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Fwd: Re: crushing case

Errington Thompson errington at erringtonthompson.com
Sun Apr 15 06:39:01 BST 2012


See below.

Errington C. Thompson, MD
Trauma/Surgical Critical Care
sent from my cool new Droid
---------- Forwarded message ----------
From: "Errington Thompson" <wtoblog at gmail.com>
Date: Apr 15, 2012 1:36 AM
Subject: Re: crushing case
To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>

ER thoracotomy for blunt trauma??? Really? Now this is going to be
interesting. Where's the data for this?

Errington C. Thompson, MD
Trauma/Surgical Critical Care
sent from my cool new Droid
On Apr 14, 2012 7:09 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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>>>>>  --
>>>>>>>>>>
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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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