EMS World

JAN 2018

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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48 JANUARY 2018 | EMSWORLD.com CONTINUING EDUCATION port to the CT scanner. A warming blanket is applied to raise his body temperature. Cardiac, renal, liver, sepsis, and toxicol- ogy bloodwork are drawn. A chest x-ray shows large volumes consistent with COPD and a slightly enlarged heart. There is no evidence of pneumonia. The man is sent for a CT scan. Bloodwork reveals increased creatinine, CK, and troponin, and a diagnosis of rhab- domyolysis is made secondary to nontrau- matic crush injury. A complete blood count and blood cultures are normal. The patient's lactate is mildly elevated, labs are positive for ethanol and negative for drugs of abuse, and the liver panel is normal. Coagulation bloodwork is slightly elevated. The CT scan shows a large right-sided subdural hemorrhage with no skull fracture. There is no evidence of ischemic stroke. The man is flown to a neurosurgical hospital by a critical care helicopter crew; there he undergoes a craniotomy. He is discharged 11 days later. Conclusion What at first glance sounds like a very rou- tine low-acuity call can in fact be a serious life-threatening emergency. On close exam, this patient had head trauma, likely secondary to a fall from being intoxicated or possibly assault. Because of this he sustained a subdural hemorrhage that rendered him immobile on a cold night. He became hypothermic and suffered non- traumatic crush injury. In people with alcoholism, brain atrophy increases the risk of subdural hemorrhage from delicate bridging veins, leading to bleeding that is often less dramatic than arterial bleeds in the epidural or subarach- noid space. In patients with prolonged immobiliza- tion, nontraumatic crush injury can lead to rhabdomyolysis, acute kidney failure, hyperkalemia, and acidosis. It is often easy to draw the wrong con- clusions when faced with an unconscious patient; a drunk at a shelter can quickly be hauled to the hospital with little consid- eration for other pathology. In this case a careful examination and consideration of environmental, anatomic, and physiologic factors revealed a traumatic brain injury requiring neurosurgery, a life-threatening electrolyte imbalance requiring prehospital therapy, and hypothermia that could have contributed to coagulopathy and worsen- ing intracranial hemorrhage. ABOUT THE AUTHOR After a decade working as a helicopter paramedic, Blair Bigham, MD, MSc, EMT-P, completed medical school in Ontario, Canada, where he is now a resident physician in the emergency department. He has authored over 30 scientific articles, led major national projects to advance prehospital research, and participated in multiple collaboratives, including the Resuscitation Outcomes Consortium. E-mail him at blair.bigham@medportal.ca. NAEMT.ORG /NAEMTFriends /NAEMT_ 1-800-34-NAEMT Evidence-based Designed to improve performance The trusted brand in EMS continuing education CHOOSE THE BEST FOR YOURSELF… AND YOUR PATIENTS. EDUCATION For More Information Circle 35 on Reader Service Card

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