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HEAPHY 1 & 2 DIAGNOSTIC John BONNING Sun 1 st Sep 2013 Session 2 / Talk 1 10:00 – 10:45 ABSTRACT William did all of the hard work – I just came along for.

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Presentation on theme: "HEAPHY 1 & 2 DIAGNOSTIC John BONNING Sun 1 st Sep 2013 Session 2 / Talk 1 10:00 – 10:45 ABSTRACT William did all of the hard work – I just came along for."— Presentation transcript:

1 HEAPHY 1 & 2 DIAGNOSTIC John BONNING Sun 1 st Sep 2013 Session 2 / Talk 1 10:00 – 10:45 ABSTRACT William did all of the hard work – I just came along for the ride. Management of profoundly hypothermic patients is challenging and important. Therapeutic hypothermia is not accepted practice in numerous conditions from post cardiac arrest to severe head injury. I will also discuss rational use of radiological investigations, various decision instruments that dictate their use, and what it is really like working in a busy emergency department. Linked with William PIKE’s Talk

2 A life worth saving

3 Mt. Ruapehu

4 eruptions

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8 Dome shelter

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12 25 th September hrs

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15 Dome shelter occupants  2 climbers  22 year old male trapped under large boulder  Crushed legs  Lahar passed through shelter  Trapped, crush injuries, wet, cold  2030hrs  2797m mountain

16 Rescue process 2nd climber Runs to Whakapapa Snowgroomer Emergency call made Return to Dome shelter

17 Emergency response timeline  Preparation  Taupo helicopter  Waikato ED  2215hrs – initial call  2222hrs Taupo helicopter mobilised  ?Flying conditions at the mountain  Taumarunui amb. Sent to Iwikau village

18 Timeline  2314hrs DOC advises against helicopter use on the mountain  Ash – 5,000 metres  Further small eruptions occuring  At Dome shelter the rock cannot be moved by the 2 rescuers  0017hrs – Pt. GCS 3/15, status 1  Still trapped  Waikato team heads into the unknown

19 Timeline  0102hrs Turangi ambulance with AP to Iwikau village arrives  0101hrs Taupo helicopter sent to National Park arriving  0112hrs Taumarunui amb. Leaves Iwikau HR 60, BP 120/95, GCS 3/15  0130hrs rendezvous at National Park  0157hrs Taupo helicopter leaves  0212hrs arrives Taumarunui  Waikato team awaiting

20 Taumarunui Hospital  0220hrs into Taumuranui ED (T+6 hours)  Feathers and wet clothes HR 99, BP 94/35, RR 26, GCS 3/15  RSI: Fentanyl + Thio + Sux  Handle with care  Warm, dry blankets  Warmed IV fluids, IDC placed  0325hrs departs for Waikato

21 Hypothermia  Protective (therapeutic) – cardiac, brain  Mild – – shivering, cerebral effects  Moderate – – cardiac/brain slowing  Severe - <29 0 – shut down, risk VF  Therapeutic hypothermia

22 Therapeutic hypothermia 1  Initial trials in 2002 – Melbourne and US  Improved (neurological outcome) post VT/VF arrest  NNT = 6  Only other “proven” therapy is defibrillation  Chest compressions improve ROSC but not RONF  Subsequent studies observational (but supportive)  Also looked at in pure TBI and prem neonates

23 Therapeutic hypothermia 2  Reduces tissue glucose & O 2 demand  esp brain and myocardium  decreased free radicals, brain oedema, seizures  How?  4 0 saline 2L, ice pack, coolers  Complications:  Shivering, coagulopathy, immunity  Impaired drug metabolism

24 T + 7½ hours  Receives total: 100mcg adrenaline in 6 split doses and some morphine  (circulatory support? – not responsive due to hyothermia)  HR bpm slow AF  Systolic BP 65-88mmHg (Pressure of output)  GCS 3 (Intubated and ventilated and sedated)  0356hrs arrives in Waikato – T+7½ hours

25 Waikato Hospital  Mechanism:  Crush injury to legs by boulder.  Trapped for prolonged period at moderate altitude.  Wet and cold.  Injuries:  Severe crush injuries to legs.  Profound hypothermia.  Unconscious  Vital signs:  Temp 27.7 O C, HR 40, BP 65/29, SaO2 100%,  GCS 3/15 in drug-induced coma

26 Trauma team  ED, ICU, Anaesthetic, Orthopaedic, Surgical teams.  A: Intubated pre-hospital  B: Ventilated, RR 20, AE equal bilaterally  C: HR 45, BP 77/29, FAST scan –ve, 3L saline  D: GCS 3 in drug-induced coma  E: 1 unsalvageable leg, another badly injured  Investigations

27 Arrival investigations  Hb 76 – may show haemoconcentration  WCC 19.9 – systemic inflammatory response  Platets 260 – thrombocytopaenia  INR 3.0 – coagulopathy  Na + 145, K – expecting hyperkalaemia  Creat 160 – ARF  CK 1130 – rhabdomyolysis  pH 6.86 – resp alk to met/resp acidosis  Lactate 13 – hyper/hypo-glycaemia, raised lipase

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30 0605hrs leaves ED for ICU  Coagulopathic – bleeding from right leg  5L N saline, 4 units rbc, 4 units ffp  HR 65, BP 105/51  Temperature 27.7 degrees  Pre-op warming, prevention of VF, consideration of ECMO  OT once temperature >32 0  CT pan-scan and angiograms

31 Clinical aspects  ABC  Handle with care  Resuscitation drugs don’t work  Investigations  Arrhythmias  Rewarming  Endogenous – 1 o /hr  External – clothes, air (1-2 o /hr) and fluid  Core – warmed O 2, body cavities (2-3 o /hr)  ECMO – 10 o /hr

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34 In theatre  Right below knee amputation  Left leg and foot fasciotomies:  Fracture fixation – left patella and great toe  Post-op right thigh noted to be swollen  High compartment pressures  Right thigh fasciotomy  Multiple subsequent procedures  Skin grafts, wound care

35 Ongoing issues  ARF secondary to rhabdomyolysis  CK 92,000, creatinine 814  Daily haemodialysis  Sepsis  Respiratory (citrobacter koseri)  BKA stump (bacillus cereus, coliform, non-haemolytic strep)  Extubated day 2

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