Michaelson developed specific recommendations for a patient with crush syndrome following prolonged limb compression. These can help reduce serious complications to the patient. The author is from Rambam Medical Center in Haifa, Israel.
Although patients may initially appear to have minor injuries, they should be admitted to the ICU.
Monitoring:
(1) Vital signs hourly.
(2) Urine volume and pH hourly.
(3) Osmolarity and electrolytes in blood every 6 hours.
(4) Blood gases every 6 hours (at least initially).
(5) Peripheral pulses (if absent, additional vascular injuries may be present)
Hazards:
(1) intravascular hypovolemia
(2) acute renal failure from myoglobin toxicity (risk increased by oliguria and acid urine)
(3) hemorrhage from damaged muscles
(4) severe pain on nerve recovery
(5) infection
(6) loss of function below the knee
(7) distal gangrene
Hazard
Treatment
hypovolemia
infuse crystalloids
oliguria
(1) infuse crystalloids 500 mL per hour, (2) give mannitol 1 g per kg if urine output < 300 mL per hour
acidic urine (pH <= 6.5)
(1) give 22 mEq bicarbonate per hour with crystalloid infusion, (2) give acetazolamide 250 mg if blood pH > 7.45
bleeding from damaged muscles
(1) avoid fasciotomy if at all possible, (2) if fasciotomy required, resect all dead muscle at the first operation (all muscle that does not contract on stimuli)
severe pain
continuous analgesics
infection
(1) avoid debriding skin over crush injury; (2) avoid repeated debridements of muscle; (3) closely monitor surgical sites and vital signs
loss of leg function
(1) arthrodesis at the ankle; (2) avoid amputation
distal gangrene
(1) check for arterial lesion; (2) may require fasciotomy if compartment syndrome present; (3) may require amputation is due to uncontrolled infection
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