tommyk
05-20-2006, 12:07 PM
Hy 2225
A 20 year old high school football player is brought in to YOU in the ER because a giant linebacker tackled him on his legs. The patient was brought to the hospital by the EMS team who had extricated him. At the scene, his Glasgow score was 15/15, and he was alert and oriented. On arrival, the patient appears bloody, and in a significant amount of pain, but still alert. Vitals are stable. His examination reveals bilaterally crushed lower extremities with a visibly pulsating bleed. Emergency laboratory data are as follows:
Sodium............................................ .140 mEq/L
Potassium......................................... 5.5 mEq/L
Bicarbonate......................................2 0 mEq/L
Chloride .........................................100 mEq/L
Urea nitrogen...................................35 mg/dL
Creatinine........................................ 1.2 mg/dL
Creatine phosphokinase....................15,300 U/L
Aspartate aminotransferase..............112 IU/L
Alanine aminotransferase.................99 IU/L
Hematocrit.......................................3 8%
Arterial blood gas on 40% oxygen.....PO2 – 50 mm Hg, PCO2 – 37 mm Hg, pH – 7.33
What will you do?
1-IV Fentanyl
2-IV Morphine
3-20 mg oxycodone
4-6 lead EKG
5-IV crystalloid and bicarb
6-CK levels check
7-Ultrasound of abdomen
a) ans is #5. Crush injuries, such as the one sustained by this patient, often result in a massive release of muscle contents. Creatine kinase (CK) is an enzyme released by dead or damaged muscle into the blood. By itself it is harmless, but it is a marker for myoglobin, which is directly nephrotoxic. Myoglobin, which is not measured by conventional assay, is released after damage to muscle. Much data exist showing early intervention with copious alkalinized IV crystalloid can prevent renal damage. A 6-lead ECG may be useful, but given the nature of the injuries, and the fact that there are no clinical signs or symptoms suggesting myocardial ischemia, this intervention is not the most useful. The same holds true for a echocardiogram. In the case of blunt chest wall trauma, this test is indicated. However, in the case of a lower extremity crush injury, it is not immediately indicated. Because there is no reason to suspect that the heart is the source of the elevated CK, fractionated CK levels would not be useful. A concern in trauma patients is always for liver damage in the form of contusion or avulsion. This patient has relatively normal liver function tests and hematocrit. Therefore, a right upper quadrant ultrasound would not be very useful for a suspected intra-abdominal process.
A 20 year old high school football player is brought in to YOU in the ER because a giant linebacker tackled him on his legs. The patient was brought to the hospital by the EMS team who had extricated him. At the scene, his Glasgow score was 15/15, and he was alert and oriented. On arrival, the patient appears bloody, and in a significant amount of pain, but still alert. Vitals are stable. His examination reveals bilaterally crushed lower extremities with a visibly pulsating bleed. Emergency laboratory data are as follows:
Sodium............................................ .140 mEq/L
Potassium......................................... 5.5 mEq/L
Bicarbonate......................................2 0 mEq/L
Chloride .........................................100 mEq/L
Urea nitrogen...................................35 mg/dL
Creatinine........................................ 1.2 mg/dL
Creatine phosphokinase....................15,300 U/L
Aspartate aminotransferase..............112 IU/L
Alanine aminotransferase.................99 IU/L
Hematocrit.......................................3 8%
Arterial blood gas on 40% oxygen.....PO2 – 50 mm Hg, PCO2 – 37 mm Hg, pH – 7.33
What will you do?
1-IV Fentanyl
2-IV Morphine
3-20 mg oxycodone
4-6 lead EKG
5-IV crystalloid and bicarb
6-CK levels check
7-Ultrasound of abdomen
a) ans is #5. Crush injuries, such as the one sustained by this patient, often result in a massive release of muscle contents. Creatine kinase (CK) is an enzyme released by dead or damaged muscle into the blood. By itself it is harmless, but it is a marker for myoglobin, which is directly nephrotoxic. Myoglobin, which is not measured by conventional assay, is released after damage to muscle. Much data exist showing early intervention with copious alkalinized IV crystalloid can prevent renal damage. A 6-lead ECG may be useful, but given the nature of the injuries, and the fact that there are no clinical signs or symptoms suggesting myocardial ischemia, this intervention is not the most useful. The same holds true for a echocardiogram. In the case of blunt chest wall trauma, this test is indicated. However, in the case of a lower extremity crush injury, it is not immediately indicated. Because there is no reason to suspect that the heart is the source of the elevated CK, fractionated CK levels would not be useful. A concern in trauma patients is always for liver damage in the form of contusion or avulsion. This patient has relatively normal liver function tests and hematocrit. Therefore, a right upper quadrant ultrasound would not be very useful for a suspected intra-abdominal process.