Management of engineer presents with right is his recovery? arm - - PowerPoint PPT Presentation

11/6/2013 1

Management of Crush Injuries

PRESTON MAXIM

• ASSOC. PROFESSOR OF EMERGENCY MEDICINE
• DEPT. OF EMERGENCY MEDICINE

UCSF/SFGH

Case #1

28 yo male software engineer presents with right arm pain and weakness after using heroin and passed out on the couch. Exam shows wrist drop and diminished flexion and extension at elbow. Good pulse. How long and how complete is his recovery? 1. 5-10 days 2. 2-3 weeks 3. Up to 1-2 months 4. Partial at 3-6 month, no full recovery 5. Partial with surgery, but minimal functional recovery

Compressive Nerve injuries

• Three categories of injury

1. Neuropraxia – damage to myelin sheath. Most common in compression. Excellent/Full recovery – months at most 2. Axonotmesis – damage to axon and myelin, but intact

• stroma. Some regeneration possible, 1 mm/day.

3. Neurotmesis – damage to axon, myelin and stroma. No regeneration without surgical re-anastomosis

• Treatment:
• Splint in position of function.
• Early referral for Physical therapy (Neuropraxia) or nerve

conduction studies

Case #2

2 AM 36 yo F mildly intoxicated helmeted bicyclist hit by car and thigh was run over Trauma survey: isolated thigh injury. Good CSM. Negative radiographs. Patient in severe pain, unable to flex/extend

• knee. Good CSM, thigh

feels very firm

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Case #2 Continued

Call Ortho re: concern for compartment syndrome. You are told, ‘the patient is drunk and drug seeking. There is no fracture, good distal pulses, good distal

• sensation. She does not

have compartment syndrome and it would be malpractice to check her compartment pressures. Control her pain, and if you can’t, admit her to Medicine.’

• Do you:

1. Give pain meds and discharge home in an ambulance with return precautions 2. Give pain meds, follow serial exams and wait for a new resident/attending in the morning 3. Admit her to the Medicine service for pain control 4. Check her compartment pressure

Compartment Syndrome

CLASSIC FINDINGS

• Pain
• Pressure
• Paresthesias
• Paralysis
• Poikilothermia
• Pulselessness

CLINICAL FINDINGS

• Pain out of proportion
• Pain with passive

movement

• Woody feeling

Compartment Pressure

• Compartment numbers:
• Pressure > 30-45 require

fasciotomies

• High rate unnecessary

fasciotomy

• ACS Delta pressure

(Diastolic – compartment pressure):

• Less than 30 mm Hg –

fasciotomy

• Greater than 30 mm Hg –

trend for 6 hours

Compartment syndrome

• Continuous

compartment monitoring in the at risk obtunded patient

• Delayed diagnosis

increases morbidity

• Limb should be kept at

the level of the heart (no elevation)

• Only treatment is

surgical

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Case #3

Medics call: 35 M construction worker crushed under cinderblock wall from waist down. A&O times 3. BP = 120/40 HR = 90 10/10 pain after 10 mg

• Morphine. Want more

pain meds

• You reply:

1. No pain meds, it is helping maintain his BP 2. Give pain meds alone 3. Give pain meds and 500 cc of NS 4. Give pain meds and 2 liters NS 5. Give pain meds and 2 liters of LR

Earthquakes Experience

• All retrospective observational data
• 15-20% of earthquake crush injury victims develop

traumatic rhabdomyolysis

• 30-50% of those develop crush syndrome – shock and

renal failure

• CK > 75,000 – 84% dialysis
• CK < 75,000 – 39% dialysis
• Early aggressive hydration can decrease the rate of

renal failure to ~7% (Bam, Iran 2003)

• Bimodal survival relative to extrication time – high early

and late

Fluid Management

• f crush

victims

Early aggressive hydration is the key to preventing downstream renal failure

Traumatic Rhabdomyolysis

• Clinical manifestation:
• Pain from muscle injury

and/or compartment syndrome

• Hypovolemia
• Dark Urine
• Renal insufficiency

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Traumatic Rhabdomyolysis

• Creatinine Kinase –

comarker for myoglobin

• Screen with CK and Urine

dip – short myoglobin half- life

• CK starts to rise ~2 hours

after injury, peaks 24-72 hours

• Elevated CK and Myoglobin

lead to heme induced ATN

• CK > 5000 –

rhabdomyolysis

• ATN unlikely if CK < 15,000

Fluid Resuscitation and monitoring

• Initial fluid resuscitation with NS – 2 liters
• Theoretic benefit of alkalinization:
• 1 liter ½ NS with 50 meq sodium bicarbonate alternated

with 1-2 liters of NS

• Goal urine pH > 6.5
• No proven benefit
• Goal urine output of 200-300 ml/hr
• Majority of patients develop hyperkalemia

Conclusion

• Discussed management of nerve crush injuries
• Splinting in position of function and early referral
• Discussed compartment syndrome
• High index of suspicion
• Under-reliance on classic findings, rather serial exams and

clinical findings (pain, pain with passive motion and firmness)

• Early use of pressure manometer
• Discussed Crush syndrome
• Early aggressive hydration
• Follow CK levels and anticipate/expect hyperkalemia