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crushing case

John Francis surjohn at gmail.com
Sat Apr 14 23:46:02 BST 2012


My response would be along Dr. Hardcastle's line. Curious if there
would be alternative methods or suitable options?
J Francis

On 4/14/12, Jan <jwduijff at gmail.com> wrote:
> Case very interesting, just a bit over my head so I thought better to read
> posted suggestions in awe..
>
> Kind regards,
>
> Jan Duijff
> Trauma fellow
>
> Op 14 apr. 2012 om 18:23 heeft Caesar Ursic <cmursic at gmail.com> het volgende
> geschreven:
>
>> 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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