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Wed, 27 Nov 2002 17:34:20 +1030

Hi Ian,
          i think you have summed things up very well. This is an area that
has had some conflicting opinion on this and other web sites. What i am
starting to understand more now is: there appears to be no convincing
evidence suggesting an approach other than what you have stated below. Those
who continue to insist that one approach is best are probably doing a
disservice to the industry, as the good science does not appear to be there
to back up their claims. Good evidence works for me ... and we just haven't
cracked it in some of those areas yet. Roll on good quality research that
asks the right questions - and provides the answers!

Chris Cotton
Intensive Care Paramedic
South Australia. 

-----Original Message-----
From: Ian Seppelt
To: cotton.chris@saambulance.com.au; trauma-list@trauma.org
Sent: 27/11/02 12:07pm
Subject: Re: Iatrogenic coagulopathy

Chris Cotton:
I know it is an individual thing with each patient and trade offs - but
lets
do the nitty gritty. What's best? Who's right, and most importantly -
where
does the most convincing evidence lie? 

Reply:
The biggest prblem with evidence based medicine is its misuse. "Evidence
creep" is one such example, where because something is proven in a
specific population a, it gets applied to the much more general group A.

There is NO CONTROVERSY that fluid is bad if you have penetrating
truncal trauma in an urban environment with a well organised ambulance
service.

The opposite extreme is mixed multisytem blunt trauma including
neurotrauma, in a remote environment with many hours to definitive care
(I'm thinking about the Kimberley, for example, where there is a "Golden
24 hours" to definitive care). No good studies but I think we would all
support maintenance of organ perfusion above 'popping the clot' in this
extreme - anyone who is going to bleed to death will die anyway, and the
ones we can save are the ones in whom we prevent the sequelae of
multiple organ failure.

Unfortunately there is a HUGE grey zone between these two extremes,
there is no good level 1 science and we are left with the 'art' of
medicine that some of us still have to practice.

I teach residents that there are three distinct syndromes in trauma,
being 'penetrating trauma', 'multisystem blunt trauma', and
'neurotrauma', which may however coexist. It is dangerous to extrapolate
clean science from one group to another. Unfortunately the both with two
or more of the trauma syndromes is just like the patient with both
chronic severe congestive heart failure and sepsis, and a lot of art is
needed to ride the middle ground between conflicting priorities

Cheers, Ian

Ian Seppelt FANZCA FJFICM
Staff Specialist in Intensive Care Medicine
The Nepean Hospital, Sydney.

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Iatrogenic coagulopathy