›Sodium bicarbonate 50 mEq in 2nd and 3rd liter of IV fluid
›Target urine pH > 6.5
›Prevents myoglobin precipitation in renal tubules
›Urine output target
›Target UOP > 200–300 mL/hr during IV fluid resuscitation
›Mannitol 0.5–1 g/kg IV if UOP adequate but CK not clearing
›Furosemide only if volume-overloaded; avoid in hypovolemic rhabdomyolysis
Hyperkalemia management in crush syndrome
›Emergent hyperkalemia treatment for K+ > 6.5 mmol/L or ECG changes
›Calcium gluconate 1–2 g IV over 5–10 minutes (cardiac membrane stabilization)
›Onset 1–3 minutes, duration 30–60 minutes
›Repeat if ECG changes persist
›Sodium bicarbonate 50–100 mEq IV for K+ shift intracellularly
›Concurrent glucose-insulin: dextrose 50% 50 mL + insulin 10 units IV
›Potassium-lowering effect within 30 minutes
›Emergent dialysis if renal replacement required
›Indications: K+ > 6.5 mmol/L refractory, severe AKI, acidosis pH < 7.1
›Emergent fasciotomy
›Indication: compartment pressure > 30 mmHg or delta pressure < 30 mmHg
›Clinical diagnosis sufficient if pressure measurement unavailable
›Irreversible muscle damage begins within 6 hours of ischemia
›Four-compartment fasciotomy of the leg (most common site)
›Generous incisions releasing all compartments
›Wound left open; delayed primary closure or skin grafting at 48–72 hours
Traumatic brain injury management
›Prevent secondary injury
›Maintain SBP > 100 mmHg (not permissive hypotension if TBI present)
›Maintain SpO2 > 94%
›Avoid hyperventilation (target PaCO2 35–40 mmHg unless herniation)
›Osmotherapy for elevated ICP
›Mannitol 0.25–1 g/kg IV bolus; repeat q4–6h if serum osmolality < 320 mOsm/kg
›Hypertonic saline (23.4% NaCl) 30 mL IV bolus for refractory ICP or herniation
›Head of bed 30 degrees, midline position
›Seizure prophylaxis
›Levetiracetam 500–1000 mg IV q12h for 7 days in severe TBI (GCS ≤ 8)
›Phenytoin as alternative: 15–20 mg/kg IV load, then 100 mg IV q8h
›Prophylaxis reduces early post-traumatic seizures; no proven effect on long-term epilepsy
›Class IIA recommendation (Brain Trauma Foundation guidelines)
›Analgesic strategy
›Ketamine for hemodynamically unstable patients
›Sub-dissociative dose: 0.3–0.5 mg/kg IV
›Avoids opioid-related hemodynamic depression
›Opioid caution in compartment syndrome
›Avoid excessive opioids that may mask compartment syndrome pain
›Regional anesthesia (nerve blocks) with caution — monitor closely for compartment syndrome development
›Acetaminophen 1 g IV q6h as adjunct (opioid-sparing)
›Damage-control orthopedics
›External fixation initially for unstable fractures in polytrauma
›Definitive fixation delayed until patient physiologically stable
›Open fracture management
›Open fractures: antibiotics within 1 hour
›Grade I/II: cefazolin 1–2 g IV q8h
›Grade III or contaminated: add gentamicin 5 mg/kg IV q24h
›Tetanus prophylaxis: update per immunization status
›Wound irrigation and debridement in OR
Antibiotics and infection prevention
›Antibiotic prophylaxis for open fractures
›Cefazolin 1–2 g IV q8h (Grade I/II open fractures)
›Add gentamicin 5 mg/kg IV q24h for Grade III or heavily contaminated wounds
›Continue until wound closure or 72 hours maximum for prophylaxis
›Military blast wounds: higher rate of multidrug-resistant organisms
›Broaden empirically in military/combat settings
›Anticipated complications requiring active surveillance
›Delayed intracranial hemorrhage
›Repeat CT head at 6–24 hours if GCS declining
›Anticoagulated patients: lower threshold for repeat imaging
›ARDS from blast lung or massive transfusion
›PaO2/FiO2 < 200 mmHg: ARDS diagnosis
›Lung-protective ventilation strategy
›Fat embolism syndrome: days 1–3 post long bone fracture
›Petechiae, hypoxemia, confusion triad
›VTE prophylaxis
›Mechanical prophylaxis from admission
›Chemical prophylaxis when safe from hemorrhage standpoint