> -----Original Message-----
> I have read the Anaesthetic textbooks. There is a
> recognized increase in plasma potassium following
> protracted crush and then release of pressure.
Protracted crush (under fallen buildings etc), yes. MVA entrapment from 30
mph impact, no. It's going to be a difficult intubation and needs doing in a
hurry. Not a time to be switching from your usual drugs.
A few other points:
1. GCS 7. What this mean? I'd guess at E 1 (screwing up eyes because of
pain), M 5 (not in the mood to obey commands or in too much pain to listen
to what you're saying- if the patient was thrashing about we can assume M at
least 4. If he's actually pulled his line, then 5), V 1 (mandible and
maxilla gone, free floating tongue). Lot of difference between that and E 2,
M 3, V2. But don't assume lack of awareness.
2. Jugular line for IV access? Not easy if the patient is hypovolaemic (i.e.
no peripheral veins). Also, turning the head to the side (I don't believe in
clearing necks on the basis of plain x-rays in comatose patients even if you
could get good films fast enough). Not sure why cut downs failed in any
case, though.
3. Primary surgical airway. Fine if you've done a enough surgical airways in
an elective setting to be happy with your own ability. Not if your
'experience' is based on having done ATLS. Getting an airway through the
cricothyroid membrane in a patient with tracheal tug is no fun. Even worse
is failure to identify landmarks properly because of inexperience and soft
tissue swelling and cutting the superior thyroid artery- I've seen it done.
If you can't keep a line in the patient, don't assume you'll be able to keep
a cric in- you may just cause bleeding (below the cords) (subsequent efforts
to clear; increased agitation; increased ICP).
Matt
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