Crush syndrome diagnosis and management in resource-constrained settings: A Delphi study

Area of Science:

• Emergency Medicine
• Trauma Surgery
• Global Health

Background:

• Crush syndrome poses significant morbidity and mortality risks, particularly in resource-limited settings like disaster zones and areas with high rates of community violence.
• Community assault, a unique form of trauma in South Africa, leads to crush injuries through mob justice.
• Existing definitions and endpoints for crush syndrome lack consensus, hindering the development of appropriate management and scoring systems for diverse clinical environments.

Purpose of the Study:

• To achieve consensus on definitions and endpoints for crush syndrome.
• To inform the development of scoring systems tailored for community assault and resource-limited settings.

Main Methods:

• Qualitative in-depth interviews with South African clinicians identified challenges in managing crush injuries in resource-constrained environments.
• A Delphi survey process involving an international panel of experienced clinicians sought consensus on crush syndrome definitions, endpoints, and covariates.
• A 75% consensus threshold was pre-established for survey responses.

Main Results:

• Clinicians recommended maintaining a high index of suspicion for crush syndrome, especially in polytrauma patients.
• Early intravenous fluid administration, titrated to urine output and respiratory status, was advised.
• Crush injury was defined as localized muscle damage, while crush syndrome encompassed systemic complications like renal failure and hemodynamic instability. Preferred endpoints included acute kidney injury, renal replacement therapy, and respiratory support.

Conclusions:

• The study provides essential context for crush injury management in resource-limited settings.
• Clinical risk prediction models must consider the unique patient populations and data limitations prevalent in these environments.
• Developing context-specific scoring systems is crucial for improving outcomes in crush syndrome.