Rosen & Barkin's 5-Minute Emergency Medicine Consult (621 page)

• Rapid extrication in case of crush injury
  
• Early IV saline before extrication to prevent complications of restored blood flow to injured limb (hypovolemia, hyperkalemia, etc.)
  
• “Crush injury cocktail” during extrication is 1.5 L 0.9% NS per hour; consider adding 1 amp (50 mEq) bicarbonate and 10 g of mannitol to each liter (controversial)
  
• Pediatric recommendation: 10–15 mL/kg/h saline initially, then switch to hypotonic (0.45%) saline upon arrival to hospital. Add 50 mEq bicarbonate to each 2nd or 3rd liter to alkalinize urine
  

• Manage ABCs
  
• Immobilization of trauma/crush injuries
  
• Adult crush injury treatment literature extrapolated to children
  
• IV saline for hypovolemia at rate of 1–1.5 L/h (10–20 mL/kg/h). Volume restored within 6 hr helps prevent renal failure
  

• May need 12 L/d, 4–6 of which should include bicarbonate. Use CVP, urine output
  
• Diuretics only after patient’s volume restored to keep urine output 200–300 mL/h (3–5 mL/kg/h)
  
• Mannitol: Diuretic, free radical scavenger. May help compartment syndrome
  
• Furosemide and other loop diuretics if indicated in management of oliguric (<500 mL/d) renal failure; controversial
  
• Bicarbonate: Alkalinize urine (pH >6.5) most studied in crush/trauma. Most authorities recommend its use as long as urine pH and calcium are monitored.
  
• Monitor for hyperkalemia frequently with serum levels and ECG. Higher potassium correlates with more severe injury
  
• Treat hyperkalemia as usual but do not use calcium unless it is severe
  
• Hypocalcemia: Treat only if symptomatic (tetany or seizures) or arrhythmias present. Calcium infusion can lead to hypercalcemia later as precipitated calcium mobilizes
  
• Bicarbonate can trigger symptoms by increasing free calcium binding to albumin
  

FOLLOW-UP

All but the most trivial elevations in CPK (<1,000) should be admitted, since complications can occur at any level and are difficult to predict. Children seem to be less susceptible to renal complications:

• Critical care admission criteria:
  
  • Hyperkalemia or CPK levels >15,000–30,000 due to worse prognosis
    
  • Underlying severe illness
    

Levels decreased to <1,000 after therapy

• Bicarbonate; add 50 mEq bicarbonate to each 2nd or 3rd liter to keep urine pH >6.5. Discontinue if urine pH fails to rise after 6 hr or if symptomatic hypocalcemia develops
  
• Albuterol, insulin/dextrose, polystyrene resin (kayexalate), for hyperkalemia treatment. Avoid calcium if possible.
  

• Mannitol 20%: 50 mL (10 g added to each liter up to 120–200 g/d (1–2 g/kg/d)
  
• Discontinue if fail to achieve diuresis and osmolal gap >55
  

• Hemodialysis for refractory hyperkalemia, fluid overload, anuria, acidosis
  
• Consider central venous monitoring of volume
  
• Fasciotomy for compartment syndrome
  

• No renal failure—almost no mortality
  
• Renal failure—3.4–30% mortality
  
• ICU—59% if renal failure, 22% without
  

• ARF
  
• Hyperkalemia
  
• Compartment syndrome
  
• Hypocalcemia
  
• Acidosis
  

Suspect in unexplained renal failure.

• Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury.
  N Engl J Med
  . 2009;361(1):62–72.
  
• Huerta-Alardín AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis—an overview for clinicians.
  Crit Care
  . 2005;9(2):158–169.
  
• Luck RP, Verbin S. Rhabdomyolysis: A review of clinical presentation, etiology, diagnosis, and management.
  Pediatr Emerg Care
  . 2008;24:262–268.
  
• Reinertson R. Suspension trauma and rhabdomyolysis.
  Wilderness Environ Med
  . 2011;22(3):286–287.
  
• Sever MS, Vanholder R, Lameire N. Management of crush-related injuries after disasters.
  N Engl J Med
  . 2006;354:1052–1063.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Compartment Syndrome
  
• Hyperkalemia
  

CODES

• 728.88 Rhabdomyolysis
  
• 958.90 Compartment syndrome, unspecified
  

BASICS

• Constellation of symptoms and signs (Jones criteria)
  
• Follows group A streptococcal infection (GAS) also known as
  Streptococcus pyogenes
  ; usually pharyngitis
  
• Uncommon in US; most cases are in developing nations
  
• Remains a major cause of cardiac morbidity and mortality worldwide with over 230,000 deaths per year
  
• Most common in 5- to 15-yr-olds
  

• GAS infection
  
• Inflammatory, autoimmune response following GAS infection
  

DIAGNOSIS

2 major or 1 major and 2 minor elements of the
Jones criteria
plus evidence of a recent GAS infection

Jones Criteria

• Major manifestations:
  
  • Migratory polyarthritis
    in 60–75% of initial attacks:
    
    • Involves larger joints: Knees, hips, ankles, elbows, and wrists
      
    • Lower extremity joints more commonly involved
      
    • Rheumatic arthritis generally responds to salicylates
      
  • Carditis
    occurs in 1/3 to 1/2 of new cases:
    
    • Pericardium, myocardium, and endocardium may be affected (pancarditis)
      
    • Myocarditis may lead to heart failure but is frequently asymptomatic
      
    • Valvular disease and endocarditis are most serious sequelae of acute rheumatic fever (ARF)
      
    • Carditis heralded by a new murmur, tachycardia, gallop rhythm, pericardial friction rub, or CHF
      
    • Echocardiogram aids in diagnosis
      
  • Chorea
    occurs in 10% of cases:
    
    • Sydenham chorea predominantly affects teenage girls
      
    • Purposeless, uncoordinated movements of the extremities sometimes called St. Vitas dance
      
    • Movements are more apparent during periods of anxiety and disappear with sleep
      
    • Chorea may be the sole manifestation of ARF
      
    • Other neuropsychiatric symptoms of emotional lability or obsessive compulsive disorder may also occur
      
  • Erythema marginatum
    occurs in <5% of cases:
    
    • Nonpruritic pink eruptions with central clearing and well-demarcated irregular borders
      
    • Usually seen on the trunk and the extremities
      
  • SC nodules in small percentage of patients:
    
    • Crops of small SC, painless nodules located most commonly on extensor surfaces
      
• Minor manifestations:
  
  • Clinical:
    
    • Fever (>38°C)
      
    • Arthralgia
      
  • Lab:
    
    • Elevated acute phase reactants
      
    • Prolonged P-R interval
      
• Supporting evidence of recent GAS throat infection:
  
  • Positive throat culture or rapid antigen test
    
  • Elevated or increasing antibody test: Antistreptolysin O (ASO) titer
    

• Fever
  
• Sore throat (often 2–4 wk prior)
  
• Rash
  
• Joint pains
  
• Unusual movements of extremities
  
• Dyspnea
  
• Lower extremity edema
  

• Pharyngeal erythema
  
• Rash consistent with erythema marginatum
  
• SC nodules
  
• New heart murmur consistent with mitral or aortic disease
  
• Evidence of fluid overload/CHF