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Crush injury and compartment syndrome best practices

“Management of crush syndrome has to start in the rubble, in the hole, under the car, in the subway; treatment starts there.”


In this Monday, July 5, 2021, file photo, rescue workers move a stretcher containing recovered remains at the site of the collapsed Champlain Towers South condo building, in Surfside, Fla.

AP Photo/Lynne Sladky, File

NEW ORLEANS — Crush injuries are among the most challenging situations a healthcare provider can encounter, particularly in emergency or disaster scenarios where patients may be trapped for prolonged periods.

Ian C. Swords, NRP, chief of special operations for the FDNY Bureau of EMS presented a session titled, “Crush medicine: Stopping the smiling death,” during the 2023 EMS World Expo, where he sheds light on the recognition and treatment of crush injuries and compartment syndrome in the field, offering valuable best practices.

Ian Swords.jpg

Ian C. Swords, NRP, chief of special operations for the FDNY Bureau of EMS.

Courtesy photo


Here are some memorable quotes from Sword on crush injuries and compartment syndrome:

“Management of crush syndrome has to start in the rubble, in the hole, under the car, in the subway; treatment starts there.”

“We’re not always going to see signs of hyperkalemia, but we have to be prepared for it.”

“Hydrate and alkalize – fluid, fluid, fluid – goes against what we think about trauma.”

“There’s a relationship between rhabdomyolysis, compartment syndrome and crush syndrome. If you have one, there’s a good chance you have the other two going on as well.”

“Expect to treat hypotension, hyperkalemia and acidosis.”


Following are the key takeaways from Sword’s crush injuries and compartment syndrome presentation.

1. Crush injury pathophysiology and complications

Sword began by defining a crush injury – when a body part is subjected to extreme pressure, either high (short duration) or low (long duration), often due to accidents like industrial mishaps, building collapses or vehicle crashes. These injuries can result in significant tissue damage, including muscle, nerves and blood vessels. In severe cases, the release of toxins and damaged cells into the bloodstream can lead to a condition called crush syndrome, which can be fatal if left untreated.

The pathophysiology of crush syndrome can be explained into a series of events:

  • Initial crushing injury. External pressure compresses muscles, causing tissue damage
  • Ischemia and reperfusion. Once released, the affected muscles experience a sudden surge of blood flow, carrying toxins and metabolic waste products to the bloodstream
  • Release of toxins and metabolic waste. These substances, like myoglobin, flood the bloodstream, potentially overwhelming the kidneys
  • Systemic complications. Renal failure, electrolyte imbalances and cardiac arrhythmias are common fatal complications

The primary causes of death in crush syndrome are:

  • Renal failure. The kidneys struggle to filter and excrete the excess myoglobin and other waste products, leading to acute kidney injury
  • Electrolyte imbalances. Elevated levels of potassium and phosphate can disrupt the heart’s electrical activity, potentially causing fatal cardiac arrhythmias

2. Compartment syndrome pathophysiology and complications

Compartment syndrome is primarily an internal condition that occurs when elevated pressure builds within a muscle compartment. This pressure can result from muscle swelling, bleeding or edema within a confined space.

The pathophysiology of compartment syndrome involves three crucial steps:

  • Increased pressure within the compartment. Swelling or bleeding within a muscle compartment raises pressure, impeding blood flow
  • Impaired blood flow and tissue oxygenation. As pressure rises, blood vessels become compressed, further reducing blood supply to the affected area
  • Cellular damage and muscle necrosis. Prolonged ischemia can cause irreversible muscle damage

Compartment syndrome can lead to death through:

  • Gangrene. Tissue death (necrosis) may progress to gangrene, which can trigger systemic infections and sepsis
  • Multiple organ dysfunction syndrome (MODS). The release of toxins from necrotic tissue can lead to organ failure, particularly if the condition is not promptly diagnosed and treated

3. Best practices for treating crush injuries and compartment syndrome

Recognizing the signs and symptoms of both syndromes is paramount. Diagnostic tools, such as compartment pressure measurements may be beneficial. Sword shared his best practices when responding to a scene with a high potential of crush injury:

  • Continuously monitor the patient’s vital signs, pain levels and the affected limb’s color, temperature and sensation
  • Frontline treatment in the field involves immediate interventions, such as:

    -- Fluid resuscitation (with a preference for normal saline)

    -- Pain management

    -- Medications (e.g., insulin, high-dose albuterol, mannitol, lidocaine, sodium bicarbonate, calcium gluconate, tranexamic acid, etc.)

  • Maintain open communication with the patient, response crew and receiving medical facility, sharing essential information about the patient’s condition and the estimated time of arrival
  • Patients with crush injuries and potential compartment syndrome should be extricated to a medical facility as soon as possible – ensure that transportation is as gentle as possible to prevent additional harm

Adhering to best practices and ensuring effective communication between rescuers and medical facilities can greatly improve the chances of a successful outcome for patients with crush injuries. However, it’s crucial to acknowledge that providing patient care can pose challenges, such as establishing intravenous access or obtaining an EKG, which can vary depending on factors such as patient accessibility and resource availability.

Learn more about crush injuries and compartment syndrome

Nicole M. Volpi, PhD, NRP, has experience in emergency medical services, law enforcement, military/civilian disaster response and disaster management research. She currently works full-time as a paramedic, preceptor, and emergency management disaster liaison for a hospital-based emergency medical service in Marrero, Louisiana.

She serves as one of the Louisiana Department of Health Region One EMS designated regional coordinators within the southeast area, responding to various emergencies where EMS support is needed or requested on a local/state level.

She has a PhD from Capella University in Public Safety/Emergency Management and a master’s degree in Criminal Justice/Law Enforcement Administration from Loyola University in New Orleans.