island emt Posted December 24, 2012 Share Posted December 24, 2012 There are a couple of issues to deal with here. Rhabdo caused by the circulation being restricted in lower extremities and compartment syndrome caused by restriction to lower extremities by the harness leg/crotch straps. Once the pressure is released the pool of "bad blood " will recirculate and cause electrolyte imbalances which can lead to acidoses and cardiac irritability & arrhythmia's . Rhabdo causes increases in potassium in the blood as the muscle tissue breaks down releasing myoglobin. these lead to the potentially fatal arrhythmia's TX to include multiple IV's with N,S, 0.9 and ringers lactate ,TKO, cardiac monitoring and gentle handling to limit cardiac shock. Consider bicarb as pt appears to be in toxic shock prior to our arrival. Position in semi fowlers and try to restrict movement of lower extremities. Be careful with fluid administration as the kidneys are often affected quickly and renal failure is common. Link to comment Share on other sites More sharing options...
scubanurse Posted December 24, 2012 Share Posted December 24, 2012 I'd be weary about laying him down and rapidly increasing the venous flow to the heart... If only we could send someone up and get an ABG on him 1 Link to comment Share on other sites More sharing options...
DFIB Posted December 24, 2012 Share Posted December 24, 2012 Well, crap brother. Elecrolites and metabolic disorders are above my pay grade for the most part so if I can't research I am gonna be behind the 8 ball on this one. 1 Link to comment Share on other sites More sharing options...
DwayneEMTP Posted December 24, 2012 Author Share Posted December 24, 2012 There are a couple of issues to deal with here. Rhabdo caused by the circulation being restricted in lower extremities and compartment syndrome caused by restriction to lower extremities by the harness leg/crotch straps. Once the pressure is released the pool of "bad blood " will recirculate and cause electrolyte imbalances which can lead to acidoses and cardiac irritability & arrhythmia's . Rhabdo causes increases in potassium in the blood as the muscle tissue breaks down releasing myoglobin. these lead to the potentially fatal arrhythmia's TX to include multiple IV's with N,S, 0.9 and ringers lactate... Why the Ringers? ...Consider bicarb as pt appears to be in toxic shock... No history of tampon use in this patient... :-) What would be s/s for deciding on the bicarb? What would be your tipping point that would cause you to push it? How would you deliver it? How much? Be careful with fluid administration as the kidneys are often affected quickly and renal failure is common... What would be my criteria for monitoring "careful" in regards to kidney safety in this patient? How would I know if he'd had enough? Too much? I'd be weary about laying him down and rapidly increasing the venous flow to the heart... If only we could send someone up and get an ABG on him What would you be worried about specifically? No problem on the ABG. You draw a sample, send it with your partner to the lab, you should have results within the next three or four days....You're welcome. :-) Well, crap brother. Elecrolites and metabolic disorders are above my pay grade for the most part so if I can't research I am gonna be behind the 8 ball on this one. Grin, I'm behind the 8 ball too...I've seen your posts, and I'm confident that you are at least, and likely more so, able to contribute to this than I am. I learned these treatments, as many did, rote, with a satisfactory explanation for the treatments suggested, but have run across newer information stating that what I learned was wrong and counter productive..now just trying to start at the beginning and see what seems to be the most logical before exploring what other, science based institutions have declared. Will open it up to research as long as the peripheral issues are looked into and not the specific "Suspension" issues...know what I mean? Compartment syndrom, Rhabdomyolosis, pros and cons of using sodium bicarb in relation to those issues, etc are ok... Link to comment Share on other sites More sharing options...
scubanurse Posted December 24, 2012 Share Posted December 24, 2012 (edited) Grr...I'd be worried that the rapid return of venous could overload the heart and cause blood to back up into the lungs as the heart struggled to catch up to the increase in venous return? The LOC would be related to a decrease in cardiac output/gravity and venous stasis... Just throwing a random track out there...not sure if I'm on the right track or not though....more than likely I'm not. Also, I'm not sure LR would be the best option and I could be totally wrong on this but the excess electrolytes LR has could further contribute to hyperkalemia once lowered? I'm pretty sure that with rhabdomyolysis you get serum hyperkalemia. An isotonic solution would be ideal but probably not LR...I'd stick with NS, and probably even stay away from D5W? Edited December 24, 2012 by Kate_826 1 Link to comment Share on other sites More sharing options...
DwayneEMTP Posted December 24, 2012 Author Share Posted December 24, 2012 You make an awesome point, one that I would have never have considered in a hundred years... I ran across this theory in my research, so I deserve no credit, and in fact have no idea if it's even valid...Why would you worry about the heart being overloaded? I mean, it's been beating with the same amount of veinous return this patient's whole life, right? Can you think of an issue here that would compromise the heart's ability to pump at the same rate, with the same force as it was before this issue occurred? Again, if I'd not read this, I would have never guessed it or been able to reason it out...it will be a possible contractile force issues, not a conduction issue. What do you think? Link to comment Share on other sites More sharing options...
scubanurse Posted December 24, 2012 Share Posted December 24, 2012 (edited) The contractile force likely decreased with the decrease in venous return. With a rapid return of venous flow to the RA, the heart will not have the time to adjust and will be overloaded easily. The decrease occurred gradually as time progressed, but the increase would be sudden when the patient is laid down horizontal. Without doing any research this is all just speculation? ETA: Fixed my poor grammar I think... lack of sleep from studying can make anyones brain scrambled! No change in content though. Edited December 25, 2012 by Kate_826 Link to comment Share on other sites More sharing options...
DwayneEMTP Posted December 25, 2012 Author Share Posted December 25, 2012 What would happen to the pH of the pooled blood? Could a pH change have any effect on cardiac contractility? Link to comment Share on other sites More sharing options...
scubanurse Posted December 25, 2012 Share Posted December 25, 2012 That I'm not sure about... I know metabolic acidosis can cause the rapid breathing, but as far as contractility of the heart, I would have to cheat and go look at my med/surg text book. Link to comment Share on other sites More sharing options...
DwayneEMTP Posted December 25, 2012 Author Share Posted December 25, 2012 ...Just throwing a random track out there...not sure if I'm on the right track or not though....more than likely I'm not... These statements are the single most reliable marker for my very favorite discussions. The discussions where many already know the right answers and the reason for them are really not that interesting I think...Thanks for participating! I wouldn't know either, but I ran across an article that was saying that the lowered pH from the acidosis though not causing conduction issues, can possible cause contraction issues (Though it's unclear at the levels expected in this type of scenario, around 6.8). There are other electrolytes that are happy to screw with the conduction, though, theoretically, in this situation... It's a really difficult situation to study I guess... Link to comment Share on other sites More sharing options...
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