29.10 Traumatic injuries to Extremities

Question 1

PE findings for crush injury depend on

Answer 1

duration of entrapment, treatment rendered, time of victims release

Question 2

PE:
1)Initially, may appear normal just after extrication.
2)Edema develops and extremity becomes swollen, cool, and tense.
3)Pain out of proportion with examination.
4)May mimic a spinal cord injury with flaccid paralysis but there will be normalbowel and bladder function.
5)Trunk/Buttocks: May have severe pain out of proportion with examination intense compartments.

Answer 2

Crush syndrome

Question 3

Lab findings for Crush syndrome

Answer 3

(a)Creatinine phosphokinase (CPK) is elevated with values usually >100,000 IU/mL.
(b)Urine: may appear concentrated then later change color. Typical reddish-browncolor. Urine output decreases volume over time.
(c)Due to myoglobin, the urine dipstick is positive for blood
(d)Hematocrit/hemoglobin (H/H) depends on blood loss. H/H is elevated due toHemoconentration from third-spacing fluid losses.
(e)With progression, potassium and CPK increase. Creatinine and Blood UreaNitrogen will increase due to renal failure.
(f)Hyperkalemia is an ultimate cause of death from cardiac arrhythmia

Question 4

Treatment of Crush syndrome

Answer 4

(a)Key in improving outcomes is early and aggressive fluid resuscitation
(b)Remember toxins are accumulating within the entrapped limb and once extricated,
(c)The accumulated toxins wash into the central circulation.
(d)Resuscitation needs to occur before extrication to minimize to toxic effects of myoglobin and potassium before release of the limb.

Question 5

Fluid resuscitation for crush injuries

Answer 5

1)A delay in fluid resuscitation, results in renal failure in 50% of patients, a delay of 12 hours or more produces renal failure in almost 100% of patients.
2)Poorly resuscitated patients may go into cardiac arrest during extrication due to sudden release of metabolic acid and potassium into the blood stream
3)Avoid potassium and lactate containing IV solutions.
4)1 L should be given prior to extrication and up to 1L/h (short extrication time)to a maximum of 6-10 L/d in prolonged entrapments.
5)Addition of one ampule (50mEq) of sodium bicarbonate and 10 grams ofmannitol to each liter of fluid to decrease the incidence of renal failure.
6)Last resort, amputation may be necessary for rescue of entrapped casualties

Question 6

Treatment of hyperkalemia in crush injuries

Answer 6

1)Recognized by the development of peaked T waves on cardiac monitor
2)Follow standard protocol for treatment to include Sodium Bicarbonate IV Dextroseand insulin (if available).
3)Life threatening arrhythmia occurs, Calcium Chloride