Towards comprehensive care in crush syndrome: Expanding the multidisciplinary framework

Abstract

Crush syndrome demands an integrated multidisciplinary approach that spans acute surgical decisions and long-term functional recovery. In response to Khan et al’s recent systematic review, we propose complementary perspectives that address two underrepresented dimensions: Vascular surgical decision-making and psychiatric rehabilitation. We emphasize the use of intraoperative technologies such as indocyanine green fluorescence angiography and compartment pressure monitoring to guide limb salvage strategies and reperfusion management. Additionally, we advocate for the systematic integration of mental health screening and trauma-informed psychiatric care to address the high prevalence of psychological distress in survivors. Embedding these domains into standardized protocols could enhance both short- and long-term outcomes, particularly in high-impact trauma and disaster settings.

Key Words: Crush syndrome; Compartment syndrome; Reperfusion injury; Thromboembolism; Fasciotomy; Mental health; Multidisciplinary management

Core Tip: This letter expands on Khan et al’s review by emphasizing two often overlooked aspects of crush syndrome: Intraoperative vascular decision-making and psychiatric rehabilitation. We highlight the use of perfusion assessment tools and tailored anticoagulation strategies to improve limb salvage. Additionally, we advocate for early screening of post-traumatic stress disorder (PTSD), depression, and anxiety using validated tools like PTSD Checklist for DSM 5 and Patient Health Questionnaire 9. These additions aim to integrate surgical precision with trauma-informed mental health care, supporting a more holistic and outcome-focused approach to managing crush injuries, especially in disaster and high-impact trauma settings.

TO THE EDITOR

We read with great interest the recent Khan et al’s article[1]. In their systematic review the authors compiled a thorough and clinically relevant synthesis of a condition that remains a critical challenge in disaster and trauma care.

The review successfully bridges foundational knowledge with modern developments, such as the role of ferroptosis and novel biomarkers (e.g., NGAL, KIM-1, and microRNAs), which are particularly promising in early diagnosis and monitoring. This forward-thinking approach highlights translational pathways that may soon influence clinical protocols. Our attention was particularly captured by the article’s thorough overview of compartment syndrome and the essential role of fasciotomy in crush syndrome management. This focus underscores a crucial surgical intervention that remains the cornerstone of preventing permanent limb damage. However, we believe there are two critical dimensions that warrant further exploration to enhance the clinical applicability of their synthesis: (1) Vascular surgical decision-making and reperfusion-related complications; and (2) The psychological burden and long-term mental health outcomes of survivors. This letter seeks to expand on Khan et al’s review[1] by offering additional multidisciplinary perspectives, particularly in vascular surgery and trauma psychiatry, to aid clinical translation.

While Khan et al[1] provide a valuable synthesis of crush syndrome pathophysiology, their review underrepresents the critical role of vascular surgical decision-making during the acute phase—particularly in managing reperfusion injury and determining limb salvage vs amputation. Crush injuries frequently lead to prolonged ischemia, followed by reperfusion, triggering endothelial activation, oxidative stress, and microvascular thrombosis that threaten both local and systemic stability[2]. In real-world settings, vascular surgeons must rapidly assess tissue viability, restore perfusion, and weigh the risks of systemic deterioration—often under extreme time pressure[3].

Recent advances such as indocyanine green fluorescence angiography and direct compartment pressure monitoring provide objective, real-time data to guide fasciotomy and debridement decisions[4,5]. These tools, though not yet universally adopted, hold promise for reducing unnecessary amputations and improving salvage outcomes, and we advocate for their integration into standard protocols. Furthermore, thromboembolic complications following reperfusion—exacerbated by systemic inflammation and endothelial injury—require vigilant surveillance[6]. Current trauma guidelines support early thromboprophylaxis with low molecular weight heparin, transitioning to unfractionated heparin in patients with ongoing bleeding risk or evolving coagulopathy[7,8].

Importantly, viscoelastic assays such as thromboelastography or rotational thromboelastometry are increasingly employed to tailor anticoagulation based on individualized clotting profiles, a practice particularly useful in crush syndrome patients with complex coagulopathies[9]. These vascular considerations merit further emphasis in future updates of crush syndrome management protocols.

Equally important, yet often underrecognized, is the profound psychological burden associated with crush syndrome. Khan et al[1] briefly touch on this, but in our view, the psychiatric sequelae—particularly post-traumatic stress disorder (PTSD), depression, and chronic anxiety—warrant more comprehensive inclusion in both clinical care and future reviews. Several studies in trauma and disaster medicine report PTSD prevalence ranging from 30%-60% in survivors of crush injury, especially those experiencing amputation, prolonged entrapment, or intensive care unit (ICU) stays[10,11]. These symptoms frequently persist long after physical recovery and can substantially hinder functional rehabilitation and social reintegration[12].

Recent international guidelines emphasize structured mental-health care as an integral component of trauma rehabilitation. For instance, NICE NG211 guidelines[13] on traumatic injury recommends regular screening for anxiety, depression, and PTSD at critical recovery milestones (e.g., ICU discharge, rehabilitation initiation), and advocates for timely referral to psychologist-led interventions when psychological distress affects rehabilitation outcomes. Furthermore, NICE NG116 guidelines endorses early trauma-focused psychotherapies such as trauma-focused cognitive behavioral therapy and eye movement desensitization and reprocessing within one month post-injury to reduce PTSD symptoms and improve long-term functional recovery[14]. Embedding these evidence-based mental health protocols into crush syndrome care pathways would enhance holistic, multidisciplinary treatment and support improved patient-centered outcomes.

Moreover, validated screening instruments—including the PTSD Checklist for DSM 5 (PCL-5), Patient Health Questionnaire 9 (PHQ-9), and Generalized Anxiety Disorder 7 (GAD-7) have demonstrated strong psychometric performance and clinical applicability in trauma and rehabilitation settings. The PCL5 reliably identifies PTSD in trauma-center survivors up to six months post-injury, supporting its use at key transition points like ICU discharge and outpatient follow-up[15].

Furthermore, the PHQ-9 and GAD-7 exhibit high internal consistency and validity across diverse outpatient populations, affirming their utility in early screening for depression and anxiety during rehabilitation pathways[16]. We outline these tools and implementation strategies in Table 1.

Table 1 Screening and assessment tools for post-traumatic stress disorder and psychiatric sequelae in crush syndrome survivors.

Tool	Target condition	Description	When to use	Interpretation/cut-off
PHQ-9	Depression	9-item self-report questionnaire assessing depressive symptoms	Within 1-2 weeks of stabilization, repeat during rehabilitation	Score ≥ 10 indicates moderate depression
GAD-7	Anxiety	7-item screening tool for generalized anxiety disorder	Initial psychological evaluation; routine use in follow-up	Score ≥ 10 suggests clinically relevant anxiety
PCL-5	PTSD	20-item self-report tool based on DSM-5 PTSD criteria	Screen at 2-4 weeks post-injury and during long-term follow-up	Score ≥ 33 is suggestive of probable PTSD
HADS	Depression and anxiety	14-item tool (7 for anxiety, 7 for depression) commonly used in hospital settings	For patients with limited literacy or hospital fatigue	Score ≥ 8 in either subscale indicates possible clinical disorder
IES-R	PTSD	22-item impact of event scale-revised, assesses subjective distress caused by traumatic events	Useful in research and baseline trauma assessment	Score ≥ 24 indicates clinical concern for PTSD

PTSD: Post-traumatic stress disorder; PHQ-9: Patient Health Questionnaire-9; GAD-7: Generalized Anxiety Disorder 7; PCL-5: Post-traumatic stress disorder Checklist for DSM-5; HADS: Hospital Anxiety and Depression Scale; IES-R: Impact of Event Scale-Revised.

A structured approach involving trauma-informed psychiatric care and early rehabilitation coordination has been associated with improved adherence to therapy and better long-term quality of life outcomes[17].

Addressing these psychological dimensions is critical to improving quality of life, adherence to rehabilitation, and social reintegration[18]. The article’s focus on long-term functional outcomes, both physical and psychological, as core components of patient management and future research agendas, is particularly timely and important for fostering comprehensive recovery.

In conclusion, Khan et al’s work offers a timely and highly informative contribution to the understanding and multidisciplinary management of crush syndrome. Moreover, to advance clinical practice future updates should build on this foundation by refining surgical decision-making frameworks—including criteria for fasciotomy and amputation—and integrating evidence-based psychiatric rehabilitation protocols. Advancing clinical practice will also require standardized intraoperative perfusion assessment and research into long-term outcomes of combined physical and psychological rehabilitation to optimize recovery and quality of life for survivors.