September is National Cholesterol Education Month !

Check out our many articles on Cholesterol !

Risk of high cholesterol

Risk Factors

Some health conditions, as well as lifestyle and genetic factors, can put people at a higher risk for developing high cholesterol. However, everyone can take steps to lower their

• Conditions
• Behavior
• Heredity

Conditions and Cholesterol

Conditions

Age

Becausetends to rise as people get older, everyone’s risk for high cholesterol increases with age. Women’s LDL (”bad” cholesterol) levels rise more quickly than do men’s. Until around age 55, women tend to have lower LDL levels than men do.¹ At any age, men tend to have lower HDL (”good” cholesterol) levels than women do.

 

Diabetes

Having diabetes can also make you more likely to develop high cholesterol.² Diabetes affects the body’s use of a hormone called insulin. This hormone tells the body to remove sugar from the blood. With diabetes, the body either doesn’t make enough insulin, can’t use its own insulin as well as it should, or both. This causes sugars to build up in the blood.

 

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Facts – America’s Cholesterol Burden

Having high cholesterol puts you at risk for heart disease, the leading cause of death in the United States. People of all ages and backgrounds can get high cholesterol.

America’s Cholesterol Burden

• Approximately one in every six adults—16.3% of the U.S. adult population—has high total cholesterol. The level defined as high total cholesterol is 240 mg/dL and above.
• People with high total cholesterol have approximately twice the risk of heart disease as people with optimal levels. A desirable level is lower than 200 mg/dL.
• For adult Americans, the average level is about 200 mg/dL, which is borderline high risk.
• More women than men have high cholesterol in the United States.

Levels Vary by Ethnicity

Below are the percentages of people with high cholesterol in the United States.

Race or Ethnic Group	Men (%)	Women (%)
African Americans	11.2	13.0
Mexican Americans	17.7	13.8
Whites	16.0	17.9
All	15.6	16.9

 

Levels Differ by Age

These percentages of people in the United States have high cholesterol.

Age	Men (%)	Women (%)
20-34	9.5	10.3
35-44	20.5	12.7
45-54	20.8	19.7
55-64	16.0	30.5
65-74	10.9	24.2
75 and older	9.6	18.6
All	15.6	16.9

 

Americans Are Making Progress

• Compared to previous decades, fewer adults have high cholesterol. The proportion of the population ages 20-74 with high cholesterol has dropped by half, from 33% in 1960-1962 to 16.3% in 2003-2006.
• During the same time period, average cholesterol levels fell from 222 mg/dL to 200 mg/dL.

 

Talk with Your Doctor About Cholesterol

• The National Cholesterol Education Program recommends that all adults have their cholesterol levels checked once every five years.
• In 2007, nearly three-quarters—74.8%—of Americans reported that they had their cholesterol checked within the previous five years. But, almost all the rest—21.5%—said that their cholesterol had never been checked.
• According to the same data, just 52% of Hispanics had their cholesterol checked within the past five years.
• In 2006, there were 6.4 million visits to doctors’ offices that included a cholesterol test. This represents 7.1% of all visits.
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High Cholesterol–Medicines To Help You

 

Cholesterol is a kind of fat in your blood. Your body makes its own cholesterol but you also get it from the foods you eat like meat, potato chips, cookies, and eggs. Some people have too much cholesterol in their blood.

Cholesterol can build up on the inside of the blood vessels of your heart. If too much cholesterol builds up, then the blood cannot flow through to your heart. This can cause a heart attack.

Most people do not show any signs of high cholesterol. The only way to know for sure is to go to the doctor and ask for a cholesterol test.

If your doctor tells you that you have high cholesterol, there are things you can do to lower your cholesterol. You can make changes to your diet and exercise at least 30 minutes most days. There are also medicines you can take to help lower your cholesterol.

Use this guide to help you talk to your doctor about how to best control your cholesterol. This guide lists the different kinds of medicines to control cholesterol. Ask your doctor to tell you about all of the risks and benefits of taking your cholesterol medicine.

Did you know?

• High cholesterol can raise your chance of having heart attacks and heart disease.
• Women over age 20 should have their cholesterol checked by a doctor.
• Most people do not show any signs of having high cholesterol.
• Sometimes cholesterol can build up in your heart and cause chest pains.
• You can find out your cholesterol number by getting a simple blood test.
• Your total cholesterol number should be under 200.

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Good vs. Bad Cholesterol

Not all cholesterol in your blood is bad for you. There are three kinds of blood cholesterol that you should know about: HDL (good cholesterol), LDL, (bad cholesterol) and triglycerides.

 

	Good Cholesterol	Bad Cholesterol
What is it called?	HDL	LDL
What does it do to your heart?	Helps to keep the arteries from clogging up Protects against heart disease	Builds up and blocks your arteriesHelps to cause heart disease
What should your cholesterol number be?	Good level = 60mg/dL or Higher	Good level = Less than 100mg/dL if you have high risk for heart diseaseLess than 130mg/dL if you are otherwise healthy

 

Triglycerides are another form of fat in your blood that can raise your risk for heart disease. You may need treatment if your triglycerides are:

• Borderline High (150-199 mg/dL)
• High (200 mg/dL or more)

 

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Medicines to Control Cholesterol

There are different kinds of medicines to control cholesterol.

• HMG-CoA Reductase Inhibitors also called Statins 
• Bile Acid Sequestrants
• Fibrates
• Niacin
• Cholesterol Absorption Inhibitors
• Omega-3 Fatty Acid
• Combination Medicines 

There are many different medicines in each group. These medicines are listed on the next few pages. You will also find some general information about the safety warnings and side effects for the different kinds of medicine to control cholesterol. This guide only talks about some of the risks of taking these medicines. Talk to your doctor or pharmacist about all of the risks of taking your medicine.

 

Write down the important facts about your medicine here.

 

 

 

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HMG-CoA Reductase Inhibitors (also called Statins)

Brand Name	Generic Name
Altoprev	Lovastatin
Crestor	Rosuvastatin
Lescol	Fluvastatin
Lipitor	Atorvastatin
Livalo	Pitavastatin
Mevacor	Lovastatin
Pravachol	Pravastatin
Zocor	Simvastatin

Statins: What You Should Know

Warnings

• Do not use these medicines if you have liver disease.
• Do not use these medicines if you are pregnant or nursing.
• Use these medicines with caution if you are also taking Gemfibrozil, Fenofibrates, Amiodarone, Verapamil, or blood thinners (anticoagulants).
• People who use some HIV medicines, birth control pills (oral contraceptives), Nefazodone, and niacin should talk to their doctor about the specific risks of using Statins.
• Drinking a quart or more of grapefruit juice everyday may affect these “Statin” medicines.

Common Side Effects

• Gas
• Dizziness
• Constipation
• Headache
• Diarrhea
• Upset stomach

Warning Signs

Call your doctor if you have any of these signs:

• Fever
• Dark urine
• Muscle pain or weakness that happens without a good reason (like exercise or injury)

For more information about the risks and side effects for each drug, check Drugs@FDA.

 

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Bile Acid Sequestrants

Brand Name	Generic Name
Colestid	Colestipol
LoCholest (oral powder)	Cholestyramine
Prevalite (oral powder)	Cholestyramine
Questran (oral powder)	Cholestyramine
Welchol	Colesevelam

Bile Acid Sequestrants: What You Should Know

Warnings

• Do not use these drugs if you have problems with your liver or gallbladder.
• People who have bleeding problems, heart disease, stomach ulcers, kidney disease, or an under-active thyroid should talk to their doctor about the risks of taking these medicines.
• People who take Spironolactone should talk to their doctor before taking Colestipol (Colestid).

Common Side Effects

• Heartburn
• Constipation
• Gas
• Indigestion
• Nausea

Warning Signs

Call your doctor if you have any of these signs:

• Stomach pain
• Vomiting
• Sudden weight loss
• Unusual bleeding from gums or rectum

For more information about the risks and side effects for each drug, check Drugs@FDA.

 

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Fibrates

Brand Name	Generic Name
Antara	Fenofibrate
Fenoglide	Fenofibrate
Lipofen	Fenofibrate
Lopid	Gemfibrozil
Tricor	Fenofibrate
Triglide	Fenofibrate
Trilipix	Fenofibric Acid

Fibrates: What You Should Know

Warnings

• People with kidney problems, gallbladder disease, or liver disease should not use these drugs.
• Talk to your doctor before taking other medicines to control cholesterol called “Statins” (HMG-CoA Reductase Inhibitors).
• Pregnant women or women who are breastfeeding should talk to their doctor about the risks of taking these drugs.
• People who take diabetes medicines or blood thinners (anticoagulants) should talk to their doctor about the risks of taking these drugs.

Common Side Effects

• Headache
• Constipation or Diarrhea
• Dizziness
• Stomach pain

Warning Signs

Call your doctor if you have any of these signs:

• Muscle pain
• Weakness
• Jaundice (skin or eyes look yellow)

 

For more information about the risks and side effects for each drug, check Drugs@FDA.

 

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Niacin

Brand Name	Generic Name
Niaspan	Niacin Nicotinic Acid

Niacin: What You Should Know

Warnings

• Do not use Niaspan if you have liver disease or if you are taking an immediate-release niacin pill.
• Do not use Niaspan if you are pregnant or breastfeeding.
• People who are taking aspirin, high blood pressure medicines, HMG CoA Reductase Inhibitors (”Statins”), or medicines to lower bile acid should talk to their doctor about the risks of taking Niacin (Niaspan).
• People with kidney disease, peptic ulcer, diabetes, or chest pain should talk to their doctor about the risks of taking this drug.
• People who have had a heart attack or gout should talk to their doctor about the risks of taking this drug.

Common Side Effects

• Headache
• Upset stomach
• Heartburn
• Diarrhea
• Flushing (redness of the face or neck)

Warning Signs

Call your doctor if you have any of these signs:

• Fast heartbeat
• Fainting
• Dizziness
• Jaundice (skin or eyes look yellow)

 

For more information about the risks and side effects for each drug, check Drugs@FDA.

 

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Cholesterol Absorption Inhibitors

Brand Name	Generic Name
Zetia	Ezetimibe

 

Cholesterol Absorption Inhibitors: What You Should Know

Warnings

• Women who are pregnant or breastfeeding should not take Zetia with another cholesterol medicine.
• People who have liver disease should not take Zetia with another cholesterol medicine.
• Use caution if you are taking blood thinners (anticoagulants).

Common Side Effects

• Feeling Tired
• Stomach Pain

Warning Signs

Call your doctor if you have any of these signs:

• Muscle Pain, Tenderness or Weakness
• Stomach Pain
• Swelling of the Face or Lips
• Severe Itching

 

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Omega-3 Fatty Acid

Brand Name	Generic Name
Lovaza	Omega-3 Acid Ethyl Esters

 

Omega-3 Fatty Acid: What You Should Know

Warnings

• Women who are breastfeeding, pregnant, or planning to become pregnant should talk to their doctor before taking Lovaza.
• Tell your doctor if you have diabetes or liver, thyroid or pancreas problems.
• Tell your doctor if you are allergic to fish.
• Tell your doctor if you drink more than 2 glasses of alcohol each day.
• Tell your doctor if you take blood thinners or anticoagulants including aspirin, warfarin, coumarin, and clopidogrel (Plavix).

Common Side Effects

• Burping
• Infection
• Feeling like you have the flu
• Upset stomach
• Change in your sense of taste
• Back pain
• Skin rash

Other Side Effects

Lovaza may affect certain blood tests.

• Test to check your liver (ALT)
• Test to check your cholesterol (LDL-C)

 

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Combination Medicines

Brand Name	Generic Name
Advicor	Niacin and Lovastatin
Simcor	Niacin and Simvastatin
Vytorin	Ezetimibe and Simvastatin

Combination Drugs: What You Should Know

Warnings

• Do not take Vytorin or Advicor if you are pregnant or breastfeeding.
• Do not take Vytorin if you have liver disease.
• People taking Gemfibrozil (Lopid), Fenofibrate (Tricor), high blood pressure medicines, Protease Inhibitors (medicines to treat HIV) or blood thinners (anticoagulants) should use caution when taking these drugs.
• Drinking a quart or more of grapefruit juice everyday may affect these drugs.

Common Side Effects

• Headache
• Flushing (redness of the face or neck)
• Upset stomach

Warning Signs

Call your doctor if you have any of these signs:

• Dark urine
• Stomach pain
• Muscle pain, tenderness or weakness that happens without a good reason (like exercise or injury)
• Jaundice (skin or eyes look yellow)

 

For more information about the risks and side effects for each drug, check Drugs@FDA.

 

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Other Combination Medicines

Brand Name	Generic Name
Caduet	Amlodipine and Atorvastatin

 

Caduet is used to treat people who have both high blood pressure and high cholesterol.

 

Warnings

• Do not take Caduet if you are pregnant or planning to become pregnant.
• Do not take Caduet if you are breastfeeding.
• Do not take Caduet if you have liver problems.

Common Side Effects

• Swelling of the Legs or Ankles (edema)
• Muscle or Joint Pain
• Headache
• Diarrhea or Constipation
• Feeling Dizzy
• Feeling Tired or Sleepy
• Gas
• Rash
• Nausea
• Stomach Pain
• Fast or Irregular Heartbeat
• Face feels Hot or Warm (flushing)

Warning Signs

Call your doctor if you have any of these signs:

• Muscle problems like weakness, tenderness, or pain that happens without a good reason (like exercise or injury)
• Brown or Dark-colored Urine
• Skin or Eyes look yellow (jaundice)
• Feel more tired than usual

 

 

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Questions To Ask Your Doctor

• What drugs am I taking?
• What are the side effects?
• What other prescription drugs should I avoid while taking my medicines?
• What foods, herbs, or over-the-counter medicines should I avoid?
• When should I take each drug? How many times per day do I take each drug?
• Can I take my medicines if I am pregnant or nursing?

 

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What You Can Do About High Cholesterol

High cholesterol increases your risk for heart disease. People at any age can take steps to keep cholesterol levels normal.

 

Get a Blood Test

High cholesterol usually has no signs or symptoms. Only a doctor’s check will reveal it.

Your doctor can do a simple blood test to check your cholesterol levels. The test is called a lipoprotein profile. It measures several kinds of cholesterol as well as trigycerides. Some doctors do a simpler blood test that just checks total and HDL cholesterol.

The National Cholesterol Education Program  recommends that healthy adults get their cholesterol levels checked every five years.

Desirable Cholesterol Levels
Total cholesterol	Less than 200 mg/dL
LDL (”bad” cholesterol)	Less than 100 mg/dL*
HDL (”good” cholesterol)	40 mg/dL or higher
Triglycerides	Less than 150 mg/dL

 

* Note: Optimal level.

 

Eat a Healthy Diet

A healthy diet can help keep blood cholesterol levels down. Avoid saturated fat, trans fats, and dietary cholesterol, which tend to raise cholesterol levels. Other types of fats, such as monounsaturated and polyunsaturated fats, can actually lower blood cholesterol levels. Eating fiber can also help lower cholesterol.

For some people, eating too many carbohydrates can lower HDL (good cholesterol) and raise triglycerides. Drinking alcohol can also raise triglycerides. Too much alcohol can cause high blood pressure, which increases the risk for heart disease and stroke.

 

Maintain a Healthy Weight

Being overweight or obese can raise your bad cholesterol levels. Losing weight can help lower your cholesterol.

To determine whether your weight is in a healthy range, doctors often calculate a number called the body mass index (BMI). Doctors sometimes also use waist and hip measurements to measure a person’s excess body fat.

 

Exercise Regularly

Physical activity can help maintain a healthy weight and lower cholesterol. The Surgeon General recommends that adults should engage in moderate-intensity exercise for at least 30 minutes on most days of the week.

 

Don’t Smoke

Smoking injures blood vessels and speeds up the hardening of the arteries. Smoking greatly increases a person’s risk for heart disease and stroke.

If you don’t smoke, don’t start. If you do smoke, quitting will lower your risk for heart disease and stroke. Your doctor can suggest programs to help you stop smoking.

Breathing secondhand smoke increases a person’s risk for a heart attack and other heart conditions.¹

 

Treat High Cholesterol

If you have high cholesterol, your doctor may prescribe medications in addition to lifestyle changes. Controlling LDL cholesterol is the primary focus of treatment.

Your treatment plan will depend on your current LDL level and risk for heart disease and stroke. Your risk for heart disease and stroke depends on other risk factors including high blood pressure, smoking status, age, HDL level, and family history of early heart disease. In addition, people with existing cardiovascular disease or diabetes are at high risk.

Several types of medications help lower cholesterol—

Type of Medicine	How They Work
Statin drugs	Statin drugs lower LDL cholesterol by slowing down the liver’s production of cholesterol. They also increase the liver’s ability to remove LDL cholesterol already in the blood.
Bile acid sequestrants	Bile acid sequestrants help remove cholesterol from the blood stream by eliminating bile acids. The body needs bile acids and makes them by breaking down LDL cholesterol.
Niacin, or nicotinic acid	Niacin is a B vitamin that can improve all lipoprotein levels. Nicotinic acid raises HDL cholesterol levels while lowering total cholesterol, LDL cholesterol, and triglyceride levels. Treatment requires high levels of niacin with possible side effects and so requires medical supervision.
Fibrates	Fibrates mainly lower triglycerides and, to a lesser extent, increase HDL levels.

All drugs may have side effects, so talk with your doctor on a regular basis. Once your cholesterol levels have improved, your doctor will want to monitor them.

Lifestyle changes are just as important as taking medicines.

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LDL and HDL

 

“Bad” and “Good” Cholesterol

Particles called lipoproteins carry cholesterol in the blood. There are two kinds of lipoproteins you need to know about: LDL and HDL.

• Low-density lipoproteins (LDL) cholesterol make up the majority of the body’s cholesterol. LDL is known as “bad” cholesterol because having high levels can lead to a buildup in the arteries and result in heart disease.
• High-density lipoproteins (HDL) cholesterol absorb cholesterol and carry it back to the liver, which flushes it from the body. High levels of HDL, or “good” cholesterol, reduce the risk of heart disease and stroke.

 

Lowering Your Cholesterol Levels

You can take several steps to maintain a normal cholesterol level.

• Get a blood test.
• Eat a healthy diet.
• Maintain a healthy weight.
• Exercise regularly.
• Don’t smoke.
• Treat high cholesterol.

If you have high cholesterol, your doctor may prescribe medications in addition to lifestyle changes. Talk with your doctor about how to reduce your risk for heart disease.

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About High Blood Cholesterol

Cholesterol and Your Body

Cholesterol is a waxy, fat-like substance found in your body and many foods. Your body needs it to work properly and makes all that you need. Too much cholesterol can accumulate depending on the kind of foods you eat and the rate at which your body breaks it down.

Extra cholesterol can build up in your arteries. Over time, cholesterol deposits, called plaque, can narrow your arteries and allow less blood to pass through.

When plaque totally blocks an artery carrying blood to the heart, a heart attack occurs. It also can happen when a deposit ruptures and causes a clot in a coronary artery. Chest pain, also called angina, is caused by plaque partially blocking a coronary artery, reducing blood flow to the heart.

Also See

. LDL and HDL

 . Signs and Symptoms

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Physical Activity for Arthritis

Why is physical activity important for arthritis?

Scientific studies have shown that physical activity can reduce pain and improve function, mood, and quality of life for adults with arthritis. Physical activity can also help manage other chronic conditions that are common among adults with arthritis, such as diabetes, heart disease, and obesity.

How much physical activity do adults with arthritis need?

• 2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity per week OR
• 1 hour 15 minutes (75 minutes) of vigorous-intensity aerobic activity per week OR
• an equivalent combination* of moderate and vigorous activity.

AND

•  Muscle strengthening exercises on 2 or more days per week.
• Balance exercises on 3 days per week if at risk of falling.

Aerobic activity is any activity that makes your heart beat faster and breathe a little harder than when you are sitting, standing, or lying.
Muscle strengthening activities should work all the major muscle groups (e.g., legs, hips, back, chest, abdomen, shoulders, and arms) of the body.

What types of physical activity are appropriate for arthritis?

• Low-impact aerobic activities including brisk walking, cycling, swimming, water aerobics, gardening, group exercise classes, and dancing.
• Muscle-strengthening exercises including calisthenics, weight training, and working with resistance bands. These can be done at home, in an exercise class, or at a fitness center.
• Balance exercises including walking backwards, standing on one foot, and tai chi. If you are at risk of falling, balance exercises are included in many group exercise programs.

 

Other key points to remember:

Any physical activity is better than none. Moderate, low-impact physical activity is safe for people with arthritis. Activity should be in addition to doing usual daily activities. Activity can be broken up into small amounts, at least 10 minutes at a time, during the day. More health benefits are gained with more activity. The benefits of physical activity far outweigh the risks.

 

Tips for S.M.A.R.T. physical activity if you have arthritis

Start low, and go slow

People with arthritis may take more time for their body to adjust to a new level of activity. Inactive people should start with a small amount of activity, for example, 3–5 minutes 2 times a day. Adding activity in small amounts and allowing enough time for your body to adjust to the new level before adding more activity is usually safe.

Modify activity when arthritis symptoms increase, try to stay active. 

Arthritis symptoms come and go. Most people completely stop activity when their symptoms increase. It is better to first modify your activity by decreasing the frequency, duration, or intensity, or changing the type of activity to stay as active as possible without making your symptoms worse.  

Activities should be “joint friendly.”

Unsure of what types of activity are best for people with arthritis? A general rule is to choose activities that are easy on the joints like walking, bicycling, water aerobics, or dancing. These activities have a low risk of injury and do not twist or “pound” the joints too much.

Recognize safe places and ways to be active. 

Safety is important for starting and maintaining an activity plan. For inactive adults with arthritis or those who do not have confidence in planning their own physical activity, an exercise class designed just for people with arthritis may be a good option. For those who plan and direct their own activity, finding safe places to be active is important. For example, while walking in your neighborhood or at a local park, make sure the sidewalks or pathways are level and free of obstructions, are well-lighted, and are separated from heavy traffic.

Talk to a health professional or certified exercise specialist.

People with arthritis should be under the care of a health care professional. Many health professionals are a good source of information on what types and amounts of activity are appropriate for people with chronic conditions and disabilities.

What should I do if I have pain when I exercise?

Some soreness or aching in joints and surrounding muscles during and after exercise is normal for people with arthritis.  This is especially true in the first 4 to 6 weeks of starting an exercise program.  However, most people with arthritis find if they stick with exercise they will have significant long-term pain relief.  Here are some tips to help you manage pain during and after exercise:

• Modify your exercise program by reducing the frequency (days per week) or duration (amount of time each session) until pain improves.
• Changing the type of exercise to reduce impact on the joints – for example switch from walking to water aerobics.
• Do proper warm-up and cool-down before and after exercise.
• Exercise at a comfortable pace – you should be able to carry on a conversation while exercising.
• Make sure you have good fitting, comfortable shoes.

Signs you should see your health care provider:

• Pain is sharp, stabbing, and constant.
• Pain that causes you to limp.
• Pain that lasts more than 2 hours after exercise or gets worse at night.
• Pain is not relieved by rest, medication, or hot/cold packs.
• Large increases in swelling or your joints feel “hot” or are red
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Management of Crush Injuries & Crush Syndrome

After an Earthquake: Management of Crush Injuries & Crush Syndrome

Background

Crush injury and crush syndrome may result from structural collapse during an earthquake. Crush injury is defined as compression of extremities or other parts of the body that causes muscle swelling and/or neurological disturbances in the affected areas of the body. Typically affected areas of the body include lower extremities, upper extremities, and trunk. Crush syndrome is localized crush injury with systemic manifestations. These systemic effects are caused by a traumatic rhabdomyolysis (muscle breakdown) and the release of potentially toxic muscle cell components and electrolytes into the circulatory system. Crush syndrome can cause local tissue injury, organ dysfunction, and metabolic abnormalities, including acidosis, hyperkalemia, and hypocalcemia.

Previous experience with earthquakes that caused major structural damage has demonstrated that the incidence of crush syndrome is 2-15% with approximately 50% of those with crush syndrome developing acute renal failure and over 50% needing fasciotomy. Of those with renal failure, 50% need dialysis.

Clinical Presentation

Sudden release of a crushed extremity may result in reperfusion syndrome—acute hypovolemia and metabolic abnormalities.  This condition may cause lethal cardiac arrhythmias.  Further, the sudden release of toxins from necrotic muscle into the circulatory system leads to myoglobinuria, which causes renal failure if untreated.

Hypotension

• Massive third spacing occurs, requiring considerable fluid replacement in the first 24 hours; Patients may sequester (third space) more than 12 L of fluid in the crushed area over a 48-hour period
• Third spacing may lead to secondary complications such as compartment syndrome, which is swelling within a closed anatomical space; compartment syndrome often requires fasciotomy
• Hypotension may also contribute to renal failure

Renal Failure

• Rhabdomyolysis releases myoglobin, potassium, phosphorous, and creatinine into the circulation
• Myoglobinuria may result in renal tubular necrosis if untreated
• Release of electrolytes from ischemic muscles causes metabolic abnormalities

Metabolic Abnormalities

• Calcium flows into muscle cells through leaky membranes, causing systemic hypocalcemia
• Potassium is released from ischemic muscle into systemic circulation, causing hyperkalemia
• Lactic acid is released from ischemic muscle into systemic circulation, causing metabolic acidosis
• Imbalance of potassium and calcium may cause life-threatening cardiac arrhythmias, including cardiac arrest; metabolic acidosis may exacerbate this situation

Secondary Complications

• Compartment syndrome may occur, which will further worsen vascular compromise

Initial Management: Prehospital Setting 

• Administer intravenous fluids before releasing the crushed body part.  (This step is especially important in cases of prolonged crush [more than 4 hours]; however, crush syndrome can occur in crush scenarios of less than 1 hour)  
• If this procedure is not possible, consider short-term use of a tourniquet on the affected limb until intravenous (IV) hydration can be initiated

Initial Management: Hospital Setting

Hypotension

• Initiate (or continue) IV hydration—up to 1.5 L/hour

Renal Failure

• Prevent renal failure with appropriate hydration, using IV fluids and mannitol to maintain diuresis of at least 300 cc/hr
• Triage to hemodialysis as needed

Metabolic Abnormalities

• Acidosis: Alkalinization of urine is critical; administer IV sodium bicarbonate until urine pH reaches 6.5 to prevent myoglobin and uric acid deposition in kidneys
• Hyperkalemia/Hypocalcemia: Consider administering the following (adult doses): calcium gluconate 10% 10cc or calcium chloride 10% 5cc IV over 2 minutes; sodium bicarbonate 1 meq/kg IV slow push; regular insulin 5-10 U and D5O 1-2 ampules IV bolus;  kayexalate 25-50g  with sorbitol 20% 100mL PO or PR
• Cardiac Arrhythmias: Monitor for cardiac arrhythmias and cardiac arrest, and treat accordingly

Secondary Complications

• Monitor casualties for compartment syndrome; monitor compartmental pressure if equipment is available; consider emergency fasciotomy for compartment syndrome
• Treat open wounds with antibiotics, tetanus toxoid, and debridement of necrotic tissue
• Apply ice to injured areas and monitor for the 5 P’s: pain, pallor, parasthesias, pain with passive movement, and pulselessness
• Observe all crush casualties, even those who look well
• Delays in hydration of greater than 12 hours may increase the incidence of renal failure; delayed manifestations of renal failure can occur

Disposition

Patients with acute renal failure may require up to 60 days of dialysis treatment; unless sepsis is present, patients are likely to regain normal kidney function.

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