A construction worker is extricated after 6 hours under collapsed debris. He is alert with extensive thigh edema and tea-colored urine. Which intervention should the nurse anticipate as the immediate priority?
1Administer intravenous potassium chloride at a rate of 10 mEq/hr while monitoring ECG for changes
2Initiate aggressive isotonic IV crystalloid at 1 to 1.5 L/hr while monitoring urine output✓ Correct answer
3Withhold isotonic intravenous fluids until serum creatinine returns to baseline
4Apply pneumatic tourniquets to both thighs to prevent systemic release of myoglobin
Explanation
Crush syndrome causes massive myoglobin release with AKI risk and life-threatening hyperkalemia. Immediate priority is aggressive isotonic crystalloid (1-1.5 L/hr initially, target urine output 200-300 mL/hr) to flush myoglobin and prevent AKI. IV calcium gluconate stabilizes the cardiac membrane in hyperkalemia, then insulin/dextrose and beta-agonists shift K, and potassium binders or dialysis remove K. Adding KCl is contraindicated. Tourniquets are not indicated and can worsen ischemia. Withholding fluid worsens AKI and hyperkalemia.
Urine alkalinization with bicarbonate is controversial — modern guidelines emphasize aggressive isotonic fluid as the proven mainstay. Mannitol is no longer routine.
K 6.4, creatinine 2.4, CK 88,000. EKG with peaked T waves.