You are called to an industrial site where a 37 year old male has reportedly crushed his leg when a heavy pipe has fallen onto him. He is conscious and no catastrophic bleeding has been reported. As you arrive you hear the patient before you see them as they are screaming in agony. The patient has a heavy large steel pipe across his anterior thighs, knees, and proximal lower leg after it had come away from the wall and the patient was working underneath it. There has been a delay since they found the patient and he has been stuck for around an hour till this point. The fire service have been contacted and they are on their way, but a colleague of the patient has organised a forklift to arrive imminently to lift it off.
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What should be your first priority as you start your assessment?
The scene is safe so you can approach the patient, you conduct a rapid primary survey but can’t see any bleeding under the pipe or any other initial deficits. Your crew-mate starts to collect initial observations and you get pain relief set up as the patient is very difficult to assess when in this much pain. What would be the more appropriate and quickest pain relief option at this time?
You use your Penthrox as a quick pain relief and it has a good effect, the patient is still in pain but has calmed significantly. You crew-mate has initial observations of 118 HR, 26 RR, 139/86 BP, 98% Sp02 on air, 36.4 Temp, 4.8 blood sugar. Apart from the crushing pipe, there are no other injuries on a brief secondary examination of the patient’s upper body and pelvis. You look for signs of limb ischemia distal to the pipe on the lower legs and feet. What signs are you looking for?
You see pallor, swelling and extensive bruising near the pipe. The patient still has pulses but are difficult to find. You are quite concerned about crush syndrome. Crush injury and crush syndrome are very similar in definition?
As the patient is still in pain you gain IV access to top up with morphine. You also look to administer fluids due to your concerns with crush syndrome. Are you able to administer fluids with a blood pressure above 90mmHg systolic?
What is your initial bolus of fluids when giving for crush syndrome?
You start your fluid treatment and have administered small doses of morphine to maintain pain relief. The forklift arrives and they plan to lift the pipe by inserting a fork inside the pipe so there should be no risk to other people present and should be secure. You should tell the driver of the forklift to delay lifting the pipe so you can give your full fluid bolus and limit the effects of crush syndrome, True or False?
You need the pipe off as quickly as possible so you can extricate the patient and transfer to the definitive care he needs. Before they do that however, what could you do to prevent any potential catastrophic haemorrhage as the pipe is lifted?
As the pipe is lifted off you see minimal bleeding, however, the legs look crushed with major bruising and muscle damage, and now you are even more concerned about crush syndrome. What monitoring maybe required for ongoing care due to the potential effects of crush syndrome?
The patient seems comfortable with the pain relief given. There is no haemorrhage and you’ve given the medications required. You look to extricate the patient. What hospital are you going to take them to?
What complications can manifest due to crush syndrome?
What components are released from the damaged muscle tissue that can enter the circulating blood volume causing these complications?
What ECG findings may make you consider hyperkalaemia in a patient?
Critical care teams can assist in the management of crush injuries and resultant syndrome with further medications they carry, True or False?
It is universally accepted that if a patient has been crushed for over one hour regardless of how much muscle mass has been damaged that they are likely to experience crush syndrome?