Question 1 · Environmental & Analgesia · Moderate
A worker has had both legs trapped under a collapsed wall for two hours. Fire and rescue are ready to lift. What should happen before release?
- AApply tourniquets tightly to both thighs just above the wall immediately before it is lifted
- BGain intravenous access and give 500 ml warmed 0.9% saline as the lift is prepared, without delaying it
- CGive 10 ml of 10% calcium chloride intravenously as prophylaxis just before the wall is lifted
- DGive 2 litres of warmed Hartmann's intravenously and hold the lift until the infusion is complete
- EGive 10 mg of nebulised salbutamol to the trapped worker immediately before the wall is lifted
Show answer
Answer: B
Gain intravenous access and give 500 ml warmed 0.9% saline as the lift is prepared, without delaying it
The RCSEd Faculty of Pre-Hospital Care crush consensus makes the earliest possible safe release of the compressing force the treatment priority, because time is the only modifiable risk factor. While release is planned, intravenous (IV) or intraosseous (IO) access should be established if practicable; the panel considered it reasonable to give 500 ml of warmed 0.9% sodium chloride over 10 minutes before release, with a further bolus prepared for deterioration, and none of this may delay extrication. JRCALC's crush syndrome dosing follows it: 500 ml, repeated every 30 minutes if the patient deteriorates, to a maximum of 2 litres. Crystalloids without potassium are used, so Hartmann's is avoided, and holding the lift for a large infusion lengthens compression. Clinically significant hyperkalaemia is uncommon and prophylactic treatment of presumed hyperkalaemia is not supported, so calcium and salbutamol are not given before release; they are reserved for proven hyperkalaemia with ECG changes, with interval cardiac monitoring during entrapment. Tourniquets are reserved for catastrophic haemorrhage, though loose pre-positioning is a sensible precaution. The ABC (2013) described tourniquets just proximal to the entrapping force; the consensus has superseded that.
Where this comes from
- Consensus statement on the pre-hospital management of crush injuryRoyal College of Surgeons of Edinburgh, Faculty of Pre-Hospital Care, May 2025 (Wood, Cowburn, Smith, Weekes, Godfrey)·Recommendation 1: earliest possible safe release“The earliest possible safe release of the compressing force should be a treatment priority.”Open PDF at page 5
- Consensus statement on the pre-hospital management of crush injuryRoyal College of Surgeons of Edinburgh, Faculty of Pre-Hospital Care, May 2025 (Wood, Cowburn, Smith, Weekes, Godfrey)·Background: risk factors (Figure 1)“Of these, time is the only modifiable risk factor.”Open PDF at page 4
- Consensus statement on the pre-hospital management of crush injuryRoyal College of Surgeons of Edinburgh, Faculty of Pre-Hospital Care, May 2025 (Wood, Cowburn, Smith, Weekes, Godfrey)·Recommendation 7: IV or IO access and fluids“These interventions should not delay extrication.”Open PDF at page 7
- Consensus statement on the pre-hospital management of crush injuryRoyal College of Surgeons of Edinburgh, Faculty of Pre-Hospital Care, May 2025 (Wood, Cowburn, Smith, Weekes, Godfrey)·Recommendation 8: choice of fluid“Isotonic crystalloid solutions without potassium (e.g. 0.9% sodium chloride) should be used initially.”Open PDF at page 7
- Consensus statement on the pre-hospital management of crush injuryRoyal College of Surgeons of Edinburgh, Faculty of Pre-Hospital Care, May 2025 (Wood, Cowburn, Smith, Weekes, Godfrey)·Box 1: pre-loading with IV fluid“administer 500ml of warmed 0.9% sodium chloride over 10 minutes prior to release”Open PDF at page 8
- Consensus statement on the pre-hospital management of crush injuryRoyal College of Surgeons of Edinburgh, Faculty of Pre-Hospital Care, May 2025 (Wood, Cowburn, Smith, Weekes, Godfrey)·Recommendation 9: tourniquets“The application of tourniquets in patients with crush injury should be reserved”Open PDF at page 9
- Consensus statement on the pre-hospital management of crush injuryRoyal College of Surgeons of Edinburgh, Faculty of Pre-Hospital Care, May 2025 (Wood, Cowburn, Smith, Weekes, Godfrey)·Recommendation 9: tourniquets“Loose pre-positioning of tourniquets as distally as possible”Open PDF at page 9
- Consensus statement on the pre-hospital management of crush injuryRoyal College of Surgeons of Edinburgh, Faculty of Pre-Hospital Care, May 2025 (Wood, Cowburn, Smith, Weekes, Godfrey)·Recommendation 10: cardiac monitoring and hyperkalaemia“clinically significant hyperkalaemia is uncommon, even following severe injury and prolonged entrapment”Open PDF at page 9
- Consensus statement on the pre-hospital management of crush injuryRoyal College of Surgeons of Edinburgh, Faculty of Pre-Hospital Care, May 2025 (Wood, Cowburn, Smith, Weekes, Godfrey)·Recommendation 10: cardiac monitoring and hyperkalaemia“IV calcium should be administered with the aim of stabilising the myocardium”Open PDF at page 9
- Consensus statement on the pre-hospital management of crush injuryRoyal College of Surgeons of Edinburgh, Faculty of Pre-Hospital Care, May 2025 (Wood, Cowburn, Smith, Weekes, Godfrey)·Recommendation 11: no prophylactic treatment“presumed presence of hyperkalaemia following crush injury is not supported”Open PDF at page 10
- JRCALC Clinical Guidelines — Sodium chloride 0.9%JRCALC / AACE·Adult trauma emergencies: crush syndrome“Sodium chloride 0.9% — adult trauma emergencies, crush syndrome row”
- Oxford Handbook of Pre-Hospital Carep. 268Ch. 3 Trauma · Blast injury: crush injuries“There is no role for tourniquets in crush syndrome”
- ABC of Prehospital Emergency Medicine
- Ch. 19 Trauma: Suspension and Crush · Crush injury: management · p. 100“By applying arterial tourniquets just proximal to a harness or entrapping force”
- Ch. 19 Trauma: Suspension and Crush · Crush injury: management · p. 100“Administration of potassium-containing solutions (e.g. Hartmann’s) must be strictly avoided in the field”