Management of Crush Injury

Pre-Hospital and Field Management

The American College of Surgeons recommends starting IV fluids immediately upon locating the victim, even while still trapped under rubble, with 0.9% normal saline at 1000 ml/hour initially to prevent acute kidney injury and death from hyperkalemia 1, 2
Insert IV cannula in an accessible limb; if no vein is available, use an intra-osseous needle in a lower limb, as recommended by the American Heart Association 1, 3
Infuse 0.9% normal saline at 1000 ml/hour initially, and reduce infusion rate by at least 50% (to ≥500 ml/hour) if extrication takes longer than 2 hours, as suggested by the European Resuscitation Council 1, 4

Administer 3-6 liters of 0.9% normal saline in the first 24 hours based on clinical response, with a target urine output of 200-300 ml/hour until myoglobinuria clears, as recommended by the National Kidney Foundation 1, 4
Adjust fluid volumes based on volume status, signs of fluid overload, patient age, body mass, and environmental temperature, as suggested by the American College of Emergency Physicians 1
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend inserting a bladder catheter to monitor urine output, unless urethral injury is suspected 2

Assess for compartment syndrome using the "6 Ps": pain, paresthesia, paresis, pain with passive stretch, pink color, pulselessness, as recommended by the Orthopedic Trauma Association 3, 5
Remove tight-fitting dressings and avoid limb elevation if compartment syndrome is suspected, as suggested by the American Academy of Orthopaedic Surgeons 3, 5

Initiate renal replacement therapy for life-threatening acidosis, hyperkalemia, or fluid overload, as recommended by the International Society of Nephrology 1
Earlier dialysis initiation may improve survival in trauma-associated acute kidney injury, as suggested by the European Renal Association 1

Do not use mannitol before adequate volume resuscitation, as it can worsen renal injury in hypovolemic patients, as recommended by the National Institute of Diabetes and Digestive and Kidney Diseases 4
Current evidence does not support active alkalinization over aggressive fluid resuscitation alone, as suggested by the American College of Physicians 1

Triaging crush victims away from active treatment due to lack of dialysis availability is not recommended, as intensive fluid management can restore renal function and avoid dialysis need entirely, as suggested by the World Health Organization 2
Failure to recognize crush injury early, missing the critical 6-hour window for fluid resuscitation, can lead to poor outcomes, as recommended by the American College of Emergency Physicians 2, 4