A man is extricated 8 hours after being trapped under collapsed masonry crushing both lower limbs. He is conscious with dark urine and a serum potassium of 7.4 mmol/L with peaked T waves on ECG. The immediate priority in management is:

• A Aggressive sodium bicarbonate infusion alone to alkalinise the urine
• B Intravenous calcium gluconate followed by insulin-dextrose and aggressive isotonic saline before release considerations ✓
• C Immediate fasciotomy of all four limb compartments before any medical treatment
• D Loop diuretic therapy to force diuresis of myoglobin

Explanation

Crush syndrome causes rhabdomyolysis with life-threatening hyperkalaemia, the commonest cause of early death after rescue. Stabilising the myocardium with intravenous calcium gluconate, shifting potassium with insulin-dextrose, and volume loading with isotonic saline precedes other steps. Bicarbonate may help acidosis but never alone. Fasciotomy is considered only for true compartment syndrome and can worsen reperfusion injury, while diuretics come later and do not address arrhythmia risk.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.