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Medical Aspects of Urban Search

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Title: 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.
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