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Lesson

Crush Syndrome

12 min Trauma

Objective: Treat a prolonged crush as a hyperkalemia and rhabdomyolysis time bomb — volume before or as you lift when protocol allows, and calcium when the strip goes wide after extrication.

Why This Is Hard

The limb looks quiet under the slab. When you lift, potassium, myoglobin, and acid dump into the circulation. Sudden PEA after extrication is a classic crush death. Field teaching (NAEMSP/disaster and ATLS-adjacent): start IV fluid before or as soon as access exists, preferably before full release, avoid potassium-containing fluids, and treat hyperK when the ECG goes ugly (see hyperkalemia).

Say out loud
  • How long have they been trapped?
  • Access and fluid before the full lift when you can
  • No K+ in the bag (skip LR debates if your protocol says NS for crush)
  • After release: monitor, peaked T / wide QRS → calcium per protocol

Who Is at Risk

  • Prolonged compression of a large muscle mass (hours, not a 4-minute pin-in). Collapse, MVC, industrial, earthquake, “found down” on a limb.
  • The trapped limb may have little pain. That does not mean it is safe to lift and leave.

Street Sequence (Education)

  1. Scene safety. You cannot resuscitate under an unstable wall.
  2. ABCs, hemorrhage, oxygen. IV/IO as soon as it is realistic — often before technical rescue finishes.
  3. Fluid per protocol (often isotonic saline). The goal is volume before reperfusion when possible. This site does not publish a mL/kg recipe.
  4. Coordinate the lift with the rescue team. Warn them that the patient may crash when the weight comes off.
  5. After release: 12-lead / monitor, treat hyperK (calcium for ECG toxicity; albuterol shift if protocol), pain, destination with dialysis capability if they are really sick.
  6. Tourniquet-before-release is a special-operations / medical-direction decision, not a freelance default. Do not invent it on a 20-minute pin-in.

Do Not

  • Hang potassium-containing maintenance fluids as the crush bag.
  • Treat post-lift wide-complex PEA as “just VT” with amiodarone first.
  • Forget rhabdo later: dark urine is a hospital problem you can flag in the handoff.

Field Pitfalls

  • No monitor after a 6-hour extrication.
  • Waiting for the hospital to start fluid when you had a line for an hour under the dash.

Practice

60-second drill

Partner: leg under a forklift for 4 hours, alert, then PEA 2 minutes after lift. Name the chemistry, the first arrest drug class to think about, and one fluid you will not grab.

Related: Hyperkalemia on the Monitor, PEA, Traumatic Arrest.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.

1. The dangerous moment in prolonged crush is often:
2. When you can, start IV fluid:
3. Post-lift wide-complex PEA in a crush patient is treated first as:
4. A tourniquet applied just to “prevent crush syndrome” on a 15-minute pin-in:
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