There is a new medical drama called Transplant, and this is the pilot episode. I decided to give it a watch.
We aren’t even a few minutes into the first episode before we see a heroic doctor doing a precordial thump on the chest and miraculously saving them. The precordial thump should only be done for witnessed, unstable ventricular tachycardia when a defibrillator is not immediately available. It rarely works and is not as effective as electrical defibrillation. And because this person is not on a monitor, there is no way to know if her cardiac arrest was vent tachycardia, as opposed to a total absence of cardiac electrical activity, meaning asystole, or possibly PEA, meaning pulseless electrical activity. The goal of precordial thump is to restore organized electrical cardiac activity and convert the patient from ventricular tachycardia to a more stable and organized rhythm, ideally sinus rhythm. If you ever see someone unconscious, please don’t ever punch them in the chest.
This guy has a skull fracture in the same location as the right MMA, and when this happens, there is a high likelihood of an epidural hematoma. An epidural hematoma occurs as a result of bleeding, and when that blood accumulates between the skull and the dura mater. When this happens, it starts to compress the brain, and if severe enough, it can shift the brain to the point of causing herniation, where the brain starts to herniate through the big hole at the bottom of the skull, called the foramen magnum. When this happens, people die, unless there is immediate surgery to relieve the increased brain pressure, meaning intracranial pressure.. One of the telltale signs of brain herniation is as an ipsilateral dilated pupil, aka a “blown pupil.” A blown pupil means the pupil is dilated and doesn’t constrict when you shine a light in it. So when you add up all of these clinical signs together, meaning a large pupil that doesn’t react to light, that occurs on the same side as the skull fracture located in the region of the MMA, its all but certain that this is an epidural hematoma to the point of causing brain herniation, which spells impending death. In real life, we would visualize the epidural hematoma with a CT scan, before calling neurosurgery to drill a hole in the skull to relieve the pressure. In real life, the time it would take to go from the time of skull fracture with MMA rupture, to expanding epidural hematoma, to the point of causing brain herniation, develops over a few hours. So if you happen to be in this guy’s situation, I recommend you not drill a hold in someone’s head.
Fires can cause inhalation injury, which can include damage to the airways as well as the lungs themselves. It can also cause systemic toxicity. There can be numerous inhalation injuries from a fire, and it really depends on lots of different variables, such as the material being burned, types of gases inhaled, and duration of exposure. There can be a thermal injury to the mouth, nose, and throat, which can cause inflammation in these areas. Inhalation injury can also cause irritation and damage in the airways in the lungs, and this can cause inflammation and bronchoconstriction, where the airways tighten up, much like asthma. Can also be damaged to the alveoli, the tiny air sacs of the lungs, and this can cause ARDS, acute respiratory distress syndrome. The 2 most concerning gases that can be inhaled from a fire are carbon monoxide and hydrogen cyanide. Carbon monoxide is 1 of the most frequent immediate causes of death following inhalational injury. And carbon monoxide poisoning, A pulse oximeter will likely read 100%, but this is inaccurate. The pulse oximeter will always read higher than the true oxygen saturation because the pulse oximeter does not differentiate carboxyhemoglobin from oxyhemoglobin. This is why an ABG with co-oximetry is needed to get accurate measures of oxyhemoglobin saturation and carboxyhemoglobin saturation. Hydrogen cyanide is the gaseous form of cyanide and always needs to be considered in someone with smoke inhalation.
Dr. Mike Hansen, MD
Internal Medicine | Pulmonary Disease | Critical Care Medicine
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