Years ago, I had the privilege of listening to a lecture by a young amputee–a former heroin user who had fallen into a drug-induced sleep with one of her legs caught under her contorted body. In her stupor, she had fallen into a laundry basket, somehow mistaking it for her bed. When she awoke the next day, she was in the hospital, recovering from amputation of her leg. The doctors told her that she was “lucky”. Had her friends discovered her any later, she would have most likely died, a victim of crush syndrome. “It’s a stupid way to lose your leg,” she said to the high school audience.
Crush syndrome was first described after the Battle of London in 1941. German bombs destroyed countless buildings, and some who were pulled from the rubble initially appeared to be unharmed. They then developed progressive limb swelling and shock, and died of renal failure within days.
Crush syndrome is essentially a systematic breakdown of muscle cells, with a release of their contents into the circulation system, which impacts many organs. Problems in addition to acute renal failure include sepsis, acute respiratory distress syndrome, hypovolemic shock, and arrhythmias.
There are three criteria characterizing crush syndrome:
- Involvement of muscle mass
- Prolonged compression (1-6 hours)
- Compromised local circulation.
Crush injuries are common in human-induced disasters such as bombed buildings of London in 1941, and natural disasters such as earthquakes, but emergency physicians more commonly see the syndrome in patients after motor-vehicle collisions, especially with prolonged extrications. Crush syndrome also occurs in those who compress a part of their own body, such as individuals “found down” due to a stroke or intoxication. Any situation with prolonged immobility and pressure on a body part that compromises circulation can result in a crush injury.
Impacts and Treatment
Regardless of how it occurs, the crush syndrome affects many organs. Problems in addition to acute renal failure include: sepsis, acute respiratory distress syndrome, hypovolemic shock, and arrhythmias.
The initial appearance of the patient with crush syndrome may seem benign; conscious patients may only complain of extremity pain. However, the crush syndrome causes a rapid clinical deterioration unless appropriately treated. Failure to recognize the potential for its existence, and removing the compressive force prior to arrival of medical assistance, can cause major problems such as development of hyperkalemia (elevated potassium in the blood that can lead to fatal arrhythmia). Prompt ECG monitoring is considered a higher priority in crush patients than in other trauma patients.
An illustration of the importance of these early treatment and monitoring points is the 1987 case of an Amtrak passenger train derailment in Silver Spring, MD. A middle-aged woman was pinned in the wreckage for 12 hours. She was reported to be conscious, alert and oriented while the rescue was in progress. Just fifteen minutes after extrication, however, she went into sudden cardiac arrest and died despite the rapid application of advanced cardiac life support and transport to a trauma center.
Medical professional consider the most critical therapy in crush syndrome to be early and aggressive fluid resuscitation with 0.9% saline to restore circulating blood volume. Traditionally, patients were treated with IV fluids several hours after arrival at the hospital. However, more recent practices of starting IV fluid resuscitation at the scene, even before extrication or movement, have demonstrated improved outcomes, including reducing the need for renal replacement therapy (RRT), and reducing mortality.