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Sun Apr 15 00:18:05 BST 2012

This raises a question from a field provider.  As a paramedic, should
sodium bicarb play any role in the resuscitation of this individual?
 Assuming a longer transport time to an ER.

Bicarb has always been discussed (to my knowledge) in this type of
resuscitation, given the (presumed) acidotic state that led to the arrest.

Is this correct or incorrect logic?

Sahaj Khalsa

On Sat, Apr 14, 2012 at 5:09 PM, Scott Bricker <scottbricker at verizon.net>wrote:

> On arrival, do pericardial ultrasound. If there is cardiac motion, do
> resuscitative thoracotomy. If there is no cardiac motion, pronounce the
> patient dead.
>
> Scott Bricker, MD
> Harbor-UCLA Medical Center
>
> Connected by DROID on Verizon Wireless
>
> -----Original message-----
> From: Errington Thompson <errington at erringtonthompson.**com<errington at erringtonthompson.com>
> >
> To: trauma-list at trauma.org
> Cc: trauma-list at trauma.org
> Sent: Sat, Apr 14, 2012 22:52:10 GMT+00:00
> Subject: Re: crushing case
>
> I have not followed this thread. But it appears from the presentation u
> have PEA. Need to go thru the drill. Bilateral chest tubes. Pericardial
> tap. Fluids.
> Errington C. Thompson, MD
> Trauma/Critical Care
> Sent from my Verizon Wireless 4GLTE Phone
>
> -----Original message-----
> From: Jan <jwduijff at gmail.com>
> To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Cc: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Sent: Sat, Apr 14, 2012 22:13:07 GMT+00:00
> Subject: Re: crushing case
>
> 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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>>>>
>>>>> --
>>>>>>>>>>
>>>>>>>>> trauma-list : TRAUMA.ORG
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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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>>
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