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Sun Aug 26 00:28:18 BST 2007

Dear Sa'ad
The kinemtics and extent of the injuires will certainly put your patient into the high risk category for ARF and potential late death.

Estimation of the injury based on the skin appearance can be very unreliable and in fact we have had several patients with severe rhadmyolysis, from lying on the floor unconscious overnight, with no skin changes in the early stages.

The urine can be checked for myoglobin and often appears like coca-cola! CK levels in the thousands can develop within 6-12 hours and continue to rise.

Much of the work on crush has come from earthquake disaster victims and victims of severe beatings in S Africa:

Gunal AI, Celiker H, Dogukan A, et. al. Early and vigorous fluid resuscitation prevents acute renal failure in the crush victims of catastrophic earthquakes.  J Am Soc Nephrol. 2004 Jul;15(7):1862-7 

Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care Clin. 2004 Jan;20(1):171-92 

Papadopoulos IN, Kanakaris N, Triantafillidis A, et. al.  Autopsy findings from 111 deaths in the 1999 Athens earthquake as a basis for auditing the emergency response. Br J Surg. 2004 Dec;91(12):1633-40 
Knottenbelt JD. Traumatic rhabdomyolysis from severe beating-experience of volume diuresis in 200 patients. J Trauma 1994; 37:214-19 

This is one area of trauma where early aggressive fluid therapy is essential. 
Numerous treatment regimes exist but one of the current most popular is that produced by the International Nephrology Society who still support the production of a forced alkalline diuresis (3ml/Kg/hr)
They use a combination of alternating litres of 0.9% saline and 5% dextrose with 50mEq NaHCO3 added to each litre to maintain the alkaline pH 

If the target urine outputs are not achieved then interventional renal support should be considered early, especially if serum potassium levels are elevated and rising on serial results.

My good friend Jason Van Der Velde has a specialist interest in this area and I will ask him to post some more information for you on the list.

Hope that this helps, good luck!
Mark F
UK

I hope that this helps

----- Original Message ----
From: Sa'ad Lahri <slahri at webmail.co.za>
To: trauma-list at trauma.org
Sent: Saturday, 25 August, 2007 8:45:29 PM
Subject: crush injury

requesting opinions and possible suggestion for management

A 25
y old man was caught by members of his community for stealing chickens. He
was beaten with a belt (community assault) and arrived to hospital with
his relatives.

his back, both arms and thighs were bruised.

couple of questions regarding crush injury?
how do you
estimate severity? do you use % body surface area involved?
How
useful is CK measurement?
what type of fluid is used?
ringers/saline?

kind regards
Sa'ad

Dr Sa'ad
Lahri 
Emergency Medicine Registrar 
UCT/US 
Cape Town 
South Africa

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