Crush injury explained

A crush injury is injury by an object that causes compression of the body.^[1] This form of injury is rare in normal civilian practice, but common following a natural disaster.^[2] Other causes include industrial accidents, road traffic collisions, building collapse, accidents involving heavy plant, disaster relief or terrorist incidents.^[3]

Presentation

Complications

• Hypovolaemic shock. Loss of plasma volume across damaged cell membranes and capillary walls can lead directly to severe hypovolaemia.^[3] Shock can develop from myocardial depression following release of intracellular electrolytes. In addition, as a result of the mechanism of injury, blood loss from pelvic or long bone fractures may also co-exist.
• Hyperkalaemia and electrolyte imbalance. Disruption of cell membranes can result in a significant release of potassium, which is a largely intracellular cation that can precipitate cardiac arrest. Sequestration of plasma calcium into injured tissue can lead to a relative hypocalcaemia, which may worsen disruption of clotting abilities and shock. Metabolic acidosis may result from reperfusion injury and hypoperfusion related to shock.
• Compartment syndrome. Compartment syndrome is a common complication of crush injury as a consequence of oedematous tissue injury, redistribution of fluid into the intracellular compartment and bleeding. Established compartment syndrome may result in worsened systemic crush syndrome and irreversible muscle cell death.^[3]
• Acute kidney injury. Release of myoglobin by injured muscle leads to rhabdomyolysis coupled with shock leads to a significant rate of acute kidney injury, estimated as up to 15%.^[4] Acute kidney injury leads to a significantly higher mortality.

Pathophysiology

Crush syndrome is a systemic result of skeletal muscle injury and breakdown and subsequent release of cell contents.^[3] The severity of crush syndrome is dependent on the duration and magnitude of the crush injury as well as the bulk of muscle affected. It can result from both short-duration, high-magnitude injuries (such as being crushed by a building) or from low-magnitude, long-duration injuries such as coma or drug-induced immobility.^[3]

Treatment

Early fluid resuscitation reduces the risk of kidney failure, reduces the severity of hyperkalaemia and may improve outcomes in isolated crush injury.^[3]

For casualties with isolated crush injury who are haemodynamically stable, large-volume crystalloid fluid resuscitation reduces the severity of and reduces the risk of acute kidney injury.^[4]

See also

• Crush syndrome

Further reading

• Ganga hospital open injury severity score - A score to prognosticate limb salvage and outcome measures in Type IIIb open tibial fractures . Rajasekaran S. . Indian J Orthop . 2005 . 39 . 1 . 4–13 . 2016-09-06 . 2016-09-16 . https://web.archive.org/web/20160916115148/http://www.ijoonline.com/article.asp?issn=0019-5413;year=2005;volume=39;issue=1;spage=4;epage=13;aulast=Rajasekaran . dead .

Notes and References

1. Book: Ron Walls . John J. Ratey . Robert I. Simon . Rosen's Emergency Medicine: Expert Consult Premium Edition - Enhanced Online Features and Print (Rosen's Emergency Medicine: Concepts & Clinical Practice (2 vol.)) . Mosby . St. Louis . 2009 . 2482–3 . 978-0-323-05472-0.
2. Crush injuries and crush syndrome—A review . N.A. Jagodzinski . C. Weerasinghe . K. Porter . Injury Extra . July 2011 . 42 . 9 . 154–5 . 10.1016/j.injury.2011.06.368. free .
3. Consensus Statement On The Early Management Of Crush Injury And Prevention Of Crush Syndrome . Greaves, I. Porter, K . Smith, JE . Faculty of Prehospital Care, Royal College of Surgeons of Edinburgh . August 2003. 149 . 4 . 255–259 . 10.1016/S1479-666X(03)80073-2 . 15015795 .
4. Medical Complications Associated With Earthquakes. Bartels S . VanRooyen M . The Lancet. 2012 . 379. 9817 . 748–57. 10.1016/S0140-6736(11)60887-8 . 22056246 . 37486772 .