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crushing case

Caesar Ursic cmursic at gmail.com
Sat Apr 14 17:23:36 BST 2012


Interesting lack of interest in this case.  I wonder if this listserve
membership is dwindling...

On Wed, Apr 11, 2012 at 1:35 AM, Dr and Mrs T Hardcastle <
dr.tchardcastle at absamail.co.za> wrote:

> 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?
> No
> > 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?
> NO
> > E. a combination of one or more of the above?
> > F. something else entirely?
> >
> > Thank you.
> >
> > C. Ursic, MD
> > Honolulu
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> >
>
>
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-- 
'Twas brillig, and the slithy toves
Did gyre and gimble in the wabe:
All mimsy were the borogoves,
And the mome raths outgrabe.


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