally following all of these clinical symptoms your patient will have oliguria so passing less than 400 mils of urine a day or 20 mils per hour or they will stop passing urine altogether so anuria all as a result of that acute kidney injury that will develop unless we're aggressive and intervene to stop it.
Speaker 1
So Rob one last thing I guess on this sort of patient presentation one of the other things that we mentioned about under that pathophysiology section was the potential for compartment syndrome because of that sort of sequestration of the fluid into sort of muscle masses that are contained within facial planes so how are we going to spot that?
Speaker 2
Yeah and I think it's really important to mention compartment syndrome of course and you know the development of compartment syndrome in a crush injury is due to the uptake of fluid into those damaged muscle tissues which is within that restrictive compartment so that causes the blood flow to be restricted causing catastrophic damage to those muscles and nerves and nerves unless it is treated promptly and this happens when the compartment pressure exceeds the capillary perfusion pressure so that's somewhere around 30 to 40 millimeters of mercury and everything then starts becoming ischemic so pretty unpleasant and not a lot of pressure actually to be perfectly honest with you. (Time 0:14:47)
- Prehospital care for crush injuries
Key takeaways:
(* Patient safety is a key priority in the prehospital setting., * Agencies need to work closely together to ensure safe care for patients., * Risk assessments need to be undertaken by each agency.)
Transcript:
Speaker 1
Great well I reckon it's time to start the patient's journey then folks and that is clearly going to be in the pre-hospital setting so let's have a little think about what we're going to do for these patients and I think first of all when we think back to the mechanisms that may be involved in these crush injuries the safety of the patient and healthcare providers is clearly going to be a key initial priority because when we think about it the mechanism of these crush injuries is likely to result in a pretty hazardous environment you know we're thinking either industrial machinery vehicle accidents collapse buildings and so on and I think it'd be very easy to rush in and get patient focused certainly without the appropriate PPE and an absolute minimum and realistically you know we're going to have to work really closely alongside rescue agencies At a job like this ensuring that all of our mental models are shared for things like the criticality of the patient our expected time scales the risks involved and alternative plans so I think you know a little review of the Jessip principles might be a little bit useful I think so what do they say there's kind of five key principles so they say that we need to co-locate so that means we're going to have representatives from each agency in one location and then once they're there they're going to communicate we're going to ensure that there's clear and precise passage of information between the agencies and then once we've had that good communication we need to coordinate we need to identify our priorities talk about our resources our capabilities and the limitations that we're facing and with that we can kind of jointly understand the risk That we're facing in this situation and each agency should clearly be undertaking their own risk assessments because they'll be looking (Time 0:17:47)
- How to prevent crush syndrome with a large bore cannula
Key takeaways:
(* In crush injury patients, a large bore cannula or intrarautious access should be placed to start a normal saline infusion to address hypovolemic shock and renal failure., * Hypovolemic shock is the leading cause of death in the early stages of crush syndrome, and delaying fluid resuscitation can lead to death.)
Transcript:
Speaker 3
Oh Simon that's another year with the bomb bag that's left zipped up oh mate I tell you but you wear it every day you wear it every day but you know never up to over yeah I was going to say evidence-based practice is extremely important but there's no way it'll be putting pay to this one hell of a look go on the James so so what should we be doing then are there any other bits that we can do sort of try and prevent this toxic spread well thankfully yes there is and all of the guidelines and recommendations are very consistent on this and our first key clinical intervention should be to place a large bore cannula or intrarautious access depending on what you can you can get to and start a normal saline infusion and this is a priority in our crush injury patients
Speaker 1
Who are risk of developing crush syndrome because it addresses two of the main causes of morbidity and mortality that hypovolemic shock and renal failure and realistically it might also have a role in promoting renal excretion of potassium by increasing the urine output and so that's going to address three of the top three problems that we're going to face and what we do know about this is that hypovolemia is the leading cause of death in the early stages of crush syndrome and inadequate volume replacement or a delay in fluid resuscitation (Time 0:25:30)
- The Importance of Alkalization in Acute Renal Failure
Key takeaways:
(* The test for acute renal failure is important and can be used to help decide which patients need treatment., * The urine pH should be kept above 6.5 to protect the patient., * Solute alkaline diuresis can be used to alkalize the urine.)
Transcript:
Speaker 2
Awesome as I knew it would be it was a very good section Simon on CK and Rev Demialisis that was very good and I knew you were set up for that and but in all fairness it is a really good point because it is one of those issues that is frequently discussed in emergency departments and on acute medical units for that matter up and down the country regularly particularly with the you know increase in response times for ambulances and things like that particularly in the UK so this is an important thing to contextualize about how useful this test is and applying it to the right patient cohort so yes whilst we focused a little bit on those major crush injuries this is definitely part of the bundle for those that have falls and are on the floor for that long-line inverted commas so thanks for That buddy. Now regarding that acute renal failure that we keep chirping on about and we've done this loads well there are two things that are accepted to be protective for the patient and those are alkalization of the urine and the use of solute alkaline diuresis so more big words for you. What the heck does that mean? Well it is not as bad as you might expect and it's actually fairly straightforward when you come to look at what you actually have to do and this is covered beautifully in the Faculty of Pre-Hospital Care Consensus statement which we'll obviously link to in the show notes. Now the urine pH of the patient should be measured basically and that should be kept above 6.5 and you do that by adding 50 mil aliquots of 8.4 percent sodium bicarbonate to the IV fluid regime so that is the alkalization bit sorted. You do that by adding 50 miliquots of sodium bicarb to keep the above 6.5. (Time 0:42:56)
- The Importance of Alkalization and Solute Alkaline Diuresis in the Treatment of Acute Renal Failure
Key takeaways:
(* The test for determining if a patient has a crush injury is useful,., * The main protective measures for patients with crush injuries are alkalization of the urine and the use of solute alkaline diuresis.)
Transcript:
Speaker 2
Awesome as I knew it would be it was a very good section Simon on CK and Rev Demialisis that was very good and I knew you were set up for that and but in all fairness it is a really good point because it is one of those issues that is frequently discussed in emergency departments and on acute medical units for that matter up and down the country regularly particularly with the you know increase in response times for ambulances and things like that particularly in the UK so this is an important thing to contextualize about how useful this test is and applying it to the right patient cohort so yes whilst we focused a little bit on those major crush injuries this is definitely part of the bundle for those that have falls and are on the floor for that long-line inverted commas so thanks for That buddy. Now regarding that acute renal failure that we keep chirping on about and we've done this loads well there are two things that are accepted to be protective for the patient and those are alkalization of the urine and the use of solute alkaline diuresis so more big words for you. What the heck does that mean? Well it is not as bad as you might expect and it's actually fairly straightforward when you come to look at what you actually have to do and this is covered beautifully in the Faculty of Pre-Hospital Care Consensus statement which we'll obviously link to in the show notes. Now the urine pH of the patient should be measured basically and that should be kept above 6.5 and you do that by adding 50 mil aliquots of 8.4 percent sodium bicarbonate to the IV fluid regime so that is the alkalization bit sorted. You do that by adding 50 miliquots of sodium bicarb to keep the above 6.5. The solute diuresis is achieved by administering manatol at a dose of 1 to 2 milligrams per kilogram to this patient over the first four hours and that is the 20 percent not the 10 percent version and further to that you might need to (Time 0:42:56)
- Manatol for the Treatment of Urinary Tract Infection
Key takeaways:
(* The urine pH should be kept above 6.5 with 50 mil aliquots of 8.4 percent sodium bicarbonate., * Manatol should not be given to a patient who has established anuria., * The maximum dose in 24 hours is 200 grams.)
Transcript:
Speaker 2
Now the urine pH of the patient should be measured basically and that should be kept above 6.5 and you do that by adding 50 mil aliquots of 8.4 percent sodium bicarbonate to the IV fluid regime so that is the alkalization bit sorted. You do that by adding 50 miliquots of sodium bicarb to keep the above 6.5. The solute diuresis is achieved by administering manatol at a dose of 1 to 2 milligrams per kilogram to this patient over the first four hours and that is the 20 percent not the 10 percent version and further to that you might need to give more to maintain a urine output of at least at least boys eight liters per day and that is 300 mils per hour. Yes indeed I'd want to count it at that point. Yeah exactly yeah I've got really tired legs just from getting up to the toilet let alone the crush. That's the standard nighttime routine in the lank household. Yeah yeah VSA and the obvious other one. Anyway but an important note I think on that manatol there are a couple of things you need to remember so the maximum dose in 24 hours for manatol is 200 grams so you cannot be given more than that and it absolutely should not be given to a patient who has established anuria so if your patient isn't weaning and hasn't weaved for a long time manatol is not the thing to give. (Time 0:44:17)