# Medical. : Medicine.



## Muppet (May 22, 2009)

I know there is a subject on Combat Medicine but it is broad subject matter. This is a place where we can discuss and learn things regarding the Military way v/s. the civilian way. I am open to comments and help on how to make this a educational group.

F.M.


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## TLDR20 (Jun 1, 2009)

We could always do some case studies/things we have seen and lessons learned. Improving skills/knowledge can never be a bad thing.


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## Muppet (Jun 2, 2009)

That is what I am hoping for. Sounds good to me. You are welcome to start if you want.

F.M.


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## HeloMedic1171 (Jun 16, 2009)

HEY!!!!!  I guess no one wanted the resident Flight/stepchild medic to play?  geez... I feel like the nerdy white kid who got picked last on the playground....  

assholes!!  


bring on the scenarios!!


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## Muppet (Jun 16, 2009)

Don't cry bro. I love you bro.

Call:
35 y/o female, Cao x 4, obvious distress with the C/C: S.O.B./hoarse voice and dysphagia with a h/x of a tooth infection, bottom Lt. row. Pt. is tachycardic, normotensive, febrile with obvious edema and hardness of sub-mandiblar tissues noted over mandible and unable to open mouth fully.

Diff d/x. and treatment (E.M.S.) and 18D level please.

Had this call the other night.

F.M.


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## HeloMedic1171 (Jun 17, 2009)

it's an abscess, and it's definitely infected.  On assessment of the oropharynx what do you see?  also, approx which tooth was the infected one?  I suggest an I&D of the Abscess followed by Augmentin 500mg PO TID for 10 days.


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## Muppet (Jun 19, 2009)

Abcess is on the right track. As for the oropharnyx, can't open her mouth wide because of edema, sub-mandible. The d/x is LUDWIGS ANGINA. Look it up. It can kill.

F.M.


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## HeloMedic1171 (Jun 19, 2009)

i did... just chose to stay more general, next time I'll be more specific.  is the treatment correct?


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## Muppet (Jun 19, 2009)

I do not know what the E.D. did, prolly I.V. antibiotics. Maybe some 18D's can answer that?

F.M.


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## HeloMedic1171 (Jun 19, 2009)

Ludwig angina (name derived from sensations of choking and suffocation) is characterized by brawny boardlike swelling from a rapidly spreading cellulitis of the sublingual, submental, and submandibular spaces with elevation and edema of the tongue, drooling, and airway obstruction.3  The condition is odontogenic in 90% of cases and arises from the second and third mandibular molars in 75% of cases.3 If infection spreads through the buccopharyngeal gap (space created by styloglossus muscle between the middle and superior constrictor muscle of the pharynx), *potential exists for adjacent retropharyngeal and mediastinal infection*


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## Muppet (Jun 19, 2009)

DING, DING, DING. Good stuff, uh?

F.M.


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## HeloMedic1171 (Jun 19, 2009)

always :)


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## HoosierAnnie (Jul 6, 2009)

OK Guys: try this one on.  

Run call: 58 yo fem cc: left sided sub costal pain radiating up towards axilla.  VS: 156/88  P 96 R 24  Let's do it from the beginning.  What info do you want before you make a differential dix?


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## HeloMedic1171 (Jul 7, 2009)

uh, shit.  without cheating and using google...

mech of injury?  Onset? Provocation? Quality? Severity? Time/duration? Interventions?  "Ma'am, do you have any previous history of heart problems or chest pain I should know about?  what about surgeries?  any recent or past surgeries?  are you taking any medications, any over-the-counter meds, supplements, vitamins, anything?  do you drink or smoke?"

I'd start with those.   whatcha got?


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## HoosierAnnie (Jul 7, 2009)

Yes Helo, w/o using google (you dont have google in the field do ya??)

Sudden onset while doing routine housework. Onset within past hour. No hx of cardiac/ HPB. Only surgeries childbirth over 20 yrs ago. Light social drinker, lifelong non smoker.  Takes a daily multi vit and has been on low dose HRT for the past 6 mos. for perimenopausal symptom control.


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## HeloMedic1171 (Jul 7, 2009)

I wasn't asking if I could use google ... I was telling you I wasn't going to, silly!  and no I don't have it in the field, but in fairness, I don't have 58 y/o females in the field, either!! 

Provocation? Quality? Severity? does respiratory exchange cause pain? or is the pain separate from that?  any other symptoms: NVD, dizziness, etc?   

I'm not gonna lie, this is quite a bit out of my norm and comfort zone, but I'm glad for the practice.


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## HoosierAnnie (Jul 7, 2009)

yes the pain increases on deep inspiration  no NVD  no dizzy

This isn't a problem of just females, its right out of the Special Forces Med Handbook, I just made your patient female for fun.


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## HeloMedic1171 (Jul 7, 2009)

you're evil.  I need to think.  be right back :)


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## HeloMedic1171 (Jul 7, 2009)

k - how about inspection/palpation/auscultation/percussion of the chest and axilla?  is the L chest wall TTP?  any erythema/ecchymosis? deformities?


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## HoosierAnnie (Jul 7, 2009)

Slight guarding of that side, respers are shallow and a bit more tachy then your initial assessment


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## Muppet (Jul 7, 2009)

Sorry, I had a pt. with a STEMI aand a  3rd. A.V.B. I am here now.

12-lead, labs, enzymes? Ultra sound?

Diff: M.I., Pneumothorax, *****Pulmonary embolism*******

F.M.


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## HeloMedic1171 (Jul 8, 2009)

damn.  I go to sleep thinking I'm on the right rack, wake up with the answer...  damn, too slow! :)


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## HoosierAnnie (Jul 8, 2009)

FM got it in one  It's a PE at least thats what I was heading towards

Helo go read up on PE's. Remember an embolism is what killed that Today Show journalist in the early days of reporter being embedded with units.

ready  for a new one??


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## HeloMedic1171 (Jul 8, 2009)

yes, and i will. :)  next!


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## HoosierAnnie (Jul 8, 2009)

Helo says I'm evil, so here goes:

You are walking down the "street" of your FOB, minding your own biz, when you hear "MEDIC!!!" coming from the nearby quarters.  You just so happen to have your aid-bag slung on your shoulder as you are comming back from getting it resupplied.  The FOB has a TMC on it.

When you arrive, you find a male soldier lying on his rack, completely dressed conscious but working really hard to breathe, face very flushed.  His roomie tells you that your patient had just finished getting dressed for duty when he he began having speech problems and complaining of double vision. And then cried out in pain before falling back onto his rack.

next step in assessment??  anything you already suspect??


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## HeloMedic1171 (Jul 8, 2009)

AB is done, check pulses and strip him.  is he A&O? also, have roomie either get on my radio and get an ambulance over here, or get him to run to CQ or the TOC and get this guy a ride.  I don't have 02. 

 without knowing where the pain is, I'm thinking DVT, or a stroke.  anything abnormal with the head or chest? bilateral rise and fall? how's his pulse/motor/sensory? where's the pain?  any radiculopathy?  any signs of trauma?  bleeding?  deformities?


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## Muppet (Jul 9, 2009)

All standard work-up criteria including CT-scan.

Diff: Sub-aracnoid hemmorage / A.V.M.

F.M.


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## HoosierAnnie (Jul 9, 2009)

Roomie hustles off to find you some transpo.

While you are stripping off the guy, his consciousness begins slipping, his respers get even more labored and he begins to drool. At exam, body is essentially unremarkable but for the flushing and a small reddened area on one foot.

Eventually he begins jerking movements, (tetanic)


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## HeloMedic1171 (Jul 9, 2009)

I need a bird ASAFP.  Pt has been stung by a scorpion, and needs antivenom.  also - ice him down with ice packs or frozen water bottles, and treat symptoms - secure airway (I should have done that sooner!!!) and prepare to breathe for him if necesary.  also - treatment is similar to tetanus; prophylaxis with tetanus vaccine is called for if pt has not had one in past 5 years.  Also - Pen V or Doxy, alternate is Metro.


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## HoosierAnnie (Jul 9, 2009)

KACHING  He got it.  This has personal significance for me.  I was stung by one of those lil creamy white beasties while living in TX.  He crawled into my bed and got me.  Guess its only appro, since I AM a Scorpio.

I'll let the rest catch up before I post the next.


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## Muppet (Jul 9, 2009)

Sweet. Them little bastards are freaky. I stepped on one with boots on and I was freaking out. Without more info you would have thought the dude blew an A.V.M.

F.M.


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## HeloMedic1171 (Jul 10, 2009)

we found one in someone's body armor :eek:  no worries - we killed it before it got close.


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## HeloMedic1171 (Jul 24, 2009)

brain pickin' time - for Diarrhea lasting longer than, say 3-5 days....  when and why should I think about ABX vs loperamide.... or should I just try the loperamide and if it doesn't work, hit him with Levo or Metro, depending on whether it's suspected E. Coli or Giardia?

so far, I've been letting it run for 5-7 days, making the pt push fluids and seeing if it self-corrects, and if it doesn't, delve a little further.  so far, no one's had the super-foul smelling stools that go with giardia, but it's mostly the 10-15 x's a day, i-gotta-run-right-now E. coli.  3 days of Levo, and they're all better.  is there something else I could try, besides (essentially) shooting in the dark?  labs, doctors, and microscopes are not available.


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## HeloMedic1171 (Jul 24, 2009)

note:  this is not overly common.... most guys are fine after a few days, without the aid of meds.


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## Muppet (Jul 26, 2009)

Here is a new one, right from the past USAR Medical course I took.

Highschool Pancake collpase, all haz-mats mitigated, multiple patients. Your pt. is pinned from waist below and lethargic. Thinking about crush/Rhabdo, what would you do assuming you are trained in USAR? OR civilian E.M.S. What are the considerations in regards to treatment? 

F.M.


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## HoosierAnnie (Jul 26, 2009)

OK  treatment at site  Since you've said we already have a lethargic patient, I have to assume there's pretty significant blood loss issues.  Get two big bore IV's going, one straight fluids  say Ringers. The other a volume expander (like hespan) if you got it.  O2/airway support.  While extrication in process, make sure you dont have any closed head injuries, monitor VS, LOC, pupils.  You have to assume some spine damage, so c-spine immobilization needs done, not to mention back board and such for post extrication.

Helo and I discussed the merits of do you or do you not have MAST ready?  Unless your patient is the luckiest SOB alive, youre prob gonna have a para or worse post freeing him/her.  MAST might also buy some blood loss time to preserve cerebral and core functions until you can transpo for surgcal intervention.  In the most grim of situations, it may also buy family some precious last words time.


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## HeloMedic1171 (Jul 27, 2009)

concur - except hold expanders til after you determine (if possible) the likelihood of a head injury.  otherwise, x2.


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## Muppet (Jul 28, 2009)

On it like flynn. Add treatment for crush/rhabdomyolisis. I.V. fluids, bicarb and calcium if needed for alkanization, membrane stabilzation, albuterol, d50 and insulin for potassium exchange to intracellular and possible hypoglycemia secondary to liver/kidney failure.

F.M.


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## HoosierAnnie (Aug 18, 2009)

OK Boyz n Girlz  Ready for zee next scenario??

While riding in convoy on troop pullout, you hear an explosion several vehicles ahead of you.  You of couse grab your bag and hump it forward.

One of the first few vehicles in convoy triggered an IED.  Luckily, no one was killed, but the vehicle that triggered it was pitched forward into the rear of the preceeding vehicle from the explosion.  Your patient is the driver of the pitched vehicle.

Initial head to toe after extrication: VS P-92 but regular, respers 16 w/ no audible wheezes or gurgles.  PERRL. 3cm lac above right eye. Both hands abraded. Body armour intact.  Obvious deformity of R tib/fib.

Initial actions after assessment??


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## Muppet (Aug 18, 2009)

(2): A.B.C.'s, typical P.H.T.L.S. primary / secondary survey, spinal prec, transport--> Civilian world: Level-2 trauma, Army world: Urgent status, Medevac, I.V.'s kvo, monitor and look for blast injuries especially hollow organ injuries (blast lung). Pain mangement as long as no head injury / splint if time permits. What is the G.C.S. / neuro. status. I am worried about internal / blast issues and the poss. of shock (even know the v/s. don't show it YET). 

(1):Triage of course, # of patients, injuries, resources needed, scene secure / perimeter secure?

F.M.


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## Muppet (Aug 18, 2009)

I have one:
Male, 20's finds his girlfriend screwing another guy. Said male attempts to beat second dude up and tries to take his knife. Second dude stabs pt. in neck. Pt. runs and hops back fence. Dude runs after pt. and strikes pt. with a baseball bat prior to hopping said fence. I find pt. awake, pissed off and crying with a stab wound neck (zone 2 injury Lt. side) and a large occipital lac. / bleeding.

Questions: What to do (w/o laughing), what are you looking for and what is a zone 2 injury?

F.M.


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## HoosierAnnie (Aug 18, 2009)

Two main concerns with a neck injury: occult bleeding and soft tissue swelling that could occlude the airway. Is the blade still in the stab wound?? If so, do NOT remove it!! Pad it, stabilize it however you can for transpo. It might be the only thing standing between you and an arterial pumper. Use backboard for transpo, securing the head/shoulders from as much movement as you can.  Monitor LOC, VS for s/s of shock, and continue to assess airway, providing O2 support (canula through intubation if needed).  Of couse get your IV access via large bore cannula, 2 sites if you can.

I will leave it to the EMT guys to fill me in on the zone designation


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## HoosierAnnie (Aug 18, 2009)

FM - Remind me to make sure I have my car crash in your AO.  Good going on keeping internal issues in mind while you're focusing on the obvious broken and bleeding.  I was heading down the intra-abdominal bleeder route with this one


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## Muppet (Aug 18, 2009)

God forbid Annie! The first thing to think about w/o seeing obvious trauma is the inside stuff, especially with blast, as I am sure our warriors in the suck can atest too.

F.M.


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## Muppet (Aug 18, 2009)

Annie: You are spot on in regards to your t/x. The knife was out when we got there. I will leave the zone issue until others can read this. Go to E-medicine and look up neck injuries. Good stuff.

F.M.


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## HeloMedic1171 (Aug 19, 2009)

quoted for reference:  (2): A.B.C.'s, typical P.H.T.L.S. primary / secondary survey, spinal prec, transport--> Civilian world: Level-2 trauma, Army world: Urgent status, Medevac, I.V.'s kvo, monitor and look for blast injuries especially hollow organ injuries (blast lung). Pain mangement as long as no head injury / splint if time permits. What is the G.C.S. / neuro. status. I am worried about internal / blast issues and the poss. of shock (even know the v/s. don't show it YET). 

(1):Triage of course, # of patients, injuries, resources needed, scene secure / perimeter secure?

F.M.

also:  MACE test if patient is AOx3 or better.  use best judgement.  most of my guys are never AOx3, because the days run together, and let's face it, some of them are just retarded on a good day.  you probably won't make it throught the whole test before v/s start showing problems, but you can have an idea how well they got their bell rung.


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## HeloMedic1171 (Aug 19, 2009)

fuck me.  you go to bed early just 1 night, and miss all the damn fun.  silly Helo.  :)

don't know about zones - but if the wound isn't spurting, bulky dressing, secure it well.  lightly but securely bandage occip. wound, and monitor for changes in mentation, pupillary mismatching, things like that.  what's his GCS?  AOx3?  PEARRL?  Keep him talking to A) keep him from going to sleep and B) to assess his airway - if it gets difficult, I may have to intervene.give him a once over to make sure I didn't miss anything, and then get him to the ER.  try to get my partner to stop laughing so I can keep a straight face.  (yeah right!!)  No pains meds - sorry Chuck, should've fucked her at YOUR house.


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## Muppet (Aug 19, 2009)

Right on Helo. What is the MACE test?

F.M.


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## HeloMedic1171 (Aug 19, 2009)

Military Acute Concussion Evaluation.  short little test they give you before and after an event to register your brain function... the one before you deploy gives you a control, the one you give the patient and any subsequent exams related to the significant event give you an indication of what, if any, changes have occured.  it's a nice tool to help you know if your guy just got the piss knocked out of him, or just a little shaken up, r somewhere in between.  once you've done a couple, you can give one in 5 minutes or less.


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## Muppet (Aug 25, 2009)

Here is a new one:

16 y/o male, overdose on amytrpitiline (spelling wrong) (what is this / I know already )?
B/P: 98/60. HR: 140, RR: 22, ECG: Sinus tach with widened QRS'S, TEMP: 100.2, Mental: combative with periods of calmness then seizures..................Hint: Really bad! No other meds., drugs or ETOH. No recent illness, trauma or h/x of overdoses.

What is the diff. diagonosis?
What is anticolinergic syndrome?
What is the neumonic for the above syndrome?
What can this med and meds like this do to you?

F.M.


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## HeloMedic1171 (Aug 25, 2009)

◦Amitriptyline

essentially, anticholinergic syndrome is where there is an interference with the autonomic nervous system receptors - i.e. sweat glands, salivary glands, GI/GU tracts and the Heart.  all of these function automatically, and there are a host of drugs that can chemically alter how they function, either directly, like promethazine, cyclobenzaprine, and benedryl, and others, like the one above, do it through control of the body's natural hormones.  in this case, the drugs shut them off, hence why the patient isn't sweating.  also - the seizures come from a build-up of acetylcholine at the end of the nerve... essentially - the signal is getting transmitted, but it's not being processed, only stored - and the acetylcholine continues to build.

and it's red as a beet, dry as a bone, blind as a bat, mad as a hatter, and hot as a hare.  it's similar to some chemical agents.  more to follow, I just wanted to beat everyone else to the punch


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## HeloMedic1171 (Aug 25, 2009)

what I would do - 

again, similar to nerve agent exposure.  Diazepam 5mg for seizures, Narcan 2mg, I don't have Thiamine, but you probably do, watch his vital signs closely.  IV access is a must, check his blood sugar if possible.  he needs ALS, which I may not be prepared to give here, definitely point that out in a call to higher, whether that's dispatch, or Dustoff.

Diff diag is antidepressant toxicity.  meds like this can kill you.


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## Muppet (Aug 25, 2009)

Sweet. You hit the nail on the head. Meds. like this can kill you, especially kids with 1 or 2 pills. Good job brother.

F.M.


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## HeloMedic1171 (Aug 26, 2009)

:: happy dance ::


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## HoosierAnnie (Aug 29, 2009)

Ditto the good job helo!!  We've had a rash of OD's recently and actually I expect to see more with the econ as depressed as its been.  Locally we depend on lots of smaller manufacturing companys for local jobs and things are getting dicey.  We had one a couple of weekends ago, girl shot up H for the first time and resp arrested


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## Muppet (Jan 12, 2010)

NEW ONE:

911 call for a man down. Temp. outside is COLD. Male found in prone position, full cardiac arrest. What do you do. Do we presume death? What is the t/x. plan?

F.M.


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## HoosierAnnie (Jan 12, 2010)

attach cardio leads  get strip  get core temp  if no contraindications get pt onto cart and into bambulance  warm blankies


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## Muppet (Jan 12, 2010)

Yep, as stated, temp. of 88 / asystolic, Etc02 of 20 after intubation in the field by yours truly.

F.M.


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## HoosierAnnie (Jan 12, 2010)

You carry warmed IV fluids???


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## Muppet (Jan 12, 2010)

Yea, warm fluids, hot packs and stuff like that. He DID not get ECMO, but he did get warmed foley cath lavage and warm o/2, no chest tubes, no ECMO, but was pronounced dead @ 92degress.

F.M.


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## Pacer (Jan 29, 2010)

Good set of threads, though as I read them we have a few unanswered cases floating around.

Didn't check dates, so I don't know how old they are (and don't care)/

Unsolved one: Infectious diarrhea concerns. Question of when it IS NOT safe for loperamide. Basic answer, with minimal lab support, is if the troop has fever, signs of paralysis, of blood in the stoool. With a little bitty field "microscope" in an austere medics 'tool kit (you know the one, oto-ophthalmosope-fischer scientific tube mircoscope) you can looke for WBC's as well. Actually, that is the only time antibiotics are indicated for diarrhea, besides C-DIFFICILE , which is an infectious diarrhea typically resulting from antibiotics.

Unsolved two: Zone two injury. I see no concern about AIR EMBOLISM voiced (Zone 1 and 3 are at the root of the nek and base of skull, you figure out which is which. Don't forget about MAJOR DEEP aortic, svc, or lung invlovement with a blade in zone 1.

Doc Pacer


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## Pacer (Jan 29, 2010)

Incomplete 3: amitriptyline

While you have hit the anticholinergic syndrome, you have partially missed the boat on the critical toxicity of Tricyclic antidepressants.

What does the ECG Show?

I expect intial tachycardia, followed by a widening QRS interval, followed by ideoventricular and arrest.

NaHCO3 (actually for the sodium initially, the HCO3- is helpful in reducing the ionization) given stat plus an alkalinization drip will help to reduce the cardiac toxicity of the drug, and the risk of cardiac arrest. As I recall, the use of most anti-arrythmics (especially procain/amiodarone) is contraindicated.

Check out either AHLS (Advanced HazMat Life Support or Ellenhorns' Medical Toxicology)

Doc Pacer


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## Muppet (Jan 31, 2010)

ZING.Thanks Doc. Good info.

F.M.


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