ERDoc

Not to mention that not every fx results in swelling or discoloration (or even pain for that matter). I have seen sprained ankles the size of softballs with ecchymosis you wouldn't believe. I've seen pts with fxs that you couldn't even tell were injured. They came in because of pain when the were bearing weight.

Sorry Hammer, my bad. I misread what you wrote. Guess that was my misinterpretation! 8) I do realize how slanted it is. If USAT is referring to the study that SAEM had listed on their site, the title is Cardiac Arrest Survival Rates Depend on Paramedic Experience . Sure sounds like USAT has put a very interesting slant on it and the conclusions they are coming to don't fit the title. Sorry Dust, I meant meaningful statistics, like odds ratios, p values, etc.

I believe the study was done by a small hospital called the Ohio State University. Before everyone rips apart a study based on an article in USAToday that does not present any of the statistics or results, we should look at the study and judge it based on scientific merit and look over the statistics and analysis. I am unfortunetly not at the SAEM conference where this was presented, but I'm sure we will see it published in a few months.

A few quick questions: Hammer: What statistical misrepresentation? I didn't see any statistics presented. Rid: Do you have the reference to the study and article that you are talking about. The study this article was about has yet to be published.

I see we need a little reeducation on compartment syndrome vs. rhabdomyolysis. I'll provide a few links at the end, but to give a brief synopsis: A muscle compartment (most commonly the compartments in the shin or the forearm) suffers some for of injury. This injury can be a fracture of the bone (tibia, radius/ulna), crush injury, hypoperfusion, etc. The comparment fills with fluid (could be edema or blood) and the pressure in the compartment begins to rise. The compartment has no place to release the additional volume (this is Compartment Syndrome). The pressure inside the compartment gets to the point that it is higher than the perfusion pressure in the muscle and so the blood supply is cut off leading to necrosis and muscle breakdown (this is rhabdomyolysis). So, compartment syndrome can lead to rhabdomyolysis, but hopefully it will be caught before it gets to this point. Compartment syndrome causes the 5 Ps (pain, pallor, parasthesia, pulselessness and poikliothermia). There is no lab test that can be used to diagnose Compartment syndrome. The diagnosis is made by putting a needle into the compartment and measuring the pressure. Treatment is an open fasciotomy (the fascia covering the muscle compartment is cut to reduce the pressure and improve perfusion). There is also an abdominal compartment syndrome, but I won't go into the details (see the link below). Rhabdomyolysis is the breakdown of muscle tissue. There are many causes (trauma and nontraumatic). To diagnose rhabdo you need a blood test (CPK). The treatment is fluid, fluid, fluid, diuresis, correction of electrolyte abnormalities, monitoring of renal function (dialysis if needed, possibly permanently) and alkalinization of the urine. Hope this helps clear up some confusion. http://www.emedicine.com/orthoped/topic55.htm http://www.emedicine.com/orthoped/topic596.htm http://www.emedicine.com/emerg/topic508.htm http://www.emedicine.com/emerg/topic935.htm

Might have gotten gestational age from fundal height. Could be pregnant, could be fibroid. Guess we'll wait and see.

Uhm, what blood test would you want to confirm compartment syndrome? How would bicarb help? Are you sure about your understanding of compartment syndrome?

If you needle the chest this guy is going to end up with a chest tube in the ER. If you don't needle him, he will end up with a chest tube (and from the sounds of it he may end up with a full thoracostomy in the OR). I would say that if you are concerned and there is REAL evidence of a tension pneumo, do the needle (but follow your local protocols).

Dang, and I wasted all of those years in med school.

Does anyone carry a Bullard scope on their ambulance? It's expensive, but it works great. I've used it on a few difficult airways and on a few that I thought were going to be difficult.

Here in NY it is legal for 10 year olds to drive snowmobiles (some of which can go 100mph off the shelf) without a parent or guardian. I don't get why this is okay, but they can't drive a car until they are 16.

I'm amazed that it made it 15 pages period, but without a thread lock, yup that's even more amazing. The person below me is a member of the mile high club.

It is the frequent fliers that scare me the most, especially the drunk ones. They always get put in a corner and forgotten about. I don't want to be the one on duty the day that they actually have something and it gets missed because everyone thinks they are just drunk again and end up in the corner. Another technique that I find works (very similar to Rids) is to tell someone that if they don't wake up and start talking that I will have to assume the worst and put a tube down their throat to make sure they keep breathing and a tube in their penis. A colleage of mine likes to ask the nurse, in front of the "unconscious" patient, to get 5cc of that new drug Nakel (NaCl). He makes a point to say, "It's a good thing for him he really is unconsious, because if he wasn't this new drug could kill him." I have never tried it, but he claims a 100% success rate.

A little nailbed or knuckle pressure is a very noxious stimulus with little chance of causing any real harm and family members may not notice it if they are crowding around.

On that note, scalp wounds can be very bad also. They can look minor, but the scalp is so vascularized that they bleed like stink. The pt can bleed out and you will never know because it is pooling in the sheets behind them. I have seen several cases of pts dropping their pressures because of a scalp wound that was not cared for properly.

Sorry I didn't conclude this case. chbare, you are very close. The seizures are from INH toxicity, not necessarily an OD. Can you tell me how the INH causes seizures?

Not to get off the topic, but what about this patient made you think he was hypoglycemic?

Hemorrhage can cause hypovolemic shock. Anything that causes you to have less volume in you blood vessels can cause hypovolemic shock (ie dehydration, third spacing, etc).

With all of the evidence that has been published, about the only thing that has really panned out is that large volume fluid resuscitation in pts with injury to the large arteries can be detrimental, and permissive hypotension might be the best way to treat these pts. As previously stated when you increase the pressure, you have the potential to blow off whatever clot has formed. The same has not been shown for less severe injuries such as splenic and liver lacs and things such as extremity trauma. Obviously, in the field, with blunt abd/chest trauma you have no way of knowing what is injured so, I don't think you will ever see any conclusive evidence either way, so you will end up at the mercy of your medical director and his/her beliefs. At my hospital, the way we do it is two large bore IVs (not necessarily with fluids going). Any pt with AMS or hypotension gets one cordis by the ER and usually the trauma service will put in a second one. If they are hypotensive and do not respond to the first fluid bolus they get blood going, this is usually after CTs have been obtained and we know what their injuries are.

Craniorectal inversion.

Anthony, before we start talking treatment, let's talk diagnosis. You are on the right track, but just haven't quite hit the nail on the head.

Call medical control!! 8)

Has the pt ever been given Haldol before? How hot is hot (get a rectal temp)? I suspect that this pt has a syndrome that is probably malignant, but I guess we'll see.

He will make a great internist some day, don't laugh too hard at him (okay, maybe the period thing). I just had a crew bring in a CVA and the medic told me, "She doesn't have her dentures in but her gait is still off." Those must be some heavy dentures.

Must.........stop..........looking...........ahhhhhhh!!! I can't fight it! 8)