Thursday, July 9, 2015

Access II

Similar case as the last one. An adult comes in as a major trauma alert. He was involved in a high speed car accident with a prolonged extrication. Unfortunately, all four extremities are mangled, and there is no place to put intravenous access. In addition, all sites for intraosseous access are contraindicated as well; he has tibial plate fractures, sternal fractures, and humeral head fractures.

In your emergency department, he goes into a ventricular fibrillation arrest, potentially from cardiac contusions sustained in the accident. As you start advanced cardiac life support, you wonder how you can give the epinephrine.

Challenge: Any ideas?

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3 comments:

RaH said...

So.. this is a very unlucky man.

i dont know the answer, but endotracheal administration (with compensatory elevation of dosage could be considered)
alternatives are central line (jugular veins) or intracardiac injection, like we used to see in movies, like pulp fiction :)

FIRECRACKER said...

Endotracheal! (Unless mouth is mangled too?)
N-Naloxone
A-Atropine
V-Vasopressin
E-Epinephrine
L- Lidocaine

Craig Chen said...

yep! i've personally never given any drugs endotracheally, but it's always a consideration. It was definitely reviewed in neonatal resuscitation algorithms and used to be in the old adult ACLS. Nice mnemonic with NAVEL. I like to use ALIEN+V (atropine, lido, isoproterenol, epi, naloxone, vaso).
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Access II

Although this has fallen out of favor in ACLS, epinephrine can be given 2-2.5mg every 3-5 minutes until return of spontaneous circulation in the setting of asystole, pulseless arrest, and pulseless VT/vfib.

Source: UpToDate.