Crush injury with prolonged entrapment at community festival

Patient Information

Dispatch: You are called to a patient at the Northbridge Street Festival. A 29YO male has been trapped under a collapsed temporary stage structure for approximately 25 minutes. DFES have just freed him. (Marcus Holt)
Patient: Marcus Holt — 29yr (80kg)
Incident History: Pt was working as a stage hand when a temporary stage structure collapsed, trapping both lower limbs beneath heavy metal scaffolding for approximately 25 minutes. DFES extricated the patient immediately prior to EHS arrival. Bystanders report pt was conscious and calling out during entrapment but is now quiet and pale.
Emergency Contact: Karen Holt (Wife) — 0412 774 391

Initial Rapid Assessment

Response: Voice
Airway: Patent. No airway obstruction. No stridor. Able to vocalise.
Breathing: Respiratory rate elevated. Shallow effort. No audible wheeze or crackles. SpO2 92% on room air.
Circulation: Rapid and weak radial pulse. Skin pale, cool and diaphoretic centrally. Obvious deformity and swelling to bilateral lower limbs. Slow CRT >3 seconds bilateral feet.
Disability: GCS 13 (E3V4M6). Oriented to person only. Confused, answering questions but disoriented to time and place. Pupils equal and reactive.
Exposure: Significant swelling, deformity and bruising bilateral lower legs consistent with fractures. Skin intact overlying both limbs — no open wounds. No other visible injuries on initial exposure.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	92% (RA)	Moderate	24	118	88/60	>3s bilateral feet	13	4 4 ++	36.1	5.4 mmol/L	8
10 mins	97% (O2 NRB 15L/min)	Mild	20	124	84/58	>3s bilateral feet	11	4 4 ++	35.9	5.4 mmol/L	6

History Taking

Treatment Response

Diagnosis

This patient is suffering from crush injury with developing crush syndrome following prolonged bilateral lower limb entrapment, complicated by suspected bilateral lower leg fractures and hypovolaemic shock secondary to reperfusion injury and fluid shifts.

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not apply high-flow oxygen within 2 minutes of patient contact, SpO2 drops to 88% and respiratory distress worsens to Severe — facilitator prompts: 'The patient looks increasingly breathless and his lips are turning blue.')
! (If trainees do not recognise signs of hypovolaemic shock — low BP, tachycardia, poor CRT, confusion — and fail to request urgent ambulance via CSP and ambulance backup within 5 minutes, patient GCS drops to 9 and BP falls to 76/50 — facilitator states: 'Marcus becomes increasingly unresponsive, barely opening his eyes when you call his name.')
! (If trainees attempt to splint bilateral lower limbs before oxygen and haemodynamic assessment are completed, facilitator prompts: 'Your partner asks — should we be doing something about his breathing and blood pressure first?')
! (If trainees do not recognise the prolonged entrapment duration as a crush syndrome risk factor and fail to communicate this to the incoming ambulance crew during handover, facilitator prompts during IMISTAMBO: 'The paramedic asks — how long were the legs trapped?')
! (If trainees do not assess and document bilateral lower limb neurovascular observations — CWMS — before and after any splinting attempt, facilitator states: 'After you apply the splint, Marcus says his foot feels completely numb now and he can't wiggle his toes on the right side.')
! (If trainees attempt to walk or mobilise the patient to the FAP rather than keeping him supine and managing on scene, facilitator states: 'As you ask Marcus to stand, he immediately becomes pale, diaphoretic and nearly collapses — his BP drops to 70 systolic.')

Treatment Objectives

1 Ensure scene safety — confirm DFES have declared the collapsed structure safe before approaching patient.
2 Don appropriate PPE — gloves and eye protection given blood and body fluid exposure risk.
3 Perform Primary Survey with C-spine consideration — mechanism does not suggest axial loading but note confusion and mechanism of injury.
4 Administer Oxygen via non-rebreather mask at 10–15 litres per minute targeting SpO2 94–98%. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
5 Position patient supine — do NOT mobilise or walk patient; risk of cardiovascular collapse post-reperfusion.
6 Perform Vital Sign Survey — GCS, SpO2, RR, BP, HR, CRT, BGL, Temperature.
7 Identify and communicate signs of hypovolaemic shock: BP 88/60, HR 118, CRT >3s, GCS 13, pale and diaphoretic — call for urgent ambulance via CSP backup and advise CSP of findings immediately.
8 Perform Secondary Survey — assess bilateral lower limbs for deformity, swelling, bruising, open wounds, and neurovascular status (CWMS) distal to injury bilaterally.
9 Document bilateral distal neurovascular observations: colour, warmth, movement, sensation, and capillary refill at toes — record findings before any intervention.
10 Recognise prolonged entrapment >20 minutes as a crush syndrome risk factor — anticipate systemic deterioration including hyperkalaemia, metabolic acidosis, and acute kidney injury following reperfusion.
11 Immobilise bilateral lower limbs with soft splinting in position found — do not attempt to realign; pad natural hollows and bony prominences.
12 Re-assess distal neurovascular observations after splinting — document any change.
13 Keep patient warm — apply blankets to prevent hypothermia (temperature 36.1°C and trending down; prolonged entrapment and shock increase hypothermia risk).
14 Monitor and record full observations every 5 minutes given time-critical status.
15 Do NOT attempt to administer pain relief — analgesia (Methoxyflurane) may be considered but note patient's altered GCS (13) — Methoxyflurane requires ability to self-administer and cooperate; GCS 13 with disorientation contraindicates Methoxyflurane in this presentation.
16 Prepare for clinical deterioration and potential cardiac arrest — have AED and resuscitation equipment immediately available.
17 Communicate crush syndrome risk clearly in IMISTAMBO handover: entrapment duration 25 minutes, bilateral lower limbs, signs of hypovolaemic shock, neurovascular compromise bilateral lower limbs, GCS declining.
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 · Hypovolemic Shock · Limb Trauma · Fractures & Dislocations — Splinting · Oxygen Delivery · Primary Survey · Secondary & CNS Survey · Pulse & Respirations · Blood Pressure · Pulse Oximetry · Blood Glucose Monitor · Tympanic Thermometer · Pain Assessment · Methoxyflurane (Penthrox)

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