Learning objectives

• The course and symptoms of crush injuries/crush syndrome
• Anesthetic management of crush injuries

Definition and mechanisms

• Crush injuries are the result of physical trauma from prolonged compression of the torso, limb(s), or other parts of the body
• Muscles are grossly swollen, hard, cold, insensitive, and necrotic
• Extended entrapment with compression may cause:
  • Crush syndrome
  • Traumatic rhabdomyolysis
  • Compartment syndrome
• Rhabdomyolysis is characterized by skeletal muscle disintegration and the release of myoglobin and other proteins and electrolytes into the circulation:
  • Magnesium, phosphate, acids, creatine phosphokinase, and lactate dehydrogenase 
  • ↑ Potassium → cardiac arrhythmias
  • Sodium, calcium, and fluids → raised muscle volume and tension
  • NO →  muscle vasodilatation and aggravation of hypotension
• Myoglobuniuria and hypovolemia may lead to AKI
• • Tubular obstruction
  • Direct and ischemic tubular injury
  • Intrarenal vasoconstriction
• DIC may rarely happen with severe rhabdomyolysis
• Ultimately, patients go into shock affecting respiratory gas exchange due to lung edema

Signs and symptoms

• Petechiae
• Blisters
• Muscle bruising
• Superficial injuries 
• Myalgia
• Muscle paralysis 
• Sensory deficit
• Fever
• Cardiac arrhythmia
• Pneumonia
• ‘Tea or cola’ colored urine
• Oliguria 
• Renal failure
• Nausea
• Vomiting
• Agitation 
• Delirium

Management

D5W, dextrose 5% in water

Suggested reading

• Pollard BJ, Kitchen, G. Handbook of Clinical Anaesthesia. Fourth Edition. CRC Press. 2018. 978-1-4987-6289-2.
• James Williams, MBBCh FRCA FFICM, Chris Thorpe, MBBS FRCA FFICM, Rhabdomyolysis, Continuing Education in Anaesthesia Critical Care & Pain, Volume 14, Issue 4, August 2014, Pages 163–166.
• Rajagopalan S. Crush Injuries and the Crush Syndrome. Med J Armed Forces India. 2010;66(4):317-320.