PCP Special Directives

As discussed in your previous MedicASK, this is a complex patient requiring prolonged and nuanced management. An early discussion with a BHP is recommended to develop a comprehensive care plan.

Our focus should remain on interventions proven to save lives. Evidence shows that 13–40% of early deaths can be prevented through vigilant, straightforward measures such as effective airway control, prevention of blood loss, fracture stabilization, providing timely fluid resuscitation, and hypothermia management.

Inadequate volume replacement, or delaying fluid resuscitation for more than six hours after a crush injury, significantly increases the risk of acute kidney injury (AKI). In many cases, AKI can be prevented with timely, aggressive isotonic saline administration. Initiate this as soon as possible. Typically, a 1000 mL/hour bolus of normal saline is initially administered to adults for two hours, then reduced to 500 mL/hour. Ideally, paramedics should patch to an OMC BHP for direction

Hyperkalemia is a potential complication of crush injuries due to muscle damage and rhabdomyolysis, though it typically develops hours later. Importantly, the absence of ECG abnormalities does not rule out hyperkalemia. In addition, ECG changes associated with hyperkalemia are not always specific. For example, peaked T-waves can also be seen in healthy individuals, myocardial infarction, intracranial bleeding, myocardial rupture, or hemopericardium. In the setting of crush injury, however, any suspicious findings should be treated as hyperkalemia until proven otherwise.

In crush syndrome, there are other higher-priority interventions (e.g., fluid resuscitation, bleeding control, rapid transport) that have clearer impact on outcomes than prophylactic calcium. These cases are relatively low-incidence (both hyperkalemia and crush syndrome), while the risk of harm from inappropriate or premature calcium use is significant. Finally, in crush injuries, mortality can approach 48%, and up to 50% develop acute kidney injury that drives hyperkalemia. The bigger opportunity for prehospital care may be in preventing AKI and secondary hyperkalemia.

Paramedic treatment considerations:

span stCalcium Gluconate

• Calcium gluconate (10%) restores myocardial membrane excitability and should be reserved for life-threatening arrhythmias. Note that calcium may accumulate in traumatized muscles, contributing to hypercalcemia during recovery. Additionally, extravasation may cause local tissue necrosis.

ACP Scope:

• If ECG changes consistent with hyperkalemia are present [e.g., peaked T-waves, widened QRS (>120ms),loss of P waves and/or a QRS complex with a “sine wave” appearance], ACPs should treat accordingly.
• As a reminder, as per the ALS-PCS, the patient should be pre-arrest with one of more of the following: hypotension, altered levels of awareness, or symptomatic bradycardia.

PCP Scope:

• Under the ALS PCS, they are not authorized to administer IV calcium formulations.

span stSalbutamol
In this specific case, salbutamol would be a reasonable intervention. Since it already falls within the PCP scope of practice, they may patch to OMC for authorization to administer it in this context.

Beta-2 adrenergic agonists shift potassium into cells, lowering serum potassium, but can also cause tachycardia, arrhythmias, or angina. Use cautiously in patients with active coronary artery disease or arrhythmias. Keep in mind, its onset of action is approximately 30 minutes, meaning there is no immediate effect, and it’s effect is temporary (lasting 2–4 hours), with onset of action 30 min, and potassium will rebound unless the underlying cause is treated or excretion is enhanced (dialysis, resins, diuretics) and the patient will be handed over to hospital by the time of medication start to kick in.

Bottom line: In crush injuries, PCPs may patch for authorization to administer salbutamol and IV fluids but cannot administer calcium gluconate. ACPs may administer calcium only when ECG changes consistent with hyperkalemia are present and the patient is pre-arrest.