Initial assessment (ABCDE) (**ABCDE** primary survey · document **entrapment duration**, **affected muscle mass**, concurrent trauma, and **hypovolemia** from bleeding · **release time is critical** — potassium, myoglobin, and inflammatory mediators surge on **reperfusion** · neurovascular exam **distal to injury** before and after extrication (ATLS pediatric, WHO crush injury guidance, ERC trauma))
Localized crush — lower crush-syndrome risk (Short entrapment (<1 h) · **small muscle mass** (hand, forearm, foot) · no systemic signs · normal perfusion and mental status — still requires IV access, fluids, serial labs, and admission observation if entrapment occurred (WHO, ATLS, pediatric trauma principles))
Max 1000 mg/dose · Duration: 5–20 min · 10–20 mL/kg over 5–20 min (calculator: mL = 10–20 × weight kg) — for hypovolemia or shock; reassess perfusion; repeat only if shock persists; see fluid_bolus card for cumulative limits (ATLS, AAP PALS, WHO)
• **Start fluids BEFORE release:** when entrapment ongoing and IV access available, begin isotonic crystalloid **before extrication** — anticipates reperfusion surge of potassium, myoglobin, and inflammatory mediators; do not delay extrication for fluids if life-threatening entrapment (WHO crush injury guidance, ATLS pediatric).
• **Initial bolus (if hypovolemic):** **10–20 mL/kg** isotonic crystalloid over 5–20 min (calculator: mL = 10–20 × weight kg) — for hypovolemia, poor perfusion, or concurrent hemorrhagic shock; reassess after each bolus; hemorrhage requires **blood products** not crystalloid alone (ATLS, AAP PALS, fluid_bolus card).
• **Maintenance + replacement:** after bolus or if euvolemic, continue isotonic fluids at **maintenance (Holliday-Segar) + deficit replacement** — titrate to **urine output 1–2 mL/kg/h** in children to maintain renal myoglobin clearance and prevent AKI (WHO crush injury, pediatric trauma, rhabdomyolysis principles).
• **Compartment syndrome vigilance:** pain out of proportion, pain with passive stretch, tense compartment, paresthesia, pulselessness (late) — differentiate from expected post-crush pain; measure compartment pressure if available; clinical diagnosis often sufficient in children; urgent orthopedic consult if suspected (ATLS, pediatric orthopedics).
• **Admission criteria:** all significant crush with entrapment, large muscle involvement, elevated CK, myoglobinuria, electrolyte abnormalities, need for fasciotomy, or inability to monitor UOP/labs — observe minimum 24–48 h for delayed crush syndrome (WHO, ATLS, AAP trauma).
Enter weight on Kids to calculate doses
Compartment pressure monitoring • procedure
Duration: PRN · Measure compartment pressure if available — delta pressure (diastolic BP − compartment pressure) <30 mmHg or absolute >30 mmHg supports diagnosis; in children clinical exam often sufficient; do not delay fasciotomy if clinical picture clear (ATLS, pediatric orthopedics)
• Fasciotomy indications: **confirmed or strongly suspected compartment syndrome** with neurovascular compromise — pain out of proportion, passive stretch pain, tense compartment, paresthesia; urgent orthopedic/vascular consult; perform **after extrication** if indicated (ATLS, WHO).
• NOT prophylactic fasciotomy: crush injury alone without compartment syndrome signs does **not** mandate fasciotomy — avoid unnecessary soft-tissue damage; clinical monitoring and compartment pressure measurement when equivocal (pediatric orthopedics, ATLS).
• Rhabdomyolysis labs: obtain baseline and serial **CK**, **myoglobin**, **BMP** (K+, creatinine, bicarbonate), **urinalysis** — myoglobinuria = positive blood on dipstick **without RBCs**; trend q6–12 h in first 24 h (WHO, rhabdomyolysis guidelines).
• Mannitol/furosemide: **limited evidence** — **not routine** per WHO if adequate IV hydration achieves target UOP; consider only under specialist guidance if oliguria despite fluids (WHO crush injury).
• Balanced crystalloids: LR or Plasma-Lyte acceptable alternative to 0.9% NaCl at same volumes — may be preferred with large-volume resuscitation and acidosis concern (ATLS, pediatric critical care).
Clinical notes
• Initial assessment: **ABCDE** survey — document entrapment duration, affected muscle mass, concurrent trauma, bleeding; **neurovascular exam distal to injury** before and after extrication; release time critical as toxins surge on reperfusion (ATLS, WHO, ERC).
• Crush syndrome recognition: systemic muscle injury → hypovolemia + hyperkalemia + metabolic acidosis + myoglobinuria → AKI; risk increases with entrapment **>1–4 h** and large muscle mass (thigh, pelvis, trunk); watch for dark urine, rising CK, hyperkalemia, arrhythmia after release (WHO crush injury guidance).
• Fluid resuscitation mainstay: start **IV isotonic crystalloid BEFORE release** when possible; **10–20 mL/kg boluses** if hypovolemic; maintenance + replacement targeting **UOP 1–2 mL/kg/h**; avoid hypotension; treat hemorrhagic shock with blood products concurrently (WHO, ATLS, AAP PALS).
• Compartment syndrome: pain out of proportion, passive stretch pain, tense compartment, paresthesia, pulselessness (late) — differentiate from expected crush pain; fasciotomy only for confirmed/suspected compartment syndrome with neurovascular compromise, not prophylactic for crush alone (ATLS, pediatric orthopedics).
• Hospital admission: all significant crush with entrapment or large muscle involvement, elevated CK, myoglobinuria, electrolyte abnormalities, fasciotomy need, or inability to monitor — observe 24–48 h minimum for delayed crush syndrome (WHO, ATLS, AAP trauma).
• WHO — Clinical management of crush injuries (mass casualty and disaster settings) (2022)
• ATLS — Advanced Trauma Life Support (pediatric trauma and crush injury principles) (2024)
• AAP — Pediatric Advanced Life Support (PALS) shock and fluid resuscitation (2024)
+ 2 more
• ERC — European Resuscitation Council Guidelines (pediatric trauma and resuscitation) (2021)
• WHO — Pocket Book of Hospital Care for Children (trauma and IV fluids) (2022)
