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Fri Sep 7 09:17:05 BST 2007

Dear Dr Sa'ad,

Your beaten man is something we also see in the United States, but the etiology of the battering is, for the most part, distinctly different. Usually, a man in Detroit is beaten for drugs, money, women, or no reason at all - not for stealing chickens. My daughter spent time in Africa, and told me that a man who is caught stealing chickens should be beaten. But, the pathophysiologic result of the beating is the same for all, irrespective of the sociologic explaination. Your questions regarding the management of such a patient are intriguing, and the subject warrants my further investigation. But, I'll do that next week.

Use your clinical judgement to manage the battered patient. They are the same as the patient who is found down, lying on terra firma and unable to get up for 12 or more hours. The most immediate problem is injured muscle, and the fact that intravascular debris from the muscle can make its way to the kidneys and other organs - and reap havoc.

After establishing that airway, breathing, perfusion pressure, and electrolytes are okay (identify and treat hyperkalemia), move toward maintaining a positive right heart filling pressure (measure and maintain CVP above 8 -12 cm H20), and gentily lean toward over-hydration and a generous urine output (>1 mL/kg/hr). Consult the appropriate surgeon (be it the trauma or othopedic surgeon). Maintain clinical surveilence (pulses, measured limb circumference, pain out of proportion) keeping in mind that a compartment syndrome or vasular injury is the evil that lurks...

In terms of biochemical markers and measuring anatophysiologic injury or deterioration, my opinion is old school. In the short term the CO2 (electrolytes) is probably the most useful. Remember that CO2(e) reflects buffering capacitiy, and deteriorating buffering capacity is always bad and should tell you that you need to do more for the patient (consult nephrology, etc.). I believe that the most usefule marker (short term) is the electrolyte CO2 if you can get it. I would also follow the serum creatine phosphokinase, maybe LDH (muscle and RBCs), blood pH and urine, and the serum lactate level. If the urine is acidic, you might want to consider administration of intravenous bicarbonate.

Hope this helps. 

DB
Don M. Benson, DO, FACEP
Emeregency Medicine Residency Program Director and Associate Professor
St. John Hospital and Medical Center/Wayne State University School of Medicine
Detroit, MI, USA

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Beaten Man