Crush injuries are difficult to manage in the best of circumstances. In an austere environment by a practitioner with little to no experience they can be overwhelming. In deciding which problem to address in depth first, crush syndrome seemed to be a great choice. The Clinical Practice Guideline is well on it’s way to being released very soon. As discussed in the podcast, our recommendations are an amalgamation of best practices adapted for our difficult environment. It is an injury that can happen anywhere to anyone and the correct initial management can make all the difference in patient outcome. Enough out of me, I’ll let Doc Riesberg explain it via his talk he gave earlier this year to the Joint Trauma System Teleconference.
Take a couple minutes and test your knowledge:
Next episode we have a great discussion with Doc Riesberg, Doc Powell, Erik and myself in which we will discuss your answers as well as the following case presentation on the topic of crush injury:
During our last deployment, we were tasked with training local police in vehicle mobility. The original “house” we were using must have been around forever. We didn’t have our Engineer Sergeant out with us at the time that building was put up and didn’t know if the house was rated to hold the weight of the large water tank on the roof.
One night we all woke up to a loud crash and screaming. As we scrambled to make sense of what had just happened, we found Josh under a pile of debris as he continued to call for help and grunt in pain.
I was on the other end of the building and grabbed my aid bag. As I made my way through the rubble, I clicked on my headlight and crawled over to where his screams were coming from. His abdomen, torso and arms appeared uninjured, but his legs were not visible. Josh was in the worst pain I had ever seen anyone in. I gave him 100mg of Ketamine IM, which wasn’t as effective as I had hoped it would be, and started a Ketamine drip before the initial dose wore off He didn’t have any respiratory distress, beside the dust, so I gave him 2mg of midazolam as well. His right tib/fib was clearly broken and I had someone splint it. It was at this point that someone started to manage the scene and worry about secondary collapse. Some shop lights were brought in and set up so that we could properly assess the situation. Our team leader started making calls: the TSOC, the B Team etc. The 250cc bag of NS I had running wide open quickly ran out and I switched it for a 500cc bag of LR. I knew the longer he was trapped, the worse it would be when we finally got him out.
We didn’t have a crane or a winch. After about an hour of running around someone finally thought of drilling a hole in the bottom of the tank to let the majority of the remaining water out. The iron supports and muddy bricks were still pinning him down.
I knew he was probably going to need a Foley but didn’t want to do it in that ridiculously dirty environment. At this point I had given him nearly 2 liters of LR and knew he was probably going to pee soon. I emptied a Nalgene and put it where I thought it would catch his urine if he did go. I had also started up some Invanz IV. I also hooked up the new tempus monitor with the 12 lead. We hadn’t figured out how to network the vitals back to a receiving station yet, but could email pictures of rhythms.
By the time we thought we were ready to jack the mangled iron off of his leg. He had been trapped with his leg crushed for over 3 hours and I had used roughly 4 liters of fluids and 600mg of Ketamine. I organized my notes and called the Virtual Critical Care Consult:
- Using the PFC casualty card and the Telecom cheat sheet, what do you want to tell them?
- What do you want them to help you with?
- What follow on problems are you worried about?
- What will you do to address them?
Questions and comments are always welcome below or on our Facebook Page.