Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XVII: Crush Injury

General Management

United States Department of Defense

Intravenous therapy should be initiated immediately after extrication or even, when possible, while the casualty is still trapped. Glucose-saline is the solution of choice; however, Ringer's solution may be used. The early objective is to achieve a constant diuresis of at least 300 cc's per hour with a urine pH of greater than 6.5. An indwelling urinary catheter is inserted. A central venous or pulmonary artery wedge pressure catheter should be utilized to guide fluid infusion and reliably monitor central pressures.

1. In the presence of an appropriate urinary response, crystalloid solution is administered at the rate of 500 cc/hour. Bicarbonate, 44.5 mEq, is added to the crystalloid solution every other hour.

2. Urine volume and pH are monitored hourly.

3. Serum electrolytes, osmolality, and arterial blood gasses are evaluated at six hour intervals.

If the urinary volume is less than 300 cc per hour, mannitol. (1.0 g per kilogram body weight) should be given intravenously. If the arterial pH reaches 7.45 or the urine pH is below 6.5, 250 mg acetazolamide should be given intravenously. This therapy should continue until myoglobin disappears from the urine. It usually takes about 60 hours to achieve this goal.

The earlier one starts intravenous therapy, the better the chance of preventing acute renal failure. When fluid therapy is delayed for six hours following, extrication, acute renal failure is almost assured. If the desired urinary output cannot be achieved, the use of diuretics, preferably furosemide, should be considered. The majority of crush injury victims who do not receive intravenous therapy early enough and who do not respond to enforced alkaline diuresis go on to develop renal failure and the requirement for hemodialysis. If renal failure develops, prompt reduction in fluid administration is indicated.

Infection, which contributes to the development of acute renal failure, should be prevented by all possible means. Wide-spectrum antibiotics, including agents which are effective against anaerobic microorganisms, are indicated. Tetanus toxoid should be given according to the casualty's state of immunization.

The clinical features of crush syndrome may not become evident until just before the patient is to be evacuated on the basis' of his other injuries. If renal insufficiency seems to be developin& the patient should be evacuated, as soon as the other injuries permit, to a medical facility that is capable of monitoring and treating the condition with renal dialysis.

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Operational Medicine 2001

Health Care in Military Settings

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