Learn about Crush Syndrome in Emergency Situations, its causes, symptoms, and treatments to prevent cardiac arrest and kidney failure during disasters.
Understanding Crush Syndrome
Crush syndrome, also known as compression syndrome, is a critical condition often observed in disasters and traffic accidents. It is characterized by a high mortality rate compared to other conditions.
Historical Context in Japan
Crush syndrome became widely recognized in Japan during the Great Hanshin-Awaji Earthquake. Out of 372 patients with crush syndrome, 50 died. Although medical professionals were aware of crush syndrome, they struggled to manage it effectively in the field.
Global Incidents of Earthquakes and Crush Syndrome
| Earthquake | Death Toll | Crush Syndrome Patients |
|---|---|---|
| Armenia Earthquake (1988) | 25,000 | 600 |
| Iran Earthquake (1990) | 40,000+ | Unknown |
| Great Hanshin-Awaji Earthquake (1995) | 5,000 | 372 |
| Turkey Marmara Earthquake (1999) | 17,000+ | 639 |
| Taiwan Chi-Chi Earthquake (1999) | 2,405 | 52 |
| Pakistan Earthquake (2005) | 80,000+ | 118 |
Rescue workers often face the ruins and debris of collapsed buildings. Crush syndrome occurs when heavy objects like debris trap parts of the body such as the waist, arms, or thighs for an extended period. When the pressure is relieved, toxins like myoglobin and potassium, released from damaged muscle cells, enter the bloodstream, causing severe complications and often leading to death. Even if patients survive initially, they might suffer from kidney failure later.
Key Characteristics
- Delayed Onset: Crush syndrome typically manifests after rescue, not before. Individuals who appear healthy immediately after rescue can suddenly deteriorate and die, leading to the term “Smiling Death.”
Treatment Methods
Emergency Treatment
- Fluid Therapy: The primary treatment involves administering saline or lactated Ringer’s solution at 1,000–1,500 mL per hour. Sodium bicarbonate or mannitol may be added as needed.
- Note: In Japan, saline use in emergencies is prohibited.
- Cardiac Monitoring: To prevent cardiac arrest caused by hyperkalemia, AED pads should be pre-applied. Monitoring the ECG for T-wave elevations can help estimate serum potassium levels.
Even with appropriate treatment, one in four patients with crush syndrome develops acute renal failure. Information should be provided to receiving hospitals in advance, and preparations for emergency blood purification therapy should be made.
First Aid by Laypersons
- Hydration: Encourage the patient to drink a large amount of water (at least 1 liter) to dilute toxins.
- Caution: Ensure the patient does not choke.
- Tourniquet Method: Applying a tourniquet can help prevent the spread of toxins to the heart and kidneys.
Four Key Points to Know About Crush Syndrome
Crush syndrome can occur following prolonged entrapment during natural or man-made disasters. Timely care before releasing compression can be life-saving. It is essential for EMS providers, whether in urban or rural settings, to be prepared for such situations.
Causes of Crush Syndrome
- Hypovolemia: Reduced blood volume.
- Life-threatening Arrhythmias: Abnormal heart rhythms.
- Renal Failure: Kidney failure.
Crush syndrome often affects patients trapped for more than 4 to 6 hours. EMS providers must be ready to manage these cases across various scenarios, including earthquakes and building collapses.
Pathophysiology
When the body is compressed for 4 to 6 hours, the following occur at the cellular level:
- Immediate cell damage near the compression site.
- Decreased circulation leads to anaerobic metabolism, producing lactic acid. Cell walls become permeable, leaking toxic substances like potassium and myoglobin.
- These toxins can cause severe complications if released into the bloodstream suddenly.
- The release of compression leads to rapid dissemination of toxins, potentially causing heart arrhythmias, kidney failure, and other systemic failures.
Patient Evaluation and Management
- Assessment: Identify the cause and duration of entrapment. Look for signs of significant body part compression.
- Treatment: Provide high-flow oxygen if hypoxic, establish IV or IO access before releasing compression, and administer fluids. Monitor ECG for hyperkalemia signs.
- Advanced Care: Use calcium chloride IV for suspected life-threatening hyperkalemia and consider aerosolized albuterol to help shift potassium intracellularly.
ECG Changes in Crush Syndrome
- Mild Hyperkalemia (6-7 mmol/L): Peaked T-waves.
- Moderate Hyperkalemia (7-8 mmol/L): Flattened P-waves, prolonged PR intervals, ST-segment depression, peaked T-waves.
- Severe Hyperkalemia (8-9 mmol/L): Atrial arrest, extended QRS duration, more pronounced T-wave peaks.
- Life-threatening Hyperkalemia (>9 mmol/L): Sinusoidal wave pattern.
Proper monitoring and timely intervention are crucial for managing crush syndrome effectively.
