EMT STANDING ORDERS:

• Routine Patient Care. Administer oxygen as appropriate with a target of achieving 94 - 98% saturation.
• Initiate spinal motion restriction if indicated.
• Acquire and transmit 12-lead ECG if available. If extrication is prolonged, obtain multiple ECGs.
• Call for AEMT/Paramedic intercept. & Assisst AEMT/Parmedic in patient care. Patients who have experienced suspension or vertical entrapment injuries should be rapidly extricated to a supine position to restore blood flow to heart and brain.
• Assess and treat for traumatic injury. See Traumatic Emergencies Protocol.
• See Shock Protocol - Adult and Pediatric, and Trauma Triage and Transport Decision Policy.

AEMT Standing Order:

• Establish IV/IO access. Do not delay transportation to initiate IV/IO access, however, if the patient is entrapped it is preferable that IV/IO access be initiated and a fluid bolus of 1,000 - 2,000 mL 0.9% NaCl (Pediatric: (20 mL/kg 0.9% NaCl) be administered prior to extrication.)
• Assess pain level. Consider pain control measures. See Pain Management Protocol - Adult & Pediatric (43 Medical).

PARAMEDIC Standing Order:

• For significant crush injuries or prolonged entrapment/suspension, consider:
  • Sodium bicarbonate 1 mEq/kg (maximum dose 50 mEq) IV/IO bolus over 5 minutes.
• Consider the following:
  • Monitor for dysrhythmias or signs of hyperkalemia before and after extrication.
  • If ECG is suggestive of hyperkalemia, consider administering the following:
    • Calcium chloride (10% solution) 1-gram IV/IO over 5 minutes, may repeat in 10 minutes (Pediatric: 20 mg/kg IV/IO (maximum dose 1 gm)) OR
    • Albuterol continuous 10 - 20 mg nebulized.

AEMT/PARAMEDIC EXTENDED CARE ORDERS:

• Secondary to initial bolus, consider sodium bicarbonate infusion:
  • 150 mEq in 1000 mL 0.9% NaCl or D5W at a rate of 250 mL/hr or 4 mL/min.
• In the event that adequate fluid resuscitation is not available, consider applying a tourniquet on the affected limb and do not release until adequate IV fluids and/or medications are available.
• If extrication is prolonged > 1 hour, contact online Medical Direction for additional considerations prior to extricating the patient.

PEARLS:

• Compression syndrome: An indirect muscle injury due to a simple, slow compression of a group of muscles leading to ischemic damage and release of toxic substances into the circulatory system. (For example, a patient who fell and has been on the floor for 2 days).
• Compartment syndrome: A localized rapid rise of tension within a muscle compartment, which inevitably leads to metabolic disturbances akin to rhabdomyolysis.
• Crush syndrome: Involves a series of metabolic changes produced due to an injury of the skeletal muscles of such a severity as to cause a disruption of cellular integrity and release of its contents into the circulation.
• Suspension syndrome: A state of shock caused by blood pooling in dependent lower extremities while the body is held upright without any movement for a period of time. May lead to a relative hypovolemic state and cardiovascular collapse.
• Causes of mortality in untreated crush syndrome:
  • Immediate: severe head injury, traumatic asphyxia, torso injury with intrathoracic or intra-abdominal organ injury
  • Early: hyperkalemia, hypovolemia/shock,
  • Late: renal failure, coagulopathy, hemorrhage and sepsis
• Suspect hyperkalemia if T waves become peaked, QRS prolonged > 0.12 seconds, absent P waves, or prolonged QTc. Hyperkalemia may be delayed up to 24 hours after extrication.
• A patient with a crush injury may initially present with very few signs and symptoms, therefore, maintain a high index of suspicion for any patient with a compressive mechanism of injury.