Back in the box: Crush injury

[MARK FORREST]

HI Tim,
Good to have your comments on this thread.
As  intensivists we abandoned forced alkaline diuresis in Rhabdo a number of years ago, as you suggest. However, we have had to recently review our crush managment protocol in light of the guidelines from the INS and their wealth of earthquake crush experience where they still support the use of both Mannitol and bicarb in certain cases.
Regards
Mark F
UK


----- Original Message ----
From: "Hardcastle, Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za>
To: Trauma-List (E-mail) <trauma-list at trauma.org>
Sent: Saturday, 1 September, 2007 4:40:04 PM
Subject: Back in the box: Crush injury


Hi all

I have been off-list for a week or so (Was at ISW2007 - great conference): I believe, from the archives, people (?Ross) were wanting my comment: So here it is!

CK is a screening test - if over 500 there is certain muscle damage. Repeat values are USELESS. You need to follow the urea and creat values to guide therapy. They may be up initially, but if "volume flush" - (its not loading!) does not drive them down, your patient will end on dialysis. Also don't be fooled by an initial normal U&E, as urea and creat may be going up, even if still within the normal limits. You need at least three "normal" and/or improving (no increasing standard deviation) U&E with a good output prior to discharge. Some people say to aim for an SG of 1005, although this is not based on any good science.

Suggest you look at the paper from Brown et. al. in J Trauma (USC) where they proved that most often alkalinisation and mannitol/furosemide are NOT required, with a few, notable exceptions. We see around three of these type of cases a week at TBH and we have only used mannitol twice in the last three years, while sodabic has been used a little more often.

We have just looked at the BSA correlation to injury severity; it applies mostly to this type of scenario (community mob-justice). It helps to predict who may develop renal failure, yet it is not useful in the context of entrapment or penetrating injury.

Sa'ad as a member of the EM dept, you can get a copy of our guidelines from me when you rotate here or by off-list direct e-mail.

Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS  instructor and DSTC Cape Town Course Director
Intern program Coordinator: Surgery
M.Med (Emergency Medicine) Executive Committee member
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Division of Surgery (General) Room 4064
Department of Surgical Sciences
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa
e-mail: tch at sun.ac.za
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302


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