Podcast Episode 14: Crush Injury Round Table PFC Case Discussion
This podcast is a follow up from our last post on managing crush injuries in austere environments. We included a scenario discussion with
LTC Riesberg, Dennis, Eric and myself. To cap it all off we included a new quiz below which is similar yet slightly different from the poll in the earlier Crush post. You will get immediate feedback after answering all 4 questions.
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Click Here to Take Our New 4-Question Crush Quiz!
Below you will find the PFC Card and transcript from the case presentation in the podcast if you would like to read through it at your own pace or use it in the future for your own training scenario:
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?
Prolonged Field Care Card v17.1
Current TMEPS Pages (v.9) Regarding Crush Injury:
The full Tactical Medical Emergency Protocols are available from the JSOM online store.
The austere environment is very different from the civilian world, yet you seemed to have accomplished, somewhat the pain your brother was dealing with. Yet with such prolonged impingement, sodium bicarb has been our saving grace aside from Ketamine as well as chemically controlling his airway if expedient transport were available, but in a prolonged environment that would nearly be impossible. Yet, from what I see and understanding you you did bravo zulu work…
I have a question on the use of D50 on its own without insulin. Its seems to me that this is a possibility since the D50 will bind to the potassium. Then with the increased blood glucose the pancreas (in a healthy non- diabetic) will release insulin thus pulling potassium back into the cells. Is this an option that has validity in the abscence of insulin?
This is a good thought, using the bodies own insulin to teat hyperkalemia, however in practice this doesn’t bear out. There are a few reasons for this:
1. Dextrose doesn’t bind to K+, it’s the insulin that acts as a co-transporter to bring both glucose and K+ into the cell.
2. In a trauma patient or patient in shock or even just pain, the sympathetic NS and stress response releases cortisol, this hormone acts to antagonize insulin. This causes an increase in glucose levels in the blood (i.e., if you gave the patient glucose in this state they wouldn’t be able to bring it into the cell and the blood glucose levels would just go up (hyperglycemia).
3. D50 is a transient hypertonic solution. This increase in serum osmolality would cause a transient shift of fluid into the vascular space (seems good), but that extra water would dilute the normal buffer capacity within the blood and cause a decrease in serum pH (acidosis), when the body does get around to utilizing the dextrose, all that will remain is the hypotonic water left behind and again causing more acidosis.
This acidosis can actually cause and increase in serum potassium levels (more hyperkalemia).
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Question: Since TMEPS and SOF Med handbook warn against the use of LR in Crush injuries (hyperkalemia concerns). Can you just talk through your decision to use 500mL LR at POI almost immediately. Not armchair quarterbacking so much as seeking an adult opinion.
Rob
Thanks for the question. In this scenario, my first priority would go to restoring perfusion. Not just to keep my BP up, but also to maintain a high UOP, and avoid injury to the kidneys. It is true that LR contains K+, however at 4mmol/L, it is a small drop in the bucket. My worry with giving solely NS in this case is the fact that after a couple of litters hyperchloremic acidosis is a very real concern. Adding this to a patient that probably already metabolic acidosis (and maybe some respiratory acidosis as well), would increase the badness. For more information on fluids, I would ask you to review the PFC Fluid therapy under the position paper tab. In the end though, giving any crystalloid is better than giving nothing. We always have to remember to keep our priorities straight.
Thanks again for the question