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waltwhitman83 t1_j2tbfx4 wrote

can somebody with a medical background give an update as to what we're most likely to expect in the coming updates that we're waiting for?

a quick google shows that after you are put into a medically induced coma, you usually aren't attempted to be brought out of it for at least 24-72 hours. does that mean we're facing 2 more days with no update (or more?)

did they do a scan of his brain when he arrived or not yet? are we just waiting to hear whether he sustained a brain injury or not? what other outstanding medical conditions might we be waiting to hear about? if he didn't sustain a brain injury, is he most likely to be basically 100% ok?

he's still having machines breathe for him if he's in a medically inducted coma. when they try to bring him out of the coma, will they then know if his body can breathe on its own?

those seem to be the 2 biggest unknown things from what i've read/gathered. would love if somebody more in the know could shed more detail.

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theMurseNP t1_j2tcbzk wrote

Too much to speculate at this point. They do therapeutic hypothermia for 1-3 days in many arrest cases. Gives the body time to catch up while probably fighting some inflammation. He has youth and physical fitness on his side. It’s fair not to expect anything new for another 1-2 days.

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waltwhitman83 t1_j2td2y3 wrote

is it fair to expect he is conscious and functioning in the next 2 days?

if not, is it fair to expect it’s worse than we all suspect?

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RasputinsAssassins t1_j2trmof wrote

Just speaking from having been an induced coma patient (not a medical person), this is pretty much just 'hurry up and wait.' Nothing can be gleaned from what WE know, though some things might be gleaned from what HIS DOCTORS may know.

He will remain induced until he can breathe on his own. That may be two hours, two days, two weeks, two months, two years, or just never.

The longer he remains on a ventilator is perhaps an indicator of some bad outcome, but even then, it's all about letting the body heal. That happens faster in some than others.

IMO, it's not fair to expect anything at this point. He seems to have received top shelf medical care almost immediately, and that will have more impact on the outcome than how long he is on a ventilator, IMO.

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waltwhitman83 t1_j2tsdhk wrote

> He will remain induced until he can breathe on his own

I don't get this. He's in a coma, therefore he needs a ventilator.

They're going to try to bring him out of the coma, turn the ventilator off, he tries to breathe with it still in his throat, if it fails they turn it back on and put him back out?

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RasputinsAssassins t1_j2tu2bf wrote

They can dial back how much assistance the ventilator is providing, I believe. That's what they did with me (or at least how it was explained to me).

When they brought me out to check brain function, the tube was still down my throat. It hurts, it triggers the gag reflex...it is not pleasant, and it almost feels like you are choking. That's one reason (among the others) people are typically sedated when on a ventilator. It can easily cause you to freak out and start thrashing, which runs counter to the whole idea of getting rest and healing.

So, they may take it from 100% assistance to 90%, to 80%, etc. It will reach a point where they think the body can do it on its own, and that's when they will consider bring him out.

Think of it like those machines (like the assisted pull up machine) in the gym that have a weight assist on them. You can dial back how much of the work is being done by the machine assist. It allows you to continue with the exercise so that you can do it properly and reap the benefits, and as you get stronger, you can turn down how much assist the machine is giving, until you are at a point you can do it all on your own.

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tkp14 t1_j2u0thq wrote

A couple of years ago I contracted a norovirus which was extremely unpleasant and causes a person to violently expel from both ends. (Such a charming experience.) I ended up being taken to the ER because the expelling would just not stop. They put in an IV to re-hydrate me and to give me antiemetic drugs. They also put in a nasogastric tube - a very thin, soft tube that goes in through the nose, down the throat, and into the stomach. They were concerned that the uncontrollable vomiting might start up again and suffocate me. The tube had to remain in for 24 hours, though I’ve read that often patients have to endure it for a lot longer. And “endure” is the right word. That skinny little tube hurt like a bitch. It put the whole “get Covid and wind up on a ventilator” in perspective. I cannot begin to imagine how awful a ventilator feels.

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waltwhitman83 t1_j2tufi6 wrote

> That's what they did with me (or at least how it was explained to me).

when you were conscious or in a coma?

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RasputinsAssassins t1_j2tzmq3 wrote

>when you were conscious or in a coma?

They didn't explain much to me while I was in the coma. If they did, I have no recollection.

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RasputinsAssassins t1_j2u01gk wrote

They aren't going to wake him up from the coma until they think he can breathe on his own. They determine that by dialing back how much help the ventilator is providing.

They may bring him out long enough to ask a question and stick him with a pin to see if he still has cognitive function.

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waltwhitman83 t1_j2tuhyl wrote

> That's one reason (among the others) people are typically sedated when on a ventilator.

if you're sedated, can't you "not breathe on your own" without the ventilator? or is it like being asleep? or are there different levels?

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RasputinsAssassins t1_j2tzfn1 wrote

I'm not sure I understand what you are trying to find out.

A ventilator assists your breathing. It can do 100% of it for you, or it can do (I don't know the number) 10% of the breathing, and your body does the remaining 90%.

Again, I was a coma patient; I am not a medical; professional. A person who is sedated for something like a minor procedure (think a colonoscopy or an eye surgery) is awake and may be aware, or they may be simply put to sleep with drugs. Those folks can still breathe on their own and don't need a ventilator, because they are only partially sedated.

As you get more drugs for a deeper level of sedation, you breathing slows down.

A person who is put into a deeper level of sleep, like for a major surgery, may or may not get intubated with a ventilator. They may still be able to breathe on their own, but the drugs cause respiration to slow, and that can be dangerous, depending on what's happening. So they may go on a ventilator, if it is felt is needed.

A person who is medically induced is, I believe, usually intubated with a ventilator. They let the ventilator do the heavy lifting so the body can repair itself. Again, they heavy drugs slow respiration.

The ventilator does tit's work whether or not you are sedated. They sedate you because it's a scary friggin' experience to have a tube shoved down your throat, completely blocking it. It felt like a hard or corrugated plastic, and it was not pleasant. I began to freak a little, but they calmed me down enough to get their test done and then put me back under.

Those commercials that have been running in some areas of the US about not having a glass of wine with your Oxy? It's warning you because that combo is effectively sedating you to a level where your respiration can slow to a stop.

I do not remember anything about my coma, except a very weird thing when they put me back under. it's not the same as being asleep, IMO. I had no concept of the passage of time. I woke up five days later and thought it had been a couple of hours. I had a follow up surgery months later where I was just under general anesthesia for the surgery (knocked out) and it felt like I was out for 15 minutes. It had been 7 hours. I felt like Scott Lang in the Quantum World.

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tmahfan117 t1_j2u2baz wrote

It depends on how deeply you’re sedated.

But like the vast majority of the time people can breathe on their own while sedated. Like anytime someone gets knocked out for a planned/routine surgery they’re sedated.

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strykerdoc t1_j2u3idp wrote

Not a doctor. Former paramedic and current nursing student.

You are typically given two different drugs. One is for sedation, can be propofol (what killed Michael Jackson) or versed, or a couple others depending on doctor preference and local protocols. The other drug is a paralytic, so that you're not fighting the tube or mechanical breathing.

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Greener441 t1_j2uie2i wrote

>They’re going to try to bring him out of the coma, turn the ventilator off, he tries to breathe with it still in his throat, if it fails they turn it back on and put him back out?

without getting technical, yes, pretty much.

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RasputinsAssassins t1_j2tqqxk wrote

I can give you my experience. I do not have a medical background, though.

I was medically induced for a massive infection (perforated colon from undiagnosed diverticulitis led to sepsis and septic shock). I was in a coma for 5 days, and was for this reason (let the machines do the work to allow the body to heal itself). They brought me out once on about day 3 to see if I had cognitive function. The drugs used to induce the coma are extremely powerful, and they can cause damage, as can the massive infection I had.

It is certainly a different situation, as my lungs, kidneys, and liver were shutting down. I also am not an in-shape professional athlete.

That said, as it was explained to me, putting someone in a coma and on a ventilator is sort of a risk in itself. The ventilator tube can easily breed bacteria that leads to lung infections, and the drugs used can do damage as well. It's better than the alternative, but it's also not necessarily a sign of improvement. It's more a sign of 'stable at the moment, we'll assess the damage later.'

While I was under, they did some tests and scans and diagnostics, but I don't know to what extent they did any CT or MRI or advanced scans (if any). I would think being on the ventilator limits where and how they can move the patient.

I believe they will assess the lungs' ability to work on their own by dialing back the machine a little at a time. They will also do some cognitive and brain testing if they have not done so. But they will do more after he is brought out.

It sounds like he received immediate lifesaving care, which is great. But there is just too much unknown at the moment, and some things that are known for now may change later. My take is that we should offer up whatever support we can and let the process happen. He's a young, strong, fit, athletic guy and that gives him a big head start on a recovery.

But however you spread good juju in the world, whether it be prayers or thoughts or incense or incantations or whatever, the Hamlin family can use all the support they can get right now.

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OSU725 t1_j2thy75 wrote

As someone else mentioned there is to many unknowns to speculate right now. What is most important and gives him a leg up is that there were trained medical personnel on hand that gave him life saving measures immediately. That is absolutely huge for the prognosis no matter what exactly caused it.

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CodeBlue614 t1_j2uohdl wrote

ICU doctor here.

The decision about therapeutic hypothermia (cooling) is made based on the initial neuro exam. Typically, if they’re not following commands, you do it. There’s some debate about whether it’s helpful to actually cool them (target a central body temperature of 32-34 C) vs just preventing fevers (hold central body temp at 36 C). The deeper cooling can cause a lot of metabolic problems, and needs deep sedation and sometimes a paralytic (if they shiver uncontrollably). At my hospital, most patients get 36 C these days. It may be different at UC, I can’t comment on their practice patterns.

Prior to all of the cooling studies, the prognosis was based on the initial exam and the exam between 72-96 hours (3-4 days in). In short, if you’re awake and following commands by then, good sign you’ll be at least semi-independent (for self care) at 6 months. Obviously, if the patient improves in less time, that’s great. Cooling pushes the timeline back. I have had patients wake up and start following commands during cooling, in which case we stop.

During this time, Mr. Hamlin will be reassessed frequently, looking at things like cranial nerve reflexes (from nerves that come directly off the brain and not the spinal cord). These include nerves that control the pupils reacting to light, eye movements, cough and gag reflexes, and blinking. If they are impaired, that’s a bad sign, as they tend to be more resilient than the “higher function” areas of the brain.

As the updates come in during the coming days, look for reports about wakefulness and following commands. If he is off the ventilator at some point this week, he would need to be awake and following commands, so that is a good proxy. If he’s out of ICU in the next 7-10 days, he would need to be off the ventilator.

I’m happy to answer questions if you have them.

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waltwhitman83 t1_j2uwbm3 wrote

we have no clue

  1. his preliminary CT scan results

  2. if he's had an MRI yet while intubated (unlikely)

  3. if he's being cooled or not

correct?

if there aren't reports that he's awake and off the ventilator within the next 7-10 days, is he most likely going to be a vegetable/dead or is there some kind of "healing" that could happen while he's in a coma for, 14, 21, 30+ days?

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CodeBlue614 t1_j2uzoz0 wrote

The preliminary CT if the head is really only good for looking for bleeding or massive stroke. The changes you see from anoxic injury don’t show up for a while. The neuro exam is actually you’re best tool (better than MRI, if you can believe it), so those assessments will be ongoing. MRI may occur in the next few days, I usually wait until we’re 3-4 days in and the exam hasn’t improved to see if there’s a correlation on imaging.

You’re correct that we don’t know if he’s being cooled or not. He is probably receiving some sort of temperature control therapy, but at some hospitals that may be 36 C (that’s what we do at my hospital) and other may still use 32-34 C. It’s not clear that the lower temperature is better, and it causes some weird things to happen metabolically. I don’t know what they do at UC, since I’m not there.

If he shows no significant neurologic improvement in 7-10 days, it’s very likely that he has severe brain damage, likely irreversible. That could include a vegetative state. He could progress to brain death. The cases where you see someone wake up several weeks later are head traumas. There’s a lot of swelling pushing on the brain cells, but the cells themselves don’t have irreversible damage. In this case, brain cells die from lack of oxygen delivery while the heart isn’t beating. I’m not aware of any anoxic injuries that wake up that far down the road.

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waltwhitman83 t1_j2v1b16 wrote

so he went into the tackle, had trauma into his chest area, heart stopped due to the timing of the hit

we had enough blood/oxygen for like 10 seconds to stand up/move

goes down

sideline medical crew rushes over

check him for concussion/spinal injury

how many minutes between going down and getting treatment was his brain starved from oxygen

if it was more than 5 minutes, is he most likely doomed?

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CodeBlue614 t1_j2v360r wrote

Usually, we think of 3 minutes as being when damage starts to occur. I believe I read that his pulseless time was around 8 minutes. I have seen people recover nicely from 10 or even 15 minutes of down time, but that isn’t guaranteed. Once you’re around 20 minutes, the outcomes start to look bad. It’s possible to support someone with ECMO during a prolonged cardiac arrest and still have decent outcomes.

In his favor, he’s young and in good physical condition. His heart was in great shape prior to the arrest, so hopefully it isn’t stunned too badly and is able to pump blood effectively. He likely has healthy blood vessels that feed his brain. He did receive medical attention quickly. The tricky thing is that these are just so unpredictable. I’ve seen them go better than expected and worse.

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waltwhitman83 t1_j2v3xw3 wrote

thank you very much

i really appreciate you

remindme! 2 days follow up with this nice doctor

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CodeBlue614 t1_j33koxl wrote

I heard that Mr. Hamlin is awake and communicating in writing, but still on the ventilator. So neurologically, that is a massive improvement and gives me a lot of reassurance about how his brain is doing. The ventilator is there to help his lungs recover at this point, but I expect continued improvement there in the next few days.

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waltwhitman83 t1_j34p6h7 wrote

when do you expect the ventilator will come out/why is he still on it if they let the sedation wear off?

they must have known before hand how he'd react based on what they saw from CT scan or something?

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CodeBlue614 t1_j34zibf wrote

There was a report that he had been pronated (turned face down) during the first 24 hours. We really only do that when patients have severe respiratory failure needing high ventilator settings. In this case, it is common to have saliva, vomit, or refluxed stomach acid go into the lungs during CPR, which we call an aspiration event. It is also common to have lungs contusions (essentially bruises) from CPR. Either could cause him to need high ventilator settings early on.

The decision to pronate (flip the patient face down) is based on the ratio between oxygen level in the blood stream to amount supplied by the ventilator (the atmosphere is 21% oxygen, ventilators are usually set between 30-100%). These patients also get chest x-rays using a special portable device, and that x-ray combined with the ratio I mentioned can give you a pretty good idea of how bad things are, even without the CT scan. The problem with the CT scan is you have to leave the ICU on a portable ventilator to get it, so there’s some risk involved if the patient is unstable. I will often delay CT scans if I think they’re too risky for the info I expect to receive.

Without knowing his current ventilator settings, it’s hard to know how much longer until he comes off. He’s probably on little to no sedation currently, since he’s writing. Believe it or not, patients tolerate the ventilator with very little sedation much of the time (sometimes none). Typically we don’t keep sedation that light if the ventilator settings are really high, because there’s so little room for error if the patient and ventilator stop being synchronized. I expect he will get the opportunity to show he’s ready to come off the ventilator every morning going forward, and they’ll take him off when he can past those tests.

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waltwhitman83 t1_j35b9r1 wrote

what tests does he need to perform/pass in the morning(s) before being taken off ventilatior? understood that putting it back in, not easy

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CodeBlue614 t1_j35ors4 wrote

First step is just being on low enough ventilator settings. I usually want to see the oxygen no higher than 40%, because that is similar to what a regular nasal cannula can do. Second is waking up and following commands when the sedation is turned down or off, which he’s already doing. Third is called a spontaneous breathing trial. The ventilator mode is changed so that the patient has more control, and we see how they do with minimal support. Usually, that lasts for 30 minutes, but we might do 1-2 hours if we’re worried about how things are going to go. If the patient’s breathing becomes rapid and shallow, they aren’t ready. Finally, we check a cuff leak. The breathing tube has a balloon shaped like a donut called a cuff that forms a seal against the trachea. We deflate the cuff and check to see that air can escape around the breathing tube. It’s a way to screen for upper airway swelling.

You certainly don’t want to be taking the tube out and putting it back in repeatedly, but there will be times when it has to go back in. In Damar’s case, he’s young and healthy and it’s only been a few days, so I would expect he does well once it comes out.

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waltwhitman83 t1_j36cjfy wrote

how would they know he’d “wake up” and his brain would be ok enough to follow commands instead of letting him sleep 2-5 more days in a coma?

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CodeBlue614 t1_j36st7w wrote

There’s no way to know when/if he will wake up at the beginning. Usually we try to use the least sedation possible to keep the patient comfortable (based on non-verbal signs) and in synch with the ventilator. If that can be achieved with a low to medium dose, then the patient can wake up once their brain recovers enough. If he’s condition had been such that he needed deeper sedation, then sedation would be lightened when those other problems improved.
The brain isn’t going to benefit from the sedatives, especially at high doses. The more time a patient spends on high-dose sedation, the more confused they get. Sedation is dosed at “just enough to get the job done”. The nurses have protocols for adjusting sedation doses based on what’s going on. If you every hear of someone being in a medically-induced coma, think of it as a necessary evil to help facilitate other therapies to support one or more failing organ systems, rather than a therapy in and of itself. There are rare instances when the sedation is the therapy (e.g. continuous seizures that we can’t break), but usually it’s there to facilitate other therapies.

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waltwhitman83 t1_j2uwgi2 wrote

> During this time, Mr. Hamlin will be reassessed frequently, looking at things like cranial nerve reflexes (from nerves that come directly off the brain and not the spinal cord). These include nerves that control the pupils reacting to light, eye movements, cough and gag reflexes, and blinking. If they are impaired, that’s a bad sign, as they tend to be more resilient than the “higher function” areas of the brain.

it seems highly unlikely that they'll release this information to the press/media/fans, despite the fact that basically millions of people will most likely look at football differently if a player dies from a routine tackle, no?

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Ajax444 t1_j2uyc8x wrote

I don’t think people will look at football differently. I have seen 2 basketball players die on the court, and heard about the Price brothers (Mark and Brent-ex NBA players) father collapsing after a pick-up game, and Pete Maravich.

A soccer player recently had cardiac arrest on the field (last year?). I remember the Detroit Lions player that got paralyzed on the field. These sports go on, and these instances are soon out of sight/out of mind.

I mean, the UFC has 2 barely protected people in the ring looking to concuss their opponent. It’s not going anywhere soon.

These gentlemen (and ladies) know the potential consequences, and choose to participate. While it may not he in their best interest, physically and mentally, it is their right to make that decision.

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CodeBlue614 t1_j2v0cn2 wrote

I doubt we’ll hear those smaller details. I added that part to help people understand the process a little better. I’d expect a bigger picture, more general update once a day. If he wakes up, I would imagine that’s a story that warrants an urgent update by sports outlets, and it would definitely be cause for relief.

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waltwhitman83 t1_j2v1fgz wrote

if we don’t hear that he’s awake in 2 more days, would you say it’s most likely bad?

is there any way they could’ve already woken him up if they saw all positives?

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CodeBlue614 t1_j2v44st wrote

In a few cases, I’ve had people wake up during CPR. That’s rare. Waking up within the first few hours does happen, and those people tend to do well. The longer he goes without waking up, the more worried I get. When we get to 7-10 days, it’s pretty clear that things aren’t going to go well. Additionally, if I see cranial nerve reflexes that are absent or sluggish, or new seizures, I know things are going badly. If he’s 2 days in, not awake yet, but his reflexes are all normal, he can still have a good recovery.

I know these are long answers, but this stuff is complicated.

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waltwhitman83 t1_j2v4lid wrote

will they be testing his reflexes if he’s sedated on purpose/being cooled?

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CodeBlue614 t1_j2wnq05 wrote

It depends on the depth of sedation. In most patients, we’re aiming to keep a patient calm, but awake, or at most drowsy. If they made the decision for cooling to 32-34 C, he would be more deeply sedated. You can still check reflexes under those circumstances. If they had to use a paralytic to control shivering, then most of those reflexes won’t be there. The pupils will still react to light, so those are still checked. When we do temperature control at 36 C, I keep sedation pretty light, because there tends to be a lot less shivering, and I can greatly reduce the amount of drugs the patient is exposed to.

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loupr738 t1_j2u1iy5 wrote

I don’t know if it’s any different but if you remember the most recent UEFA European championship, Christian Eriksen suffered a cardiac arrest too and he had to be revived on the field. He was playing soccer a couple of months later, of course the NFL is a whole different animal but at least I hope the kid recovers his normal outside of the nfl life

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beel11 t1_j2u33dp wrote

My guess: Therapeutic hypothermia potentially for next 48-72 hours. Let him wake up after that. Let him walk out of hospital within a week. Huge debate whether he needs a device (prob not) and whether he can play for the playoffs (maybe but who will have the balls to allow it). It’s more likely he plays next season instead if he does play again. If he’s not being cooled, then he gets extubated soon and we hear the good news.

This is all assuming CPR was adequate and initiated quick enough.

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waltwhitman83 t1_j2u8qab wrote

> Let him walk out of hospital within a week.

if he can that is, right? is there a 50% chance he's a vegetable/his brain is fucked?

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beel11 t1_j2uacj5 wrote

I think the most important question for him is - how quickly did they recognize arrest and start CPR after he collapsed. Also how quickly did they shock him. This plays huge implications for the nfl and what personnel they have on the field. If it was quick, he should be completely fine and back to 100% soon (hopefully). This is assuming it was just pure commotio cordis and nothing else.

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acgasp t1_j2u9gx1 wrote

My husband went into cardiac arrest when he was 21 (yeah, super young, I know) and he was sedated and intubated for at least 24 hours. They tried weaning him off the sedation the day after but he kept fighting the breathing tube, so they kept him on it until he came out of the sedation on his own and then they extubated him.

He turned out perfectly fine, no lasting effects except now he has an implanted defibrillator in his chest in case it ever happens again.

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Gs1000g t1_j2ud98r wrote

I’ll try and answer your questions

So, they induce therapeutic hypothermia in cardiac arrest with ROSC to help preserve brain function and decrease oxygen demand and inflammation by the neural tissues. The old protocol we used was the patient was intubated on the ventilator sedated and chemically paralyzed to reduce oxygen demand. Remember everything at this point is about preservation of tissues. So we would start cooking and after target temp is reached we let the patient stay at that temp 24ish hours. Afterwards we started the warming process. It’s slow because the warming causes potassium to exit the cell and too fast warming can cause arrhythmias. Once the patient is warmed they assess neurological function (follows commands, brain stem reflexes, ect)

A medically induced coma requires a breathing tube, ventilator, and medications for sedation because a ET tube (tube down the windpipe) is stimulating to the majority of people. After a deemed amount of time the sedation is shut off and the assess the patients neurological function. If they can breath on their own with minimal machine assistance generally they can protect their own airway and the tube can be removed. If the sedation is shut off and the patient does nothing (follows commands, take a deep breath) then the tube stays in place. This typical will be in for 2 weeks before they talk about doing a tracheostomy.

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PutzerPalace t1_j2u93il wrote

This happened to my grandfather. It took almost a week to pull him out of the cold coma and when they did he was brain dead due to slow action to start CPR.

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