Max Shacknai EMS Report

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.
 
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
 
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.)
 
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.
 
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!
 
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
:woohoo:

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?:banghead:
 
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.
 
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
:woohoo:

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?:banghead:

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.
 
More on cardiovascular collapse and blunt head trauma:

http://circ.ahajournals.org/content/112/24_suppl/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.1–4 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.3–6 Cardiac arrest in the field due to blunt trauma is fatal in all age groups.
 
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.
 
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.
 
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?
 
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.
 
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.
 
It would be extremely interesting to know what the timing was of Dr. Peterson's comments were to the family-- and particularly the timing as it relates to CT and MRI imaging. I'm not convinced that he "believed" Max was suffocated, but that his explanations for the global hypoxic encephalopathy were misunderstood if he used "suffocation" as an example of hypoxia anywhere in his explanation.

I give him much professional leeway, as I think it is very possible he was misunderstood. He has remained completely out of the public eye, and has not offered to make any public statements, nor has he appeared with Dina to plead for Max's case to be reopened, or made any written supportive statements. (I'm sure the hospital attorneys have a lot to do with that.) The person Dina quotes again and again as first putting forth a theory of assault on Max.....has been completely silent. That makes me scratch my head. Why did Dina hire only Dr. Melinek? Why not also plead with Dr. Peterson to support her quest to reopen Max's death investigation?

However, this presumed suffocation comment could have become motive for hurting Rebecca. And that's why I think it's extremely relevant, and why release of Max's medical records would be so compelling. They tell the story of who knew what, and when, IMO. But I seriously doubt that Max's records will be released. If Dina is very earnest and sincere in her quest to find out what happened to Max, that would be a good first step towards truth. Let experts who are not paid by her examine the record and weigh in. This could be compelling to persuade authorities to reopen Max's case, or not.
 
One more I didn't get around to posting earlier today-- a San Diego pediatric trauma and cardiac arrest study over 12 years.

http://www.ncbi.nlm.nih.gov/pubmed/10460086

Cardiac arrest induced by blunt trauma in children.

Since 1984, all traumatically injured children in San Diego County, California, have been treated at San Diego Children's Hospital. This review encompasses 10,979 pediatric trauma patients evaluated from August 1, 1984 through September 30, 1996.

In this large metropolitan county, 65 children suffered cardiac arrest following blunt trauma. All but one of these patients died despite resuscitation. Ninety-four percent of these children died within the first 24 hours of injury. The single survivor was discharged in a vegetative state. Solid organs were obtained from 9% of the patients.

CONCLUSION: The outcome from blunt cardiac arrest in children is rapidly and nearly uniformly fatal despite resuscitation.

BBM
 
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.


OK I misunderstood? I was thinking that we were being told that the moment the brain injury occured that the heart stopped.
That was where I got confused!

It can happen even hours later.
So do I understand correctly Max could have been SOB at the time of the 911 call perhaps even have said Ocean... and it escalated prior to EMT's arriving on the scene?

OR are you thinking Max was asysatolic (not speaking or breathing)
from the time 911 was called?


After reading the EMT report my view has cleared somewhat.
Brain injury was #1 on the list .

Funky accidents occur... that's a fact.

BUT RZ, LE, EMT's, ER DOCS, THE ME, AND EVEN FORENSIC SPECIALIST ETC... HAVE NEVER HAD A MEETING OF THE MINDS TO SETTLE HOW THIS ACCIEN OCCURED.

As a mother being told a different version by every person from the moments prior to the accident until over a year later can you blsme her for thinking her child was attacked/murdered???

As a mother and nurse, I would need a straight line from point A to point B.
With that I could walk away and celebrate my child's life.

Dina has been given a SPIROGRAPGH to attempt to decipher!

moo
 
I think Max was immediately unconscious, and rapidly aystolic from the moment of impact on the floor.

I'm extremely doubtful he said anything after impact. Before he fell, he may have called out "Ocean" or something, but not after.

I also want to comment that the "vomit" discussed on the paramedic report was passive regurgitation up the esophagus, not active vomiting.

Dr. Melinek commented in her report that Max had a severe aspiration pneumonia during his hospitalization. It's extremely likely that this is a result of his full stomach and regurgitation at the time of the accident from what we can see of the paramedics comments. Aspiration pneumonitis is like a chemical burn of the lung tissue from stomach acid and partially digested stomach contents. This can be quite severe, and interfere with oxygenation, despite high levels of oxygen delivered by ventilator in ICU.
 
It would be extremely interesting to know what the timing was of Dr. Peterson's comments were to the family-- and particularly the timing as it relates to CT and MRI imaging. I'm not convinced that he "believed" Max was suffocated, but that his explanations for the global hypoxic encephalopathy were misunderstood if he used "suffocation" as an example of hypoxia anywhere in his explanation.

I give him much professional leeway, as I think it is very possible he was misunderstood. He has remained completely out of the public eye, and has not offered to make any public statements, nor has he appeared with Dina to plead for Max's case to be reopened, or made any written supportive statements. (I'm sure the hospital attorneys have a lot to do with that.) The person Dina quotes again and again as first putting forth a theory of assault on Max.....has been completely silent. That makes me scratch my head. Why did Dina hire only Dr. Melinek? Why not also plead with Dr. Peterson to support her quest to reopen Max's death investigation?

However, this presumed suffocation comment could have become motive for hurting Rebecca. And that's why I think it's extremely relevant, and why release of Max's medical records would be so compelling. They tell the story of who knew what, and when, IMO. But I seriously doubt that Max's records will be released. If Dina is very earnest and sincere in her quest to find out what happened to Max, that would be a good first step towards truth. Let experts who are not paid by her examine the record and weigh in. This could be compelling to persuade authorities to reopen Max's case, or not.

Here's an except from Nina's audio interview on this topic:

(Begins at 33:30 of audio)
Then Thursday, Dr. Peterson had a meeting with Dina and Jonah and said that the extent of the damage in Max’s brain, there was no way that he could have had CPR within two minutes, like, it wasn’t, it wasn’t possible that he had CPR within two minutes of, you know, not having enough oxygen. It just wasn’t possible. So my sister said, “Well, what, like, what could cause this? What could cause a six year old to go into full cardiac arrest? A healthy six year old to go into full cardiac arrest? And he said, “Well, a possibility is suffocation.” That’s how it came up.

(Please note it was Nina who said "That's how it came up" in reference to the possibility of Max being suffocated. That's part of the transcript, not an editorial comment by me.)
 

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