Crush Syndrome: A Case Report and Review of the Literature
Crush Syndrome: A Case Report and Review of the Literature
Background: Crush trauma to the extremities, even if not involving vital organs, can be life threatening. Crush syndrome, the systemic manifestation of the breakdown of muscle cells with release of contents into the circulation, leads to metabolic derangement and acute kidney injury. Although common in disaster scenarios, emergency physicians also see the syndrome in patients after motor-vehicle collisions and patients "found down" due to intoxication.
Objective: The objectives of this review are to discuss the pathophysiology of crush syndrome, report on prehospital and emergency department treatment, and discuss the relationship between crush syndrome and compartment syndrome.
Discussion: We present the case of a young man found down after an episode of intoxication, with compartment syndrome of his lower extremity and crush syndrome. Although he eventually required an amputation, aggressive fluid resuscitation prevented further kidney injury and metabolic derangement.
Conclusions: Early, aggressive resuscitation in the prehospital setting, before extrication if possible, is recommended to reduce the complications of crush syndrome. Providers must be aware of the risk of hyperkalemia shortly after extrication. Ongoing resuscitation with i.v. fluids is the mainstay of treatment. Compartment syndrome is a common complication, and prompt fasciotomies should be performed when compartment syndrome is present.
Crush trauma to the extremities, even if not involving vital organs, can be life threatening. The term crush injury refers to the damage resulting directly from the crushing force. Conversely, crush syndrome, also known as traumatic rhabdomyolysis, is the systemic manifestation of the breakdown of muscle cells with release of contents into the circulation. Crush syndrome leading to acute kidney injury (AKI) is one of the few life-threatening complications of crush injuries that can be prevented or reversed.
Crush syndrome was first described after the Battle of London by Bywaters and Beall in 1941. Patients pulled from the rubble initially appeared to be unharmed, but then these patients developed progressive limb swelling and shock and died of renal failure a few days later. Postmortem examination revealed muscle necrosis and brown pigment casts in the renal tubules. Crush injuries are common in natural disasters such as earthquakes, but emergency physicians more commonly see the syndrome in patients after motor-vehicle collisions, especially with prolonged extrications, as well as in victims of assault. Crush syndrome also occurs in patients who compress a part of their own body, such as patients "found down" due to a stroke, intoxication, or mental illness. Any condition that results in prolonged immobility can result in a crush injury. In the United States, heroin is a common etiology and alcohol has been found to be the most common etiology of crush syndrome, compartment syndrome, and rhabdomyolysis in many industrialized countries. Patients might regain consciousness within several hours, but due to pain in limbs are unable to get up off the floor, leading to ongoing compression.
Abstract and Introduction
Abstract
Background: Crush trauma to the extremities, even if not involving vital organs, can be life threatening. Crush syndrome, the systemic manifestation of the breakdown of muscle cells with release of contents into the circulation, leads to metabolic derangement and acute kidney injury. Although common in disaster scenarios, emergency physicians also see the syndrome in patients after motor-vehicle collisions and patients "found down" due to intoxication.
Objective: The objectives of this review are to discuss the pathophysiology of crush syndrome, report on prehospital and emergency department treatment, and discuss the relationship between crush syndrome and compartment syndrome.
Discussion: We present the case of a young man found down after an episode of intoxication, with compartment syndrome of his lower extremity and crush syndrome. Although he eventually required an amputation, aggressive fluid resuscitation prevented further kidney injury and metabolic derangement.
Conclusions: Early, aggressive resuscitation in the prehospital setting, before extrication if possible, is recommended to reduce the complications of crush syndrome. Providers must be aware of the risk of hyperkalemia shortly after extrication. Ongoing resuscitation with i.v. fluids is the mainstay of treatment. Compartment syndrome is a common complication, and prompt fasciotomies should be performed when compartment syndrome is present.
Introduction
Crush trauma to the extremities, even if not involving vital organs, can be life threatening. The term crush injury refers to the damage resulting directly from the crushing force. Conversely, crush syndrome, also known as traumatic rhabdomyolysis, is the systemic manifestation of the breakdown of muscle cells with release of contents into the circulation. Crush syndrome leading to acute kidney injury (AKI) is one of the few life-threatening complications of crush injuries that can be prevented or reversed.
Crush syndrome was first described after the Battle of London by Bywaters and Beall in 1941. Patients pulled from the rubble initially appeared to be unharmed, but then these patients developed progressive limb swelling and shock and died of renal failure a few days later. Postmortem examination revealed muscle necrosis and brown pigment casts in the renal tubules. Crush injuries are common in natural disasters such as earthquakes, but emergency physicians more commonly see the syndrome in patients after motor-vehicle collisions, especially with prolonged extrications, as well as in victims of assault. Crush syndrome also occurs in patients who compress a part of their own body, such as patients "found down" due to a stroke, intoxication, or mental illness. Any condition that results in prolonged immobility can result in a crush injury. In the United States, heroin is a common etiology and alcohol has been found to be the most common etiology of crush syndrome, compartment syndrome, and rhabdomyolysis in many industrialized countries. Patients might regain consciousness within several hours, but due to pain in limbs are unable to get up off the floor, leading to ongoing compression.
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