Wednesday, February 17, 2010

Blunt Trauma Arrest

Nodar Kumaritashvili, a Luger from the Republic of Georgia, died instantly in an accident on the Whislter track (pictured above). Evidently he had premonitions of danger and, unfortunately, they were justified.

I don't think you need to be a doctor or nurse watching this horrible accident to know that the impact was almost instantly fatal. This was no different than a person falling onto concrete from a height of around 50 feet. There are all kinds of equations and etotheipi can, no doubt, get to the nut of the math better than I can, but I have a different purpose in this post than crunching numbers.

"LD50" means "lethal dose 50%" or the dose (height, mass, speed, etc...) at which 50% of humans will die. Thus we can speak of an LD50 for aspirin or an LD50 for a jump from height. The science of death is a morbidly interesting one and one that matters a lot in this particular case.

The question for the medical personnel at the site of this accident was not how best to save the patient, it was, rather, when to pronounce him dead. And this points to a very important distinction made in emergency medicine on a daily basis. This distinction matters more in residency training programs than in your everyday ER, but it matters.

Mr. Kumaritashvili, had he been transported to a facility where ER and trauma surgery residents are trained, would have been 'coded' long enough for the residents to practice inserting high volume resuscitation lines and chest tubes, AND long enough to run through the ACLS protocols (trying to start a stopped heart), but no one, at any point in the resuscitation, would have held out any hope of the patient actually walking out of the hospital.

In a non-residency affiliated ER he would likely have been pronounced dead in the field by someone like me, over the radio, after consultation with the paramedics.

Why? Well, unfortunately, for Mr. Kumaritashvili, he would have had a lot better chance of survival had he been shot, stabbed, or pierced with a samurai sword. Why? Think about it for a minute. With the latter means of injury you could expect damage to one, two, or three organ systems. For instance, a gunshot wound to the chest might damage the lungs and the heart, and might even travel to the abdomen, but a brain injury would be highly unlikely.

Contrarily, Mr. Kumaritashvili went from 90 mph to 0 mph in the space of about 3 to four inches (the distance his body compressed while hitting the steel post). But, also for Kumaritashvili, the number of organ systems involved in the damage of this accident are not limited like they are with penetrating trauma (gun, knife, etc...).

Therefore, with the most respect for this brave man who pushed the envelope of human performance and lost, I give you a non-exhaustive list of causes of death from this accident, and, at the same time, hope to give you an idea why the ER hops and pops with a patient who has been shot or stabbed and is dying, but why ER docs and nurses move at a slower and less frantic pace when the jumper or the car crash victim with no pulse and no pressure is brought in by ambulance. Penetrating versus blunt trauma is also the key take-off point for whether we perform the most gruesome of ER procedures, the ER thoracotomy... It is occasionally performed and occasionally succeeds (with the gunshot or knife victim), but nearly never succeeds to hospital discharge with the blunt trauma arrest patients...

Potential Causes of Death for Mr. Kumaritashvili...

1. Massive intracranial trauma
2. Hangman's fracture or similar
3. Carotid dissection
4. Massive hemo-pneumothorax
5. Carotid arch avulsion at ligamentum-arteriosum
6. Cardiac tamponade
7. Massive intra-abdominal hemorrhage
8. Ruptured Spleen
9. Ruptured liver
10. Atlanto-occcipital disassociation
11. Open-book pelvic fracture with exsanguination
12. Cardio-pulmonary contusion leading to fatal arrhythmia

That's an off the top of my head list and no doubt there are many other possibilities as to the causes of death, but this is why blunt trauma arrest patients die 99 times out of 100 and unless we make some Star Trek like advancements in trauma care soon the blunt trauma arrest patients will continue to die at this rate.

The moral of the story... If the devil approaches you and says you can choose between being in a bad car crash or being stabbed in the gut... pick the knife... you will probably live.


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  1. He was sadly, as we first responders occasionally say, DRT. (dead right there)

    In this instance, the massive media presence, the potential political pressure and the large number of spectators, would likely have precluded us from determining death unless one of the determining factors was SO obvious that not determining death would be viewed as incompetence.

    For me the most horrific component of the video was the sound the victim made when he impacted the pillar. Ouch.

    Thanks for the post.

  2. Piloting a Sled at 100mph is dangerous?!?!?!? Next thing you'll tell me that that fur wearing Skater's a Homo... Its Evolution, 5 Billion years from now we'll be a race of Giant Headed Geniuses who won't crash sleds at 100mph...

  3. Atlanto-Occipital dislocation with cord transection and death. Sad..
    But the soon to be lawyer feeding frenzy will be sadder..

  4. If you watch the video closely, you will observe Vladimir Putin sneaking away with a banana peel.

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  6. Of course in Denver they still advocate the thoracotomy for blunt trauma. Can't say I'm a believer, but I actually have a friend who lived following a terrible MVC and getting a thoractomy.

    That said I'm sure the outcomes a little better with a few truama surgeons opening a chest rather than me.