Medical Aspects of Urban Search

1
Medical Aspects ofUrban Search Rescue

• David C. Cone, MD
• Chief, Division of EMS
• Yale Emergency Medicine
• Medical Team Manager
• FEMA Penn. USR Task Force 1

2
Objectives First Hour

• 1. Introduce federal response system for USR
  incidents (briefly)
• 2. Describe medical aspects of USR
• 3. Introduce confined space medicine

3
Objectives Second Hour

• Detailed coverage
• crush injury
• compartment syndrome
• crush syndrome

4
USR Definition

• The process of locating, extricating, and
  providing medical treatment to victims trapped as
  a result of structural collapses and other
  natural or man-made catastrophes.

5
USR Definition Contd.

• USR also has application toward a wide range of
  other advanced technical rescue incidents such as
  rescuing victims from floods, swift-water,
  high-rise fire incidents and cave-ins as well as
  rescuing survivors of confined space, trench
  collapse, mass-transportation, climbing and
  industrial machinery accidents

6
OFDA / USAID

• Deployed Miami-Dade and Fairfax VA teams to
  Mexico City earthquake 1985
• Also sent teams to Soviet Armenia (1988) and
  Philippines (1990)
• Limited to overseas deployments

7
Domestic Development

• Loma Prieta earthquake (1989) led to development
  of USR plan in California
• Hurricanes Hugo 1989 Andrew 1992
• SMRT - western PA - mine rescue
• FDNY heavy rescue / collapse unit

8
Stafford Act - 1988

• Resulted in development of Federal Response Plan
  (FRP)
• Outlines 12 Emergency Support Functions
• Provides personnel, technical expertise,
  equipment, and other resources to supplement
  local and state assets.

9
Emergency Support Functions

• 1. Transportation
• 2. Communications
• 3. Public works and engineering
• 4. Firefighting
• 5. Information and planning
• 6. Mass care

• 7. Resource support
• 8. Health and medical services
• 9. USR
• 10. Hazardous materials
• 11. Food
• 12. Energy

10
FEMA USR Task Forces

• 28 teams
• Fully self-sufficient for first 72 hours
• Functional for at least 10 days

11
Task Force Structure

• 62 persons ( canines) in two shifts
• Four teams
• Medical 2 physicians, 4 medics/nurses
• Search canines, specialized
• Rescue 4 squads of six
• Technical rigging, hazmat, structural
  engineering, tech info, commo, logistics

12
FEMA USR Task Forces

• Generally gt150 members
• 6 hour mobilization requirement
• 56,000 pound equipment cache

13
Task Force Missions

• Physical search rescue
• Emergency medical care for response personnel and
  limited of victims
• 10 critical, 15 moderate, 25 minor
• Recon assess damage, determine needs, survey
  hazmat and structural
• Communications support (DoD compatible equipment)

14
Caring For Our Own

• Providing for the health and medical needs of
  responders is the 1 priority in the USR
  environment
• How do we do this?
• by ensuring that all aspects of medical care are
  provided by us, since affected area may not be
  able to.

15
Medical Team Roles

• Prospective preparedness
• On-Site
• Retrospective after-action

16
Prospective Roles

• Health fitness standards
• NFPA
• Helps ensure adequate performance
• Helps minimize health risks during operations
• Use health forms / questionnaires to review for
  potential problems
• Ensure immunizations

17
Prospective Roles

• Medical cache maintenance
• Policies and procedures for drug cache
• MOUs with local hospitals for drugs

18
Prospective - Drills

• Thoroughly integrate medical operations into all
  drills and exercises

19
Confined Space Simulator
20
Arrival On Scene

• Establish and staff a dedicated medical treatment
  area as soon as possible
• Make sure everybody knows where it is
• Establish and staff a forward medical area as
  soon as it is needed
• Make sure everybody knows where it is

21
Medical Intelligence Gathering

• Begins immediately upon activation, continues
  during check-in and transport
• Likely numbers and types of victims
• Weather
• Hazardous materials
• Evacuation routes for injured personnel
• Same as for victims?
• Status of local medical resources

22
No two events are alike

• Building occupancy and time of day can help
  predict victims ages, medical issues, numbers,
  etc
• Building construction may help predict injury
  patterns
• Punctures/lacerations in wood structures
• Dust airway impaction in adobe/brick

23
Interaction with local EM/EMS

• Availability of EMS resources
• is there somebody to hand patient off to?
• hand-off to less sophisticated level of care is
  SOP by FEMA policy
• medical team must remain with TF
• Availability of ED/hospital resources
• Level of support field team(s) can expect from
  local medical system

24
Medical Intelligence Gathering

• Are additional local sources of equipment
  available?
• Are you relying only on your gear?
• How will you (or even can you) re-stock gear as
  the event progresses?

25
Food Beverage Safety

• Strict handwashing before eating
• Food and beverages should ONLY be accepted from
  known, approved sources

26
Water

• Contaminated water can render all of your
  personnel non-operational quickly
• Your own water is the most reliable
• Enforce rehydration
• Small amounts frequently
• No caffeinated beverages

27
Other Medical Team Roles

• Media relations
• Veterinary care for canines
• Paperwork

28
Retrospective Roles

• Provide adequate follow-up for injuries and
  exposures
• Reconstitution of cache/supplies
• Paperwork

29
CSM Definition

• An emerging body of knowledge concerned with
  treatment and rescue of victims in a collapsed
  structure with limited access and egress, and
  unfavorable environmental conditions.

30
Confined Space Medicine

• Sophisticated medicine in an austere environment
• Given the time, effort, risk, and expense of
  responding, locating, and extricating USR
  victims, we should maximize the chances of
  survival.

31
CSM Two general categories

• A confined space that is intact power vaults,
  grain silos, sewers
• OSHA CFR 1910.146 Permit required confined spaces
  for general industry
• 35 of victims are would-be rescuers
• A structural collapse building, trench, highway,
  bridge, crane, tower...

32
Either way

• Not the same as typical EMS operations
• Less reliable sources of supplies help
• Less reliable medical back-up
• Delays in reaching patients (whether trapped or
  not)

33
Why is it hard to operate?

• Poor lighting, ventilation, temp control
• Exposure to blood/body fluids, liquids
• Tight spaces
• Need for PPE
• Crime scene

34
Situational Considerations

• Atmosphere (90 of non-collapse injuries and
  deaths)
• Oxygen-deficient
• CO from fires and tools
• Broken gas lines
• Hazardous materials
• Risk of secondary collapse/device
• shoring, stabilizing

35
Situational Considerations

• Electrical service
• Propane and heating oil tanks
• Domestic water
• Sewage

36
Basic CSM Principles

• Forget scoop and run
• Cant scoop
• Often nowhere to run
• Team must expect to spend hours in the rubble
  with the patient
• Complications not typically seen in the
  pre-hospital setting may have already begun

37
How CSM decreases MM

• Provide rapid stabilization in the rubble
• Expedite extrication
• immobilize (only) as needed
• provide pain control improve cooperation
• anatomic/physiologic advice for moving pt
• prepare patient for hand-off to EMS (if any)
• Prevention of renal failure due to crush syndrome
  is the biggest advance

38
Problems We Cant Control

• Patients pre-injury health
• Entrapment
• Severity of injury
• Deterioration before we reach them

39
Focus on what we can control

• Speed of rescue
• Early medical treatment
• Personnel safety
• Avoid the temptation to extricate immediately
• Assess and stabilize in the rubble

40
Personnel Safety

• Hearing protection
• Safety glasses/goggles
• Helmet with light
• Footwear steel toe shank
• Flashlight, backup
• Respiratory protection
• Knee elbow pads

41
Gloves

• Somewhat controversial
• Leather fire gloves generally do not provide
  adequate BBP protection
• Medical gloves under fire gloves provides good
  BBP protection, but
• Hazardous in heat exposure

42
Respiratory Protection

• FEMA recommends cartridge respirator masks until
  asbestos and other toxic dusts ruled out
• Standard dust mask at a minimum
• SCBA in certain IDLH / unknown confined space
  entries

43
Atmospheric Monitoring

• All USR medical personnel should have a working
  knowledge of TLV, IDLH, LEL/UEL, etc.
• All new voids should be monitored before entry
• All unusual odors (and liquids) need to be
  evaluated

44
Blood Body Fluids

• Soak up with absorbent pillows
• Cover with plastic sheeting
• Bridge with cribbing material

45
Lifelines

• Somewhat controversial does risk of tangle
  (preventing rapid exit) outweigh benefit of
  rescue?
• FEMA feels mandatory for tight confined spaces,
  or when out of sight of team attached to both
  ankles

46
Acquire patient data early

• As early as possible
• Bystanders family may be able to provide
  information before you reach the patient
• Only voice contact is needed to begin evaluation
  of patient

47
Anticipate and Communicate

• Anticipate what the next step or intervention is
  have all the needed equipment and personnel ready
• Communicate your needs early
• Be sure to communicate with the rescue personnel
  as well as medical personnel

48
FEMAs Five Functions

• Provider
• Anticipator/Communicator
• Physician
• Recorder/Safety Officer
• Equipment/Supply Officer
• There are other ways to do this, of course-

49
Provider(s)

• Performs evaluation treatment
• Works out loud so the anticipator knows what is
  going on

50
Anticipator

• Listens to providers narration
• Communicates needs backwards
• Prevents down time by asking what is needed and
  getting it brought in

51
Physician

• Assists with orders for meds, advanced
  procedures, etc.
• May serve as provider or anticipator if
  appropriately trained and credentialled to
  function in these roles with the team NO
  FREELANCING

52
Recorder / Safety Officer

• Records and times assessments, vital signs,
  interventions
• Assures safety, atmosphere monitoring
• Tracks accountability

53
Equipment / Supply Officer

• Obtains supplies as requested
• Assembles (or strips) as needed

54
Impact of rescue operations

• On your personnel as well as on victim
• Dust
• CO production
• Movement of rubble/structure

55
Patient Safety Gear

• Have a packet ready to get to patient
• Dust mask, goggles, hearing protection
• Cervical collar
• Helmet
• Wet gauze
• Remove jewelry, wet clothing, etc.

56
Intervention How Much?

• Safety of structure / confined space
• Presence of hazardous materials
• Time to extrication
• Time to definitive care after extrication
• Number of victims
• Degree of treatable injury

57
Packaging

• Think mobilization, not immobilization
• Example An LSP Half-Back may be preferable to a
  standard long-board
• The more immobilized a patient is, the harder the
  extrication is likely to be
• Consider protocols for selective spine
  immobilization (in everyday practice as well as
  in the USR environment)

58
Packaging

• Keep it simple.
• I like rigging as much as the next guy, but.

59
Re-Evaluation

• After each significant extrication move
• Particularly watch for signs of crush syndrome
  (stay tuned), airway deterioration, etc.

60
Usual medical problems

• Lacerations, contusions, abrasions
• Dehydration
• Hypothermia (rarely hyperthermia)
• Head injuries
• Fractures / dislocations
• Burns

61
Unusual medical problems

• Dust airway impaction
• Hazmat exposure / injury
• Prolonged untreated trauma
• Blast injury
• Dehydration / starvation
• Crush injury / crush syndrome

62
Dust

• Building materials contain silica, calcium,
  asbestos, wood, mineral fibers
• Masonry, sheet rock, plaster, tiles, insulation
• Impair both ventilation and gas transfer
• Major cause of death in Kobe quake
• Provide all patients with dust masks

63
Other Respiratory Problems

• Airway obstruction (blood, teeth, vomitus, facial
  fractures, etc)
• Ventilation problems (debris limiting chest wall
  expansion, PTX/HTX, pulmonary contusion)

64
Inhalation Injuries

• Displacement / consumption of oxygen
• e.g. methane from ruptured gas line
• Thermal injury hot gases gtgt edema
• Noxious gases / particulates
• Cellular toxins (CO, cyanide)

65
Assessment Treatment

• A talking patient has a patent airway
• and in fact has pretty good ABCs
• A cough works better than suction
• if the patient can do it
• Humidified air or oxygen very helpful
• Balance benefits of oxygen with risks (fire) and
  logistics

66
Automatic (Transport) Vents

• Pro avoid prolonged hand-bagging
• Con tend to use oxygen fairly quickly
• Some can be set at 50, conserving oxygen
  others can only do 100 O2

67
Hypovolemia

• Dehydration/starvation
• Gen. no intake, but continued losses
• Frequent ileus with vomiting
• Blood loss (may recur during extrication)
• Edema / third spacing (extremities, GI)
• Burns (thermal or chemical)

68
Third Spacing

• You have roughly 14 liters of extra-cellular
  fluid
• Almost all of it can be sequestered in damaged
  muscle within a few hours

69
Assessment

• Thirst
• Sensorium (consider empiric D50)
• Vital signs (esp. changes over time)
• Mucous membranes
• Urine output Foley catheter

70
Treatment options

• NPO if at all possible to avoid vomiting, and in
  case intubation or surgery is needed
• IV hydration preferable
• Pay particular attention to antiseptic technique
  when starting lines

71
Hypothermia (common)

• Wet skin, indoor clothing, cold concrete
• Warm IV fluids and warm oxygen
• Warm the environment if possible, remove wet
  clothes, wrap with space blanket, insulate from
  cold surfaces

72
Types of blast injury

• Primary the blast force itself
• blunt trauma
• Secondary fragments and debris
• penetrating trauma
• Tertiary impact of victim thrown against solid
  object
• Quartinary structural collapse after blast

73
Blast injury

• Significantly higher MM if in enclosed space
  than if out in the open
• Frequent complications
• air embolism
• ARDS
• splenic rupture
• pneumoperitoneum
• ocular injury

74
Infection Considerations

• Open wounds sepsis and wound infxn
• Contamination with air- and water-borne agents,
  as well as own stool/vomitus
• Pulmonary coccidiomycosis following Northridge
  earthquake

75
Field considerations for ID

• Drain abscesses if delay in extrication
• Local wound care and ABX for other infections
  (cellulitis, etc) - splint
• Consider oral, IM, or IV antibiotics

76
Orthopedic Injuries

• All open fractures get splints, also IV ABX if
  definitive care will be delayed
• Be generous with pain meds
• Immobilize spine only if needed

77
Prior Medical Conditions

• Take a history
• Baseline medical conditions havent been tended
  to since the patient became trapped

78
Patient medications

• Patients likely do not have their meds
• Some are time-sensitive
• insulin
• digoxin
• anti-convulsants

79
Pain Medications

• Improve examination
• Facilitate extrication
• Improve cooperation
• Consider sedation in addition to analgesia

80
Part 2 Crush

• Seen in 3-20 of earthquake victims
• Seen in up to 40 of extricated survivors from
  multi-story building collapses
• Armenian earthquake of 7 Dec 1988
• 800 patients admitted to Yerevan Hospital
• 460 (58) with crush syndrome
• 185 with acute renal failure

81
Prediction for Southern CA

• 7.58.0 mag. at Newport / Inglewood or
• 8.3 mag. at San Andreas
• 100,000 casualties
• 20,000 crush injuries

82
Four Clinical Entities

• Crush Injury
• Compartment Syndrome
• Crush Syndrome
• Traumatic asphyxia

83
The Summary

• Extremity is crushed
• Cells are disrupted, stuff leaks in out
• Leaking cells, bleeding, and edema lead to
  increased tissue pressure
• When pressure is released, all the stuff enters
  the circulation, killing the patient
• We can prevent this last step, if we begin
  treating the patient in the rubble.

84
Marmara Earthquake

• 17 August 1999, 0302 hrs
• Magnitude 7.4
• Northwestern Turkey
• 17,000 fatalities
• 40,000 injuries
• 600,000 homeless

85
Response

• First national team in 6 hrs
• First international team in 22 hrs
• the most critical period for effective rescue
  work was left to the efforts of unqualified
  locals.
• No patients received IV fluids prior to hospital
  admission

86
Two papers

• 1. 33 pediatric patients admitted to a nearby
  university hospital
• Iskit et al, J Ped Surg, Feb 2001
• 2. Renal Disaster Relief Task Force
• Vanholder et al, Kidney Intl, Feb 2001
• International Society of Nephrology
• created after 1988 Armenia earthquake

87
Peds Paper Case Definition
88
33 Pediatric Patients

• Age 14 days 16 years
• 30 were trapped in rubble, 1-110 hrs

89
Crush Injury

• Seen in 15 of the 33 patients (45)
• 23 extremities involved
• 6 upper extremities
• 9 lower extremities
• No amputations needed
• Three with permanent disabilities due to muscle
  damage

90
Compartment Syndrome

• 6 patients
• 9 extremities with fasciotomy performed
• All arrived on third day or later
• One wound infection required skin graft

91
Acute Renal Failure

• In 10 of the 15 crush injury patients
• No correlation with time buried/trapped
• All were already in ARF at admission
• 2 required dialysis
• Others did well with fluids, diuretics, and urine
  alkalinization

92
Case DefinitionRenal Disaster Relief TF
93

• 5000 dialysis sessions
• 600 patients
• 17 mortality for dialyzed patients
• Compare to 40 in other earthquakes

94
Crush Our Definitions

• Crush injury
• mechanical cell disruption, gen. lt1 hour
• ischemia over gt4 hours
• Crush syndrome
• systemic manifestations when muscle is released
  from compression
• If not properly treated, crush injury will lead
  to crush syndrome

95
Crush Definitions

• Traumatic rhabdomyolysis
• the leaking of two proteins (myoglobin and
  albumin) from damaged cells
• Traumatic asphyxia
• Damage caused by brief, severe compression of the
  torso
• No specific treatment needed, will ignore for
  today

96
Crush INJURY

• Muscle cell damage due to compression with enough
  severity and duration to disrupt cellular
  function
• High pressure / short duration pinned briefly
  between two car bumpers
• Low pressure / long duration prolonged
  entrapment with legs under dashboard

97
Effects of crush on circulation

• Crush usually impairs venous outflow
• Arterial inflow may or may not be impaired by
  crush
• but the patient loses either way

98
If arterial perfusion is maintained

• Edema worsens and third spacing can cause
  hypovolemia, but
• Muscle cells remain viable longer
• (though they continue to produce waste products)

99
If arterial perfusion is disrupted

• Third spacing is prevented, and
• Intravascular volumes is maintained, but
• Cell death from ischemia begins in about 4-6 hrs

100
Pulses

• May still have distal pulses, even when perfusion
  of compressed muscle is compromised
• 14 crush syndrome patients from Kobe
• all with lower extremity crush injuries
• all with neurological deficits
• all with palpable dorsalis pedis pulses

101
Pulses

• Pulses are unreliable in diagnosing compartment
  syndrome. Pulses can be present, weak, or absent,
  and should not be used as an indicator of
  compartment status.
• von Schroeder, Hand Clinics Aug 1998

102
Typical Crush Presentation

• Cold
• Hard
• Limited or absent sensation
• Diaphoretic

103
Patient Assessment

• Dont forget ABCs
• Dont forget all the CSM stuff we just talked
  about an hour ago
• Inspect and palpate the crushed limb for open
  wounds fractures
• Gather as much patient history as possible before
  the crush is released

104
Cellular effects of crush

• Ischemic cells switch from aerobic to anaerobic
  metabolism
• produce lactic acid
• Cell membrane is disrupted
• cell integrity is lost

105
Stuff leaks into cells

• Calcium can cause systemic hypocalcemia, also
  toxic to muscle cells
• Fluid can reduce intravascular volume and cause
  hypotension

106
Stuff leaks out of cells

• Potassium
• 70 of bodys K is in the muscles
• leak can cause hyperkalemia, with cardiotoxicity
  worsened by hypocalcemia and hypotension
• Myoglobin can cause renal failure

107
Stuff leaks out of cells

• Thromboplastin disrupts clotting
• Lysosomal enzymes
• Leukotrienes inflammatory mediators
• Phosphates

108
Consequences of Crush Injury

• 1. Compartment Syndrome
• 2. Crush Syndrome

109
Compartment Syndrome Def.

• ...the local manifestations and sequelae of
  neuro-muscular ischemia due to increased pressure
  within osteofascial compartments
• Kikta et al. Arch Surg, Sept 1987
• Too much stuff in too little space
• Stewart, JEMS July 1999

110
Compartments

• Fibrous sheaths of fascia that do not stretch
• Particularly in the forearm (3) and lower leg (4)

111
Compartment Syndrome

• Increase in compartment pressure
• edema inside closed compartment
• bleeding inside closed compartment
• external compression
• impairment of venous outflow with continued
  arterial inflow

112
Consequences

• Increased pressure further damages / kills muscle
  and nerve tissue
• Prolonged compartment syndrome results in death
  of the limb

113
Formal Diagnosis

• Compartment pressure measurement
• Involves invasive manometry
• Several techniques, all need special equipment

114
Clinical Diagnosis

• The Five Ps
• Pain (on passive stretch - nonspecific)
• Pulselessness
• Paralysis
• Pallor (generally late)
• Paresthesias (more specific)

115
Quick Dirty Diagnosis

• If the compartment is tense, and
• There is impaired vibration sense (first) or
  two-point discrimination (later), then
• There is likely compartment syndrome

116
Treatment Options

• Open the compartment, or reduce the size of the
  contents
• Israel good results with using mannitol to
  decrease the edema in the limb

117
Fasciotomy

• Controversial
• Some use compartment pressure as the criteria
  (gt40 mmHg for gt8 hrs)
• Others recommend only when distal vascular supply
  is clearly compromised
• Dead tissue bleeds profusely, gets infected, and
  isnt helped by fasciotomy

118
Fasciotomy Controversy

• fasciotomy does not give good results and the
  few deaths that are reported in the literature
  following crush injury are directly related to
  fasciotomy.
• Michaelson, World J Surg, Sep 1992
• The standard treatment is rapid decompression
  with surgical fasciotomy
• Abassi et al, Seminar Neph, Sep 1998

119
Austere Environment

• Fasciotomy generally not indicated after 4-8 hrs
• Dead muscle will be exposed
• Infection much more likely
• Amputation likely preferable

120
Crush SYNDROME

• Post-extrication deterioration and death from
  potentially treatable mechanisms
• Leading cause of death in earthquake victims who
  survive to medical care

121
History

• Crush syndrome described in 1909
• Messina, Italy earthquake
• Bywaters syndrome
• WW II - Bywaters Beal
• Syndrome of swollen limbs, shock, dark urine, and
  renal failure
• Urine pigment identified as myoglobin 1941

122
History

• 1975 Mubarek Owen described traumatic
  rhabdomyolysis, compartment syndrome, and crush
  syndrome as a spectrum of injury
• If you see one, suspect the other two

123
Crush SYNDROME

• Death by hypovolemia and arrhythmia (early),
  renal failure and infection (late)
• Essential to begin treatment in the hole, before
  the crush / pressure is relieved

124
Other Clinical Scenarios

• Prolonged immobility due to drug overdose or CO
  poisoning
• Fractures
• tibia or fibula, rarely femur
• elbow supracondylar
• Child abuse
• MAST (one case report)

125
Physical Exam - Nonspecific

• Tachycardia
• Hypotension
• Tachypnea (due to acidosis)
• Red-brown urine can be a helpful clue
• Maintain high index of suspicion

126
Clinical Bottom Line

• The low-tech prehospital ALS intervention of
  adequate fluid via IV infusion is necessary,
  practical, and cost-effective in saving lives.
• Raynovich, JEMS Jan 2000
• Oxygen, IV fluids, and bicarbonate are within the
  paramedic scope of practice

127
Releasing compressionThree early effects

• Hypovolemia, shock
• Metabolic acidosis
• Hyperkalemia gtgt various arrhythmias
• Hypocalcemia and hyperphosphatemia contribute to
  cardiac instability

128
Hyperkalemia ECG Findings

• Peaked T waves
• Wide QRS complexes
• Depressed ST segments

129
Reperfusion Reoxygenation

• Reperfusion may create oxygen free radicals,
  superoxides, thromboxane

130
Calcium

• Serum calcium level falls
• Intracellular calcium rises in the injured muscle
  tissue
• Increased mitochondrial calcium impairs cellular
  respiration and ATP production

131
Should you give calcium?

• Not unless absolutely necessary to treat
  ventricular ectopy
• even then it is controversial
• will only transiently correct hypocalcemia
• will need a continuous infusion
• will be deposited in the injured muscle

132
Late effects renal

• Myoglobin and uric acid gtgt renal failure
• Only 200 gm of muscle tissue need to be crushed
  to develop clinically significant myoglobinuria
• not a hand or foot

133
Causes of renal failure

• 1. Ferrihemate and other decomposition products
  of myoglobin
• 2. Direct tubule obstruction by CPK, myoglobin,
  and uric acid crystals
• 3. Hypovolemia

134
Myoglobin

• Overflow appears in urine - red / brown
• At high levels, precipitates in kidney tubules
• Detect with urine dip-stick
• Solubility in urine is pH-dependent
• 0 precipitates at pH gt 7.5
• 73 precipitates at pH lt 5.0

135
Late effects non-renal

• Leukotrienes and other inflammatory agents can
  cause ARDS, cellular liver injury, etc.

136
Combat Hypovolemia

• Have good IV access in place before release
• Use normal saline (LR contains potassium and
  lactate)
• Carefully monitor fluid status vital signs,
  urine output, chest sounds, edema, etc

137
Hyperkalemia Acidosis

• Sodium bicarbonate
• Insulin dextrose
• Beta-2 agonists (albuterol)
• Calcium? (preferably gluconate)
• Kayexelate (not while trapped!)
• Dialysis

138
Prevent Renal Injury

• Ensure renal perfusion with IV fluids
• Carefully alkalinize urine with sodium
  bicarbonate
• Monitor both amount and pH (prefer gt6.5)

139
Crush Injury Cocktail

• During extrication
• Saline 1.5 liters per hour
• Consider adding 1 amp bicarbonate and 10 grams of
  mannitol to each liter

140
Crush Injury Cocktail

• After extrication
• 500 cc crystalloid per hour (after initial bolus,
  if needed for hypotension)
• ? saline alternating with 5 glucose
• Add 1 amp bicarb per liter - keep urine pH above
  6.5
• Give mannitol if urine output lt 300 cc/hr

141

• The aim of treatment is to produce diuresis of
  300 cc per hour, with a urinary pH of not below
  6.5.
• Michaelson, World J Surg, Sep 1992

142
Sodium Bicarbonate

• Some recommend empiric administration
  pre-release
• combats metabolic acidosis
• shifts K to intracellular space
• promotes renal excretion of K
• begins urine alkalinization

143
Mannitol

• Osmotic diuretic promotes urine flow
• but need adequate hydration status! (300 cc/hr)
• Effective scavenger of free radicals
• Helps protect against cell swelling
• 1 gm/kg IV bolus
• some recommend 10 gm/liter of IV fluid

144
Acetazolamide

• Give acetazolamide if blood pH lt 7.45
• 250 mg IV bolus
• Diuretic
• not a loop diuretic like furosemide
• loop agents tend to acidify the urine
• Will correct the metabolic alkalosis caused by
  the added bicarbonate
• Will also help increase urine pH

145
Care of the compressed limb

• Protect open wounds
• Non-compressive splint (no MAST)
• Monitor for signs of compartment syndrome
• Provide adequate pain control
• Keep level with heart
• too high decrease perfusion
• too low increase edema

146
Does early treatment work?

• Two groups of patients with similar injuries from
  Israel
• Lower extremity crush injuries
• Average time of 12 hrs in the rubble

147
1978 Seven patients

• First IV fluids about 6 hours after extrication
• Despite an average of 11 L/day, all seven
  developed renal failure requiring dialysis
• ICU stay of 12-39 days

148
11 Nov 1982 Tyre, Lebanon

• Eight-story building collapse
• 80 of 100 occupants killed
• 20 live victims extricated
• Seven with crush injuries
• Helicopter (20 minutes) to Haifa, Israel

149
1982 Eight patients

• All started on IV fluids during extrication
• 1.5 to 3 liters by arrival at hospital
• Forced alkaline diuresis begun within two hours
  of extrication
• None developed renal failure
• ICU stay 5-7 days

150
Hanshin-Awaji Earthquake

• 17 January 1995
• 7.2 magnitude
• 92,000 buildings collapsed
• 5,500 deaths
• 41,000 injuries
• Report of 372 crush syndrome patients at 95 area
  hospitals

151
372 Crush Syndrome Patients

• 50 deaths (13.4)
• 23 from hypovolemia
• 202 with renal failure (54.3)
• 123 needed dialysis (33)

152
Their Own Criticisms

• Crush syndrome was not properly recognized in
  some cases.
• Most of these patients received only 2,000 to
  3,000 mL/day of infused fluids during the initial
  3 days.
• we need to avoid such failure to recognize
  crush syndrome and to start infusion without
  delay.