What is the optimum fluid resuscitation strategy in suspected crush injury?

Date First Published:

July 17, 2026

Last Updated:

July 17, 2026

Report by:

Rhiannon Wilkinson, Senior Registrar, Anaesthetics (Royal Infirmary of Edinburgh)

Search checked by:

Felix Wood, Senior Registrar, Emergency Medicine

Three-Part Question:

In a patient who has suffered crush injury is there evidence to support a particular fluid resuscitation strategy to improve morbidity and mortality?

Clinical Scenario:

A 28 year old lorry driver comes in to ED following an RTC. His legs were trapped and crushed and due to the location of the incident, it took a very long time for the fire service to extricate him. When he presents to ED, you ask yourself - I know this man is at risk of rhabdomyolysis and needs intravenous fluids to manage this but - what is the best fluid resuscitation strategy?

Search Strategy:

Please see below URL for full search strategy:
https://drive.google.com/file/d/1V6-7tLUxy84xU7ICpK4k9dpZbwXX8eRe/view

Search Details:

A search was conducted on the 2nd and 6th of December 2022 and updated on 19th November 2024 to include any new articles published in the intervening years. The search was conducted of the following databases:
Medline on EBSCO platform
CINAHL on EBSCO platform
EMBASE on Ovid platform

Outcome:

44 abstracts identified for review
No systematic reviews or clinical trials were found comparing fluid strategies in crush injury.
Thirteen articles were identified for full article screening
Five are summarised below

Relevant Paper(s):

Study Title	Patient Group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
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. 07/07/2009 Turkey	Seven rhabdomyolysis patients rescued from Zümrüt apartment collapse	Of 29 individuals rescued from the rubble 9 were hospitalised for crush syndrome and 7 followed up in this study (remaining 2 were excluded due to transfer to centres where records were inaccessible) Entrapped for approximately 11.1 +/- 7.3 hours. Highest CPK of the patients was 79049.	Requirement for haemodialysis	Intervention: Primary intervention - prophylactic mannitol-bicarbonate solution (40mEq Sodium Bicarbonate, 50ml of 50% mannitol into 1000ml 0.45%NaCl and 5% Dextrose). Between 4-8L of fluid daily, on average 5580 +/- 3300ml of fluid within first 24 hr. Bicarbonate was adjusted to urinary pH. Other - CVP monitoring.	- Small number of patients - Loss of 2 to follow up – extracted on day 6&7 (those included extracted within 24hr) - Authors attribute the recovery of 5 individuals not requiring haemodialysis to mannitol-bicarbonate but this is not based on comparison with a group receiving an alternative regimen

				Result:
				- 2 of 7 developed acute renal failure and required haemodialysis for hyperkalaemia (one required 69 units of blood & plasma and the other 35 units of blood & plasma due to bleeding from fasciotomy wounds)

				- 5 of 7 required fasciotomies (8 fasciotomies total)

				- No cases of permanent renal failure or death
Response to delayed fluid therapy in crush syndrome Ensari et al. December 2002 Turkey	38 individuals diagnosed with "Crush Injury" following the Marmara Earthquake	Of 38 individuals presenting with Crush Injury 27 developed Crush Syndrome (ARF). Of these 27, 10 required dialysis and 17 did not. These two groups were compared to see if delayed fluid therapy had contributed to risk of dialysis. Intervention: IVF, mannitol, diuretics, alkalization to target urine pH >6.5. No intravenous fluids given pre-hospital due to scale of incident.	Trapped time	Results:	Study does not detail how much fluid the individuals received Small study Authors conclude that delayed fluid therapy can prevent development of ARF, but this is not based on comparison with a group receiving different treatment
			Time spent between event and beginning treatment (admission time)
			Site and extent of injury	17 recovered with the above regime while 10 proceeded to dialysis.
			Systolic blood pressure, heart rate, central venous pressure, blood studies.
			Number of fasciotomies.	All 27 had Crush Injury in at least a lower limb. In the dialysis group a significantly higher number had Crush Injury in more than one extremity (80% vs 29%)

				The dialysis group had a significantly lower SBP and CVP at time of admission, and higher creatinine, BUN, CK, CRP and fibrinogen. No significant difference in K+

				Between the two groups there was no significant difference in age, trapped time, admission time (time to treatment commencing).
A Systematic Review of Iranian Experiences in Seismo-Nephrology Hashemi et al. March 2016 Iran	Individuals >15 years old with rhabdomyolysis in the aftermath of the BAM earthquake. No history of CKD or other causes for ARF		Effect of DFT (delay to fluid therapy)	638 individuals included with rhabdomyolysis. 134 developed AKI and, of these, 110 required dialysis	Generally robust study - contemporaneous data collection, questionnaire designed on day of earthquake, designated individual at each site to ensure data collection. Limitations Data on oral intake was not collected due to lack of precise records. No data on type of fluids used. Multicentre study with different hospitals using different fluid protocols.
			TUR (time under rubble)
			Level of CPK and VFR (volume of IV fluid received per day) on the formation of AKI and need for dialysis	Results:

				DFT in AKI group was significantly longer when compared to rhabdomyolysis group (2.8 days vs 1.2, P<0.001)

				TUR in AKI group was significantly longer when compared to rhabdomyolysis group (6.3 hours vs 2.4. P<0.001).

				VFR in AKI group was significantly lower when compared to rhabdomyolysis group (2.8 vs 4L per day for first 5 days, P<0.001).

				It was noted in the Univariate analysis that as the VFR in first 5 days increases from 6L the need for dialysis and incidence of AKI significantly decreases (P<0.001 and P<0.05). This can be broken down further

				An increase in VFR from 15000 U/L and TUR>5 hours, VFR>6L was associated with reduced rates of AKI compared with those receiving less IV fluid.

				Multivariate analysis – DFT lost its significance but CPK, TUR and VFR affected the occurrence of AKI and need for dialysis

				Conclusion: In patients with rhabdomyolysis following crush injury, VFR 6L was associated with lower rates of AKI compared with more restrictive administration.
Effect of fluid therapy on prevention of acute renal failure in Bam earthquake crush victims Sagheb et al. July 2009 Iran	Twenty individuals who developed acute renal failure following BAM earthquake		Duration of acute renal failure	Of 20 individuals who developed acute renal failure 7 received standard fluid therapy and 13 received variable hydration and volume treatment.	Small numbers Attributes lower rates of renal failure to standard fluid therapy but no comment on the differences between the standard fluid and the variable fluid groups. The latter had longer under the rubble, and there is no comment on the injury profile across the two groups
			Requirement for dialysis
				Fluid therapy was 0.9% saline, as well as bicarbonate 50mmol/L, and mannitol in those with UO>20ml/hr to target 300ml/h – unclear if this is the standard or variable protocol

				15 required dialysis

				Individuals receiving standard treatment had a significantly shorter duration of ARF (7 vs 19d, P0.008) and less need for dialysis (1 vs 6, p0.007)

				Mortality = 3 individuals
Prevention of Crush Syndrome through Aggressive Early Resuscitation: Clinical Case in a Buried Worker Mardones et al. March 2016 Chile	Case study - 40 year old with crush injury		Development of AKI	Landslide victim buried for 19 hours	Case report

				Pre-hospital care commenced two hours after landslide

				Victim administered 1.0L/hr 0.9% saline for 3 hours, and 0.5L/h thereafter

				Victim diagnosed with compartment syndrome in left leg requiring fasciotomy, and CK 118,700 U/L

				No observed increase in plasma electrolytes and no requirement for haemodialysis

				Comments made by the authors:

				Potassium containing fluids should be avoided

				With the lack of RCTs aggressive early fluid therapy holds the consensus – 0.9% Saline at 1.0L/h for two hours, followed by 0.5-1.0L/h thereafter.

				In the case of this individual AKI was prevented despite high CK scores

Author Commentary:

Najafi et al3 was the only identified study to quantify the relationship between volume of fluid resuscitation and acute kidney injury as an outcome. Their univariate analysis demonstrated a 19.2%ARR and 48.9%RRR of AKI when 1-3L of intravenous fluid is given per day for treatment of crush injury, when compared to less than 1L. They demonstrated a further though less dramatic decline with fluid resuscitation between 3-5L per day. However in their multivariate analysis they did identify that individuals with markers for greater severity of injury, a CPK >15000 and TUR>5 hours, had no significant benefit when volume of resuscitation was less than or equal to 3L/day, but volumes of greater than 6L per day were preventative. This would support the suggestion that volume resuscitation needs to be tailored to the severity of injury.

Current guidelines6 recommend the use of 0.9% Saline for the treatment of crush injury at a rate of 1.0L/h for the first two hours, followed by a rate of up to 0.5L/h thereafter. This should be started in the prehospital environment if possible. Overall it is recommended that 3-6L should be administered and further fluid should be guided by the urine output, risk of overload and the ability to provide close monitoring. Isotonic solutions are generally preferred due to the theoretical risk of contributing to hyperkalaemia with the use of potassium-containing solutions. Three of the studies above used a saline/bicarbonate/mannitol solution but the use of bicarbonate and mannitol will not be discussed further here.

Bottom Line:

The evidence would suggest an improvement in morbidity when at least 1-6L of intravenous fluid is given per day, with higher volumes being indicated in individuals suspected of having more severe injuries and prolonged extractions.

Level of Evidence:

Level 2: Studies considered were neither 1 or 3

References:

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
Ensari et al.. Response to delayed fluid therapy in crush syndrome
Hashemi et al.. A Systematic Review of Iranian Experiences in Seismo-Nephrology
Sagheb et al.. Effect of fluid therapy on prevention of acute renal failure in Bam earthquake crush victims
Mardones et al.. Prevention of Crush Syndrome through Aggressive Early Resuscitation: Clinical Case in a Buried Worker