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crushing case

Errington Thompson errington at erringtonthompson.com
Mon Apr 16 09:29:08 BST 2012


Here's that paper. 

E

Errington C. Thompson, MD, FACS, FCCM
Trauma Surgeon/Surgical Critical Care
Radio Talk Show Host - Podcasts
Asheville, NC  

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Dr and Mrs T Hardcastle
Sent: Monday, April 16, 2012 2:57 AM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: crushing case

Ian

AfJEM is free full text on the publisher (Elsevier) website

> I can't access AfJEM - is it possible to post the paper?
>
> Ian
>
> Sent from my iPhone
>
> On 15/04/2012, at 15:56, "Dr and Mrs T Hardcastle"
> <dr.tchardcastle at absamail.co.za> wrote:
>
>> Short answer - now we know it does not help: Study by Brown et al 
>> from California in J Trauma and one from Cape Town (AfJEM 2011) 
>> showed no difference in need for RRT or mortality.
>>
>> Tim Hardcastle
>>
>>> 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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>>>>>>
>>>>>>> --> '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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