Crush syndrome in adult patients and challenges associated with its management in the acute phase

Crush syndrome is defined as the local and systemic response to a traumatic rhabdomyolysis caused by compartment syndrome (prolonged compression of a large muscle mass leading to ischemia). It is not usually an isolated event, and may go unnoticed in the first 24 to 48 hours of a severe polytrauma. Ignored crush syndrome can lead to acute renal failure secondary to myoglobinuria occurring in a hypovolemic patient, with acidosis and hyperkalaemia. Crush syndrome is a medical and surgical emergency, frequently occurring after disasters such as earthquakes or major explosions with collapse of buildings. The acute revascularization syndrome that can occur after decompression (either surgical, or removing the weight from the crushed body part or removing a tourniquet) can cause irreversible cardiac arrest due to acute hyperkalaemia and hypovolemia. Early fluid resuscitation (starting pre-hospital and lasting over the first 24 hours) is crucial to restore and maintain normovolemia, and a urine output of 1-2ml/kg/hour is recommended during the first 24 hours. Diuretics may help to maintain this high urine output, and preventing tubular precipitate of myoglobin in acidic urine via bicarbonate may be useful. Early nutrition targets may be obtained using early “prophylactic” haemodialysis.