New EMT, don't understand a couple of calls.

[Lifeguards For Life]

And that same fast ball hits you in the thorax, it could probably break ribs, no?

commotio cordis

 

[TransportJockey]

commotio cordis

bingo!

 

[Lifeguards For Life]

bingo!

that was meant to be a hint, as i assumed he would have to look it up

 

[TransportJockey]

that was meant to be a hint, as i assumed he would have to look it up

He probably still will, cause most basics I know have no idea what that is

 

[JPINFV]

It depends on the force behind the ball, where on the body part the victim was hit, and the protective gear the victim is wearing.

Because a fast ball thrown by Randy Johnson that pegs you in the head with no helmet on could certainly cause some sort of brain injury - if not a skull Fx. - depending upon where it hits.

And that same fast ball hits you in the thorax, it could probably break ribs, no?

Assume proper match up (i.e. Randy Johnson isn't facing a 12 year old) and proper safety equipment (i.e. batting helmet).

 

[adamjh3]

Hm... I had considered something along those lines, but discounted it thinking the sternum was stout enough to protect the heart. Interesting, less than one in five that experience Commotio Cordis survive.

But as to it being "worse" it would depend on when in the cardiac rythym the victim was struck. There's a very small window for Commotio Cordis to occur. So being struck in the head can still be "worse."

 

[8jimi8]

Generally patients must pass the "blue test" to get 15lpm via NRB, ie, they must be blue in order to get it. There are some exemptions to this, but for the most part unless a patient is blue they get a cannula first (that is if oxygen is indicated at all).

I will chime in only to disagree with this statement.

Please do not teach new emt's that patient's have to be blue before they get an NRB w/15 l/min.

If you are going to talk about treatments, please list the reasons why you would/n't, not strange generalizations that are not 100% true.

 

[medichopeful]

So far as I am aware, that only happens in massive, uncontrolled shock. Do you have a citation for it occurring otherwise?

I was a little unclear. This would be due to shock, not just blood loss:

"Other signs of shock that you may encounter include thirst, dilated pupils, and in some cases cyanosis around the lips and nail beds" (Limmer and O'Keefe, "Emergency Care 11th Edition", page 620).

Symptoms may include:

Weakness
Altered mental status
Cool and clammy skin
Low blood pressure
Decreased urination
Weak and rapid pulse
Slow and shallow or rapid and deep breathing
Lackluster (dull) eyes
Dilated pupils
(http://www.aurorahealthcare.org/yourhealth/healthgate/getcontent.asp?URLhealthgate="165038.html")

Unless I'm reading it wrong, it doesn't have to be "massive shock" for dilated pupils to occur. But if I'm wrong, please correct me. You have more education, and I might be able to learn something*

*Reading this, it sounds sarcastic but it isn't meant to be

 

[usafmedic45]

Unless I'm reading it wrong, it doesn't have to be "massive shock" for dilated pupils to occur. But if I'm wrong, please correct me. You have more education, and I might be able to learn something

You normally only see it (at least in my experience) in patients where perfusion to the brain is being impeded somehow. This is why a person's pupils will dilate just before they pass out from being put in a choke hold. Given that the heart and the brain are the last organs to be perfused, you normally have to get a pretty major hit going on before you are going to get to that point. Given that in most people (short of persons with clotting disorders (hemophilia, VWD, etc) or on potent anticoagulants, it is exceedingly rare* to bleed to death from an isolated vascular injury below the knee or elbow I would seriously doubt she was in shock.

*Sufficiently rare that I would actually write it up as a case report for publication.

Reading this, it sounds sarcastic but it isn't meant to be

No worries even if it was meant to be sarcastic. You're going to learn whether you like it or not.

Which is worse, taking a baseball to the head or taking a baseball to the chest?

I'd take my chances with the baseball to the chest before a baseball to the head. The incident of commotio cordis is really quite low, especially in comparison to the much greater risk of a skull fracture, intracranial bleed or concussion from a direct shot to the head.

But as to it being "worse" it would depend on when in the cardiac rythym the victim was struck. There's a very small window for Commotio Cordis to occur. So being struck in the head can still be "worse."

What he said.

Randy Johnson isn't facing a 12 year old

Have you seen the pitching ability of some of the minor leaguers these days? Dear God...

Because a fast ball thrown by Randy Johnson that pegs you in the head with no helmet on could certainly cause some sort of brain injury - if not a skull Fx. - depending upon where it hits.

I'm pretty sure if it did not cause a skull fracture, he'd be getting his contract renegotiated because obviously he's slacking off.

 

[lightsandsirens5]

About the diabetic call:
I've had a few patients that were frequent fliers that a 'low' CBG was in the 200's, they normally stayed at 3-400. Not everyone is text book for 'normal vitals'

Yet another reson I hate the current textbooks........and the "Within Normal Limits" moniker or whatever you call those things

 

[TransportJockey]

Yet another reson I hate the current textbooks........and the "Within Normal Limits" moniker or whatever you call those things

Ya know what else WNL stands for don't ya?

 

[adamjh3]

I'm pretty sure if it did not cause a skull fracture, he'd be getting his contract renegotiated because obviously he's slacking off.

Touche`, I'm still new to learning MOI's and what not, I wasn't positive if it would or not, so I didn't want to make a general sweeping statement and make myself look a fool.

I'm not much of a baseball fan anyway h34r:

 

[LucidResq]

Oh boy oh boy oh boy.... sudden cardiac death in young athletes is my favorite. I have written quite a few papers on it.... though usually focused on intrinsic causes.

Commotio cordis is extremely rare, and like Adam stated, one must be hit in a specific 10-30 millisecond long segment of the cardiac cycle, in the right spot as well. Postmortem exam usually reveals no internal trauma or hemorrhage... occasionally a little bruising but nothing that would normally be fatal or even problematic. It truly is an electrical phenomenon.

Research has been done on chest protectors commonly used in sports but they do little to nothing to guard against commotio cordis.

Resuscitation is futile, especially considering how most victims are healthy and young.

 

[usafmedic45]

I'm still new to learning MOI's and what not, so I wasn't positive if it would or not, so I didn't want to make a general sweeping statement and make myself look a fool

MOIs are pretty much my area of expertise anymore. The general rule is that the human skull is like most Marines in a barfight. It's tough, but not as tough as a lot of people like to believe.

 

[LucidResq]

As for the discussion of force.... bear in mind that force has little to do with commotio cordis. It happens most with young athletes, so the kid pitching or what not is probably not throwing that hard.

I agree with USAF too.... I'd rather take the very small risk of commotio cordis and get hit in the chest. Even if you did fall victim to it, it'd be a quick and painless way to go. Head injuries scare me much more than death.

 

[adamjh3]

MOIs are pretty much my area of expertise anymore. The general rule is that the human skull is like most Marines in a barfight. It's tough, but not as tough as a lot of people like to believe.

I showed that to my brother (Ex-Army 75th ID) and he's about in tears right now.

 

[usafmedic45]

Resuscitation is futile, especially considering how most victims are healthy and young.

I like you, but you're being hyperbolic. I wouldn't call it "futile", not even close to it. The survival rate is still better than most cardiac arrest events, even better than many in-hospital non-ICU resuscitation rates.

The overall survival rate in known victims of CC is only 15% [1]

Of 68 cases in which early resuscitation was instituted (< 3 minutes), 17 survived (25%). In the cases where resuscitation was substantially delayed (> 3 minutes) only 1 out of 38 survived (3%).

The problem then is obviously not the mechanism (as you are implying, intentionally or otherwise), it's a failure to have timely access to an AED. This is why if someone on this forum wants to make a difference in their community in terms of patient outcomes, assuring that every organized sporting event has ready (<3 minutes) access to an AED would be a great project.


[1]Madias C, Maron BJ, Alsheikh-Ali AA, Estes Iii NA, Link MS. Commotio cordis. Indian Pacing Electrophysiol J. 2007 Oct 22;7(4):235-45.

 

[usafmedic45]

From the same article I just cited....emphasis is my own.

Since being initiated in 1996, the United States Commotio Cordis Registry (USCCR - Minneapolis, Minnesota) has now accrued more than 180 cases [3-5]. As awareness of this phenomenon grows, CC is being reported with increasing frequency, with most cases in the registry (75%) clustered from the years 1988 to present [6]. However, the actual incidence remains unknown as many cases are still likely missed due to continued lack of recognition and underreporting. CC has most commonly been described in the setting of organized sport (Table 1), with most victims having been struck in the chest by standard projectiles used in the game [3]. Generally, projectiles that result in CC have a dense solid core, such as a baseball, hockey puck, or lacrosse ball. Only 2 cases in the USCCR have been attributed to impact with a cricket ball. However, this low incidence likely reflects the relative lack of popularity of cricket in the US and the fact that chest impact in cricket is a rare event. Projectiles with a non-solid core tend to collapse on contact and absorb much of the impact energy. Only a single event has been attributed to chest impact with an air-filled soccer ball. In almost all cases, chest impacts that resulted in CC occurred to the left of the sternum, directly over the cardiac silhouette. Estimated velocities of pitched baseballs were 48 to 80 km/h (30-50 mph). Interestingly, 38% of the individuals competing in organized sports were wearing standard commercially available chest wall protection at the time of their event [7]. However, in 25 of these 32 cases, the chest wall protector did not adequately cover the left chest or precordium at the time of impact.

The force- rather than the velocity, don't confuse the two which are related but not the same thing- does play a role. It's the dissipation and transfer of that force that matters. The reason a solid baseball (about 145 grams and roughly three inches in diameter) is going to impart more force through the chest wall (measured in joules/square inch) at the same speed than say, a 29" and 600 gram basketball.

 

[VirginiaEMT]

Here's something to chew on for the new EMTs.

Which is worse, taking a baseball to the head or taking a baseball to the chest?

I would think the would depend on the age of the person as a younger child's ribs would be more flexible, and although internal injuries would be possible, a flail chest is far less likely to happen causing more serious internal injuries.

 

[usafmedic45]

I would think the would depend on the age of the person as a younger child's ribs would be more flexible, and although internal injuries would be possible, a flail chest is far less likely to happen causes more serious internal injuries.

This is also an issue. Nice point. Well done newb.