OUT OF THE COLD
RETURN TO CASE
Not knowing the mechanism of injury, your crew places the patient in
a cervical collar and logrolls him onto a long backboard before moving him to the stretcher and loading him into the rig. In the back of
the ambulance, you turn up the heat while your partner places the
patient on high-flow oxygen and connects the patient to the monitor. A quick glance at lead 2 shows atrial fibrillation at a rate of
28 bpm, and you palpate a correspondingly slow carotid pulse.
During the eight-minute transport time to the closest trauma
center, you place an IO in the left tibia and begin to infuse a saline
bolus per protocol. As you offload the patient and the stretcher locks
in the up position, you see on the monitor that the patient’s rhythm
has suddenly changed to v fib. You quickly charge the defibrillator,
deliver a shock, and begin CPR and BVM ventilations as you roll
into the trauma bay.
In the trauma bay, the initial ECG shows asystole and CPR is continued as the patient is intubated. An esophageal probe shows the patient
has a temperature of 84.6 degrees F ( 29. 2 degrees C). The trauma team
places two chest tubes in the patient’s left chest and begins lavage of
the thoracic cavity with warmed saline.
After 65 minutes of CPR and continuous left chest lavage, the
patient re-develops v fib as his core temperature reaches 93.5 degrees
F ( 34. 2 degrees C) and he’s shocked into sinus tachycardia with pulses.
Laboratory testing reveals that his blood ethanol level was four times
the DUI limit at the time of his ED arrival. His head CT scan shows
no intracranial injury and he’s admitted to the ICU.
After a weeklong hospitalization, the patient is discharged to a
rehab facility for intense therapy. He remains moderately cognitively
impaired, but is able to perform normal daily activities such as feeding and bathing himself. JEMS
Daniel Du Pont, BA, EMT, is a fourth-year medical student at the University of Pennsylvania and
an EMT at Radnor Fire Company in Wayne, Pa. Contact him at email@example.com.
Edward T. Dickinson, MD, NRP, FACEP, is interim department chair and a professor of Emergency Medicine at the hospital of the University of Pennsylvania. He serves as the director of
EMS field operations at University of Pennsylvania Department of Emergency Medicine, and
medical director of PennStar Flight Division of Trauma and Critical Care at the Department of
Surgery at the University of Pennsylvania School of Medicine. He also serves as the medical
editor of JEMS and on the JEMS Editorial Board.
Learn more from Edward Dickinson at the EMS Today Conference, Feb. 21-23,
in Charlotte, N.C. EMS Today.com
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