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crushing case

Dr and Mrs T Hardcastle dr.tchardcastle at absamail.co.za
Wed Apr 11 12:35:46 BST 2012

Caesar - my comments between your questions:
Tim Hardcastle
> A case submitted for your consideration:
> 43 yo male construction worker suddenly had large amount of gravel, rocks
> and dirt fall on him, burying him up to his neck.  Co-workers dug him out
> with shovels (took them ten minutes) and he remained awake and alert
> during
> this time.  Finally freed of the rubble he collapsed and lost
> consciousness.
> Paramedics arrive  two minutes after his collapse.  No bystander CPR is
> being performed.  He has no palpable pulses or spontaneous respiratory
> efforts.  Pupils reported as 5 mm bilaterally and unresponsive. The medics
> begin closed chest compressions, place him on a spine board and load him
> into the ambulance.  They perform rapid sequence intubation (successful on
> first try) and start two IVs en route to the hospital.  They give two
> doses
> (1 mg) of IV epinephrine en route to the hospital.  They do not feel
> return
> of palpable pulses.  Transport time is 16 minutes.
> On arrival to ER he is undergoing closed chest compressions.  He still has
> no palpable pulses at the carotid or the femoral arteries bilaterally but
> on ECG monitor his *heart rate is 140/min*.  The endotracheal tube seems
> to
> be in the correct position on visual inspection with the laryngoscope
> (i.e.
> it is going through the vocal cords). He has bruising and abrasions of the
> chest wall but no lacerations or external bleeding.  Rib fractures are
> palpable bilaterally. Breath sounds are equal bilaterally and he is easy
> to
> ventilate using the bag-valve.  There are two 16 gauge antecubital IV
> catheters already in place and one of the medics is squeezing in a bag of
> 0.9 NS (they have given 300 ml so far).  Total pre-hospital CPR is
> estimated at 20 minutes (includes time at scene and transport time to ER).
> What would you do at this point?
> Would you:
> A. pronounce him dead on arrival?
> B. continue closed chest compressions, give more fluid (crystalloid?
> blood
> products?) and intravenous epineprhine or other vasopressor?
Yes and check blood gas POTASSIUM and IONISED CALCIUM: this is an acute
reperfusion - typically occurs about 10 minutes to one our after release.
The underlying "tachy" PEA fits with hyperkalemia
> C. insert bilateral chest tubes?
Not empirically
> D. perform ER thoracotomy?
> E. a combination of one or more of the above?
> F. something else entirely?
> Thank you.
> C. Ursic, MD
> Honolulu
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