Podcast 786: Smiling Death

<strong>Contributor: Nick Hatch, MD</strong> <p><strong>Educational Pearls:</strong></p> <ul> <li style="font-weight: 400;" aria-level="1"><span style= "font-weight: 400;">“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.  </span></li> <li style="font-weight: 400;" aria-level="1"><span style= "font-weight: 400;">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. </span></li> <li style="font-weight: 400;" aria-level="1"><span style= "font-weight: 400;">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. </span></li> <li style="font-weight: 400;" aria-level="1"><span style= "font-weight: 400;">Standard techniques for controlling hyperkalemia by intracellular shifting may be less effective. Early dialysis may be useful. </span></li> </ul> <p><strong>References</strong></p> <p><span style="font-weight: 400;">Gonzalez D. Crush syndrome.</span> <em><span style="font-weight: 400;">Crit Care Med</span></em><span style="font-weight: 400;">. 2005;33(1 Suppl):S34-S41. doi:10.1097/01.ccm.0000151065.13564.6f</span></p> <p><span style="font-weight: 400;">Better OS. Rescue and salvage of casualties suffering from the crush syndrome after mass disasters.</span> <em><span style="font-weight: 400;">Mil Med</span></em><span style="font-weight: 400;">. 1999;164(5):366-369.</span></p> <p><em><span style="font-weight: 400;">Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD</s