Contributor: Nick Hatch, MD

Educational Pearls:

• "Smiling Death" describes the prehospital phenomenon of a person who is happy to be extricated from an extended period of crush injury, but dies suddenly soon after the rescue.
• Smiling Death is caused by Crush Syndrome. Crush Syndrome begins when large areas of tissue are damaged by compression and subsequent impeded blood flow. Resultant cell death is followed by release of myoglobin and efflux of electrolytes including potassium. Upon removal of the crushing force, high levels of potassium enter circulation and cause cardiac arrhythmias leading to sudden death.
• Prevention measures include aggressive hydration using normal saline before extrication. An acceptable starting rate is 1L per hour, but providers should take patient status into consideration and titrate appropriately.
• Standard techniques for controlling hyperkalemia by intracellular shifting may be less effective. Early dialysis may be useful.

References

Gonzalez D. Crush syndrome. Crit Care Med. 2005;33(1 Suppl):S34-S41. doi:10.1097/01.ccm.0000151065.13564.6f

Better OS. Rescue and salvage of casualties suffering from the crush syndrome after mass disasters. Mil Med. 1999;164(5):366-369.

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD

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