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Wed, 11 Dec 2002 00:23:09 -0000

CBM wrote:
 ' LR.  Its relatively cheap, stays in the vascular space for quite a while
> and does not require very much special storage.  Of course it does
> nothing to increase the pt's Hb levels, but it keeps the perfusion
> pressures up, at least until you can get them to a trauma centre.'
Consider this  again.....
LR -think how much actually stays in the vascular space at 1 hour?
        - the majority that leaks into third space impairs oxygen delivery
        - dilutes haemoglobin and coagulation factors
        - contains lactate
        - do you want to 'keep perfusion pressure up' that high?

There may be better alternatives!
Regards
Mark F
----- Original Message ----- 
From: "Christopher Massa" <cmassa1@jhu.edu>
To: <trauma-list@trauma.org>
Sent: Tuesday, December 10, 2002 2:57 PM
Subject: RE: Spurters and airways ... or is that - airways and spurters?!


> Chris, I could not agree with you more.
> 
> As for the question about pre-hospital fluids, I'm pretty much all for
> LR.  Its relatively cheap, stays in the vascular space for quite a while
> and does not require very much special storage.  Of course it does
> nothing to increase the pt's Hb levels, but it keeps the perfusion
> pressures up, at least until you can get them to a trauma center.
> 
> ~CBM
> 
> -----Original Message-----
> From: trauma-list-admin@trauma.org [mailto:trauma-list-admin@trauma.org]
> On Behalf Of Cotton, Chris (SAAS)
> Sent: Tuesday, December 10, 2002 1:55 AM
> To: 'trauma-list@trauma.org'
> Subject: Spurters and airways ... or is that - airways and spurters?!
> 
> Sheree wrote:
> I think you get the impression that I totally disagree with the 
> principle of applying pressure to an obvious 'spurter'. This is far from
> 
> the case and it obviously would be something that could (& should) be 
> done. But at the risk of not securing an airway...?? I'm not talking 
> about c-spine immobilisation and preparing & delivering oxygen. I am 
> very simply talking about an airway - whether that be a simple chin lift
> 
> or artificial. 
> I would imagine that the majority of patients, especially one in the 
> scenario you've described would clinically clear their own c-spine (or 
> not as the case may be). I know that I certainly wouldn't be lying still
> 
> if I had no neck pain & a gaping spurting leg wound. 
> Unfortunately, Mark, some people do need didactic teaching because they 
> seem unable to 'think outside the square'. 
> Sheree 
> 
> Me writes:
> 
> An eminent trauma specialist quoted to me once ... "blood on the floor
> is
> forever lost to the patient". Worth remembering, i thought.
> 
> If their airway collapses or is compromised when you get to a patient
> and
> they still have a "spurter", i'd generally go for the spurter. Stemming
> massive haemorrhage normally only takes seconds (to, at the very least
> slow
> it down). They should have enough FRC and ability from Haldane's law to
> hook
> up oxygen on to available Hb to last them a while. But, if you don't
> have
> the Hb in the first place - what's the point in having the oxygen
> available,
> coz you've got nothing to transport it to the brain and other vital
> organs
> with? Mark, Terry, Tim and i aren't disagreeing with you - rather just
> pointing out the practicalities of how the ABC's are actually managed on
> the
> front line. The airway is very important, but there are timelines. Yes -
> i
> know this needs fixing ... but do i need to do this part of it right
> now, or
> can i afford to delay it for 20 - 30 seconds whilst this equally
> important
> component is managed? Some timelines with airways are absolute - others
> are
> relative. The more one practises the art of medicine, the more one
> understands the value of relativity. 
> 
> Holistically of course, this is all done in unison, with a good team
> leader
> calling the shots (in a way that others don't even realise) to those
> assembled around the casualty. That "team" might be other ambo's, or it
> might just be members of the public that happen to be near by at the
> time. A
> good, confident and competent practitioner can get almost anything
> achieved
> by directing the team assembled to specific tasks as necessary so the
> patient benefits. How do i know this? This is my bread and butter.
> Paramedics (and others, i'm sure) do it every day. They wing it - with
> an
> understanding of the priorities of management and the over all situation
> as
> they make these decisions for their patients.
> 
> When teaching the ABC's to laymen, it is important to give them rigid
> structure. As one's knowledge advances along the medical continuum
> however,
> the more the distinctions can become blurred. Be prepared to come down
> from
> the trees as our minds expand.  ;o)
> 
> If we may be so bold now as to move on ... What would be good to
> administer
> when that precious Hb is lost however, is something that can be stored
> on
> the frontline that has an oxygen carrying capacity similar to Hb.
> Something
> that can be stored easily, with a long shelf life and not cost
> squillions
> for every millilitre infused ... (oh, and didn't bring up their BP too
> much
> to pop clots forming - had to put that bit in!)
> 
> Chris Cotton
> Intensive Care Paramedic
> South Australia. 
> 
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Spurters and airways ... or is that - airways and spurters?!