You and your partner are dispatched as the first due responding ALS unit for an industrial rescue. The dispatch notes indicate that one worker is trapped after an accident, but no other workers are injured. You see that you have a heavy rescue, a rescue-engine and ladder company responding with a chief officer. Enroute, you and your partner start discussing how you will approach the extrication and the medical treatments that may be necessary.
The scenario described above falls into the category of low frequency, high impact. Simply stated, they don’t happen all that often, but when they do, they are time and resource intensive. You may only have an annual refresher on technical rescue and the medical treatment of these types of patients. Lastly, with the low frequency of these events, we are not able to refine our skills through repetition on the job. With any technical rescue, the first consideration should be, “Is the scene safe?” You will need to consider what other resources you may need on scene such as a second or third ALS unit for other victims and the rescuers.
Typical High-Pressure Air Bag Kit. Source: IFSTA
Arriving on scene you are directed to a staging area that will allow suitable egress from the incident. You find the victim conscious, alert and oriented with a patent airway. There is a large concrete pipe laying across the patient’s right femur. His chief complaint is leg pain, and he denies any other injuries. You attach your cardiac monitor and see that other than a slightly elevated normal sinus rhythm heart rate, all other vital signs are within normal limits. You establish two large bore IVs and follow your protocol for pain control with analgesia. By now the rescue company has determined that the best way to extricate the victim will be by using air bags to lift the pipe. The patient’s right leg has been pinned by the concrete pipe for 45 minutes. The rescue company say that they are ready to lift and are waiting for you to give the go ahead. Coordinated extrication is key in the removal of any victim, but with crush syndrome it is paramount due to the type of injury.
Crush injuries differ from other types of blunt force trauma. After as little as thirty minutes, the damage to large muscle groups will have a profound effect on your patient. When cells are crushed the cell membrane is compromised, and everything inside the cell is suddenly let out. The inflicting object, in this case a concrete pipe, prevents the spilling out of these harmful contents until it is removed or lifted from the muscle. You will be most concerned about the sudden release of potassium into the patient’s blood stream. Continuous ECG monitoring is key as you will be watching for ECG changes to determine the presence of excess potassium, known as hyperkalemia. The progression of changes during hyperkalemia will go from peaked T waves, to ST depression / prolonged PR intervals and eventually to a wide QRS / V-tach which is life threatening.
Sodium bicarbonate is a key medication used for treating crush syndrome. Calcium chloride and albuterol are other medications used.
We treat hyperkalemia with an array of medicines each carrying out a separate task. The first is by introducing a chemical buffer to offset the impending acidosis. This is achieved by pushing sodium bicarbonate. The timing of this administration is key. It must be done when the object is lifted and the sudden release of potassium hits the bloodstream. Secondly, we want to protect the myocardium which is especially sensitive to potassium by administering calcium chloride. This will precipitate if mixed with sodium bicarbonate, so use your second IV to accomplish this. Lastly, an albuterol treatment can be applied as it will help to drive potassium out of the bloodstream and back into uninjured cells. As soon as the victim is extricated be prepared to open your IV fluids wide open to obtain a systolic blood pressure greater than 100 and to give additional sodium bicarbonate and calcium chloride if ECG changes are observed. The patient should be promptly packaged and transferred to the nearest trauma center.
The key to the successful treatment of crush syndrome involves the coordination of all parties involved. You should not hesitate to call for additional resources such as another ALS unit or for a physician response team that may carry additional medication outside of your ALS protocol. As with any incident, scene safety and communication is key. Let your patient know what you’re doing and when you’ll be doing it. While time is of the essence, don’t rush through the extrication as not coordinating the administration of medication with the rescue company can have life-threatening effects. A rescue like this may be a once-in-a-career event, but your patient will be depending on your expertise to save them.
Author’s note: Always refer to your medical director and local protocols for clinical guidelines in your jurisdiction.
Larry Durland, BSN, RN, PHRN, CFRN, CEN
Elder Technical Rescue Services, LLC
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