Does sodium bicarbonate improve outcomes in crush injury?
Date First Published:
July 17, 2026
Last Updated:
July 17, 2026
Report by:
Peter Gimson, Resident Doctor (Cambridge University Hospitals)
Search checked by:
Felix Wood, Senior Registrar, Emergency Medicine
Three-Part Question:
In [patients with suspected crush injury] does the [administration of sodium bicarbonate] [improve morbidity and mortality]?
Clinical Scenario:
A 16 year old girl is brought into the Emergency Department after falling from a horse, which subsequently rolled on top of her and she has sustained crush injuries to both her legs. You are aware that the sequalae of crush injuries include hyperkalaemia and metabolic acidosis - logically you question whether the administration of intravenous sodium bicarbonate may be of benefit to this patient and want to know if there is any evidence to support its use.
Search Strategy:
Please see link below for comprehensive search strategy:
http://tiny.cc/CrushBestBETsLitSearch
http://tiny.cc/CrushBestBETsLitSearch
Search Details:
A search was conducted on 2nd and 6th December 2022 and updated on 19th November 2024 to include any relevant articles published in the intervening period. The following databases were searched:
- Medline on EBSCO platform
- CINAHL on EBSCO platform
- EMBASE on Ovid platform
Limiters:
- English language
- Last 10 years
- Conference abstracts excluded
- Medline on EBSCO platform
- CINAHL on EBSCO platform
- EMBASE on Ovid platform
Limiters:
- English language
- Last 10 years
- Conference abstracts excluded
Outcome:
68 articles were identified for review.
No systematic review was identified comparing sodium bicarbonate treatment vs placebo or vs alternative treatment.
Five literature reviews relating to the management of crush injury discussed the use of sodium bicarbonate. Three of these advocated the use of sodium bicarbonate in reducing renal failure through urinary alkalization. One argued there was no benefit vs active fluid resuscitation. One argued the evidence was unclear
Two cases reports were included. Administration of sodium bicarbonate did not prevent renal failure.
One RTC involving animal testing was included.
A consensus statement and a review of guidance both advocate the use of sodium bicarbonate in preventing renal failure.
No systematic review was identified comparing sodium bicarbonate treatment vs placebo or vs alternative treatment.
Five literature reviews relating to the management of crush injury discussed the use of sodium bicarbonate. Three of these advocated the use of sodium bicarbonate in reducing renal failure through urinary alkalization. One argued there was no benefit vs active fluid resuscitation. One argued the evidence was unclear
Two cases reports were included. Administration of sodium bicarbonate did not prevent renal failure.
One RTC involving animal testing was included.
A consensus statement and a review of guidance both advocate the use of sodium bicarbonate in preventing renal failure.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Consensus statement on the early management of crush injury and prevention of crush syndrome Greaves I, Porter K, Smith JE December 2003 United Kingdom | Consensus Statement | Consensus Statement published by group of subject experts. | Acute Renal Failure | Urine pH should be kept above 6.5 by administration of 50mls 8.4% sodium bicarbonate to fluid regime. Thought to decrease metabolic acidosis and decrease precipitation of myoglobin in the renal tubules. | No data - consensus statement |
| Currently no evidence on pre-hospital administration / administration immediately post extraction. This should be explored further. | |||||
| Crush injuries and crush syndrome — a review. Part 1: the systemic injury Jagodzinski NA, Weerasinghe C, Porter K June 2010 South Africa | Crush injury in disaster settings | Literature review | Acute Renal Failure | Intervention with sodium bicarbonate can prevent the need for dialysis if used for urine alkalinisation by preventing pigment nephropathy. Urine pH should be kept above 6.5. 50 mEq l sodium bicarbonate to each 2nd and 3rd litre after admission to hospital. | Data from rhabdomyolysis from different aetiologies. Treatment included mannitol as well as sodium bicarbonate for some patients. |
| Hyperkalaemia | |||||
| Sodium bicarbonate can also counteract hyperkalaemia. | |||||
| Acetazolamide can be used to manage metabolic alkalosis. | |||||
| Post-traumatic rhabdomyolysis patients in a single study (Brown et al.) found that bicarbonate and mannitol did not prevent ARF, the need for dialysis or mortality when CK >5000 U/L | |||||
| Disaster nephrology: crush injury and beyond Gibney RT, Sever MS, Vanholder RC May 2014 USA | Crush injury in disaster settings | Literature review | No specific measures | Current evidence does not suggest benefit from alkalinization over active fluid resuscitation. May worsen hypocalcaemia associated with crush injury. | No data provided. Expert opinion based. |
| Crush injury and rhabdomyolysis Malinoski D, Slater M, Mullins R January 2024 USA | Patients with crush injury and rhabdomialaysis | Literature review | Acute Renal Failure | Relative benefits of early fluid resuscitation versus forced solute diuresis are unclear. Acetazolamide required to prevent alkalaemia. Bicarbonate may be useful but lack of class 1 evidence. Not assessing pre-hospital use. | No data provided to support bicarbonate use. |
| Crush injury patients in disaster settings Sever MS, Vanholder R April 2012 United Kingdom | Review of current guidelines | Acute Renal Failure Hyperkalaemia |
Aute Renal Failure | Bicarbonate added to half-isotonic saline may prevent tubular deposition of myoglobin and uric acid, correcting metabolic acidosis and reducing hyperkalaemia. | No data provided to support bicarbonate use Appears to reference study from 1990 to support above results |
| Hyperkalaemia | |||||
| Early and intensive fluid replacement prevents acute renal failure in the crush cases associated with spontaneous collapse of an apartment in Konya Altintepe et al. July 2009 Turkey | Earthquake related crush injuries | Case report | Acute Renal Failure | Mannitol-bicarbonate administered to all 9 hospitalised patients with crush syndrome. 2 developed ARF. | No comparison group ARF still occurred Patients were also treated with aggressive fluid management - not accounted for |
| Management of crush-related injuries after disasters Sever MS, Vanholder R, Lameire N March 2006 USA | Earthquake related crush injuries | Literature review | Acute Renal Failure | Addition of 50 mEq of sodium bicarbonate to each second or third litre of saline will maintain urinary pH above 6.5 and prevent intratubular deposition of myoglobin. This will reduce risk of ARF. | Statement - no linked evidence. No comparison of fluids alone vs fluids with bicarbonate. |
| Crush Syndrome in Disaster Yokota J July 2005 Japan | Disaster victims with crush syndrome | Review article - expert opinion | No specific outcome | 44mEq/l Sodium bicarbonate should be added to every other 500 ml. Adjust to maintain urinary pH above 6.5. Improves hyperkalaemia and metabolic acidosis, prevent myoglobin and uric acid deposition in the renal tubules. Requires correction with acetazolamide if urinary pH goes above 7.5. | Statement - no comparison with other treatments or linked evidence |
| Amputation in crush syndrome: A case report Arango-Granados MC, Cruz Mendoza DF, Salcedo Cadavid AE, García Marín AF June 2020 Columbia | Case report | 29 year old patient trapped in landslide | Not reported | The patient received sodium bicarbonate but this did not prevent renal failure from developing. Consideration of the adverse effects of sodium bicarbonate should be given. | Single patient. No details on timing of administration of intervention. No comparison. |
| Astragaloside‑IV prevents acute kidney injury and inflammation by normalizing muscular mitochondrial function associated with a nitric oxide protective mechanism in crush syndrome rats Murata I et al. September 2017 Japan | Animal Study | Randomised control trial. | Survival at 48 hours. Pathological changes to the nephron at 3hrs, 24hrs and 48hrs. | Anaesthetised rats underwent hind limb compression using a tourniquet for 5 hours. One of the six groups received normal saline plus 25mEq/l sodium bicarbonate. This was compared with no treatment, normal saline, and normal saline plus differing doses of NaNO2. | Small sample sizes (60 rats split between different groups). Animal study in laboratory conditions. |
| The sodium bicarbonate group showed reduced pathological dilation of distal convoluted tubules at 24 hours compared to the control group and saline only group. | |||||
| The sodium bicarbonate group had a higher survival rate than the control and saline only group. Survival was higher in the NaNO2 group. | |||||
| Crush Syndrome Gonzalez D January 2005 N/A | Patients with crush injuries of mixed etiologies. | Literature review | Acute Renal Failure | Use of 40 mEq / l sodium bicarbonate added to intravenous fluids. Aim for pH >6.5. This diminishes myoglobin renal toxicity by increasing solubility of heme pigments. | Discussion rather than any evidence to support treatment. No comparison with alternative treatments e.g. saline alone. |
| Acetazolamide may be of benefit if urinary pH is >7.5. |
Author Commentary:
The literature on the use of sodium bicarbonate is broadly in agreement. Sodium bicarbonate should be added to intravenous fluids to facilitate urinary alkalisation, keeping urine above a pH of 6.5. This is done to help prevent renal failure from developing. There is theoretical evidence to support this, as it will help to prevent cast formation, improve heme pigmentation solubility, and prevent myoglobin deposition. It is also suggested that sodium bicarbonate will help address other complications of crush injury, such as hyperkalaemia and metabolic acidosis. There is a general consensus that treatment should be delivered following admission to hospital.
There is very limited evidence to support this intervention. There is no tier one evidence demonstrating that sodium bicarbonate improves specific outcomes, such as ARF, or improves overall mortality. There is some discussion regarding whether sodium bicarbonate provides any additional benefit to aggressive, early fluid resuscitation. Comment is also made regarding potential side effects of sodium bicarbonate, as well as the need to use acetazolamide if urinary pH rises above 7.5.
Further specific research would be required to assess whether sodium bicarbonate provides any improvement in outcomes. This could also be explored with mannitol, which is frequently referred to in the literature as a treatment given in combination with sodium bicarbonate. Currently, there is no hard evidence that sodium bicarbonate improves outcomes.
There is very limited evidence to support this intervention. There is no tier one evidence demonstrating that sodium bicarbonate improves specific outcomes, such as ARF, or improves overall mortality. There is some discussion regarding whether sodium bicarbonate provides any additional benefit to aggressive, early fluid resuscitation. Comment is also made regarding potential side effects of sodium bicarbonate, as well as the need to use acetazolamide if urinary pH rises above 7.5.
Further specific research would be required to assess whether sodium bicarbonate provides any improvement in outcomes. This could also be explored with mannitol, which is frequently referred to in the literature as a treatment given in combination with sodium bicarbonate. Currently, there is no hard evidence that sodium bicarbonate improves outcomes.
Bottom Line:
There is a clear consensus that sodium bicarbonate reduces the likelihood of developing acute renal failure. There is no tier one evidence to support this view.
Level of Evidence:
Level 2: Studies considered were neither 1 or 3
References:
- Greaves I, Porter K, Smith JE. Consensus statement on the early management of crush injury and prevention of crush syndrome
- Jagodzinski NA, Weerasinghe C, Porter K. Crush injuries and crush syndrome — a review. Part 1: the systemic injury
- Gibney RT, Sever MS, Vanholder RC. Disaster nephrology: crush injury and beyond
- Malinoski D, Slater M, Mullins R. Crush injury and rhabdomyolysis
- Sever MS, Vanholder R. Crush injury patients in disaster settings
- Altintepe et al.. Early and intensive fluid replacement prevents acute renal failure in the crush cases associated with spontaneous collapse of an apartment in Konya
- Sever MS, Vanholder R, Lameire N. Management of crush-related injuries after disasters
- Yokota J. Crush Syndrome in Disaster
- Arango-Granados MC, Cruz Mendoza DF, Salcedo Cadavid AE, García Marín AF. Amputation in crush syndrome: A case report
- Murata I et al.. Astragaloside‑IV prevents acute kidney injury and inflammation by normalizing muscular mitochondrial function associated with a nitric oxide protective mechanism in crush syndrome rats
- Gonzalez D. Crush Syndrome