RESUMEN
Although the surgical cricothyrotomy procedure is used on combat casualties in the most challenging environments, we are unaware of any published report in the United States of surgical cricothyrotomy performed in a wilderness recreational setting. We describe a 31-year-old male rock climber who fell 24.4 m (80 feet), sustaining serious injuries and requiring rescue from the base of the cliff by a cave/cliff rescue team. Ultimately, a surgical cricothyrotomy proved necessary because of ongoing oropharyngeal bleeding, facial fractures creating an unstable airway, and the need to place the patient in the litter. The patient survived a prolonged and arduous evacuation. This report presents the management of the patient during the rescue and the challenges faced by the rescue team physician and others that led to the decision to perform an improvised surgical cricothyrotomy.
Asunto(s)
Obstrucción de las Vías Aéreas/cirugía , Cartílago Cricoides/cirugía , Músculos Laríngeos/cirugía , Montañismo/lesiones , Traqueotomía/métodos , Adulto , Tratamiento de Urgencia , Humanos , Masculino , Resultado del Tratamiento , Medicina SilvestreRESUMEN
A 29-year-old man was caving and could not ascend his rope. He was rescued after 4+ hours of hanging after which he could not feel his legs and could not move one of them. He was shivering but still alert. In the field, he received calcium chloride, normal saline, and bicarbonate. At the hospital, he was found to have elevated creatine phosphokinase levels that resolved after continued intravenous fluid. Suspension trauma can include early syncope and late rhabdomyolysis. Persons suspended passively must be rescued immediately and given intravenous fluid to prevent rhabdomyolysis and renal failure.
Asunto(s)
Ambiente , Rabdomiólisis/epidemiología , Rabdomiólisis/etiología , Lesión Renal Aguda/prevención & control , Adulto , Fluidoterapia , Humanos , Masculino , Rabdomiólisis/terapiaRESUMEN
STUDY OBJECTIVE: We determine the overall use of a 6-step accelerated chest pain protocol to identify and exclude acute coronary syndrome (ACS) and to confirm previous findings of the use of serial 12-lead ECG monitoring (SECG) in conjunction with 2-hour delta serum marker measurements to identify and exclude acute myocardial infarction (AMI). METHODS: A prospective observational study was conducted over a 1-year period from January 1, 1999, through December 31, 1999, in 2,074 consecutive patients with chest pain who underwent our accelerated evaluation protocol, which includes 2-hour delta serum marker determinations in conjunction with automated SECG for the early identification and exclusion of AMI and selective nuclear stress testing for identification and exclusion of ACS. In patients not undergoing emergency reperfusion therapy, physician judgment was used to determine patient disposition at the completion of the 2-hour evaluation period: admit for ACS, discharge or admit for non-ACS condition, or immediate emergency department nuclear stress scan for possible ACS. A positive protocol was defined as a positive result in 1 or more of the 6 incremental steps in our chest pain evaluation protocol: (1) initial ECG diagnostic of acute injury or reciprocal injury; (2) baseline creatine kinase (CK)-MB level of 10 ng/mL or greater and index of 5% or greater or cardiac troponin I level of 2 ng/mL or greater; (3) new/evolving injury or new/evolving ischemia on SECG; (4) increase in CK-MB level of +1.5 ng/mL or greater or cardiac troponin I level of +0.2 ng/mL or greater in 2 hours; (5) clinical diagnosis of ACS despite a negative 2-hour evaluation; and (6) reversible perfusion defect on stress scan compared with on resting scan. All patients were followed up for 30-day ACS, which was defined as myocardial infarction (MI), percutaneous coronary intervention/coronary artery bypass grafting, coronary arteriography revealing stenosis of major coronary artery of 70% or greater not amenable to percutaneous coronary intervention/coronary artery bypass grafting, life-threatening complication, or cardiac death within 30 days of ED presentation. RESULTS: Discharge diagnosis in the 2,074 study patients consisted of 179 (8.6%) patients with AMI, 26 (1.3%) patients with recent AMI (decreasing curve of CK-MB), and 327 (15.8%) patients with 30-day ACS. At 2 hours, sensitivity and specificity for MI (AMI or recent AMI) of SECG plus delta serum marker measurements was 93.2% and 93.9%, respectively (positive likelihood ratio 15.3; negative likelihood ratio 0.07). At the completion of the full ED evaluation protocol (positive result in >or=1 of the 6 incremental steps), sensitivity and specificity for 30-day ACS was 99.1% and 87.4%, respectively (positive likelihood ratio 7.9; negative likelihood ratio 0.01). CONCLUSION: An accelerated chest pain evaluation strategy consisting of SECG, 2-hour delta serum marker measurements, and selective nuclear stress testing in conjunction with physician judgment identifies and excludes MI and 30-day ACS during the initial evaluation of patients with chest pain.
Asunto(s)
Dolor en el Pecho/diagnóstico , Enfermedad Coronaria/diagnóstico , Electrocardiografía/métodos , Infarto del Miocardio/diagnóstico , Dolor en el Pecho/sangre , Enfermedad Coronaria/sangre , Creatina Quinasa/sangre , Forma MB de la Creatina-Quinasa , Diagnóstico Diferencial , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Isoenzimas/sangre , Masculino , Persona de Mediana Edad , Infarto del Miocardio/sangre , Estudios Prospectivos , Sensibilidad y Especificidad , TennesseeRESUMEN
No information is currently available regarding optimal cut-off values of the ST-vector magnitude (ST-VM) for predicting acute myocardial infarction (AMI) in emergency department (ED) chest pain patients undergoing vectorcardiographic (VCG) monitoring. A prospective observational study was performed in 1,722 chest pain patients with suspected acute coronary syndrome and absence of bundle branch block (BBB) and left ventricular hypertrophy (LVH) on initial ECG who underwent continuous VCG ST-segment monitoring during the initial ED evaluation. Three cut-off values for baseline ST-VM are reported and represent the smallest values in which the positive likelihood ratio (+LR) for AMI is greater than 5, 10, and 20, respectively. AMI occurred in 158 of 1,722 patients (9.2%) without BBB or LVH on initial ECG. Optimal cut-off values at the predetermined +LR values of 5, 10, and 20, were 121 microV (sensitivity, 41.8%; specificity, 92.0%), 151 microV (sensitivity, 29.1%; specificity, 97.1%), and 175 microV (sensitivity, 25.9%; specificity, 98.7%), respectively. Combining the earlier-mentioned cut-off values with physician judgment of initial pretest probability (high, intermediate, or low, respectively) resulted in a relative increase in identification of injury of 37.5% as compared with the ED physician's interpretation of initial ECG (41.8% v 30.4%; P <.0001), and 65.2% as compared with the official ECG interpretation (41.8% v 25.3%; P <.0001). Increasing ST-VM results in increasing likelihood of AMI. Clinical studies need to be performed to determine if ST-VM cut-off values of 121, 151, and 175 microV in conjunction with physician pretest probability of AMI can be used as criterion for emergent reperfusion therapy in patients without LVH or BBB on the initial ECG.