|| Try This Traumatic Arrest
Sat, 31 May 97 04:02:18 UT
From: Merlin Curry [firstname.lastname@example.org]
An interesting case we had just
yesterday. I believe this is a case where an experienced trauma
surgeon, well aware that CPR in blunt trauma is useless, declared
a patient dead without really looking at the scenario.
@ 59 year old male, restrained driver
of large American car was witnessed to lose consciousness swerve
irradically striking several vehicles then collide head on with
another vehicle. Upon our arrival the patient had strong peripheral
pulse and agonal respirations. We performed rapid extrication
and intubation and initiated rapid transport to a level 1 trauma
hospital. Enroute the patient was hyperventilated with 100% O2,
an IV was established (only to be dislodged accidentally 5 minutes
later) and the monitor was applied (we already suspected a medical
event as causing the accident). The monitor showed a wide complex,
perfusing bradycardia which quickly deteriorated to vfib. The
patient was defibed three times enroute and full ACLS was institued.
On our arrival the patien was in a hypotensive sinus bradycardia,
skin was showing signs of "pinking up". Things were looking good
despite the fact there was no palpable pulse.
We moved into the trauma resuscitation
room and within two minutes the trauma surgeon called the code,
declaring the man dead. I believe this decision was made on the
basis that blunt trauma cardiac arrest is death. However this
was more likely a medical code (that seemed somewhat responsive)
comlicated with trauma, not visa versa. Either way the man died
without ever having had a patent large bore IV in place, died
without a fluid challenge, died without any IV Epinephrine (all
Epi to this point was given ET), died without any IV Atropine
(we did give 2 mg Atropine ET), in other words died without proper
I want to clarify that I would by
no means second guess this trauma surgeon, whom I consider a personal
hero and role model. And that I truly believe that even if the
patient had recieved the standard of care including a fluid challenge,
epi, etc. that the outcome would have been the same.
Your comments are encouraged, this
is a way for me to vent steam as well and I appreciate your feedback.
|| Date: Sat, 31 May 1997
08:03:11 -0400 (EDT)
From: Ken Mattox [KMATTOX@aol.com]
As described, this case of what
was thought to be a medical event leading to an auto accident
raises many issues. Hyperventilation prehospital for possible
head injury is now OUT. Atropine and Epinephrine in large doses
and some would say even ANY dose for the case described would
be contraindicated. With wide complexes pre hospital, it is highly
unlikely that any treatment would have reversed what ever he had,
up to and including putting him on cardiopulmonary bypass in the
emergency department, which I did for a group of similiar patients
early in my career with results equal to those in this patient.
Thank goodness, that physicians are beginning to recognize for
both surgical and medical patients just which ones are not reversiable
and where both ATLS and ACLS (which really needs to be completely
reanalyzed for the effectiveness of many of its components) are
not indicated. Thank you for sharing this case with us.
|| Date: Sat, 31 May 1997 07:14:06
From: Keith Wesley [email@example.com]
By your entry I assume you are a paramedic.
Did you discuss this case with the surgeon? Did you make your case
of a medical condition aware to him? I can sense your frustration
and awe that this individual you respected let you down. Physicians
sitting on the pedestal should take a lesson from this case. What
we sometimes dismiss off easily is perceived differently by our
EMS colleagues. While agree that the outcome may have been the same
in this elderly man there is room for doubt. This doubt I am sure
will haunt your relationship with this surgeon unless you talk it
out with him/her.
Keith Wesley, MD
Director, EMS Education & Trauma Care
Sacred Heart Hospital
Eau Claire, WI
|| Date: Mon, 2 Jun 97 04:59:35
From: Merlin Curry [firstname.lastname@example.org]
Thank you for your response. This
is truly an interesting case and as I was not afforded the ability
(for whatever numerous reasons) to talk with the Dr. at the time
I look forward to future contact. I don't see this as a horrible
life altering event. We all learn, and the sooner the better!
Thank you for your words.
Further information: 1) the patient
exhibited scars associated with CABG or similar open chest surgery
and had a cardiac history one could assume the wide complex sinus
rhythm the patient died with was normal electrical activity (a
normal intraventricular conduction delay). 2) I understand the
theory of limiting hyperventilation in head injury, however when
one is faced with an extremely gray/cyanotic patient who is barely
breathing it feels intuitively right to provide strong, high FiO2
FYI the patient was witnessed, by
another close by car, to loose consciousness in some manner prior
to the crash, your guess is as good as mine as to why, the peripheral
pulses were factual. I agree with the vfib onset with 100% O2
hyperventilation being a prognostic factor.