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Zorluk: Çok zorInitial Stabilization and Triage

Emergency extraction teams airlift a 31-year-old construction worker to the regional trauma center after he was buried under a collapsed concrete retaining wall for over four hours. On presentation, the patient is minimally responsive and pale.

Vital signs show a blood pressure of 72/40 mmHg, a pulse of 134/min, and a respiratory rate of 26/min. Oxygen saturation is 94% on a non-rebreather mask.

Primary survey demonstrates a patent airway and equal bilateral breath sounds. The pelvis is mechanically stable to applied pressure. Point-of-care ultrasound shows a hyperdynamic heart with a completely collapsible inferior vena cava and no free intraperitoneal fluid. Both lower extremities are exquisitely tense, visibly swollen, and cold to the touch. Dorsalis pedis pulses are absent bilaterally via Doppler.

A bedside electrocardiogram demonstrates a regular rhythm with widened QRS complexes and prominent, peaked T waves.

Which of the following initial stabilization steps should be ordered simultaneously? (Select two)

  1. Intravenous administration of calcium gluconateCevap
  2. Aggressive volume expansion with intravenous isotonic crystalloidCevap
  3. C
    Rapid sequence intubation utilizing etomidate and succinylcholine
  4. D
    Emergent magnetic resonance imaging of the bilateral lower extremities
  5. E
    Immediate transfer to the intensive care unit for serial compartment pressure monitoring

Cevap

The correct simultaneous interventions are the intravenous administration of calcium gluconate and aggressive volume expansion with intravenous isotonic crystalloid.
This patient presents with crush syndrome, severe hypovolemic shock, acute compartment syndrome, and life-threatening hyperkalemia. Calcium gluconate is the most critical initial step to stabilize the cardiac myocyte membrane, temporarily preventing fatal arrhythmias caused by the elevated potassium levels. Simultaneously, aggressive isotonic crystalloid administration expands intravascular volume, treats the hypovolemic shock, and helps prevent myoglobinuric acute kidney injury. Both steps are mandatory and must occur concurrently during the initial resuscitation phase.

Adım Adım Çözüm

1
Identify the primary pathophysiology and injury pattern.
Prolonged entrapment causing severe crush injury, which leads to massive rhabdomyolysis, third-spacing of fluids, and massive intracellular potassium release.
Recognizing crush syndrome establishes the high risk for specific metabolic and hemodynamic complications.
2
Interpret the clinical and diagnostic findings.
Widened QRS complexes and peaked T waves confirm life-threatening hyperkalemia. Tense, pulseless extremities confirm acute compartment syndrome. A collapsible IVC and hypotension confirm severe hypovolemic shock.
Diagnostic data dictates which life-threatening conditions must be reversed first during triage.
3
Select the immediate life-saving stabilization orders.
Order intravenous calcium gluconate for cardiac membrane stabilization, and aggressively infuse isotonic crystalloids to treat the hypovolemic shock and flush the kidneys of myoglobin.
Hyperkalemia threatens immediate cardiac arrest, while profound hypovolemia threatens systemic perfusion; both must be addressed concurrently before any definitive surgical intervention.
4
Rule out contraindicated or delaying actions.
Avoid succinylcholine due to hyperkalemia risk, and avoid imaging or serial monitoring that delays emergent surgical fasciotomy.
Inappropriate drug selection or unnecessary testing can lead to immediate fatality or irreversible limb loss.

Anahtar Kavram

Simultaneous stabilization in crush syndrome requires immediate cardiac membrane stabilization for hyperkalemia, massive fluid resuscitation for hypovolemia/rhabdomyolysis, and emergent surgical decompression for compartment syndrome.
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Initial Stabilization and Triage

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