Off Label

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Off Label last won the day on September 20 2016

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  1. Medical conditions causing crush syndrome

    You might be drifting into the tall weeds here. To break it down, "crush injury" for the purposes here is distinct from blunt trauma, although blunt trauma is obviously a major component in the crush syndrome. Crush syndrome or injury or whatever you want to call it is a constellation of problems that are superimposed on the blunt trauma problem, and, as your question suggests, does not require blunt trauma to set in motion. So....the problems we've identified so far... 1. Massive liberation of muscle protein, myoglobin, into the vascular space leading to renal damage/failure (rhabdomyolysis) 2. Sudden release of severe, blood flow restricting limb/pelvis compression after an extended period of entrapment. Accumulation of anaerobic metabolites and cellular release of potassium from cell death, (to say nothing of vascular injury and thrombus formation) is capable of causing sudden and catastrophic cardiovascular collapse via sudden and profound metabolic acidosis and hyperkalemia. How can these present through a medical mechanism? 1. Rhabdomyolysis can occur when a poorly conditioned athlete attempts an activity that is far out of his depth, ie a marathon. Hyperthermic emergencies, diabetic emergencies, drug reactions, certain infectious diseases can all have the same effect. 2. As far as this goes, a scenario will be instructive...Say a poorly conditioned alcoholic is on a binge one weekend and spends the weekend on the couch drinking and goes into a fib (maybe has a history of p-afib). He ignores it and continues to drink until Monday when he sobers up. As the week progresses he notices pallor pain in both legs which he ignores for a couple of days until the pain is unbearable. He's admitted to the hospital for pulseless lower extremities 2/2 embolization of thrombus most likely caused by is immobility and a fib. Several days of no flow to both legs from a clot does the same thing as a two ton concrete block on the pelvis. When the surgeon fishes out those clots and reperfuses the lower half of the body, that "acid wash" will occur and the consequences are the same as if he were extricated from a building collapse...get it? Obviously, the severity of the syndrome with vary with the situation. While these things can occur, most times the degree to which they present are not clinically significant and resolve on their own with no treatment except rest and fluids.
  2. Medical conditions causing crush syndrome

    Good article, Ruff... there are "medical" v. "traumatic" causes of the syndrome, which is actually a misnomer, IMO, because while the syndrome can be caused by crush or blast injuries, the actual cause of end organ damage isn't exclusive to trauma. It'd be like calling the effects of acute, significant blood loss a "syndrome" like "penetrating hepatic trauma syndrome". You can have the same "syndrome" from an acute GI bleed. Might be kind of splitting hairs, but there is a lot in medicine that is confusing that doesn't have to be...so to the OP, the cause of the end organ damage that is caused by blast or crush injury is identified in the posted link.
  3. Pathophysiology of cyanide poisioning

    Kenny, I just ask because I don't understand what cytochrome oxidase at cytochrome A3 is let alone cytochrome A3. I was asking because I was curious as to the back round you were bringing to your training. Good news for me is that I don't need to know that stuff to treat cyanide poisoning!
  4. Pathophysiology of cyanide poisioning

    Do you know what all of this means?
  5. FENTANYL AND CARFENTANIL

    Reversing carfentanil and reversing fentanyl is the difference between pushing a car and pushing a shopping cart.
  6. CHF & Low BP

    Curious as to choosing NE instead of an inotrope like epi or even dopamine. Is there a specific element here that you like NE for?
  7. CHF & Low BP

    Counter intuitive, giving volume in that situation. Then take it off with Lasix. Perhaps just a stop gap measure to get the coronary perfusion pressure up.
  8. CHF & Low BP

    O2 for SaO2 > 92, epi for MAP > 70 mmHg (start with .03/kg/min) while en route. Determining DNR is a good idea, verbal is OK just to tell the receiving hospital what the patient said in the event he becomes unresponsive. A pretty hard buy to not resuscitate then and there based on what the guy says in his living room or back of the ambulance unless someone produces a document or corroborator. Based on hx/ PE, I'd say his LV was pooping out (as opposed to his RV 2/2 PHTN). If he pulls through, someone could suggest palliative care?
  9. Afib RVR

    Sound like the Afib here was 2/2 the type of surgery and problem the patient was having. I'm going to guess he didn't have a CHADS score that would suggest risk of a LA thrombus. I'd say you were pretty safe in DCCV'ing this guy (not that it sounded like you had much of a choice.) Good call on the pads. I can't say I'd have thought to do that.
  10. Spinal Restriction

    They'd have found a week old summer catfish in their boots...at the very least...gross.
  11. Spinal Restriction

    I think with the evolving understanding of crystalloid volume resuscitation and permissive hypotension in trauma, the MAST should get a second look, imo.....
  12. All of our Stoner Ford Type II's (mid/late 80's) had stretcher hooks you could suspend over the squad bench and put a third patient "bunk bed" style on a scoop or flat folding stretcher over the bench patient.
  13. Smartest thing youve ever seen a patient/family member do

    This guys mom walked him down three flights of stairs and had him sit down on the lawn after she called us for his asthma exacerbation. If he was under 375, I couldn't tell. She did it before he wouldn't be able to, cause he couldn't by the time we got there. Don't know if the trip down the stairs made it worse or not, but I could have kissed that old gal.
  14. Dumb question on NREMT

    Whoops...I got it. Was referring to OP of 120/80 blood pressure, not Ruff's post. Good point. LVADs are becoming so much more common around larger metro areas, not so much in "flyover" towns. Worth paying attention to, though, as people with LVAD's get into cars and drive to places far, far away from the centers that place them.
  15. Dumb question on NREMT

    That'd be some kinda lvad