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  1. #1
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    Max Shacknai EMS Report

    Max Shacknai's Pre-Hospital Care Report has been posted on the maxshacknai.com site. (Paramedic run report.)

    http://www.maxshacknai.com/wp-conten...CFD_Report.pdf

  2. #2
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    Implications of bilaterally fixed, dilated pupils

    One thing to keep in mind as you read the EMS report is that Max was in full asystole (no heartbeat at all) upon arrival of the paramedics. Meaning, he had no circulation whatsoever at that point.

    You cannot have brain swelling without circulation. He did not yet have global hypoxic cerebral edema at the point that EMS arrived. Global edema with increased intracranial pressure can also cause compression of cranial nerve 3 (oculomotor nerve) producing fixed, dilated pupils. But because he was in asystole, he had no circulation to produce the edema that was present later after circulation was restored.

    His pupils were fixed and dilated bilaterally, without circulation upon arrival of EMS. That is indicative of the brain and spinal cord trauma being the source of the fixed and dilated pupils-- not global edema, which would not occur until he was resuscitated and some measure of altered perfusion was restored to his brain.

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    Decorticate posturing at the first hospital

    We also know from the AR that Max had decorticate posturing (not decerebrate) on arrival at the first hospital-- IIRC. This also further argues that the brain and spinal cord trauma were the primary injuries that produced the cardiac arrest at the scene.

    This is very ominous-- full arrest, fixed and dilated pupils, and decorticate posturing in the first ER. All of this portends a very, very poor outcome. There are numerous scholarly articles which delineate the survival prognosis for a child with head trauma, and cardiac arrest outside of the hospital.

    This is one abstract; there are othere, and one in particular was done by researchers at the San Diego Children's Hospital with a similar finding of 1-2% survival. Of the very few chidren who survived, all had some vital signs at the scene, and at least one reactive pupil. In one study the only survivor was discharged in a persistent vegetative state.

    Cardiac arrest outside the hospital as a consequence of head trauma carries an extremely dismal prognosis. I do not think that this would have ever been presented as a hopeful situation to Max's parents. I can believe that his mother may have been in complete denial due to shock, but I cannot believe his doctors were puzzled as to what caused Max's cardiac arrest for "days", as Dina has said.

    Prognosis for Children in Cardiac Arrest Shortly After Cranial Trauma

    The records of all the children who, within a 6-year period, suffered cardiac arrest at the scene of injury, during transport or in the emergency department of a level one pediatric trauma center, as a consequence of blunt cranial trauma, form the basis of this study.
    The average cardiopulmonary resuscitation time was 36 (2-107) minutes. A sinus rhythm was established in 50% but was not sustained in most. The sole survivor was an 8-year-old boy who was ejected and had asystole at the scene. At discharge, he was walking well but had cranial nerve deficits and learning disability. CONCLUSION:: Survival in 40 consecutive children with documented cardiac arrest caused by blunt cranial trauma was 2.5%. This series, when combined with other published reports, is supportive of the position that aggressive resuscitation is rarely successful after 10 minutes and futile after 20 minutes.
    http://lib.bioinfo.pl/pmid:20173663

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    Intravascular volume and brain swelling

    As a 6 year old, Max is documented to weigh around 18 kg. Estimated total blood volume for a 6 year old is about 80cc/ kg, or around 1500cc total. EMS started a 1000cc IV bag on the intraosseous needle. Depending on how much of that infused rapidly, his intravascular blood volume could have increased in a very short period of time, further contributing to the cerebral edema. I'm not saying the EMT's did the wrong thing, but just demonstrating how the global edema could progress quickly.)

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    Quote Originally Posted by K_Z View Post
    As a 6 year old, Max is documented to weigh around 18 kg. Estimated total blood volume for a 6 year old is about 80cc/ kg, or around 1500cc total. EMS started a 1000cc IV bag on the intraosseous needle. Depending on how much of that infused rapidly, his intravascular blood volume could have increased in a very short period of time, further contributing to the cerebral edema. I'm not saying the EMT's did the wrong thing, but just demonstrating how the global edema could progress quickly.)
    In my experience (PICU RN) an intraosseous needle WITHOUT a pump - in other words, just a bag of fluid hanging as one would expect in the field, does not run very rapidly. It is unlikely that a great quantity of fluid infused prior to arrival in the ED.

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    Quote Originally Posted by marycarney View Post
    In my experience (PICU RN) an intraosseous needle WITHOUT a pump - in other words, just a bag of fluid hanging as one would expect in the field, does not run very rapidly. It is unlikely that a great quantity of fluid infused prior to arrival in the ED.
    Thank you!

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    Quote Originally Posted by marycarney View Post
    In my experience (PICU RN) an intraosseous needle WITHOUT a pump - in other words, just a bag of fluid hanging as one would expect in the field, does not run very rapidly. It is unlikely that a great quantity of fluid infused prior to arrival in the ED.
    Initial dispatch SOB (shortness of breath due to fall)
    dispatched at 10:12
    arrived at scene 10:16 *cardiac arrest
    IO inserted L tibia 10:19
    left scene 10:30 * spontaneous return of pulse
    arrived destination 10: 38


    So how was the estimated duration of CPR 25-30 min???
    see autopsy summary A-1

    I get 8 min of CPR
    but, how long did he lay there not breathing???
    Long enough for his heart to stop 3-5 min?
    ~ my opinion only

  8. #8
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    If CPR was started by whoever found him (sorry, I do not follow this thread) when the 911 call was made, and stopped with spontaneous return of pulse, I see at least 18 minutes of CPR.

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    Severe blunt cranial trauma can cause cardiovascular collapse

    Quote Originally Posted by gngr~snap View Post
    Initial dispatch SOB (shortness of breath due to fall)
    dispatched at 10:12
    arrived at scene 10:16 *cardiac arrest
    IO inserted L tibia 10:19
    left scene 10:30 * spontaneous return of pulse
    arrived destination 10: 38


    So how was the estimated duration of CPR 25-30 min???
    see autopsy summary A-1

    I get 8 min of CPR
    but, how long did he lay there not breathing???
    Long enough for his heart to stop 3-5 min?
    In severe blunt trauma, as in Max's enormous skull fracture (7 1/2 inch saggital fracture from AR), and very high spinal cord injury (top 2 cm of spinal cord from AR), the blunt trauma is the source of the cardiovascular collapse-- not respiratory arrest.

    http://www.ncbi.nlm.nih.gov/pubmed/8198295

    Outcome of cardiovascular collapse in pediatric blunt trauma.

    STUDY OBJECTIVES:

    To determine the survival and functional outcome of pediatric blunt trauma victims demonstrating cardiovascular collapse, including pulseless cardiopulmonary arrest or severe hypotension, on initial presentation in an emergency department.
    CONCLUSION:

    No child who presented with pulseless cardiac arrest or severe hypotension following blunt trauma achieved functional survival. Reimbursed care for pediatric victims of blunt trauma demonstrating cardiovascular collapse is disproportionately poor compared with that for pediatric patients who maintain hemodynamic integrity in the ED. Half of all patients who were stabilized sufficiently for transfer to the pediatric ICU were eligible potential organ donors. Therefore aggressive resuscitation of these patients may be justified if organ donation is seriously contemplated and aggressively pursued.

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    More on cardiovascular collapse and blunt head trauma:

    http://circ.ahajournals.org/content/...pl/IV-146.full

    Cardiopulmonary deterioration associated with trauma has several possible causes:

    Hypoxia secondary to respiratory arrest, airway obstruction, large open pneumothorax, tracheobronchial injury, or thoracoabdominal injury

    Severe head injury with secondary cardiovascular collapse
    Despite a rapid and effective out-of-hospital and trauma center response, patients with out-of-hospital cardiac arrest due to trauma rarely survive.14 Those patients with the best outcome from trauma arrest generally are young, have treatable penetrating injuries, have received early (out-of-hospital) endotracheal intubation, and undergo prompt transport (typically ≤10 minutes) to a trauma care facility.36 Cardiac arrest in the field due to blunt trauma is fatal in all age groups.


  11. #11
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    Quote Originally Posted by K_Z View Post
    In severe blunt trauma, as in Max's enormous skull fracture (7 1/2 inch saggital fracture from AR), and very high spinal cord injury (top 2 cm of spinal cord from AR), the blunt trauma is the source of the cardiovascular collapse-- not respiratory arrest.

    http://www.ncbi.nlm.nih.gov/pubmed/8198295

    Outcome of cardiovascular collapse in pediatric blunt trauma.
    Does this put this subject matter finally to rest? The injuries you cite were devastating in and of themselves that even fully trained emergency personnel required major efforts to bring poor Max back to the degree they did? Sorry, I'm so not medically in-the-know.
    All of my posts are simply thought-starters and are not meant to be implications in any way, shape or form.

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    Quote Originally Posted by justice be served View Post
    Does this put this subject matter finally to rest? The injuries you cite were devastating in and of themselves that even fully trained emergency personnel required major efforts to bring poor Max back to the degree they did? Sorry, I'm so not medically in-the-know.
    It would be confirmatory to release Max's medical records to a panel of medical experts, who could explain that Max had a very dismal prognosis due to his cardiovascular collapse at the scene. No professional would have held out unreasonable hope to the family that this child had potential for any kind of meaningful functional recovery.

    Regardless of whether the spinal cord injury was seen on the first CT, or whether it was evident on the first MRI, the fact of Max's severe blunt cranial trauma, non-reactive pupils, GCS of 3 (lowest possible and still be alive), and decorticate posturing evident at the first emergency dept after cardiac resuscitation foreshadowed a very, very grim picture. It would be helpful to have neuroimaging and ICU specialists who have seen the imaging and records discuss this publicly, imo.

    I understand that Dina claims publicly that she did not accept or acknowledge this prognosis until much later (days later-- and she leads people to believe it happened suddenly), but my point is that the doctors would not have been as puzzled and confused as she has stated publicly. And they would not have painted a rosy picture to the parents.

    I wish Dr. Melinek had explored all of this more thoroughly in her report.

  13. #13
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    Quote Originally Posted by K_Z View Post
    It would be confirmatory to release Max's medical records to a panel of medical experts, who could explain that Max had a very dismal prognosis due to his cardiovascular collapse at the scene. No professional would have held out unreasonable hope to the family that this child had potential for any kind of meaningful functional recovery.

    Regardless of whether the spinal cord injury was seen on the first CT, or whether it was evident on the first MRI, the fact of Max's severe blunt cranial trauma, non-reactive pupils, GCS of 3 (lowest possible and still be alive), and decorticate posturing evident at the first emergency dept after cardiac resuscitation foreshadowed a very, very grim picture. It would be helpful to have neuroimaging and ICU specialists who have seen the imaging and records discuss this publicly, imo.

    I understand that Dina claims publicly that she did not accept or acknowledge this prognosis until much later (days later-- and she leads people to believe it happened suddenly), but my point is that the doctors would not have been as puzzled and confused as she has stated publicly. And they would not have painted a rosy picture to the parents.

    I wish Dr. Melinek had explored all of this more thoroughly in her report.
    In your opinion, then, does it seem practical that Max's condition did not suddenly turn grim on the last night of Rebecca's death evidenced by Jonah's call to Rebecca that Max would not make it - which was SDSO's pivotal point to Rebecca's impetus for suicide?
    All of my posts are simply thought-starters and are not meant to be implications in any way, shape or form.

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    I think it's likely that he finally herniated that night. But I firmly believe that the procedures for diagnosing and confirming brain death were in progress well before that. IMO.

  15. #15
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    Also, Dina mentions in the Boy Interrupted article that the "last" MRI (meaning the most recent one she is referring to before Max was declared brain dead and made preparations for organ donation) demonstrated extensive infarct and damage to the basal ganglia. That would have been damage that progressed over time-- not damage that suddenly appeared.

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