Management of Crush

& Blast Injuries to the

Extremities

Kathleen L. Watts, Maj, USAF, BSC, MSPAS, PA-C

Orthopaedic Surgery Physician Assistant

RAF Lakenheath, UK

*I have no financial interests to disclose with regard to this subject or

the contents of the presentation.*

Objectives Demonstrate the principles of management of a trauma

patient with Orthopedic related injuries.

To understand, identify, and properly manage blast injuries of an extremity.

To understand, identify, and properly manage crush injuries of an extremity with concurrent systemic and soft tissue complications.

*Some images may be graphic*

Picture yourself…

You are the PA with an Army unit who’s on foot patrol

performing perimeter sweeps when all of a sudden, an

IED explodes

First things first… How do you respond?

• Relay on training and experience

• Tactile Casualty Care Combat (TCCC)

TCCC: Care Under Fire

Guidelines

1. Return fire and take cover.

2. Direct or expect casualty to remain engaged as combatant if

appropriate.

3. Direct casualty to more to cover and apply self-aid if able.

4. Try to keep the casualty from sustaining additional wounds,

5. If needed, more casualty to safety.

6. Stop life-threatening external hemorrhage (tourniquet)

7. Airway management usually deferred until next phase.

Priorities: MARCHTactical Field Care

Massive Hemorrhage: control life threatening bleeding

Airway: establish and maintain patient airway

Respiration: decompress suspected tension PTX, seal

open chest wounds, and support ventilation/oxygenation

as required

Circulation: establish IV/IO access, fluids to treat shock

Head Injury/Hypothermia:

prevent/treat hypotension and hypoxia to prevent worsening

of brain injury

prevent/treat hypothermia

Other considerations.. What equipment do you have

with you?

M: Tourniquets, Combat Gauze/

QuickClot

A: Airway: Jaw Thrust, NPA, OPA,

ET

R: Occlusive dressing, Needle

C: IV Access, IO, Hextend, LR

H: Blanket

Splints, Pelvic Binder or PASG

Pain Control: Combat Pill Pack

Mobic, Tylenol, Abx, TXA?

Evacuation options? Timing?

Secondary Survey (Hospital) History

Mechanism of Injury

Environment

Preinjury Status & Predisposing Factors

Prehospital observations and care, timing

Physical Exam: Head to toe exam

Assess: Skin, Neuromuscular Function, Circulatory

Status, Skeletal & Ligamentous Injury

Look & Ask, Palpate, Distal Pulses, X-Ray

Ortho Exam Inspect & Assess: Skin, Neuromuscular Function,

Circulatory Status, Open Wounds, Contamination, Open

Fractures

Eval extremity for vascular status

Detailed motor and sensory exam before any intervention

XR: at least 2 views of long bone along with joint above and

below

Prophylactic ABX & Tetanus status

Removal any gross contamination/irrigation

Reduction, if indicated, & splint before taken to OR

OR for operative debridement & stabilization

Blast Injuries

Blast Injury Types Primary: Direct effect of blast

wave

MC in air-filled organs due to pressure changes

Middle Ear, Lungs, GI Tract

Secondary: Objects strike individual

Fragments (nails, glass, metal)

Tertiary: individual strikes objects

Blunt trauma

Quaternary: Burns, Infections, Crush Injuries, Delayed Collapse

Umbrella Effect

Soft tissues, vessels, and nerves are stripped from the bone.

Resulting in a more proximal injury than may be clinically

apparent and requires a reasoned approach to amputation.

Blast Injury Work Up

MARCH, Secondary Survey

Systematic MSK, Neuro, Vascular exam for each

extremity

Open Wounds: document size, exposed bone, type of

contamination, ideally photographed

Radiologic exam: ID bony injury & foreign bodies

Blast Injury Management Open fractures = contaminated

Early ABX (1st gen Cephalosporin &/or Aminoglycocide,

extended spectrum PCN)

Contaminated wounds

Remove gross contamination

Copiously irrigated with sterile saline

Dress w/ moist to dry sponges until taken to OR*

Tetanus Prophylaxis

Splint Extremity Fractures

Surgical Management

Initial debridement

Aggressive debridement of necrotic and contaminated tissue

Low pressure pulse lavage

Bony Stabilization: External Fixator

Soft Tissue: Wound Vac

Repeat Debridements q24-72h

Permanent Fixation of fractures

Soft Tissue Reconstruction: Flaps/Grafts (Plastic Surgery)

Crush Injuries

Crush Injuries MARCH, Secondary Survey

Time since injury ( Pre-hospital phase)

Systematic MSK, Neuro, Vascular exam for each extremity

Document Exams, Photographs, XR

Gross Decon, Irrigate, Cover, Splint

Surgical Management

Serial Irrigation & Debridements

Bony Stabilization (External Fixator)

Soft tissue coverage (Wound Vacuum)

Crush Syndrome

Crush injury: compression of extremities that causes muscle

swelling &/or neurologic disturbances

Most Common: Lower Extremities

Crush Syndrome: localized crush injury with systematic

manifestations

Traumatic rhabdomyolysis (muscle breakdown) releases toxic

muscle cell components and electrolytes into circulatory system

Crush Syndrome Clinical Presentation

Hypotension

Renal Failure

Hypocalcemia

Hyperkalemia

Metabolic Acidosis

Cardiac arrhythmias/arrest due to K & Ca imblance

Crush Syndrome Tx

Prehospital

Administer IV fluids before releasing crushed body part or

consider Tourniquet until IV initiated

Hypotension: IV up to 1.5L/h

Renal Failure: Hydration via IV & Mannitol to maintain

diuresis (Hemodialysis prn)

Metabolic Abnormalities

Acidosis: alkalization of urine = critical (Sodium Bicarb)

Hyperkalemia/Hypocalcemia: Ca Gluconate or Ca Cl

Monitor for Compartment Syndrome

Compartment Syndrome

May occur in any site in which muscle is contained

within a closed fascial space

Tibial & Forearm Fractures

Crush injury to muscle

Tight dressings/cast, excessive exercise

Develops when pressure within the osteofascial

compartment of muscle causes ischemia & subsequent

necrosis

Compartment Syndrome S/Sx

5 P’s: Pain, Pallor, Paresthesia, Pulselessness, Paralysis

#1: Pain out of proportion to exam, increases by passive

stretching of involved muscles

Pallor: pale color

Paresthesia: sensation/functional loss of nerves that

transverse involved compartment

Palpable, tense swelling of involved region

Peripheral pulses: can be present

If absent = Late sign

Paralysis of involved compartment (late sign)

Timing of Crush Injury… Documentation of time from the prehospital phase to the

hospital phase is CRITICAL!!!

New Research Suggests:

Closed injury & presents >8h after injury:

Fasciotomy may not be needed

Muscle is already necrotic

Increase risk of infection, surgical complications

Joints splinted in functional positive and ROM started ASAP

Avoids contractures and paralysis

Compartment Syndrome

Compartment Pressure Monitor (unconscious patients)

Inadequate perfusion/relative ischemia when tissues

pressure rises to within 10-30 mm Hg of the diastolic BP

Compartment Syndrome Treatment: Fasciotomy of affected compartments*

Wrap Up:

Demonstrate the principles of management of a trauma patient with Orthopedic related injuries.

To understand, identify, and properly manage blast injuries of an extremity.

To understand, identify, and properly manage crush injuries of an extremity with concurrent systemic and soft tissue complications.

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