Crush Syndrome after Structural Collapse

Rescue crews stand on top of a mountain of rubble with the remains of a collapsed building in front of them.
Photo/Miami-Dade Fire Rescue

At approximately 1:15 a.m., on June 24, 2021, a 12-story residential building collapsed in Miami-Dade County (FL). A massive search and rescue effort, on a scale not seen since September 11, 2001, began immediately and is ongoing. More than 40 fatalities have been confirmed and there are dozens of people still unaccounted in the pile of mangled steel and concrete.1

The rescuers remain hopeful that some of the victims may be found alive but with each passing hour the probability of survival decreases. There are a variety of case reports of victims surviving in void spaces in collapsed structures for periods longer than 12, 17, or even 27 days. This survival is predicated on the accessibility of clean air and some form of water for hydration within the space.2 For these reasons, the urban search and rescue (USAR) teams working on the pile continue to operate in “rescue” mode. If a victim were to be found alive today, crush syndrome and its associated sequelae would be the preeminent concern for the USAR medical specialists who would be tasked with their care in the field.

Crush Syndrome

Crush injuries occur when the body’s tissues are compressed. They are common among people who have been immobile on hard surfaces for extended periods of time, patients entrapped after motor vehicle or industrial accidents, as well as victims entombed in collapsed buildings. Crush syndrome occurs when significant crush injuries cause regional tissue ischemia, cell membrane compromise, and the release of intracellular toxins. Crush syndrome can occur after as little as 30 minutes under compression.

The most pernicious intracellular substances that are released include myoglobin and potassium. Their release leads to rhabdomyolysis, renal failure, hyperkalemia and cardiac arrest. Patients whose tissues remain under compression may appear stable until the pressure is released and then they will suddenly decompensate, deteriorate and experience cardiac arrest. In order to prevent this, USAR medical specialists are trained to initiate aggressive care while the patient is still entrapped and their tissues are under compression.

Related

The initial care for a patient with suspected crush syndrome should begin as soon as they are accessible to rescuers and will include large boluses of warmed crystalloid solution. It is common to provide 20mL/kg per hour or enough to produce 300mL/hour of urine output if it can be monitored.3 Rescuers must work to minimize hypothermia and the associated coagulopathy and work to keep the patient insulated in addition to the warm fluid administration. The patient’s EKG should be monitored continuously, and pain management should be prioritized.

It is common to use ketamine in this environment due to its dual benefit of analgesia and disassociation. The patient’s airway should be monitored and managed as needed. Supplemental oxygen should be considered. However, in a structural collapse environment enriching the oxygen content in the ambient air may increase the risk of explosive combustion and that hazard may out way the potential benefits to the patient. Immediately before the crushing force on the patient is released, 1 mEq/kg of sodium bicarbonate should be administered.

If hyperkalemia is suspected from EKG changes such as peaked T-waves or widening QRS complexes, then 10mL of 10% calcium chloride solution should be administered. Keep in mind that if sodium bicarb and calcium chloride are mixed a salt precipitate forms. If this occurs in a patient’s vein, it can be catastrophic. It is recommended that the medications are administered through separate IV lines. If only one point of access is available, a large fluid bolus should be given in between the medications. Additionally, continuous albuterol treatments as well as insulin and glucose can be considered to help increase the cellular reuptake of potassium and stabilize the patient’s myocardium. Finally, during an extended extrication, prophylactic broad spectrum antibiotics may be considered to help prevent infection.4

Once the patient is released and extricated, transport to definitive care should not be delayed. During transport additional fluid boluses should be administered, supportive care should be provided, and if evidence of hyperkalemia and acidosis are present than additional doses of sodium bicarbonate and calcium chloride may be considered. Take note, specially trained physicians are an integral part of the USAR medical team, and they deploy in the field along with the medical specialists who are all paramedics. This provides for an increased scope of practice and an expanded pharmacopeia compared to the average EMS provider.

Conclusion

The Champlain tower collapse is an unimaginable tragedy and will have a significant and long-term impact on the victims, their loved ones and rescuers. In the event that one or more victims are found alive in the coming days, they will be aggressively treated by highly trained medical specialists who will manage their complex needs. Crush syndrome is associated with a high incidence of mortality and morbidity but if it is recognized early, the interventions provided in the field can save lives.

References

1. Hernandez, Joe, Escobar Natalie. Florida Condo Deaths Climb To 36 As Officials Try To Pinpoint The Number Of Missing. NPR website. Available at: https://www.npr.org/sections/live-updates-miami-area-condo-collapse/2021/07/06/1013376004/the-death-toll-in-surfside-climbs-to-32-as-efforts-continue-to-identify-the-miss. Accessed July 6, 2021.

2. How Long Can Survivors Last Under Rubble? BBC News Website. Available at: https://www.bbc.com/news/world-32485586. Accessed July 6, 2021.

3. Pennsylvania Department of Health ALS Protocol 6004. Crush Syndrome. Available at: http://pehsc.org/wp-content/uploads/2014/05/2019-PA-ALS-Protocols-FINAL.pdf. Accessed July 6, 2021.

4. The Medical Management of the Entrapped Patient with Crush Syndrome. International Search and Rescue Advisory Group (INSARG). Medical Guidance Note. Available at: https://www.insarag.org/wp-content/uploads/2016/05/07_MWG_The_Medical_Management_of_the_Entrapped_Patient_with_Crush_Syndrome.pdf. Accessed July 6, 2021.

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