ARM INJURY 2P-2

SETTING
EMS/Pre-hospital: An ambulance has been dispatched to a backyard for a patient with Occupational Health/Industrial: An ambulance has been dispatched to the fabrication
their arm pinned under a vehicle. shop for a patient with their arm stuck in the industrial press.
Learning Objec�ves Key Points
The learner will be able to: 1. Poor perfusion and a lack of oxygen delivery causes the tissues to switch to
• State what types mechanisms of injury allows for a Focused Exam to be anaerobic metabolism, which results in the buildup of toxic metabolites such as
performed. lactic acid.
• Accurately assess and manage a crush injury. 2. Most extremities can tolerate up to four hours of ischemia before cell death
occurs – though tissue hypoxia can happen in as little as one hour.
• Describe possible associated trauma with the crush injury (e.g., fractures and
crush syndrome). 3. When circulation is restored, those toxic products are carried throughout the
body and affect many organ systems.
4. Frequent Reassessments and close monitoring of vital signs is required.
5. Aggressive hydration with normal saline is required – it is believed that alkalizing
the urine with intravenous sodium bicarb may reduce the risk of renal damage.
6. Consider application of a tourniquet when administering fluids or medications
prior to releasing the entrapped body part is not possible.
HISTORY INJURIES
S Pain to right arm 1. Crushed right lower arm.
A None 2. Possible closed fractures associated.
M None 3. Potential for crush syndrome to develop.
P Family history of diabetes and hypertension
L Toast and coffee
E As described in the se�ng
Assessment and Interven�on Synopsis Pa�ent Instruc�ons
• Recognize the mechanism of injury and stable vital signs and perform a Focused Patient should be alert, but anxious and complaining of right arm pain. Clearly explain
Exam and start treatment on scene. mechanism of injury and that only the lower arm got trapped – no other associated
• Recognize significance of crush injuries and the potential for rapid deterioration trauma. Speak in full sentences and in mild respiratory distress due to pain. No head,
after releasing the entrapped body part (compartment syndrome). neck or back pain and no loss of consciousness.
• Initiate aggressive fluid therapy prior to releasing entrapped body part.
MOULAGE
• Splint crushed extremity as there is potential for fractures to occur as well.
Lower right arm swelling – reddening encircled around entire lower right arm.
• Consider intravenous sodium bicarb – to reduce the risk of renal damage.
• Consider applying a tourniquet proximal to crushed area if fluids and
medications cannot be provided.
• Consider pain management.

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 LOC: Alert and oriented CIRCULATION:
ARM INJURY 2P-2 AIRWAY: Patent Pulse: Rapid, strong and regular (radial)
SCENE SIZE-UP: One pa�ent and scene is safe, crush injury to lower right arm, BREATHING: Regular, slightly elevated due to and caro�d pulses present
extremity is s�ll entrapped. Rescuers can easily release the entrapped limb without pain, adequate �dal volume Bleeding: None noted
addi�onal resources.
Ven�la�on instruc�ons: Consider providing Capillary Refill: <2 seconds in
supplemental oxygen unaffected extremity
INITIAL ASSESSMENT Skin: Pale, cool, moist
GENERAL IMPRESSION: The pa�ent is kneeling with their lower right arm pinned.
Life-Threatening Bleeding: No
WHAT SIGNS FROM THE INITIAL ASSESSMENT INDICATE THE PATIENT MAY BE IN SHOCK?
Anxiousness, tachycardia, tachypnea, pale, cool and moist skin (Obj. 8.2, Page 157).

RAPID TRAUMA SURVEY – MAY CHOOSE
TO DO – NOT REQUIRED
Head: No injuries or pain noted
Neck: No injuries or pain noted, Trachea:
Midline, Neck veins: Flat
Chest: Look: No injuries present, Listen:
Clear and equal, no abnormal breath
sounds Feel: No injuries or pain noted,
Percussion: Resonant,
Heart Tones: Normal S1, S2
Abdomen: No injuries of pain noted.
Pelvis: Stable
Extremi�es: Legs: No injuries or pain
noted, Pulse, Motor and Sensory: Intact,
Arms: Left: No injuries or pain noted
(good distal pulses, movement sensa�on),
Arms: Right: Crushed right lower arm,
extensive pain, and swelling, Pulse, Motor
and Sensory: Intact
Posterior: No injuries or pain noted
History: Obtain from pa�ent
REASSESSMENT
Subjec�ve Changes: No changes
LOC: Alert and oriented
Pupils: 5 mm, equal and reac�ve
GCS: 4/5/6 = 15
Airway: Patent
Breathing: Regular, slightly elevated due
to pain, adequate �dal volume
Circula�on: Pulses: 120 with no
treatment; 112 with appropriate bolus,
Skin: Pale, cool and moist, Capillary Refill:
<2 seconds in unaffected extremity, >4
seconds in injured extremity
Neck: No changes, Trachea: Midline,
Neck veins: Flat
Chest: No changes
Abdomen: No changes
Iden�fied Injuries: Right Arm: Crushed
right lower arm, extensive pain, and
swelling, Pulse, Motor and Sensory: Intact
before and a�er splin�ng
FOCUSED EXAM– MAY CHOOSE TO
MOVE DIRECTLY TO FOCUSED EXAM
Right: Crushed right lower arm, extensive
pain, and swelling,
Pulse, Motor and Sensory: Intact
SECONDARY SURVEY
Airway: No changes
Breathing: Regular, slightly elevated due
to pain, adequate �dal volume
Head: No injuries or pain noted
Neck: No injuries or pain noted, Trachea:
Midline, Neck veins: Flat
Chest: Look: No injuries present, Listen:
Clear and equal, no abnormal breath
sounds, Feel: No injuries or pain noted,
Percussion: Resonant,
Heart Tones: Normal S1, S2
Abdomen: No injuries of pain noted
Pelvis: Stable
Extremi�es: Legs: No injuries or pain
noted, Pulse, Motor and Sensory: Intact,
Arms: Left: No injuries or pain noted
(good distal pulses, movement sensa�on),
Arms: Right: Crushed right lower arm,
extensive pain, and swelling,
Pulse, Motor and Sensory: Intact
Posterior: No injuries or pain noted
History: Obtain from pa�ent

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 ARM INJURY 2P-2
VITAL SIGNS & NEUROLOGICAL
RR: 18, HR: 122, B/P: 136/70 mmHg
LOC: Alert, but anxious, Pupils: 5 mm,
equal and reac�ve, Sensory and Motor:
Intact
ETCO2: 36 mmHg
SPO2: 98%
GCS: 4/5/6 = 15
RAPID TRAUMA SURVEY QUESTION
What injuries might you expect to find
based on the mechanism of injury?
So� �ssue injury, compartment syndrome
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TRANSPORT
What priority is this pa�ent? Medium
priority with poten�al to deteriorate
Where should this pa�ent be transported
to? Trauma Center
Should alterna�ve transport be
provided? Consider resources that can
provide intravenous sodium bicarb.
What interven�ons should be done?
Pa�ent should have aggressive fluid
therapy and consider applying a
tourniquet before releasing the entrapped
extremity to slow the release of toxins.
The extremity should be splinted
appropriately a�er it is released.
REASSESSMENT QUESTION
Could the crush injury to the lower arm
affect other body systems? The heart may with the working impression/diagnosis?
pump less effec�vely due to acidosis and
hyperkalemia. The accumula�on of
myoglobin may affect the kidneys causing
renal damage (Obj. 14.5, Page 272).
How can you minimize these risks?
Aggressive fluid therapy before releasing
the entrapped extremity, alkaliza�on of
the urine with intravenous sodium bicarb,
applying a tourniquet proximally before
releasing the entrapped extremity if fluids
or medica�on cannot be administered
(Obj. 14.2, Page 272).
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INTERVENTIONS
Oxygen therapy:
What liter flow should be used? High-
flow O2 at 12-15 liters/minute.
IV ini�a�on:
How much fluid should be administered?
Large boluses should be ini�ated to assist
in flushing out the toxins (Obj. 14.2, Page
272). Normal saline is preferred as
lactated ringers contains potassium.
The lower arm should be splinted a�er
being released.
Consider pain management.
FOCUSED EXAM QUESTION
Are any of these findings inconsistent
VITAL SIGNS & NEUROLOGICAL
BP: 136/70 mmHg (without pain control);
124/64 mmHg (with pain control)
HR: 122, strong and regular (without pain
control); 90, strong and regular (with pain
control)
RR: 18, Regular, slightly elevated due to
pain, adequate �dal volume
LOC: Alert, Pupils: 5 mm, equal and
reac�ve, Sensory and Motor: Intact
ETCO2: 36 mmHg
SPO2: 98%
ECG: Sinus tachycardia or normal sinus
rhythm (depending on pain)
GCS: 4/5/6 = 15
Blood Glucose: 90 mg/dl (5.0 mmol/L)
SECONDARY SURVEY QUESTION
What are the indica�ons or
circumstances when a Secondary Survey
should or should not be performed? A
Secondary Survey may be performed on
scene if the Primary Survey does not
reveal a cri�cal condi�on. A Secondary
Survey may not be performed if
interven�ons during transport do not
allow �me for a Secondary Survey
(Obj. 2.8, Page 43).
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 ARM INJURY 2P-2
ADDITIONAL QUESTIONS
1. What is the most serious complica�on with crush injuries? The build-up of toxins that could affect other body systems.
2. Could there be fractures associated with the crush injury? Yes.
3. What are some cri�cal interven�ons for pa�ents with crush injuries? Recognizing the risk of releasing the entrapped extremity and providing appropriate treatments prior
to release to decrease future complica�ons.

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