Crush injury with prolonged entrapment and lower limb fractures

Patient Information

Dispatch: You are called to the maintenance compound at the rear of Optus Stadium following reports of a female worker who has been trapped under a collapsed equipment pallet. DFES have released the patient and are on scene. (Sarah Brennan, 33YO female)
Patient: Sarah Brennan — 33yr (65kg)
Incident History: Pt was restocking event supplies in the compound when a heavy timber pallet stack collapsed and pinned her lower legs. Bystanders estimate she was trapped for approximately 25–30 minutes before DFES freed her. Pt is now supine on the ground, conscious but distressed.
Emergency Contact: Marcus Brennan (Husband) — 0412 874 331

Initial Rapid Assessment

Response: Alert
Airway: Patent. Nil airway obstruction. Nil stridor. Pt able to speak in full sentences.
Breathing: Breathing present, unlaboured. RR elevated. Nil audible wheeze or crackles.
Circulation: Radial pulse rapid and weak. Skin pale and diaphoretic. Significant swelling and deformity to bilateral lower legs noted post-release. No active external haemorrhage. CRT 3 seconds.
Disability: GCS 14 (E3V5M6). Alert, oriented to person and place, mildly confused about events. Reports severe pain to bilateral lower legs.
Exposure: Bilateral lower leg deformity with significant oedema and bruising from mid-tibial region to ankles. Right leg angulation consistent with fracture. Skin intact overlying both limbs. No open wounds. No evidence of compartment syndrome skin changes at this time.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	96% (RA)	Mild	22	118	94/62	3s	14	4 4 ++	36.4	5.8 mmol/L	9
10 mins	98% (O2 NRB 15L)	Mild	24	126	88/58	4s	13	4 4 ++	36.2	5.6 mmol/L	7

History Taking

Treatment Response

Diagnosis

This patient is suffering from crush injury with early signs of crush syndrome following prolonged entrapment of greater than 25 minutes, complicated by bilateral lower limb fractures and haemodynamic compromise (hypotension, tachycardia, delayed capillary refill) consistent with hypovolaemic and reperfusion-mediated shock. The tingling to both feet raises concern for early compartment syndrome and neurovascular compromise distal to the fractures.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does not perform neurovascular assessment — pulse, CRT, colour, warmth, movement and sensation — to both lower limbs before and after any splinting: facilitator states that Sarah begins to cry out that her right foot feels completely numb and she cannot move her toes on that side.)
! (If the trainee does not apply oxygen within 3 minutes of arrival: Sarah's SpO2 drops to 93% on room air and her RR increases to 26.)
! (If the trainee attempts to stand or mobilise Sarah for any reason: facilitator states Sarah becomes acutely dizzy and her BP drops further to 80/50. Remind trainees — do not mobilise haemodynamically compromised patients.)
! (If the trainee does not recognise the prolonged entrapment duration and fails to communicate crush syndrome risk in their IMISTAMBO handover: facilitator asks 'What is your concern about this patient given the duration of entrapment?' — expected answer includes crush syndrome, rhabdomyolysis, hyperkalaemia and acute kidney injury risk.)
! (If bilateral lower limb fractures are not splinted or immobilised before transport: facilitator notes the right leg deformity is worsening and there is visible blanching of the right foot — prompt reassessment of neurovascular status.)
! (If pain is not addressed with Methoxyflurane (Penthrox): Sarah becomes increasingly distressed, her HR rises to 132 and she begins hyperventilating, RR 28.)
! (If the trainee does not reassess vitals at 10 minutes: facilitator announces Sarah's GCS has dropped to 13 and she is asking 'why do I feel so dizzy?' — prompt urgent transport and urgent IMISTAMBO handover.)

Treatment Objectives

1 Ensure scene safety — confirm DFES have declared scene safe and the pallet stack is stabilised before approaching.
2 Don appropriate PPE and approach patient.
3 Perform Primary Survey — airway patent, breathing adequate, circulation compromised (tachycardia, hypotension, delayed CRT — identify haemodynamic compromise).
4 Position patient supine on firm surface — do NOT allow patient to stand or mobilise.
5 Administer oxygen via non-rebreather mask at 10–15 L/min — target SpO2 94–98%. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
6 Perform bilateral lower limb neurovascular assessment BEFORE splinting: assess pulse, CRT, colour, warmth, movement and sensation to both feet — document findings.
7 Administer Methoxyflurane (Penthrox) 3 mL via inhaler device for analgesia — patient self-administers. Note: patient must be alert and cooperative to self-administer. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
8 Apply soft or rigid splinting to bilateral lower legs — immobilise joint above and below deformity. Right leg: immobilise tibia/fibula fracture with formable splint and broad bandages. Left leg: immobilise with soft splinting and padding. Do not attempt to realign.
9 Reassess bilateral lower limb neurovascular status AFTER splinting — compare findings to pre-splint baseline. Document any change.
10 Perform Vital Sign Survey — full set of observations including BGL, GCS, BP, HR, RR, SpO2, CRT, temp.
11 Perform Secondary Survey and CNS Survey — assess for additional injuries including pelvic, abdominal and thoracic.
12 Continuously monitor for signs of haemodynamic deterioration: falling BP, rising HR, worsening GCS — record full observations every 5 minutes given time-critical status.
13 Communicate crush syndrome risk clearly — prolonged entrapment >20 minutes increases risk of rhabdomyolysis, hyperkalaemia and acute kidney injury on reperfusion. Document entrapment duration on ePCR.
14 Minimise on-scene time — ensure early ambulance handover with detailed mechanism, crush duration, and limb involvement.
15 Request urgent ambulance via CSP with IMISTAMBO handover to receiving ED — communicate entrapment duration, haemodynamic compromise, bilateral lower limb fractures, neurovascular findings and crush syndrome risk.
16 Reassess pain score after Methoxyflurane administration and document pre- and post-intervention scores.
17 Keep patient warm with blankets — temperature regulation may be impaired.
18 Scenario ends on arrival of ambulance and IMISTAMBO handover.
19 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Crush Injury · Haemorrhage · Limb Trauma · Hypovolemic Shock · Primary Survey · Secondary & CNS Survey · Oxygen Delivery · Penthrox Inhaler Administration · Fractures & Dislocations — Splinting · Pain Assessment

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