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Burns analgesia- KETAMINE

Alejandro Cabrera , M.D. trauma-list@trauma.org
Sat, 23 Feb 2002 14:08:26 -0600 

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Thanks, we will consider it because of the hypotension caused by the =
opiates.
Alejandro Cabrera, M.D.
  ----- Original Message -----=20
  From: John & Rebecca Black=20
  To: trauma-list@trauma.org=20
  Sent: Saturday, February 23, 2002 5:03 AM
  Subject: Burns analgesia- KETAMINE


  Alejandro,

  The agent that I would strongly urge you all to consider using in the =
situation you describe is an analgesic dose of ketamine (0.1 - 0.5mg/kg) =
mg . It is immensely valuable in the prehospital phase of patient's care =
and, unlike morphine, is probably the analgesic agent of choice if your =
patient also has a significant volume issue. Low dose midazolam may be =
added to reduce the risk or emergence dysphoria in less serious burns.

  If the patient requires a definitive airway, and/or aeromedical =
evacuation is being considered, ketamine (1- 4mg/kg IV or IM) is also an =
extremely attractive induction agent.

  John Black
  Consultant Emergency Medicine
  John Radcliffe Hospital
  Oxford UK



  Message: 9
  From: "Timothy J Coats" <t.j.coats@qmul.ac.uk>
  Organization: MDS QMW
  To: trauma-list@trauma.org
  Date: Fri, 22 Feb 2002 08:50:31 BST
  Subject: Re: Burn patients.
  Reply-To: trauma-list@trauma.org

  Alejandro,

  Standard pain control would be to cover burns with clingfilm
  (=3Dsaranwrap in the USA I think) to prevent air movement over them,
  plus large doses of opiates (morphine) as part of balanced =
anaesthesia.

  Not sure about flying out the patient you describe - maybe terminal
  care by a local physician near to home with easy access for relatives
  would be nicer. However, I guess the local docs may not feel that they
  can cope with this.

  Tim.

  Timothy J Coats MD FRCS FFAEM
  Senior Lecturer in Accident and Emergency / Pre-Hospital Care
  Royal London Hospital, UK.

   -----Original Message-----
  From: Avi Roy Shapira [mailto:avir@bgumail.bgu.ac.il]
  Sent: Friday, February 22, 2002 2:00 PM
  To: trauma-list@trauma.org
  Subject: Re: Burn patients.



  Give iv morphine. My practice is to dilute 10 mg in 9 ml of saline, in =
a
  10 ml syringe, give 3-5 iv push, and then add mg by mg until pain =
free.

  Repeat as needed.

  Avi


  On Thu, 21 Feb 2002, Alejandro Cabrera , M.D. wrote:

  > Hy:
  > We've been flying a few patients with 90%(+) BSP burns of second and =
third
  > degree, and, some bettween 50 and 90% and I was wondering which are =
your
  > protocols for pain management obviously they were intubate because =
airway
  > burned , the place where we flew from has no ABG's  (little town) , =
but
  one
  > of them with more than 90% with renal failure, and, coagulopathy.
  > I know it's not life compatible but we must do the best we can, what =
do
  you
  > suggest?
  > Alejandro Cabrera, M.D.
  >
  >
  >
  > --
  > trauma-list : TRAUMA.ORG
  > To change your settings or unsubscribe visit:
  > http://www.trauma.org/traumalist.html
  >

  =
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D
  Aviel Roy-Shapira, M.D.              Soroka University Hospital &
  Dept. of Surgery A. and              Ben-Gurion University Medical =
School
  the Critical Care Unit               POB 151, Beer Sheva, Israel


    ----- Original Message -----
    From: trauma-list-request@trauma.org
    Sent: 22 February 2002 21:13
    To: trauma-list@trauma.org
    Subject: trauma-list digest, Vol 1 #1286 - 13 msgs

    Send trauma-list mailing list submissions to
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    Today's Topics:

       1. v-fib seizure (Vergote Lieven)
       2. Re: v-fib seizure (CrnbryEMT@aol.com)
       3. RE: ORIGINS OF AVPU (bobby smith)
       4. Re: Burn patients. (Avi Roy Shapira)
       5. RE: Burn patients. (Bjorn, Pret)
       6. Re: PANCREATIC TRAUMA - more info to ICU guys (MARK FORREST)
       7. Re: v-fib seizure (Nick Nudell)
       8. Re: v-fib seizure (Ian Seppelt)
       9. Re: Burn patients. (Timothy J Coats)
      10. Tension Pneumothorax (Ian Cross)
      11. Re: v-fib seizure (FtLaudALSTeam@aol.com)
      12. RE: v-fib seizure (Bjorn, Pret)
      13. Re:v-fib (FtLaudALSTeam@aol.com)

    --__--__--

    Message: 1
    From: Vergote Lieven <lieven.vergote@asz-aalst.be>
    To: "'trauma-list@trauma.org'" <trauma-list@trauma.org>
    Subject: v-fib seizure
    Date: Fri, 22 Feb 2002 13:57:16 +0100
    Reply-To: trauma-list@trauma.org

    In my opinion this is a seizure due to cerebral hypoxia in a patient =
with
    CRA.
    As Always treat the appropriate way: ABCD what you have done


    --__--__--

    Message: 2
    Date: Fri, 22 Feb 2002 08:11:28 EST
    From: CrnbryEMT@aol.com
    Subject: Re: v-fib seizure
    To: <trauma-list@trauma.org>
    Reply-To: trauma-list@trauma.org

    "Ouch" for the slam. (Knowing "why" makes me a better medic.)

    "Thanks" for the defense. (Exactly why I posed the question.)

    And "Thanks!" for the answers. (It's as I thought, now I know for =
sure.)

    I beleive I stated in my question that I thought v-fib seizures were =
due to hypoixa. (v-fib =3D poor perfusion =3D hypoxia) I was simply =
wondering if there was another mechanism at work.

    No, I am not a "cookbook medic" as someone so eloquently put it ... =
but my treatment of a patient in v-fib is the same whether they had a =
seizure or not! My paramedic course was very progressive and in depth, =
however never mentioned v-fib seizures ... I was simply trying to find =
if there were evidence to show that an seizure could lead to v-fib.

    -Greg Clopp, MICP


    --__--__--

    Message: 3
    Date: Fri, 22 Feb 2002 05:49:15 -0800 (PST)
    From: bobby smith <bobbyrn_2000@yahoo.com>
    Subject: RE: ORIGINS OF AVPU
    To: trauma-list@trauma.org
    Reply-To: trauma-list@trauma.org

    --0-1499779953-1014385755=3D:4594
    Content-Type: text/plain; charset=3Dus-ascii


    Pret
    To better set a time line I was taught AVPU in the late 70's in =
prehospital care classes.
    Bobby
      "Bjorn, Pret" <pbjorn@emh.org> wrote: Laurie, Thanks very =
kindly--this is more than I expected.  Sadly, however, my quest =
continues. First and foremost, I'm suspicious at the assertion that AVPU =
is an ACS invention.  I no longer possess a 1993 ATLS Manual (listed =
among the references), but if anyone is able to relate to me where it =
states anything like "the College has created the AVPU method as a =
useful alternative to the Glasgow Coma Scale," I'd be eager to hear =
about it. Also, the paper provides an unconvincing argument in favor of =
AVPU, at best amplifying its poor sensitivity to describe or recommend =
much of anything.  Among the highlights of the discussion:  "Patients =
who are responsive only to a painful stimulus will usually have a GCS of =
8 or less and therefore may be at risk of airway problems."   A curious =
conclusion, being that 46% of these patients have a GCS of 9 or more...  =
Strange (perhaps telling) that the investigators spent so much time =
collecting numbers, but never subjected them to any real statistical =
analysis. Finally, consider the objectives: to associate AVPU with GCS, =
presumably because AVPU is easier, and GCS only works with trained =
practitioners; however, within the conclusion and discussion, it is =
repeatedly suggested that AVPU suffers from a lack of an objective =
assessment guideline, and practitioners of AVPU are undertrained.  If =
you're going to go to all that effort to improve upon a tool which is so =
clearly inferior to GCS, why not simply improve the utilization of GCS? =
On and on, round and round... Pret  ----Original Message-----
    From: Laurie [mailto:ggh@bentonrea.com]
    Sent: Tuesday, February 19, 2002 9:04 PM
    To: trauma-list@trauma.org
    Subject: Fw: ORIGINS OF APUV


    Dear Pret, Attached you will find the answer to your quest.  Laurie =
GrimesResearch fiend

    =
http://www.google.com/search?q=3Dcache:KbAYukdct-oC:www.basics.freewire.c=
o.uk/Templates/DLMar00/9919.pdf+neurological+assessment+tool+%27APUV%22&h=
l=3Den


    ---------------------------------
    Do You Yahoo!?
    Yahoo! Sports - Coverage of the 2002 Olympic Games
    --0-1499779953-1014385755=3D:4594
    Content-Type: text/html; charset=3Dus-ascii

    <P> Pret
    <P>To better set a time line I was taught AVPU in the late 70's in =
prehospital care classes.
    <P>Bobby
    <P>&nbsp; <B><I>"Bjorn, Pret" &lt;pbjorn@emh.org&gt;</I></B> wrote:
    <BLOCKQUOTE style=3D"BORDER-LEFT: #1010ff 2px solid; MARGIN-LEFT: =
5px; PADDING-LEFT: 5px"><!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 =
Transitional//EN">
    <META content=3D"MSHTML 5.00.2919.6307" name=3DGENERATOR>
    <STYLE></STYLE>

    <DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN =
class=3D980573612-20022002>Laurie,</SPAN></FONT></DIV>
    <DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN =
class=3D980573612-20022002></SPAN></FONT>&nbsp;</DIV>
    <DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN =
class=3D980573612-20022002>Thanks very kindly--this is more than I =
expected.&nbsp; Sadly, however, my quest continues.</SPAN></FONT></DIV>
    <DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN =
class=3D980573612-20022002></SPAN></FONT>&nbsp;</DIV>
    <DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN =
class=3D980573612-20022002>First and foremost, I'm suspicious at the =
assertion that AVPU is an ACS invention.&nbsp; I no longer possess a =
1993 ATLS Manual (listed among the references), but if anyone is able to =
relate to me where it states anything like "the College has created the =
AVPU method&nbsp;as a useful alternative to the Glasgow Coma Scale," I'd =
be eager to hear about it.</SPAN></FONT></DIV>
    <DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN =
class=3D980573612-20022002></SPAN></FONT>&nbsp;</DIV>
    <DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN =
class=3D980573612-20022002>Also, the paper provides an unconvincing =
argument in favor of AVPU, at best amplifying its poor sensitivity to =
describe or recommend much of anything.&nbsp; Among the highlights of =
the discussion:&nbsp; "<EM>Patients who are responsive only to a painful =
stimulus will usually have a GCS of 8 or less and therefore may be at =
risk of airway problems</EM>."&nbsp;&nbsp; A curious conclusion, being =
that&nbsp;46% of these patients have a GCS of 9 or more...&nbsp; Strange =
(perhaps telling) that the investigators spent so much time collecting =
numbers, but never subjected them to any real statistical =
analysis.</SPAN></FONT></DIV>
    <DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN =
class=3D980573612-20022002></SPAN></FONT>&nbsp;</DIV>
    <DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN =
class=3D980573612-20022002>Finally, consider the objectives: to =
associate AVPU with GCS, presumably because AVPU is easier, and GCS only =
works with trained practitioners; however, within the =
conclusion&nbsp;and discussion, it is repeatedly suggested that AVPU =
suffers from a lack of an objective assessment guideline, and =
practitioners of AVPU are undertrained.&nbsp; If you're going to go to =
all that effort to improve upon a tool which is so clearly inferior to =
GCS, why not simply improve the utilization of GCS?</SPAN></FONT></DIV>
    <DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN =
class=3D980573612-20022002></SPAN></FONT>&nbsp;</DIV>
    <DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN =
class=3D980573612-20022002>On and on, round and =
round...</SPAN></FONT></DIV>
    <DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN =
class=3D980573612-20022002></SPAN></FONT>&nbsp;</DIV>
    <DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN =
class=3D980573612-20022002>Pret</SPAN></FONT></DIV>
    <DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN =
class=3D980573612-20022002></SPAN></FONT>&nbsp;</DIV>
    <DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN =
class=3D980573612-20022002></SPAN></FONT><FONT face=3DTahoma =
size=3D2></FONT>&nbsp;</DIV>
    <DIV><FONT face=3DTahoma size=3D2>----Original =
Message-----<BR><B>From:</B> Laurie =
[mailto:ggh@bentonrea.com]<BR><B>Sent:</B> Tuesday, February 19, 2002 =
9:04 PM<BR><B>To:</B> trauma-list@trauma.org<BR><B>Subject:</B> Fw: =
ORIGINS OF APUV<BR><BR></DIV>
    <BLOCKQUOTE></FONT>
    <DIV>&nbsp;</DIV>
    <DIV><BR></DIV>
    <DIV>Dear Pret,</DIV>
    <DIV>&nbsp;</DIV>
    <DIV>Attached you will find the answer to your quest. </DIV>
    <DIV>&nbsp;</DIV>
    <DIV>Laurie Grimes</DIV>
    <DIV>Research fiend<BR></DIV>
    <DIV>&nbsp;</DIV><BR>&nbsp;<A =
href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002/3D"http://www.google.com/search?q=3Dcache:KbAYukdct-oC:www.basics.fr=
eewire.co.uk/Templates/DLMar00/9919.pdf+neurological+assessment+tool+%27A=
PUV%22&amp;hl=3Den">http://www.google.com/search?q=3Dcache:KbAYukdct-oC:w=
ww.basics.freewire.co.uk/Templates/DLMar00/9919.pdf+neurological+assessme=
nt+tool+%27APUV%22&amp;hl=3Den</A> </BLOCKQUOTE></BLOCKQUOTE><p><br><hr =
size=3D1><b>Do You Yahoo!?</b><br>
    <a href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002/3D"http://sports.yahoo.com/oly">Yahoo! Sports</a> - Coverage =
of the 2002 Olympic Games
    --0-1499779953-1014385755=3D:4594--


    --__--__--

    Message: 4
    Date: Fri, 22 Feb 2002 21:00:09 +0200 (IST)
    From: Avi Roy Shapira <avir@bgumail.bgu.ac.il>
    To: trauma-list@trauma.org
    Subject: Re: Burn patients.
    Reply-To: trauma-list@trauma.org


    Give iv morphine. My practice is to dilute 10 mg in 9 ml of saline, =
in a
    10 ml syringe, give 3-5 iv push, and then add mg by mg until pain =
free.

    Repeat as needed.

    Avi


    On Thu, 21 Feb 2002, Alejandro Cabrera , M.D. wrote:

    > Hy:
    > We've been flying a few patients with 90%(+) BSP burns of second =
and third
    > degree, and, some bettween 50 and 90% and I was wondering which =
are your
    > protocols for pain management obviously they were intubate because =
airway
    > burned , the place where we flew from has no ABG's  (little town) =
, but one
    > of them with more than 90% with renal failure, and, coagulopathy.
    > I know it's not life compatible but we must do the best we can, =
what do you
    > suggest?
    > Alejandro Cabrera, M.D.
    >
    >
    >
    > --
    > trauma-list : TRAUMA.ORG
    > To change your settings or unsubscribe visit:
    > http://www.trauma.org/traumalist.html
    >

    =
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D
    Aviel Roy-Shapira, M.D.              Soroka University Hospital &
    Dept. of Surgery A. and              Ben-Gurion University Medical =
School
    the Critical Care Unit               POB 151, Beer Sheva, Israel

    email:avir@bgumail.bgu.ac.il         Fax:972-7-6403260 =
voice:972-7-6403390





    --__--__--

    Message: 5
    From: "Bjorn, Pret" <pbjorn@emh.org>
    To: "'trauma-list@trauma.org'" <trauma-list@trauma.org>
    Subject: RE: Burn patients.
    Date: Fri, 22 Feb 2002 14:08:39 -0500
    Reply-To: trauma-list@trauma.org

    Us too.  Morphine.  Lots and lots of Morphine.  Given by the tens if
    necessary.

    Pret Bjorn, RN
    Bangor, ME  USA


    email:avir@bgumail.bgu.ac.il         Fax:972-7-6403260 =
voice:972-7-6403390




    --
    trauma-list : TRAUMA.ORG
    To change your settings or unsubscribe visit:
    http://www.trauma.org/traumalist.html


    --__--__--

    Message: 6
    From: "MARK FORREST" <atacc.doc@virgin.net>
    To: <trauma-list@trauma.org>
    Subject: Re: PANCREATIC TRAUMA - more info to ICU guys
    Date: Fri, 22 Feb 2002 00:31:29 -0000
    Reply-To: trauma-list@trauma.org

    This is a multi-part message in MIME format.

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    Dear Alster,
    Thank you for the additional info. Both of these patients clearly =
had =3D
    something catastrophic going on in their abdomens. These kind of =
numbers =3D
    are very severe and will have been rising for some time. To me they =
=3D
    clearly indicate major ischaemia, even allowing for ARF, and the =
need =3D
    for urgent laparotomy (which would probably demonstrate =3D
    ischaemic/infarcted bowel)
    Although a fan of high flux HF or HDF in sepsis, it will not salvage =
=3D
    patients like this who need surgical intervention. Such renal =
therapies =3D
    merely put the 'brakes' on the numbers and mask the severity of the =
=3D
    condition until it is too late.

    The second case appears to have developed overwhelming ARDS as a =
result =3D
    of the initial insult, the subsequent abdominal inflammation and =3D
    possibly overzealous fluid resuscitation in obvious SIRS. In our =
unit we =3D
    firmly believe that the battle is often lost pre-hospital or in =
resus =3D
    where patients are over-filled with resus fluid, before theatre and =
more =3D
    fluid, before blood transfusion and then finally ITU after 10-20 =
litres =3D
    of fluid for an initial true blood loss of maybe 2 litres.....LESS =
FLUID =3D
    IS BEST!?...discuss!

    Hopefully, as the concept of permissive hypotension, small volume =
=3D
    resuscitation and hypertonics becomes more frequently practised, =
then =3D
    the struggles of the intensivists will be reduced.
    Evidence base? How can an intensivist prove that the amount of fluid =
=3D
    given at the roadside etc will alter outcome after ? 10 days of ITU =
care =3D
    and all of its therapies and variables?
    Any more information Alster?
    Regards
    Mark F
    Intensivist with 'pruned' patients.....?more ARF but less ARDS, =3D
    fortunately I can easily treat the former!
      ----- Original Message -----=3D20
      From: alster=3D20
      To: trauma-list@trauma.org=3D20
      Sent: Wednesday, February 20, 2002 11:20 PM
      Subject: Re: PANCREATIC TRAUMA - more info to ICU guys


      Greetings list!

      Thank you all for your input. Well let me give you additional =
info:

      26 Y/O white latin male was victim of a gunshot wound in the RUQ =
=3D
    exiting on the back (lumbar level).=3D20
      Trauma to the pancreas (Grade III - caudal pancreatectomy =
performed), =3D
    Stomach (Grade II - sutured), Spleen (nothing done -Grade I), =
Diaphragm =3D
    (sutured) and mesentery (sutured). Pancreatic fistula (400ml/day =
from =3D
    day 5 till 10th Post Op day). U/S showed no collections elsewhere. =
No =3D
    fever.
      Suddenly, at the 12th POp day he was in abdominal pain with no =
relief =3D
    to analgesics. Plus there was a leucocytosis 15.000 (B=3D3D7% =
S=3D3D70%).
      We ordered a CT but 12h later he had to be admitted to ICU because =
of =3D
    ARDS. His oxymetry saturation reached 30% at best with =
FiO2=3D3D100%. He =3D
    died in 4 hours.

      ABGs: Basically metabolic acidosis with increased anion gap. I =
better =3D
    look his chart over again.
      CRProtein =3D3D 100.000 (nl<5). Lactate 20.

      19Y/O white latin female was also victim of a gunshot wound on the =
=3D
    back exiting at epigastric level. She got a ride from her boyfriend =
who =3D
    was driving a motorcycle when 2 other guys in a car tried to rob =
him. As =3D
    soon as he accelerated, trying to run away, his girlfriend was shot =
on =3D
    the back and he suffered only scratches in his right arm There was a =
=3D
    trauma to the tail of the pancreas.=3D20
      That trauma was only diagnosed by CT and because amylase levels =
=3D
    reached 549. Besides that, pt was doing fine. Still in noradrenalin =
but =3D
    going down with 0,15mcg/Kg/min.Based on CT findings and because =
there =3D
    was no ERCP available during weekends she was taken to the OR and a =
=3D
    distal pancreatectomy plus spenectomy was performed. No intraop =3D
    cholangiography was done. She did well till the 10th POp day when =
both =3D
    lungs got WHITE and she developed ARDS. Amylase levels diminished to =
=3D
    normal levels. Then, hepatic and renal insufficiency. Her pulse =
oxymetry =3D
    at best was 40% with FiO2=3D3D100% (last Friday) getting better when =
TGI =3D
    was instituted (80% at best). Our hemofiltration machine was broken. =
=3D
    Several U/S was done showing no collection besides 18ml around the =
=3D
    pancreas. As she was unstable no post op ct was done. She had no =
fever. =3D
    Nothing.She died at the 23 Post Op day (Saturday).=3D20

      ABGs:metabolic acidosis with increased anion gap (renal failure). =
=3D
    CRProtein=3D3D255.000. Lactate=3D3D50


        ----- Original Message -----=3D20
        From: MARK FORREST=3D20
        To: trauma-list@trauma.org=3D20
        Sent: Tuesday, February 12, 2002 5:08 PM
        Subject: Re: PANCREATIC TRAUMA - What are we missing?


        Dear Alster,
        Any more information for the non-surgical members.=3D20
        Very interested in the amount and type of fluid given during =3D
    resuscitation and inevitable SIRS period after surgery.

        Surprised that deteriorations were so rapid as although surgical =
=3D
    conditions can develop rapidly, the ARDS picture is far more likely =
to =3D
    have been developing over several days.

        Any ABGs, CRPs, lactates prior to deterioration?

        Mark F=3D20
        ITU Cons,UK
          ----- Original Message -----=3D20
          From: alster=3D20
          To: trauma-list@trauma.org=3D20
          Sent: Monday, February 11, 2002 10:35 PM
          Subject: PANCREATIC TRAUMA - What are we missing?


          Hello List!=3D20
          Where do we go from here?

          26 Y/O white latin male was victim of a gunshot wound in the =
RUQ =3D
    exiting on the back (lumbar level).=3D20
          Trauma to the pancreas (Grade III - caudal pancreatectomy =3D
    performed), Stomach (Grade II - sutured), Spleen (nothing done =
-Grade =3D
    I), Diaphragm (sutured) and mesentery (sutured). Pancreatic fistula =
=3D
    (400ml/day from day 5 till 10th Post Op day). U/S showed no =
collections =3D
    elsewhere. No fever.
          Suddenly, at the 12th POp day he was in abdominal pain with no =
=3D
    relief to analgesics. Plus there was a leucocytosis 15.000 (B=3D3D7% =
=3D
    S=3D3D70%).
          We ordered a CT but 12h later he had to be admitted to ICU =
because =3D
    of ARDS. His oxymetry saturation reached 30% at best with =
FiO2=3D3D100%. =3D
    He died in 4 hours.

          19Y/O white latin female was also victim of a gunshot wound on =
the =3D
    back exiting at epigastric level. She got a ride from her boyfriend =
who =3D
    was driving a motorcycle when 2 other guys in a car tried to rob =
him. As =3D
    soon as he accelerated, trying to run away, his girlfriend was shot =
on =3D
    the back and he suffered only scratches in his right arm. There was =
a =3D
    trauma to the tail of the pancreas as showed bellow:
           =3D20

          That trauma was only diagnosed by CT and because amylase =
levels =3D
    reached 549. Besides that, pt was doing fine. Still in noradrenalin =
but =3D
    going down with 0,15mcg/Kg/min.
          Based on CT findings and because there was no ERCP available =
=3D
    during weekends she was taken to the OR and a distal pancreatectomy =
plus =3D
    spenectomy was
          performed. No intraop cholangiography was done. She did well =
till =3D
    the 10th POp day when both lungs got WHITE and she developed ARDS. =
=3D
    Amylase levels diminished to normal levels. Then, hepatic and renal =
=3D
    insufficiency. Her pulse oxymetry at best was 40% with FiO2=3D3D100% =
(last =3D
    Friday) getting better when TGI was instituted (80% at best). Our =
=3D
    hemofiltration machine was broken. Several U/S was done showing no =
=3D
    collection besides 18ml around the pancreas. As she was unstable no =
post =3D
    op ct was done. She had no fever. Nothing.She died at the 23 Post Op =
day =3D
    (Saturday).=3D20

          What are we missing?

          CAlster, MD




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    charset=3D"iso-8859-1"
    Content-Transfer-Encoding: quoted-printable

    <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
    <HTML><HEAD>
    <META http-equiv=3D3DContent-Type content=3D3D"text/html; =3D
    charset=3D3Diso-8859-1">
    <META content=3D3D"MSHTML 5.50.4207.2601" name=3D3DGENERATOR>
    <STYLE></STYLE>
    </HEAD>
    <BODY bgColor=3D3D#ffffff>
    <DIV><FONT face=3D3DArial size=3D3D2>Dear Alster,</FONT></DIV>
    <DIV><FONT face=3D3DArial size=3D3D2>Thank you for the additional =
info. Both =3D
    of these=3D20
    patients clearly had something catastrophic going on in their =
abdomens. =3D
    These=3D20
    kind of numbers are very severe and will have been rising for some =
time. =3D
    To me=3D20
    they clearly indicate major ischaemia, even allowing for ARF, and =
the =3D
    need for=3D20
    urgent laparotomy (which would probably demonstrate =
ischaemic/infarcted=3D20
    bowel)</FONT></DIV>
    <DIV><FONT face=3D3DArial size=3D3D2>Although a fan of high flux HF =
or HDF =3D
    in sepsis, it=3D20
    will not salvage patients like this who need surgical intervention. =
Such =3D
    renal=3D20
    therapies merely put the 'brakes' on the numbers and mask the =
severity =3D
    of the=3D20
    condition until it is too late.</FONT></DIV>
    <DIV><FONT face=3D3DArial size=3D3D2></FONT>&nbsp;</DIV>
    <DIV><FONT face=3D3DArial size=3D3D2>The second case appears to have =
=3D
    developed=3D20
    overwhelming ARDS as a result of the initial insult, the subsequent =
=3D
    abdominal=3D20
    inflammation and possibly overzealous fluid resuscitation in obvious =
=3D
    SIRS. In=3D20
    our unit we firmly believe that the battle is often lost =
pre-hospital or =3D
    in=3D20
    resus where patients are over-filled with resus fluid, before =
theatre =3D
    and more=3D20
    fluid, before blood transfusion and then finally ITU after 10-20 =
litres =3D
    of fluid=3D20
    for an initial true blood loss of maybe 2 litres.....LESS FLUID =
IS=3D20
    BEST!?...discuss!</FONT></DIV>
    <DIV><FONT face=3D3DArial size=3D3D2></FONT>&nbsp;</DIV>
    <DIV><FONT face=3D3DArial size=3D3D2>Hopefully, as the concept of =
permissive =3D

    hypotension, small volume resuscitation and hypertonics becomes more =
=3D
    frequently=3D20
    practised, then the struggles of the intensivists will be =3D
    reduced.</FONT></DIV>
    <DIV><FONT face=3D3DArial size=3D3D2>Evidence base? How can an =
intensivist =3D
    prove that=3D20
    the amount of&nbsp;fluid given at the roadside etc will alter =
outcome =3D
    after ? 10=3D20
    days of ITU care and all of its therapies and =
variables?</FONT></DIV>
    <DIV><FONT face=3D3DArial size=3D3D2>Any more information =3D
    Alster?</FONT></DIV>
    <DIV><FONT face=3D3DArial size=3D3D2>Regards</FONT></DIV>
    <DIV><FONT face=3D3DArial size=3D3D2>Mark F</FONT></DIV>
    <DIV><FONT face=3D3DArial size=3D3D2>Intensivist with 'pruned' =3D
    patients.....?more ARF=3D20
    but less ARDS, fortunately I can easily treat the =
former!</FONT></DIV>
    <BLOCKQUOTE dir=3D3Dltr=3D20
    style=3D3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =
=3D
    BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
      <DIV style=3D3D"FONT: 10pt arial">----- Original Message ----- =
</DIV>
      <DIV=3D20
      style=3D3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =3D
    black"><B>From:</B>=3D20
      <A title=3D3Dalster@usp.br =
href=3D3D"mailto:alster@usp.br">alster</A> =3D
    </DIV>
      <DIV style=3D3D"FONT: 10pt arial"><B>To:</B> <A =3D
    title=3D3Dtrauma-list@trauma.org=3D20
      =
href=3D3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> =3D
    </DIV>
      <DIV style=3D3D"FONT: 10pt arial"><B>Sent:</B> Wednesday, February =
20, =3D
    2002 11:20=3D20
      PM</DIV>
      <DIV style=3D3D"FONT: 10pt arial"><B>Subject:</B> Re: PANCREATIC =
TRAUMA =3D
    - more=3D20
      info to ICU guys</DIV>
      <DIV><BR></DIV>
      <DIV><FONT face=3D3DArial size=3D3D2>Greetings list!</FONT></DIV>
      <DIV><FONT face=3D3DArial size=3D3D2></FONT>&nbsp;</DIV>
      <DIV><FONT face=3D3DArial size=3D3D2>Thank you all&nbsp;for your =
input. =3D
    Well let me=3D20
      give you additional info:</FONT></DIV>
      <DIV><FONT face=3D3DArial size=3D3D2></FONT>&nbsp;</DIV>
      <DIV>
      <DIV><FONT face=3D3DArial size=3D3D1><STRONG>26 Y/O white latin =
male was =3D
    victim of a=3D20
      gunshot wound in the RUQ exiting&nbsp;on the back =
(lumbar&nbsp;level). =3D

      </STRONG></FONT></DIV>
      <DIV><FONT face=3D3DArial size=3D3D1><STRONG>Trauma to the =
pancreas (Grade =3D
    III -=3D20
      caudal pancreatectomy performed), Stomach (Grade II - sutured), =
Spleen =3D

      (nothing done -Grade I), Diaphragm (sutured) and mesentery =
(sutured).=3D20
      Pancreatic fistula (400ml/day from day 5 till 10th Post Op day). =
U/S =3D
    showed no=3D20
      collections elsewhere. No fever.</STRONG></FONT></DIV>
      <DIV><FONT face=3D3DArial size=3D3D1><STRONG>Suddenly, at the 12th =
POp day =3D
    he was in=3D20
      abdominal pain&nbsp;with no relief to analgesics. Plus there was =
a=3D20
      leucocytosis 15.000 (B=3D3D7% S=3D3D70%).</STRONG></FONT></DIV>
      <DIV><FONT face=3D3DArial size=3D3D2><STRONG><FONT size=3D3D1>We =
ordered a =3D
    CT but 12h=3D20
      later he had to be admitted to ICU because of ARDS. His oxymetry =
=3D
    saturation=3D20
      reached 30% at best with FiO2=3D3D100%. He died in 4=3D20
      hours</FONT></STRONG>.</FONT></DIV>
      <DIV><FONT face=3D3DArial size=3D3D2></FONT>&nbsp;</DIV>
      <DIV><FONT face=3D3DArial size=3D3D2>ABGs: Basically metabolic =
acidosis =3D
    with increased=3D20
      anion gap. I&nbsp;better look his chart over again.</FONT></DIV>
      <DIV><FONT face=3D3DArial size=3D3D2>CRProtein =3D3D 100.000 =
(nl&lt;5). =3D
    Lactate=3D20
      20.</FONT></DIV>
      <DIV><FONT face=3D3DArial size=3D3D2></FONT>&nbsp;</DIV>
      <DIV><FONT face=3D3DArial><FONT size=3D3D1>19Y/O white latin =
female was =3D
    also victim of=3D20
      a gunshot wound on the back exiting at epigastric level. She got a =
=3D
    ride from=3D20
      her boyfriend who was driving a&nbsp;motorcycle&nbsp;when 2 other =
guys =3D
    in a=3D20
      car tried to rob him. As soon as he accelerated, trying to run =
away, =3D
    his=3D20
      girlfriend was shot on the back and he suffered only scratches in =
his =3D
    right=3D20
      arm There was a trauma to the tail of the pancreas. </FONT>
      <DIV><FONT size=3D3D1>That trauma was only diagnosed by CT and =
because =3D
    amylase=3D20
      levels reached 549.&nbsp;Besides that,&nbsp;pt was doing fine. =
Still =3D
    in=3D20
      noradrenalin but&nbsp;going down&nbsp;with 0,15mcg/Kg/min.Based on =
CT =3D
    findings=3D20
      and because there was no ERCP available during weekends she was =
taken =3D
    to the=3D20
      OR and a distal pancreatectomy plus spenectomy was performed. No =
=3D
    intraop=3D20
      cholangiography was done. She did well till the 10th POp day =3D
    when&nbsp;both=3D20
      lungs got WHITE and she developed ARDS. Amylase levels =3D
    diminished&nbsp;to=3D20
      normal levels. Then, hepatic and renal insufficiency. Her pulse =
=3D
    oxymetry at=3D20
      best was 40% with FiO2=3D3D100% (last Friday) getting better when =
TGI =3D
    was=3D20
      instituted (80% at best). Our hemofiltration machine was broken. =
=3D
    Several U/S=3D20
      was done showing no collection besides 18ml around the pancreas. =
As =3D
    she was=3D20
      unstable no post op ct was done.&nbsp;She had no =3D
    fever.&nbsp;Nothing.She died=3D20
      at the 23 Post Op day (Saturday). </FONT></DIV>
      <DIV><FONT size=3D3D1></FONT>&nbsp;</DIV>
      <DIV>ABGs:metabolic acidosis with increased anion gap (renal =
failure). =3D

      CRProtein=3D3D255.000. Lactate=3D3D50</DIV></FONT></DIV>
      <DIV><FONT face=3D3DArial size=3D3D2></FONT>&nbsp;</DIV>
      <DIV><FONT face=3D3DArial size=3D3D2></FONT>&nbsp;</DIV></DIV>
      <BLOCKQUOTE dir=3D3Dltr=3D20
      style=3D3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: =
5px; =3D
    BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
        <DIV style=3D3D"FONT: 10pt arial">----- Original Message ----- =
</DIV>
        <DIV=3D20
        style=3D3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =
=3D
    black"><B>From:</B>=3D20
        <A title=3D3Datacc.doc@virgin.net =3D
    href=3D3D"mailto:atacc.doc@virgin.net">MARK=3D20
        FORREST</A> </DIV>
        <DIV style=3D3D"FONT: 10pt arial"><B>To:</B> <A =3D
    title=3D3Dtrauma-list@trauma.org=3D20
        =
href=3D3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> =3D
    </DIV>
        <DIV style=3D3D"FONT: 10pt arial"><B>Sent:</B> Tuesday, February =
12, =3D
    2002 5:08=3D20
        PM</DIV>
        <DIV style=3D3D"FONT: 10pt arial"><B>Subject:</B> Re: PANCREATIC =
=3D
    TRAUMA - What=3D20
        are we missing?</DIV>
        <DIV><BR></DIV>
        <DIV><FONT face=3D3DArial size=3D3D2>Dear Alster,</FONT></DIV>
        <DIV><FONT face=3D3DArial size=3D3D2>Any more information for =
the =3D
    non-surgical=3D20
        members. </FONT></DIV>
        <DIV><FONT face=3D3DArial size=3D3D2>Very interested in the =
amount and =3D
    type of fluid=3D20
        given during resuscitation and inevitable SIRS period after=3D20
        surgery.</FONT></DIV>
        <DIV><FONT face=3D3DArial size=3D3D2></FONT>&nbsp;</DIV>
        <DIV><FONT face=3D3DArial size=3D3D2>Surprised that =
deteriorations were =3D
    so rapid as=3D20
        although surgical conditions can develop rapidly, the ARDS =
picture =3D
    is far=3D20
        more likely to have been developing over several =
days.</FONT></DIV>
        <DIV><FONT face=3D3DArial size=3D3D2></FONT>&nbsp;</DIV>
        <DIV><FONT face=3D3DArial size=3D3D2>Any ABGs, CRPs, lactates =
prior to=3D20
        deterioration?</FONT></DIV>
        <DIV><FONT face=3D3DArial size=3D3D2></FONT>&nbsp;</DIV>
        <DIV><FONT face=3D3DArial size=3D3D2>Mark F </FONT></DIV>
        <DIV><FONT face=3D3DArial size=3D3D2>ITU Cons,UK</FONT></DIV>
        <BLOCKQUOTE dir=3D3Dltr=3D20
        style=3D3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: =
5px; =3D
    BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
          <DIV style=3D3D"FONT: 10pt arial">----- Original Message ----- =
=3D
    </DIV>
          <DIV=3D20
          style=3D3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =
=3D
    black"><B>From:</B>=3D20
          <A title=3D3Dalster@usp.br =
href=3D3D"mailto:alster@usp.br">alster</A> =3D
    </DIV>
          <DIV style=3D3D"FONT: 10pt arial"><B>To:</B> <A =3D
    title=3D3Dtrauma-list@trauma.org=3D20
          =
href=3D3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> =3D
    </DIV>
          <DIV style=3D3D"FONT: 10pt arial"><B>Sent:</B> Monday, =
February 11, =3D
    2002 10:35=3D20
          PM</DIV>
          <DIV style=3D3D"FONT: 10pt arial"><B>Subject:</B> PANCREATIC =
TRAUMA =3D
    - What are=3D20
          we missing?</DIV>
          <DIV><FONT face=3D3DArial size=3D3D2></FONT><BR></DIV>
          <DIV><FONT face=3D3DArial size=3D3D2>Hello List! </FONT></DIV>
          <DIV><FONT face=3D3DArial size=3D3D2>Where do we go from =3D
    here?</FONT></DIV>
          <DIV><FONT face=3D3DArial size=3D3D2></FONT>&nbsp;</DIV>
          <DIV><FONT face=3D3DArial size=3D3D2>26 Y/O white latin male =
was =3D
    victim of a=3D20
          gunshot wound in the RUQ exiting&nbsp;on the back =3D
    (lumbar&nbsp;level).=3D20
          </FONT></DIV>
          <DIV><FONT face=3D3DArial size=3D3D2>Trauma to the pancreas =
(Grade III =3D
    - caudal=3D20
          pancreatectomy performed), Stomach (Grade II - sutured), =
Spleen =3D
    (nothing=3D20
          done -Grade I), Diaphragm (sutured) and mesentery (sutured). =
=3D
    Pancreatic=3D20
          fistula (400ml/day from day 5 till 10th Post Op day). U/S =
showed =3D
    no=3D20
          collections elsewhere. No fever.</FONT></DIV>
          <DIV><FONT face=3D3DArial size=3D3D2>Suddenly, at the 12th POp =
day he =3D
    was in=3D20
          abdominal pain&nbsp;with no relief to analgesics. Plus there =
was a =3D

          leucocytosis 15.000 (B=3D3D7% S=3D3D70%).</FONT></DIV>
          <DIV><FONT face=3D3DArial size=3D3D2>We ordered a CT but 12h =
later he =3D
    had to be=3D20
          admitted to ICU because of ARDS. His oxymetry saturation =
reached =3D
    30% at=3D20
          best with FiO2=3D3D100%. He died in 4 hours.</FONT></DIV>
          <DIV><FONT face=3D3DArial size=3D3D2></FONT>&nbsp;</DIV>
          <DIV><FONT face=3D3DArial size=3D3D2>19Y/O white latin female =
was also =3D
    victim of a=3D20
          gunshot wound on the back exiting at epigastric level. She got =
a =3D
    ride from=3D20
          her boyfriend who was driving a&nbsp;motorcycle&nbsp;when 2 =
other =3D
    guys in=3D20
          a car tried to rob him. As soon as he accelerated, trying to =
run =3D
    away, his=3D20
          girlfriend was shot on the back and he suffered only scratches =
in =3D
    his=3D20
          right arm. There was a trauma to the tail of the pancreas as =
=3D
    showed=3D20
          bellow:</FONT></DIV><IMG=3D20
          alt=3D3D"Will you operated on this pt based on CT findings?" =
=3D
    hspace=3D3D0=3D20
          src=3D3D"cid:009a01c1bb38$44ee11a0$70d1fc3e@oemcomputer" =3D
    border=3D3D0>&nbsp;<IMG=3D20
          alt=3D3D"What about this one?" hspace=3D3D0=3D20
          src=3D3D"cid:009b01c1bb38$453a5ce0$70d1fc3e@oemcomputer" =
border=3D3D0> =3D

          <DIV><FONT face=3D3DArial size=3D3D2></FONT>&nbsp;</DIV>
          <DIV>That trauma was only diagnosed by CT and because amylase =
=3D
    levels=3D20
          reached 549.&nbsp;Besides that,&nbsp;pt was doing fine. Still =
in=3D20
          noradrenalin but&nbsp;going down&nbsp;with =
0,15mcg/Kg/min.</DIV>
          <DIV>Based on CT findings and because there was no ERCP =
available =3D
    during=3D20
          weekends she was taken to the OR and a distal pancreatectomy =
plus=3D20
          spenectomy was</DIV>
          <DIV>performed. No intraop cholangiography was done. She did =
well =3D
    till the=3D20
          10th POp day when&nbsp;both lungs got WHITE and she developed =
=3D
    ARDS.=3D20
          Amylase levels diminished&nbsp;to normal levels. Then, hepatic =
and =3D
    renal=3D20
          insufficiency. Her pulse oxymetry at best was 40% with =
FiO2=3D3D100% =3D
    (last=3D20
          Friday) getting better when TGI was instituted (80% at best). =
Our=3D20
          hemofiltration machine was broken. Several U/S was done =
showing no =3D

          collection besides 18ml around the pancreas. As she was =
unstable =3D
    no post=3D20
          op ct was done.&nbsp;She had no fever.&nbsp;Nothing.She died =
at =3D
    the 23=3D20
          Post Op day (Saturday). </DIV>
          <DIV>&nbsp;</DIV>
          <DIV>What are we missing?</DIV>
          <DIV>&nbsp;</DIV>
          <DIV>CAlster, MD</DIV>
          <DIV><FONT face=3D3DArial size=3D3D2></FONT>&nbsp;</DIV>
          <DIV><FONT face=3D3DArial size=3D3D2></FONT>&nbsp;</DIV>
          <DIV><FONT face=3D3DArial=3D20
    =
size=3D3D2></FONT>&nbsp;</DIV></BLOCKQUOTE></BLOCKQUOTE></BLOCKQUOTE></BO=
DY=3D
    ></HTML>

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    P//Z

    ------=3D_NextPart_000_009C_01C1BB38.454B25C0--



    --__--__--

    Message: 7
    From: "Nick Nudell" <nick@glacierems.com>
    To: <trauma-list@trauma.org>
    Subject: Re: v-fib seizure
    Date: Thu, 21 Feb 2002 17:58:37 -0700
    Organization: Glacier County EMS
    Reply-To: trauma-list@trauma.org

    I think there is more then one plausible explanation.... try yours =
in
    reverse!

    Like this:
    Seizure activity > Anoxia > Cardiac ischemia > V-fib

    In addition, reading V-fib on a monitor during seizure activity can =
be
    dangerous. Treating your patient (meaning check for pulses) is =
probably more
    critical then reading the monitor.

    Turn this into a further discussion by asking, at times finding a =
pulse may
    be difficult during seizure activity, so would you first give a med =
(benzo
    or other relaxant) and intubate or would you jump to ACLS and Shock =
Shock
    Shock?

    Take care.
    Nick

    P.S. Your right, this is not really a trauma discussion, other then =
what if
    the seizure was caused by head injury leading to this crashing =
spiral?

    ____
    Nick Nudell, NREMT-P
    Glacier County EMS
    www.glacierems.com
    Northern Rockies Medical Center
    Cut Bank, MT
    nick@glacierems.com



    ----- Original Message -----
    From: <Nappio@aol.com>
    To: <trauma-list@trauma.org>
    Sent: Thursday, February 21, 2002 4:38 PM
    Subject: Re: v-fib seizure


    > ATTENTION:
    >
    > V-fib  >    Anoxia   >   Ischemic brain hit    >    seizure =
activity
    >
    > Mr. Ramstrom,  Mr. Clopp asked the rhetorical "stupid question" if =
you
    will,
    > and stated the truth about his knowledge deficit,,but at least he =
stepped
    > forth  and asked the question so he wouldnt be just a cook book =
ambulance
    > driver.If you want to eliminate the negative attitudes you speak =
of you
    have
    > to accept the fact that there are cook book ambulance drivers who =
need to
    be
    > educated.
    > DN
    >
    > --
    > trauma-list : TRAUMA.ORG
    > To change your settings or unsubscribe visit:
    > http://www.trauma.org/traumalist.html
    >



    --__--__--

    Message: 8
    Date: Fri, 22 Feb 2002 14:21:09 +1100
    From: "Ian Seppelt" <SeppelI@wahs.nsw.gov.au>
    To: <trauma-list@trauma.org>
    Subject: Re: v-fib seizure
    Reply-To: trauma-list@trauma.org

    "v-fib seizure" - never heard of it.
    These patients had a primary cardiac arrest and then a secondary =
hypoxic =3D
    seizure - treatment is just as you indicated with defibrillation and =
oxyg=3D
    en.

    Cheers, Ian

    Ian Seppelt
    Nepean Hospital, Sydney.

    >>> CrnbryEMT@aol.com 02/22/02 06:35am >>>
    Many apologies for tossing this to a tramua list ...

    Does anyone have information on such a thing as a "v-fib seizure"? =
In my =3D
    short experience I have been called to at least one patient that had =
seiz=3D
    ure activity followed by cardiac arrest (initial rhythm: v-fib) with =
no s=3D
    eizure history. I've been told by many that the person must have had =
a "v=3D
    -fib seizure".

    Is this a seizure that precipitates v-fib? V-vib that initially =
causes so=3D
    me sort of hypoxic seizure? As a Paramedic my treatment is =
ultimately the=3D
    =3D20same: CPR and ACLS appropriate to the presenting rhythm ... I =
just go =3D
    up a tree when I don't know "why".

    Thanks.

    -Greg Clopp, MICP

    --
    trauma-list : TRAUMA.ORG
    To change your settings or unsubscribe visit:
    http://www.trauma.org/traumalist.html

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    confidential information. If you are not the intended recipient, =
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are=3D20
    those of the individual sender, and are not necessarily the views =
of=3D20
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    --__--__--



    --__--__--

    Message: 10
    From: "Ian Cross" <ian_ff@hotmail.com>
    To: trauma-list@trauma.org
    Subject: Tension Pneumothorax
    Date: Fri, 22 Feb 2002 14:32:49 +0000
    Reply-To: trauma-list@trauma.org

    I'm a fire-fighter working in a very rural community.  We don't see =
that
    much trauma, but on occasions the country roads have a habit of =
exposing
    some nasty injuries.

    We have just been through the trapped occupant/tension pneumothorax
    experience.

    having read as much as I can on this subject, (with the small amount =
of
    literature I have available).

    The signs of a developing T.P. are well described and the procedure =
of
    needle decompression is also
    well described.

    However it is mentioned by those in the emergency services =
(paramedics who
    we occasionally get to chat with).

    Needle decompression is only successful in about 40% of cases, - fat =
cells
    are jammed into the cannula
    In needle decompression the 'classical hiss of air being released' =
is often
    not present.
    In T.P. the lung will not re-inflate once the tension has been =
relieved.

    Is all the above correct ?

    If so how would one know that the decompression has worked ?

    Does the increasing respiratory rate, slow down, does the =
respiratory rate
    decrease ?

    The the patients anxiety and distress reduce ?

    i can find no literaturew that describes the outcome of successful
    decompression and as yet no one to answer my questions.

    Can someone please help.  Not that we would be in a position to =
provide this
    procedure for a patient, it is just a question that I find very =
interesting
    and cannot find an answer.

    Ian Greaves, Fire-fighter, The highlands of Scotland



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    --__--__--

    Message: 11
    From: FtLaudALSTeam@aol.com
    Date: Fri, 22 Feb 2002 15:50:37 EST
    Subject: Re: v-fib seizure
    To: trauma-list@trauma.org
    Reply-To: trauma-list@trauma.org


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           Mr. Ramstrom, your apology is well taken and I admire you for
    responding and the way you responded. It is well taken. Have a good =
day.

    Jorge Aguiar FF/PM
    Ft. Lauderdale Fire/Rescue

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    <HTML><FONT FACE=3Darial,helvetica><FONT  COLOR=3D"#0000ff" SIZE=3D2 =
FAMILY=3D"SANSSERIF" FACE=3D"Century Gothic" LANG=3D"0"><BR>
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Mr. Ramstrom, your apology is =
well taken and I admire you for responding and the way you responded. It =
is well taken. Have a good day.<BR>
    <BR>
    Jorge Aguiar FF/PM<BR>
    Ft. Lauderdale Fire/Rescue</FONT></HTML>

    --part1_51.1989bd8a.29a8091d_boundary--


    --__--__--

    Message: 12
    From: "Bjorn, Pret" <pbjorn@emh.org>
    To: "'trauma-list@trauma.org'" <trauma-list@trauma.org>
    Subject: RE: v-fib seizure
    Date: Fri, 22 Feb 2002 15:59:04 -0500
    Reply-To: trauma-list@trauma.org

    Nick,

    Absolutely possible, but uncommon and unlikely.  Anoxia most =
frequently
    leads to bradycardia, not VF.  And although I agree that you should =
treat
    the patient, not the monitor, I can recall at least one case of a =
teenage
    girl with Long QT who was treated for several minutes as a seizure =
before
    anyone checked her pulse OR rhythm (Torsades).  Leaves a bad taste.

    I think that most folks who have witnessed a conscious patient =
suffering
    sudden-onset VF would agree that the physical manifestations could =
fairly be
    mistaken for seizure activity.  This more clearly speaks to the =
original
    post: sudden death is rarely subtle.

    Best Regards,

    Pret

    -----Original Message-----
    From: Nick Nudell [mailto:nick@glacierems.com]
    Sent: Thursday, February 21, 2002 7:59 PM
    To: trauma-list@trauma.org
    Subject: Re: v-fib seizure


    I think there is more then one plausible explanation.... try yours =
in
    reverse!

    Like this:
    Seizure activity > Anoxia > Cardiac ischemia > V-fib

    In addition, reading V-fib on a monitor during seizure activity can =
be
    dangerous. Treating your patient (meaning check for pulses) is =
probably more
    critical then reading the monitor.

    Turn this into a further discussion by asking, at times finding a =
pulse may
    be difficult during seizure activity, so would you first give a med =
(benzo
    or other relaxant) and intubate or would you jump to ACLS and Shock =
Shock
    Shock?

    Take care.
    Nick

    P.S. Your right, this is not really a trauma discussion, other then =
what if
    the seizure was caused by head injury leading to this crashing =
spiral?

    ____
    Nick Nudell, NREMT-P
    Glacier County EMS
    www.glacierems.com
    Northern Rockies Medical Center
    Cut Bank, MT
    nick@glacierems.com



    ----- Original Message -----
    From: <Nappio@aol.com>
    To: <trauma-list@trauma.org>
    Sent: Thursday, February 21, 2002 4:38 PM
    Subject: Re: v-fib seizure


    > ATTENTION:
    >
    > V-fib  >    Anoxia   >   Ischemic brain hit    >    seizure =
activity
    >
    > Mr. Ramstrom,  Mr. Clopp asked the rhetorical "stupid question" if =
you
    will,
    > and stated the truth about his knowledge deficit,,but at least he =
stepped
    > forth  and asked the question so he wouldnt be just a cook book =
ambulance
    > driver.If you want to eliminate the negative attitudes you speak =
of you
    have
    > to accept the fact that there are cook book ambulance drivers who =
need to
    be
    > educated.
    > DN
    >
    > --
    > trauma-list : TRAUMA.ORG
    > To change your settings or unsubscribe visit:
    > http://www.trauma.org/traumalist.html
    >


    --
    trauma-list : TRAUMA.ORG
    To change your settings or unsubscribe visit:
    http://www.trauma.org/traumalist.html


    --__--__--

    Message: 13
    From: FtLaudALSTeam@aol.com
    Date: Fri, 22 Feb 2002 16:01:01 EST
    Subject: Re:v-fib
    To: trauma-list@trauma.org
    Reply-To: trauma-list@trauma.org


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           I work with cook book Paramedics and have to compensate for =
them
    sometimes. Nonetheless, there is no need to slam someone when he or =
she has
    the guts to go online in a forum where there are physicians and =
others with
    an acknowledged higher education and ask a question. That is just =
showing
    lack of class, tact and decency. We do not know if he is a cook book
    medic....all he did was ask a question. Take care.

    --part1_185.407c643.29a80b8d_boundary
    Content-Type: text/html; charset=3D"US-ASCII"
    Content-Transfer-Encoding: 7bit

    <HTML><FONT FACE=3Darial,helvetica><FONT  COLOR=3D"#0000ff" SIZE=3D2 =
FAMILY=3D"SANSSERIF" FACE=3D"Century Gothic" LANG=3D"0"><BR>
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; I work with cook book =
Paramedics and have to compensate for them sometimes. Nonetheless, there =
is no need to slam someone when he or she has the guts to go online in a =
forum where there are physicians and others with an acknowledged higher =
education and ask a question. That is just showing lack of class, tact =
and decency. We do not know if he is a cook book medic....all he did was =
ask a question. Take care. </FONT></HTML>

    --part1_185.407c643.29a80b8d_boundary--



    --__--__--

    --
    trauma-list : TRAUMA.ORG
    To change your settings or unsubscribe visit:
    http://www.trauma.org/traumalist.html

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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<HTML><HEAD>
<META http-equiv=3DContent-Type content=3D"text/html; =
charset=3Diso-8859-1">
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<STYLE></STYLE>
</HEAD>
<BODY=20
style=3D"BORDER-RIGHT: medium none; BORDER-TOP: medium none; FONT: 10pt =
verdana; BORDER-LEFT: medium none; BORDER-BOTTOM: medium none"=20
bgColor=3D#ffffff>
<DIV><FONT face=3DArial>Thanks, we will consider it because of the =
hypotension=20
caused by the opiates.</FONT></DIV>
<DIV><FONT face=3DArial>Alejandro Cabrera, M.D.</FONT></DIV>
<BLOCKQUOTE dir=3Dltr=20
style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =
BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
  <DIV style=3D"FONT: 10pt arial">----- Original Message ----- </DIV>
  <DIV=20
  style=3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =
black"><B>From:</B>=20
  <A title=3Djohnjmblack@msn.com =
href=3D"mailto:johnjmblack@msn.com">John &amp;=20
  Rebecca Black</A> </DIV>
  <DIV style=3D"FONT: 10pt arial"><B>To:</B> <A =
title=3Dtrauma-list@trauma.org=20
  href=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> =
</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Sent:</B> Saturday, February 23, =
2002 5:03=20
  AM</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> Burns analgesia- =
KETAMINE</DIV>
  <DIV><BR></DIV>
  <DIV>Alejandro,</DIV>
  <DIV>&nbsp;</DIV>
  <DIV>The agent that I&nbsp;would strongly urge you all to consider =
using in=20
  the situation you describe is an analgesic dose of&nbsp;ketamine (0.1 =
-=20
  0.5mg/kg)&nbsp;mg . It is immensely valuable in the prehospital phase =
of=20
  patient's care and, unlike morphine,&nbsp;is probably the analgesic =
agent of=20
  choice if your patient also has a significant volume issue. Low dose =
midazolam=20
  may be added to reduce the risk or emergence dysphoria in less serious =

  burns.</DIV>
  <DIV>&nbsp;</DIV>
  <DIV>If the patient requires a definitive airway, and/or aeromedical=20
  evacuation is being considered, ketamine (1- 4mg/kg IV or IM) is also =
an=20
  extremely attractive induction agent.</DIV>
  <DIV>&nbsp;</DIV>
  <DIV>John Black</DIV>
  <DIV>Consultant Emergency Medicine</DIV>
  <DIV>John Radcliffe Hospital</DIV>
  <DIV>Oxford UK</DIV>
  <DIV>&nbsp;</DIV>
  <DIV>&nbsp;</DIV>
  <DIV>&nbsp;</DIV>
  <DIV>Message: 9<BR>From: "Timothy J Coats"=20
  &lt;t.j.coats@qmul.ac.uk&gt;<BR>Organization: MDS QMW<BR>To:=20
  trauma-list@trauma.org<BR>Date: Fri, 22 Feb 2002 08:50:31 =
BST<BR>Subject: Re:=20
  Burn patients.<BR>Reply-To:=20
  trauma-list@trauma.org<BR><BR>Alejandro,<BR><BR>Standard pain control =
would be=20
  to cover burns with clingfilm<BR>(=3Dsaranwrap in the USA I think) to =
prevent=20
  air movement over them,<BR>plus large doses of opiates (morphine) as =
part of=20
  balanced anaesthesia.<BR><BR>Not sure about flying out the patient you =

  describe - maybe terminal<BR>care by a local physician near to home =
with easy=20
  access for relatives<BR>would be nicer. However, I guess the local =
docs may=20
  not feel that they<BR>can cope with this.<BR><BR>Tim.<BR><BR>Timothy J =
Coats=20
  MD FRCS FFAEM<BR>Senior Lecturer in Accident and Emergency / =
Pre-Hospital=20
  Care<BR>Royal London Hospital, UK.<BR></DIV>
  <DIV>&nbsp;-----Original Message-----<BR>From: Avi Roy Shapira=20
  [mailto:avir@bgumail.bgu.ac.il]<BR>Sent: Friday, February 22, 2002 =
2:00=20
  PM<BR>To: trauma-list@trauma.org<BR>Subject: Re: Burn=20
  patients.<BR><BR><BR><BR>Give iv morphine. My practice is to dilute 10 =
mg in 9=20
  ml of saline, in a<BR>10 ml syringe, give 3-5 iv push, and then add mg =
by mg=20
  until pain free.<BR><BR>Repeat as needed.<BR><BR>Avi<BR><BR><BR>On =
Thu, 21 Feb=20
  2002, Alejandro Cabrera , M.D. wrote:<BR><BR>&gt; Hy:<BR>&gt; We've =
been=20
  flying a few patients with 90%(+) BSP burns of second and =
third<BR>&gt;=20
  degree, and, some bettween 50 and 90% and I was wondering which are=20
  your<BR>&gt; protocols for pain management obviously they were =
intubate=20
  because airway<BR>&gt; burned , the place where we flew from has no=20
  ABG's&nbsp; (little town) , but<BR>one<BR>&gt; of them with more than =
90% with=20
  renal failure, and, coagulopathy.<BR>&gt; I know it's not life =
compatible but=20
  we must do the best we can, what do<BR>you<BR>&gt; suggest?<BR>&gt; =
Alejandro=20
  Cabrera, M.D.<BR>&gt;<BR>&gt;<BR>&gt;<BR>&gt; --<BR>&gt; trauma-list : =

  TRAUMA.ORG<BR>&gt; To change your settings or unsubscribe =
visit:<BR>&gt;=20
  =
http://www.trauma.org/traumalist.html<BR>&gt;<BR><BR>=3D=3D=3D=3D=3D=3D=3D=
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D<BR>Aviel=20
  Roy-Shapira,=20
  =
M.D.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nb=
sp;&nbsp;=20
  Soroka University Hospital &amp;<BR>Dept. of Surgery A.=20
  =
and&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbs=
p;&nbsp;=20
  Ben-Gurion University Medical School<BR>the Critical Care=20
  =
Unit&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nb=
sp;&nbsp;&nbsp;=20
  POB 151, Beer Sheva, Israel<BR></DIV>
  <DIV>&nbsp;</DIV>
  <BLOCKQUOTE=20
  style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =
BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
    <DIV style=3D"FONT: 10pt Arial">----- Original Message -----</DIV>
    <DIV=20
    style=3D"BACKGROUND: #e4e4e4; FONT: 10pt Arial; COLOR: =
black"><B>From:</B>=20
    trauma-list-request@trauma.org</DIV>
    <DIV style=3D"FONT: 10pt Arial"><B>Sent:</B> 22 February 2002 =
21:13</DIV>
    <DIV style=3D"FONT: 10pt Arial"><B>To:</B> =
trauma-list@trauma.org</DIV>
    <DIV style=3D"FONT: 10pt Arial"><B>Subject:</B> trauma-list digest, =
Vol 1=20
    #1286 - 13 msgs</DIV>
    <DIV>&nbsp;</DIV>Send trauma-list mailing list submissions=20
    to<BR>trauma-list@trauma.org<BR><BR>To subscribe or unsubscribe via =
the=20
    World Wide Web,=20
    visit<BR>http://list.ftech.net/mailman/listinfo/trauma-list<BR>or, =
via=20
    email, send a message with subject or body 'help'=20
    to<BR>trauma-list-request@trauma.org<BR><BR>You can reach the person =

    managing the list at<BR>trauma-list-admin@trauma.org<BR><BR>When =
replying,=20
    please edit your Subject line so it is more specific<BR>than "Re: =
Contents=20
    of trauma-list digest..."<BR><BR><BR>Today's =
Topics:<BR><BR>&nbsp;&nbsp; 1.=20
    v-fib seizure (Vergote Lieven)<BR>&nbsp;&nbsp; 2. Re: v-fib seizure=20
    (CrnbryEMT@aol.com)<BR>&nbsp;&nbsp; 3. RE: ORIGINS OF AVPU (bobby=20
    smith)<BR>&nbsp;&nbsp; 4. Re: Burn patients. (Avi Roy=20
    Shapira)<BR>&nbsp;&nbsp; 5. RE: Burn patients. (Bjorn, =
Pret)<BR>&nbsp;&nbsp;=20
    6. Re: PANCREATIC TRAUMA - more info to ICU guys (MARK=20
    FORREST)<BR>&nbsp;&nbsp; 7. Re: v-fib seizure (Nick =
Nudell)<BR>&nbsp;&nbsp;=20
    8. Re: v-fib seizure (Ian Seppelt)<BR>&nbsp;&nbsp; 9. Re: Burn =
patients.=20
    (Timothy J Coats)<BR>&nbsp; 10. Tension Pneumothorax (Ian =
Cross)<BR>&nbsp;=20
    11. Re: v-fib seizure (FtLaudALSTeam@aol.com)<BR>&nbsp; 12. RE: =
v-fib=20
    seizure (Bjorn, Pret)<BR>&nbsp; 13. Re:v-fib=20
    (FtLaudALSTeam@aol.com)<BR><BR>--__--__--<BR><BR>Message: 1<BR>From: =
Vergote=20
    Lieven &lt;lieven.vergote@asz-aalst.be&gt;<BR>To: =
"'trauma-list@trauma.org'"=20
    &lt;trauma-list@trauma.org&gt;<BR>Subject: v-fib seizure<BR>Date: =
Fri, 22=20
    Feb 2002 13:57:16 +0100<BR>Reply-To: =
trauma-list@trauma.org<BR><BR>In my=20
    opinion this is a seizure due to cerebral hypoxia in a patient=20
    with<BR>CRA.<BR>As Always treat the appropriate way: ABCD what you =
have=20
    done<BR><BR><BR>--__--__--<BR><BR>Message: 2<BR>Date: Fri, 22 Feb =
2002=20
    08:11:28 EST<BR>From: CrnbryEMT@aol.com<BR>Subject: Re: v-fib =
seizure<BR>To:=20
    &lt;trauma-list@trauma.org&gt;<BR>Reply-To:=20
    trauma-list@trauma.org<BR><BR>"Ouch" for the slam. (Knowing "why" =
makes me a=20
    better medic.)<BR><BR>"Thanks" for the defense. (Exactly why I posed =
the=20
    question.)<BR><BR>And "Thanks!" for the answers. (It's as I thought, =
now I=20
    know for sure.)<BR><BR>I beleive I stated in my question that I =
thought=20
    v-fib seizures were due to hypoixa. (v-fib =3D poor perfusion =3D =
hypoxia) I was=20
    simply wondering if there was another mechanism at work.<BR><BR>No, =
I am not=20
    a "cookbook medic" as someone so eloquently put it ... but my =
treatment of a=20
    patient in v-fib is the same whether they had a seizure or not! My =
paramedic=20
    course was very progressive and in depth, however never mentioned =
v-fib=20
    seizures ... I was simply trying to find if there were evidence to =
show that=20
    an seizure could lead to v-fib.<BR><BR>-Greg Clopp,=20
    MICP<BR><BR><BR>--__--__--<BR><BR>Message: 3<BR>Date: Fri, 22 Feb =
2002=20
    05:49:15 -0800 (PST)<BR>From: bobby smith=20
    &lt;bobbyrn_2000@yahoo.com&gt;<BR>Subject: RE: ORIGINS OF =
AVPU<BR>To:=20
    trauma-list@trauma.org<BR>Reply-To:=20
    =
trauma-list@trauma.org<BR><BR>--0-1499779953-1014385755=3D:4594<BR>Conten=
t-Type:=20
    text/plain; charset=3Dus-ascii<BR><BR><BR>Pret<BR>To better set a =
time line I=20
    was taught AVPU in the late 70's in prehospital care=20
    classes.<BR>Bobby<BR>&nbsp; "Bjorn, Pret" &lt;pbjorn@emh.org&gt; =
wrote:=20
    Laurie, Thanks very kindly--this is more than I expected.&nbsp; =
Sadly,=20
    however, my quest continues. First and foremost, I'm suspicious at =
the=20
    assertion that AVPU is an ACS invention.&nbsp; I no longer possess a =
1993=20
    ATLS Manual (listed among the references), but if anyone is able to =
relate=20
    to me where it states anything like "the College has created the =
AVPU method=20
    as a useful alternative to the Glasgow Coma Scale," I'd be eager to =
hear=20
    about it. Also, the paper provides an unconvincing argument in favor =
of=20
    AVPU, at best amplifying its poor sensitivity to describe or =
recommend much=20
    of anything.&nbsp; Among the highlights of the discussion:&nbsp; =
"Patients=20
    who are responsive only to a painful stimulus will usually have a =
GCS of 8=20
    or less and therefore may be at risk of airway =
problems."&nbsp;&nbsp; A=20
    curious conclusion, being that 46% of these patients have a GCS of 9 =
or=20
    more...&nbsp; Strange (perhaps telling) that the investigators spent =
so much=20
    time collecting numbers, but never subjected them to any real =
statistical=20
    analysis. Finally, consider the objectives: to associate AVPU with =
GCS,=20
    presumably because AVPU is easier, and GCS only works with trained=20
    practitioners; however, within the conclusion and discussion, it is=20
    repeatedly suggested that AVPU suffers from a lack of an objective=20
    assessment guideline, and practitioners of AVPU are =
undertrained.&nbsp; If=20
    you're going to go to all that effort to improve upon a tool which =
is so=20
    clearly inferior to GCS, why not simply improve the utilization of =
GCS? On=20
    and on, round and round... Pret&nbsp; ----Original =
Message-----<BR>From:=20
    Laurie [mailto:ggh@bentonrea.com]<BR>Sent: Tuesday, February 19, =
2002 9:04=20
    PM<BR>To: trauma-list@trauma.org<BR>Subject: Fw: ORIGINS OF=20
    APUV<BR><BR><BR>Dear Pret, Attached you will find the answer to your =

    quest.&nbsp; Laurie GrimesResearch=20
    =
fiend<BR><BR>http://www.google.com/search?q=3Dcache:KbAYukdct-oC:www.basi=
cs.freewire.co.uk/Templates/DLMar00/9919.pdf+neurological+assessment+tool=
+%27APUV%22&amp;hl=3Den<BR><BR><BR>---------------------------------<BR>D=
o=20
    You Yahoo!?<BR>Yahoo! Sports - Coverage of the 2002 Olympic=20
    Games<BR>--0-1499779953-1014385755=3D:4594<BR>Content-Type: =
text/html;=20
    charset=3Dus-ascii<BR><BR>&lt;P&gt; Pret<BR>&lt;P&gt;To better set a =
time line=20
    I was taught AVPU in the late 70's in prehospital care=20
    classes.<BR>&lt;P&gt;Bobby<BR>&lt;P&gt;&amp;nbsp; =
&lt;B&gt;&lt;I&gt;"Bjorn,=20
    Pret" &amp;lt;pbjorn@emh.org&amp;gt;&lt;/I&gt;&lt;/B&gt;=20
    wrote:<BR>&lt;BLOCKQUOTE style=3D"BORDER-LEFT: #1010ff 2px solid; =
MARGIN-LEFT:=20
    5px; PADDING-LEFT: 5px"&gt;&lt;!DOCTYPE HTML PUBLIC "-//W3C//DTD =
HTML 4.0=20
    Transitional//EN"&gt;<BR>&lt;META content=3D"MSHTML 5.00.2919.6307"=20
    =
name=3DGENERATOR&gt;<BR>&lt;STYLE&gt;&lt;/STYLE&gt;<BR><BR>&lt;DIV&gt;&lt=
;FONT=20
    color=3D#800000 face=3DArial size=3D2&gt;&lt;SPAN=20
    =
class=3D980573612-20022002&gt;Laurie,&lt;/SPAN&gt;&lt;/FONT&gt;&lt;/DIV&g=
t;<BR>&lt;DIV&gt;&lt;FONT=20
    color=3D#800000 face=3DArial size=3D2&gt;&lt;SPAN=20
    =
class=3D980573612-20022002&gt;&lt;/SPAN&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DI=
V&gt;<BR>&lt;DIV&gt;&lt;FONT=20
    color=3D#800000 face=3DArial size=3D2&gt;&lt;SPAN=20
    class=3D980573612-20022002&gt;Thanks very kindly--this is more than =
I=20
    expected.&amp;nbsp; Sadly, however, my quest=20
    =
continues.&lt;/SPAN&gt;&lt;/FONT&gt;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;FONT=20
    color=3D#800000 face=3DArial size=3D2&gt;&lt;SPAN=20
    =
class=3D980573612-20022002&gt;&lt;/SPAN&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DI=
V&gt;<BR>&lt;DIV&gt;&lt;FONT=20
    color=3D#800000 face=3DArial size=3D2&gt;&lt;SPAN=20
    class=3D980573612-20022002&gt;First and foremost, I'm suspicious at =
the=20
    assertion that AVPU is an ACS invention.&amp;nbsp; I no longer =
possess a=20
    1993 ATLS Manual (listed among the references), but if anyone is =
able to=20
    relate to me where it states anything like "the College has created =
the AVPU=20
    method&amp;nbsp;as a useful alternative to the Glasgow Coma Scale," =
I'd be=20
    eager to hear about=20
    it.&lt;/SPAN&gt;&lt;/FONT&gt;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;FONT=20
    color=3D#800000 face=3DArial size=3D2&gt;&lt;SPAN=20
    =
class=3D980573612-20022002&gt;&lt;/SPAN&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DI=
V&gt;<BR>&lt;DIV&gt;&lt;FONT=20
    color=3D#800000 face=3DArial size=3D2&gt;&lt;SPAN=20
    class=3D980573612-20022002&gt;Also, the paper provides an =
unconvincing=20
    argument in favor of AVPU, at best amplifying its poor sensitivity =
to=20
    describe or recommend much of anything.&amp;nbsp; Among the =
highlights of=20
    the discussion:&amp;nbsp; "&lt;EM&gt;Patients who are responsive =
only to a=20
    painful stimulus will usually have a GCS of 8 or less and therefore =
may be=20
    at risk of airway problems&lt;/EM&gt;."&amp;nbsp;&amp;nbsp; A =
curious=20
    conclusion, being that&amp;nbsp;46% of these patients have a GCS of =
9 or=20
    more...&amp;nbsp; Strange (perhaps telling) that the investigators =
spent so=20
    much time collecting numbers, but never subjected them to any real=20
    statistical=20
    =
analysis.&lt;/SPAN&gt;&lt;/FONT&gt;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;FONT=20
    color=3D#800000 face=3DArial size=3D2&gt;&lt;SPAN=20
    =
class=3D980573612-20022002&gt;&lt;/SPAN&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DI=
V&gt;<BR>&lt;DIV&gt;&lt;FONT=20
    color=3D#800000 face=3DArial size=3D2&gt;&lt;SPAN=20
    class=3D980573612-20022002&gt;Finally, consider the objectives: to =
associate=20
    AVPU with GCS, presumably because AVPU is easier, and GCS only works =
with=20
    trained practitioners; however, within the conclusion&amp;nbsp;and=20
    discussion, it is repeatedly suggested that AVPU suffers from a lack =
of an=20
    objective assessment guideline, and practitioners of AVPU are=20
    undertrained.&amp;nbsp; If you're going to go to all that effort to =
improve=20
    upon a tool which is so clearly inferior to GCS, why not simply =
improve the=20
    utilization of=20
    GCS?&lt;/SPAN&gt;&lt;/FONT&gt;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;FONT=20
    color=3D#800000 face=3DArial size=3D2&gt;&lt;SPAN=20
    =
class=3D980573612-20022002&gt;&lt;/SPAN&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DI=
V&gt;<BR>&lt;DIV&gt;&lt;FONT=20
    color=3D#800000 face=3DArial size=3D2&gt;&lt;SPAN =
class=3D980573612-20022002&gt;On=20
    and on, round and=20
    =
round...&lt;/SPAN&gt;&lt;/FONT&gt;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;FONT=20
    color=3D#800000 face=3DArial size=3D2&gt;&lt;SPAN=20
    =
class=3D980573612-20022002&gt;&lt;/SPAN&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DI=
V&gt;<BR>&lt;DIV&gt;&lt;FONT=20
    color=3D#800000 face=3DArial size=3D2&gt;&lt;SPAN=20
    =
class=3D980573612-20022002&gt;Pret&lt;/SPAN&gt;&lt;/FONT&gt;&lt;/DIV&gt;<=
BR>&lt;DIV&gt;&lt;FONT=20
    color=3D#800000 face=3DArial size=3D2&gt;&lt;SPAN=20
    =
class=3D980573612-20022002&gt;&lt;/SPAN&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DI=
V&gt;<BR>&lt;DIV&gt;&lt;FONT=20
    color=3D#800000 face=3DArial size=3D2&gt;&lt;SPAN=20
    class=3D980573612-20022002&gt;&lt;/SPAN&gt;&lt;/FONT&gt;&lt;FONT =
face=3DTahoma=20
    =
size=3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;FONT=20
    face=3DTahoma size=3D2&gt;----Original=20
    Message-----&lt;BR&gt;&lt;B&gt;From:&lt;/B&gt; Laurie=20
    [mailto:ggh@bentonrea.com]&lt;BR&gt;&lt;B&gt;Sent:&lt;/B&gt; =
Tuesday,=20
    February 19, 2002 9:04 PM&lt;BR&gt;&lt;B&gt;To:&lt;/B&gt;=20
    trauma-list@trauma.org&lt;BR&gt;&lt;B&gt;Subject:&lt;/B&gt; Fw: =
ORIGINS OF=20
    =
APUV&lt;BR&gt;&lt;BR&gt;&lt;/DIV&gt;<BR>&lt;BLOCKQUOTE&gt;&lt;/FONT&gt;<B=
R>&lt;DIV&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;BR&gt;&lt;/DIV&gt;<=
BR>&lt;DIV&gt;Dear=20
    =
Pret,&lt;/DIV&gt;<BR>&lt;DIV&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&lt;DIV&gt;Atta=
ched=20
    you will find the answer to your quest.=20
    =
&lt;/DIV&gt;<BR>&lt;DIV&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&lt;DIV&gt;Laurie=20
    Grimes&lt;/DIV&gt;<BR>&lt;DIV&gt;Research=20
    =
fiend&lt;BR&gt;&lt;/DIV&gt;<BR>&lt;DIV&gt;&amp;nbsp;&lt;/DIV&gt;&lt;BR&gt=
;&amp;nbsp;&lt;A=20
    =
href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002/3D"http://www.google.com/search?q=3Dcache:KbAYukdct-oC:www.basics.fr=
eewire.co.uk/Templates/DLMar00/9919.pdf+neurological+assessment+tool+%27A=
PUV%22&amp;amp;hl=3Den"&gt;http://www.google.com/search?q=3Dcache:KbAYukd=
ct-oC:www.basics.freewire.co.uk/Templates/DLMar00/9919.pdf+neurological+a=
ssessment+tool+%27APUV%22&amp;amp;hl=3Den&lt;/A&gt;=20
    &lt;/BLOCKQUOTE&gt;&lt;/BLOCKQUOTE&gt;&lt;p&gt;&lt;br&gt;&lt;hr=20
    size=3D1&gt;&lt;b&gt;Do You Yahoo!?&lt;/b&gt;&lt;br&gt;<BR>&lt;a=20
    href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002/3D"http://sports.yahoo.com/oly"&gt;Yahoo! Sports&lt;/a&gt; - =
Coverage of=20
    the 2002 Olympic=20
    =
Games<BR>--0-1499779953-1014385755=3D:4594--<BR><BR><BR>--__--__--<BR><BR=
>Message:=20
    4<BR>Date: Fri, 22 Feb 2002 21:00:09 +0200 (IST)<BR>From: Avi Roy =
Shapira=20
    &lt;avir@bgumail.bgu.ac.il&gt;<BR>To: =
trauma-list@trauma.org<BR>Subject: Re:=20
    Burn patients.<BR>Reply-To: trauma-list@trauma.org<BR><BR><BR>Give =
iv=20
    morphine. My practice is to dilute 10 mg in 9 ml of saline, in =
a<BR>10 ml=20
    syringe, give 3-5 iv push, and then add mg by mg until pain=20
    free.<BR><BR>Repeat as needed.<BR><BR>Avi<BR><BR><BR>On Thu, 21 Feb =
2002,=20
    Alejandro Cabrera , M.D. wrote:<BR><BR>&gt; Hy:<BR>&gt; We've been =
flying a=20
    few patients with 90%(+) BSP burns of second and third<BR>&gt; =
degree, and,=20
    some bettween 50 and 90% and I was wondering which are your<BR>&gt;=20
    protocols for pain management obviously they were intubate because=20
    airway<BR>&gt; burned , the place where we flew from has no =
ABG's&nbsp;=20
    (little town) , but one<BR>&gt; of them with more than 90% with =
renal=20
    failure, and, coagulopathy.<BR>&gt; I know it's not life compatible =
but we=20
    must do the best we can, what do you<BR>&gt; suggest?<BR>&gt; =
Alejandro=20
    Cabrera, M.D.<BR>&gt;<BR>&gt;<BR>&gt;<BR>&gt; --<BR>&gt; trauma-list =
:=20
    TRAUMA.ORG<BR>&gt; To change your settings or unsubscribe =
visit:<BR>&gt;=20
    =
http://www.trauma.org/traumalist.html<BR>&gt;<BR><BR>=3D=3D=3D=3D=3D=3D=3D=
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D<BR>Aviel=20
    Roy-Shapira,=20
    =
M.D.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nb=
sp;&nbsp;=20
    Soroka University Hospital &amp;<BR>Dept. of Surgery A.=20
    =
and&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbs=
p;&nbsp;=20
    Ben-Gurion University Medical School<BR>the Critical Care=20
    =
Unit&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nb=
sp;&nbsp;&nbsp;=20
    POB 151, Beer Sheva,=20
    =
Israel<BR><BR>email:avir@bgumail.bgu.ac.il&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;&nbsp;&nbsp;=20
    Fax:972-7-6403260=20
    =
voice:972-7-6403390<BR><BR><BR><BR><BR><BR>--__--__--<BR><BR>Message:=20
    5<BR>From: "Bjorn, Pret" &lt;pbjorn@emh.org&gt;<BR>To:=20
    "'trauma-list@trauma.org'" =
&lt;trauma-list@trauma.org&gt;<BR>Subject: RE:=20
    Burn patients.<BR>Date: Fri, 22 Feb 2002 14:08:39 -0500<BR>Reply-To: =

    trauma-list@trauma.org<BR><BR>Us too.&nbsp; Morphine.&nbsp; Lots and =
lots of=20
    Morphine.&nbsp; Given by the tens if<BR>necessary.<BR><BR>Pret =
Bjorn,=20
    RN<BR>Bangor, ME&nbsp;=20
    =
USA<BR><BR><BR>email:avir@bgumail.bgu.ac.il&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=
&nbsp;&nbsp;&nbsp;=20
    Fax:972-7-6403260 =
voice:972-7-6403390<BR><BR><BR><BR><BR>--<BR>trauma-list :=20
    TRAUMA.ORG<BR>To change your settings or unsubscribe=20
    =
visit:<BR>http://www.trauma.org/traumalist.html<BR><BR><BR>--__--__--<BR>=
<BR>Message:=20
    6<BR>From: "MARK FORREST" &lt;atacc.doc@virgin.net&gt;<BR>To:=20
    &lt;trauma-list@trauma.org&gt;<BR>Subject: Re: PANCREATIC TRAUMA - =
more info=20
    to ICU guys<BR>Date: Fri, 22 Feb 2002 00:31:29 -0000<BR>Reply-To:=20
    trauma-list@trauma.org<BR><BR>This is a multi-part message in MIME=20
    =
format.<BR><BR>------=3D_NextPart_000_009C_01C1BB38.454B25C0<BR>Content-T=
ype:=20
    =
multipart/alternative;<BR>boundary=3D"----=3D_NextPart_001_009D_01C1BB38.=
454B25C0"<BR><BR><BR>------=3D_NextPart_001_009D_01C1BB38.454B25C0<BR>Con=
tent-Type:=20
    text/plain;<BR>charset=3D"iso-8859-1"<BR>Content-Transfer-Encoding:=20
    quoted-printable<BR><BR>Dear Alster,<BR>Thank you for the additional =
info.=20
    Both of these patients clearly had =3D<BR>something catastrophic =
going on in=20
    their abdomens. These kind of numbers =3D<BR>are very severe and =
will have=20
    been rising for some time. To me they =3D<BR>clearly indicate major =
ischaemia,=20
    even allowing for ARF, and the need =3D<BR>for urgent laparotomy =
(which would=20
    probably demonstrate =3D<BR>ischaemic/infarcted bowel)<BR>Although a =
fan of=20
    high flux HF or HDF in sepsis, it will not salvage =3D<BR>patients =
like this=20
    who need surgical intervention. Such renal therapies =3D<BR>merely =
put the=20
    'brakes' on the numbers and mask the severity of the =
=3D<BR>condition until it=20
    is too late.<BR><BR>The second case appears to have developed =
overwhelming=20
    ARDS as a result =3D<BR>of the initial insult, the subsequent =
abdominal=20
    inflammation and =3D<BR>possibly overzealous fluid resuscitation in =
obvious=20
    SIRS. In our unit we =3D<BR>firmly believe that the battle is often =
lost=20
    pre-hospital or in resus =3D<BR>where patients are over-filled with =
resus=20
    fluid, before theatre and more =3D<BR>fluid, before blood =
transfusion and then=20
    finally ITU after 10-20 litres =3D<BR>of fluid for an initial true =
blood loss=20
    of maybe 2 litres.....LESS FLUID =3D<BR>IS =
BEST!?...discuss!<BR><BR>Hopefully,=20
    as the concept of permissive hypotension, small volume =
=3D<BR>resuscitation=20
    and hypertonics becomes more frequently practised, then =3D<BR>the =
struggles=20
    of the intensivists will be reduced.<BR>Evidence base? How can an=20
    intensivist prove that the amount of fluid =3D<BR>given at the =
roadside etc=20
    will alter outcome after ? 10 days of ITU care =3D<BR>and all of its =
therapies=20
    and variables?<BR>Any more information Alster?<BR>Regards<BR>Mark=20
    F<BR>Intensivist with 'pruned' patients.....?more ARF but less ARDS, =

    =3D<BR>fortunately I can easily treat the former!<BR>&nbsp; ----- =
Original=20
    Message -----=3D20<BR>&nbsp; From: alster=3D20<BR>&nbsp; To:=20
    trauma-list@trauma.org=3D20<BR>&nbsp; Sent: Wednesday, February 20, =
2002 11:20=20
    PM<BR>&nbsp; Subject: Re: PANCREATIC TRAUMA - more info to ICU=20
    guys<BR><BR><BR>&nbsp; Greetings list!<BR><BR>&nbsp; Thank you all =
for your=20
    input. Well let me give you additional info:<BR><BR>&nbsp; 26 Y/O =
white=20
    latin male was victim of a gunshot wound in the RUQ =3D<BR>exiting =
on the back=20
    (lumbar level).=3D20<BR>&nbsp; Trauma to the pancreas (Grade III - =
caudal=20
    pancreatectomy performed), =3D<BR>Stomach (Grade II - sutured), =
Spleen=20
    (nothing done -Grade I), Diaphragm =3D<BR>(sutured) and mesentery =
(sutured).=20
    Pancreatic fistula (400ml/day from =3D<BR>day 5 till 10th Post Op =
day). U/S=20
    showed no collections elsewhere. No =3D<BR>fever.<BR>&nbsp; =
Suddenly, at the=20
    12th POp day he was in abdominal pain with no relief =3D<BR>to =
analgesics.=20
    Plus there was a leucocytosis 15.000 (B=3D3D7% S=3D3D70%).<BR>&nbsp; =
We ordered=20
    a CT but 12h later he had to be admitted to ICU because of =
=3D<BR>ARDS. His=20
    oxymetry saturation reached 30% at best with FiO2=3D3D100%. He =
=3D<BR>died in 4=20
    hours.<BR><BR>&nbsp; ABGs: Basically metabolic acidosis with =
increased anion=20
    gap. I better =3D<BR>look his chart over again.<BR>&nbsp; CRProtein =
=3D3D=20
    100.000 (nl&lt;5). Lactate 20.<BR><BR>&nbsp; 19Y/O white latin =
female was=20
    also victim of a gunshot wound on the =3D<BR>back exiting at =
epigastric level.=20
    She got a ride from her boyfriend who =3D<BR>was driving a =
motorcycle when 2=20
    other guys in a car tried to rob him. As =3D<BR>soon as he =
accelerated, trying=20
    to run away, his girlfriend was shot on =3D<BR>the back and he =
suffered only=20
    scratches in his right arm There was a =3D<BR>trauma to the tail of =
the=20
    pancreas.=3D20<BR>&nbsp; That trauma was only diagnosed by CT and =
because=20
    amylase levels =3D<BR>reached 549. Besides that, pt was doing fine. =
Still in=20
    noradrenalin but =3D<BR>going down with 0,15mcg/Kg/min.Based on CT =
findings=20
    and because there =3D<BR>was no ERCP available during weekends she =
was taken=20
    to the OR and a =3D<BR>distal pancreatectomy plus spenectomy was =
performed. No=20
    intraop =3D<BR>cholangiography was done. She did well till the 10th =
POp day=20
    when both =3D<BR>lungs got WHITE and she developed ARDS. Amylase =
levels=20
    diminished to =3D<BR>normal levels. Then, hepatic and renal =
insufficiency. Her=20
    pulse oxymetry =3D<BR>at best was 40% with FiO2=3D3D100% (last =
Friday) getting=20
    better when TGI =3D<BR>was instituted (80% at best). Our =
hemofiltration=20
    machine was broken. =3D<BR>Several U/S was done showing no =
collection besides=20
    18ml around the =3D<BR>pancreas. As she was unstable no post op ct =
was done.=20
    She had no fever. =3D<BR>Nothing.She died at the 23 Post Op day=20
    (Saturday).=3D20<BR><BR>&nbsp; ABGs:metabolic acidosis with =
increased anion=20
    gap (renal failure). =3D<BR>CRProtein=3D3D255.000.=20
    Lactate=3D3D50<BR><BR><BR>&nbsp;&nbsp;&nbsp; ----- Original Message=20
    -----=3D20<BR>&nbsp;&nbsp;&nbsp; From: MARK =
FORREST=3D20<BR>&nbsp;&nbsp;&nbsp;=20
    To: trauma-list@trauma.org=3D20<BR>&nbsp;&nbsp;&nbsp; Sent: Tuesday, =
February=20
    12, 2002 5:08 PM<BR>&nbsp;&nbsp;&nbsp; Subject: Re: PANCREATIC =
TRAUMA - What=20
    are we missing?<BR><BR><BR>&nbsp;&nbsp;&nbsp; Dear=20
    Alster,<BR>&nbsp;&nbsp;&nbsp; Any more information for the =
non-surgical=20
    members.=3D20<BR>&nbsp;&nbsp;&nbsp; Very interested in the amount =
and type of=20
    fluid given during =3D<BR>resuscitation and inevitable SIRS period =
after=20
    surgery.<BR><BR>&nbsp;&nbsp;&nbsp; Surprised that deteriorations =
were so=20
    rapid as although surgical =3D<BR>conditions can develop rapidly, =
the ARDS=20
    picture is far more likely to =3D<BR>have been developing over =
several=20
    days.<BR><BR>&nbsp;&nbsp;&nbsp; Any ABGs, CRPs, lactates prior to=20
    deterioration?<BR><BR>&nbsp;&nbsp;&nbsp; Mark =
F=3D20<BR>&nbsp;&nbsp;&nbsp; ITU=20
    Cons,UK<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ----- Original Message=20
    -----=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; From:=20
    alster=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; To:=20
    trauma-list@trauma.org=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Sent: =
Monday,=20
    February 11, 2002 10:35 PM<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; =
Subject:=20
    PANCREATIC TRAUMA - What are we=20
    missing?<BR><BR><BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Hello=20
    List!=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Where do we go from=20
    here?<BR><BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 26 Y/O white latin male =
was=20
    victim of a gunshot wound in the RUQ =3D<BR>exiting on the back =
(lumbar=20
    level).=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Trauma to the =
pancreas (Grade=20
    III - caudal pancreatectomy =3D<BR>performed), Stomach (Grade II - =
sutured),=20
    Spleen (nothing done -Grade =3D<BR>I), Diaphragm (sutured) and =
mesentery=20
    (sutured). Pancreatic fistula =3D<BR>(400ml/day from day 5 till 10th =
Post Op=20
    day). U/S showed no collections =3D<BR>elsewhere. No=20
    fever.<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Suddenly, at the 12th POp =
day he=20
    was in abdominal pain with no =3D<BR>relief to analgesics. Plus =
there was a=20
    leucocytosis 15.000 (B=3D3D7% =
=3D<BR>S=3D3D70%).<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    We ordered a CT but 12h later he had to be admitted to ICU because =
=3D<BR>of=20
    ARDS. His oxymetry saturation reached 30% at best with =
FiO2=3D3D100%. =3D<BR>He=20
    died in 4 hours.<BR><BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 19Y/O white =
latin=20
    female was also victim of a gunshot wound on the =3D<BR>back exiting =
at=20
    epigastric level. She got a ride from her boyfriend who =3D<BR>was =
driving a=20
    motorcycle when 2 other guys in a car tried to rob him. As =
=3D<BR>soon as he=20
    accelerated, trying to run away, his girlfriend was shot on =
=3D<BR>the back=20
    and he suffered only scratches in his right arm. There was a =
=3D<BR>trauma to=20
    the tail of the pancreas as showed=20
    bellow:<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    =3D20<BR><BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; That trauma was only =
diagnosed by=20
    CT and because amylase levels =3D<BR>reached 549. Besides that, pt =
was doing=20
    fine. Still in noradrenalin but =3D<BR>going down with=20
    0,15mcg/Kg/min.<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Based on CT =
findings and=20
    because there was no ERCP available =3D<BR>during weekends she was =
taken to=20
    the OR and a distal pancreatectomy plus =3D<BR>spenectomy=20
    was<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; performed. No intraop =
cholangiography=20
    was done. She did well till =3D<BR>the 10th POp day when both lungs =
got WHITE=20
    and she developed ARDS. =3D<BR>Amylase levels diminished to normal =
levels.=20
    Then, hepatic and renal =3D<BR>insufficiency. Her pulse oxymetry at =
best was=20
    40% with FiO2=3D3D100% (last =3D<BR>Friday) getting better when TGI =
was=20
    instituted (80% at best). Our =3D<BR>hemofiltration machine was =
broken.=20
    Several U/S was done showing no =3D<BR>collection besides 18ml =
around the=20
    pancreas. As she was unstable no post =3D<BR>op ct was done. She had =
no fever.=20
    Nothing.She died at the 23 Post Op day=20
    =3D<BR>(Saturday).=3D20<BR><BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; What =
are we=20
    missing?<BR><BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; CAlster,=20
    =
MD<BR><BR><BR><BR><BR>------=3D_NextPart_001_009D_01C1BB38.454B25C0<BR>Co=
ntent-Type:=20
    text/html;<BR>charset=3D"iso-8859-1"<BR>Content-Transfer-Encoding:=20
    quoted-printable<BR><BR>&lt;!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML =
4.0=20
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    =3D<BR>charset=3D3Diso-8859-1"&gt;<BR>&lt;META content=3D3D"MSHTML =
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    =
name=3D3DGENERATOR&gt;<BR>&lt;STYLE&gt;&lt;/STYLE&gt;<BR>&lt;/HEAD&gt;<BR=
>&lt;BODY=20
    bgColor=3D3D#ffffff&gt;<BR>&lt;DIV&gt;&lt;FONT face=3D3DArial =
size=3D3D2&gt;Dear=20
    Alster,&lt;/FONT&gt;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;FONT =
face=3D3DArial=20
    size=3D3D2&gt;Thank you for the additional info. Both =3D<BR>of=20
    these=3D20<BR>patients clearly had something catastrophic going on =
in their=20
    abdomens. =3D<BR>These=3D20<BR>kind of numbers are very severe and =
will have=20
    been rising for some time. =3D<BR>To me=3D20<BR>they clearly =
indicate major=20
    ischaemia, even allowing for ARF, and the =3D<BR>need =
for=3D20<BR>urgent=20
    laparotomy (which would probably demonstrate=20
    =
ischaemic/infarcted=3D20<BR>bowel)&lt;/FONT&gt;&lt;/DIV&gt;<BR>&lt;DIV&gt=
;&lt;FONT=20
    face=3D3DArial size=3D3D2&gt;Although a fan of high flux HF or HDF =
=3D<BR>in=20
    sepsis, it=3D20<BR>will not salvage patients like this who need =
surgical=20
    intervention. Such =3D<BR>renal=3D20<BR>therapies merely put the =
'brakes' on the=20
    numbers and mask the severity =3D<BR>of the=3D20<BR>condition until =
it is too=20
    late.&lt;/FONT&gt;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;FONT face=3D3DArial =

    =
size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;FONT =

    face=3D3DArial size=3D3D2&gt;The second case appears to have=20
    =3D<BR>developed=3D20<BR>overwhelming ARDS as a result of the =
initial insult,=20
    the subsequent =3D<BR>abdominal=3D20<BR>inflammation and possibly =
overzealous=20
    fluid resuscitation in obvious =3D<BR>SIRS. In=3D20<BR>our unit we =
firmly=20
    believe that the battle is often lost pre-hospital or =
=3D<BR>in=3D20<BR>resus=20
    where patients are over-filled with resus fluid, before theatre =
=3D<BR>and=20
    more=3D20<BR>fluid, before blood transfusion and then finally ITU =
after 10-20=20
    litres =3D<BR>of fluid=3D20<BR>for an initial true blood loss of =
maybe 2=20
    litres.....LESS FLUID=20
    =
IS=3D20<BR>BEST!?...discuss!&lt;/FONT&gt;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;F=
ONT=20
    face=3D3DArial=20
    =
size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;FONT =

    face=3D3DArial size=3D3D2&gt;Hopefully, as the concept of permissive =

    =3D<BR><BR>hypotension, small volume resuscitation and hypertonics =
becomes=20
    more =3D<BR>frequently=3D20<BR>practised, then the struggles of the =
intensivists=20
    will be =
=3D<BR>reduced.&lt;/FONT&gt;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;FONT=20
    face=3D3DArial size=3D3D2&gt;Evidence base? How can an intensivist =
=3D<BR>prove=20
    that=3D20<BR>the amount of&amp;nbsp;fluid given at the roadside etc =
will alter=20
    outcome =3D<BR>after ? 10=3D20<BR>days of ITU care and all of its =
therapies and=20
    variables?&lt;/FONT&gt;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;FONT =
face=3D3DArial=20
    size=3D3D2&gt;Any more information=20
    =3D<BR>Alster?&lt;/FONT&gt;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;FONT =
face=3D3DArial=20
    =
size=3D3D2&gt;Regards&lt;/FONT&gt;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;FONT=20
    face=3D3DArial size=3D3D2&gt;Mark=20
    F&lt;/FONT&gt;&lt;/DIV&gt;<BR>&lt;DIV&gt;&lt;FONT face=3D3DArial=20
    size=3D3D2&gt;Intensivist with 'pruned' =3D<BR>patients.....?more =
ARF=3D20<BR>but=20
    less ARDS, fortunately I can easily treat the=20
    former!&lt;/FONT&gt;&lt;/DIV&gt;<BR>&lt;BLOCKQUOTE=20
    dir=3D3Dltr=3D20<BR>style=3D3D"PADDING-RIGHT: 0px; PADDING-LEFT: =
5px; MARGIN-LEFT:=20
    5px; =3D<BR>BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: =
0px"&gt;<BR>&nbsp;=20
    &lt;DIV style=3D3D"FONT: 10pt arial"&gt;----- Original Message ----- =

    &lt;/DIV&gt;<BR>&nbsp; &lt;DIV=3D20<BR>&nbsp; style=3D3D"BACKGROUND: =
#e4e4e4;=20
    FONT: 10pt arial; font-color:=20
    =3D<BR>black"&gt;&lt;B&gt;From:&lt;/B&gt;=3D20<BR>&nbsp; &lt;A=20
    title=3D3Dalster@usp.br =
href=3D3D"mailto:alster@usp.br"&gt;alster&lt;/A&gt;=20
    =3D<BR>&lt;/DIV&gt;<BR>&nbsp; &lt;DIV style=3D3D"FONT: 10pt=20
    arial"&gt;&lt;B&gt;To:&lt;/B&gt; &lt;A=20
    =3D<BR>title=3D3Dtrauma-list@trauma.org=3D20<BR>&nbsp;=20
    =
href=3D3D"mailto:trauma-list@trauma.org"&gt;trauma-list@trauma.org&lt;/A&=
gt;=20
    =3D<BR>&lt;/DIV&gt;<BR>&nbsp; &lt;DIV style=3D3D"FONT: 10pt=20
    arial"&gt;&lt;B&gt;Sent:&lt;/B&gt; Wednesday, February 20, =
=3D<BR>2002=20
    11:20=3D20<BR>&nbsp; PM&lt;/DIV&gt;<BR>&nbsp; &lt;DIV =
style=3D3D"FONT: 10pt=20
    arial"&gt;&lt;B&gt;Subject:&lt;/B&gt; Re: PANCREATIC TRAUMA =3D<BR>- =

    more=3D20<BR>&nbsp; info to ICU guys&lt;/DIV&gt;<BR>&nbsp;=20
    &lt;DIV&gt;&lt;BR&gt;&lt;/DIV&gt;<BR>&nbsp; &lt;DIV&gt;&lt;FONT =
face=3D3DArial=20
    size=3D3D2&gt;Greetings list!&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial=20
    size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial size=3D3D2&gt;Thank you =
all&amp;nbsp;for your=20
    input. =3D<BR>Well let me=3D20<BR>&nbsp; give you additional=20
    info:&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp; &lt;DIV&gt;&lt;FONT =
face=3D3DArial=20
    size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&nbsp;=20
    &lt;DIV&gt;<BR>&nbsp; &lt;DIV&gt;&lt;FONT face=3D3DArial=20
    size=3D3D1&gt;&lt;STRONG&gt;26 Y/O white latin male was =
=3D<BR>victim of=20
    a=3D20<BR>&nbsp; gunshot wound in the RUQ exiting&amp;nbsp;on the =
back=20
    (lumbar&amp;nbsp;level). =3D<BR><BR>&nbsp;=20
    &lt;/STRONG&gt;&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp; =
&lt;DIV&gt;&lt;FONT=20
    face=3D3DArial size=3D3D1&gt;&lt;STRONG&gt;Trauma to the pancreas =
(Grade=20
    =3D<BR>III -=3D20<BR>&nbsp; caudal pancreatectomy performed), =
Stomach (Grade II=20
    - sutured), Spleen =3D<BR><BR>&nbsp; (nothing done -Grade I), =
Diaphragm=20
    (sutured) and mesentery (sutured).=3D20<BR>&nbsp; Pancreatic fistula =

    (400ml/day from day 5 till 10th Post Op day). U/S =3D<BR>showed=20
    no=3D20<BR>&nbsp; collections elsewhere. No=20
    fever.&lt;/STRONG&gt;&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp; =
&lt;DIV&gt;&lt;FONT=20
    face=3D3DArial size=3D3D1&gt;&lt;STRONG&gt;Suddenly, at the 12th POp =
day =3D<BR>he=20
    was in=3D20<BR>&nbsp; abdominal pain&amp;nbsp;with no relief to =
analgesics.=20
    Plus there was a=3D20<BR>&nbsp; leucocytosis 15.000 (B=3D3D7%=20
    S=3D3D70%).&lt;/STRONG&gt;&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial =
size=3D3D2&gt;&lt;STRONG&gt;&lt;FONT=20
    size=3D3D1&gt;We ordered a =3D<BR>CT but 12h=3D20<BR>&nbsp; later he =
had to be=20
    admitted to ICU because of ARDS. His oxymetry =
=3D<BR>saturation=3D20<BR>&nbsp;=20
    reached 30% at best with FiO2=3D3D100%. He died in 4=3D20<BR>&nbsp;=20
    =
hours&lt;/FONT&gt;&lt;/STRONG&gt;.&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial=20
    size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial size=3D3D2&gt;ABGs: Basically =
metabolic=20
    acidosis =3D<BR>with increased=3D20<BR>&nbsp; anion gap. =
I&amp;nbsp;better look=20
    his chart over again.&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp; =
&lt;DIV&gt;&lt;FONT=20
    face=3D3DArial size=3D3D2&gt;CRProtein =3D3D 100.000 (nl&amp;lt;5).=20
    =3D<BR>Lactate=3D20<BR>&nbsp; 20.&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp; =

    &lt;DIV&gt;&lt;FONT face=3D3DArial=20
    size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial&gt;&lt;FONT size=3D3D1&gt;19Y/O =
white latin=20
    female was =3D<BR>also victim of=3D20<BR>&nbsp; a gunshot wound on =
the back=20
    exiting at epigastric level. She got a =3D<BR>ride =
from=3D20<BR>&nbsp; her=20
    boyfriend who was driving a&amp;nbsp;motorcycle&amp;nbsp;when 2 =
other guys=20
    =3D<BR>in a=3D20<BR>&nbsp; car tried to rob him. As soon as he =
accelerated,=20
    trying to run away, =3D<BR>his=3D20<BR>&nbsp; girlfriend was shot on =
the back=20
    and he suffered only scratches in his =3D<BR>right=3D20<BR>&nbsp; =
arm There was=20
    a trauma to the tail of the pancreas. &lt;/FONT&gt;<BR>&nbsp;=20
    &lt;DIV&gt;&lt;FONT size=3D3D1&gt;That trauma was only diagnosed by =
CT and=20
    because =3D<BR>amylase=3D20<BR>&nbsp; levels reached =
549.&amp;nbsp;Besides=20
    that,&amp;nbsp;pt was doing fine. Still =3D<BR>in=3D20<BR>&nbsp; =
noradrenalin=20
    but&amp;nbsp;going down&amp;nbsp;with 0,15mcg/Kg/min.Based on CT=20
    =3D<BR>findings=3D20<BR>&nbsp; and because there was no ERCP =
available during=20
    weekends she was taken =3D<BR>to the=3D20<BR>&nbsp; OR and a distal=20
    pancreatectomy plus spenectomy was performed. No =
=3D<BR>intraop=3D20<BR>&nbsp;=20
    cholangiography was done. She did well till the 10th POp day=20
    =3D<BR>when&amp;nbsp;both=3D20<BR>&nbsp; lungs got WHITE and she =
developed ARDS.=20
    Amylase levels =3D<BR>diminished&amp;nbsp;to=3D20<BR>&nbsp; normal =
levels. Then,=20
    hepatic and renal insufficiency. Her pulse =3D<BR>oxymetry =
at=3D20<BR>&nbsp;=20
    best was 40% with FiO2=3D3D100% (last Friday) getting better when =
TGI=20
    =3D<BR>was=3D20<BR>&nbsp; instituted (80% at best). Our =
hemofiltration machine=20
    was broken. =3D<BR>Several U/S=3D20<BR>&nbsp; was done showing no =
collection=20
    besides 18ml around the pancreas. As =3D<BR>she was=3D20<BR>&nbsp; =
unstable no=20
    post op ct was done.&amp;nbsp;She had no =
=3D<BR>fever.&amp;nbsp;Nothing.She=20
    died=3D20<BR>&nbsp; at the 23 Post Op day (Saturday).=20
    &lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp; &lt;DIV&gt;&lt;FONT=20
    size=3D3D1&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&nbsp;=20
    &lt;DIV&gt;ABGs:metabolic acidosis with increased anion gap (renal =
failure).=20
    =3D<BR><BR>&nbsp; CRProtein=3D3D255.000.=20
    Lactate=3D3D50&lt;/DIV&gt;&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial=20
    size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial=20
    =
size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;&lt;/DIV&gt;<BR>&nbsp;=20
    &lt;BLOCKQUOTE dir=3D3Dltr=3D20<BR>&nbsp; style=3D3D"PADDING-RIGHT: =
0px;=20
    PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =3D<BR>BORDER-LEFT: #000000 2px =
solid;=20
    MARGIN-RIGHT: 0px"&gt;<BR>&nbsp;&nbsp;&nbsp; &lt;DIV =
style=3D3D"FONT: 10pt=20
    arial"&gt;----- Original Message ----- =
&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;=20
    &lt;DIV=3D20<BR>&nbsp;&nbsp;&nbsp; style=3D3D"BACKGROUND: #e4e4e4; =
FONT: 10pt=20
    arial; font-color:=20
    =3D<BR>black"&gt;&lt;B&gt;From:&lt;/B&gt;=3D20<BR>&nbsp;&nbsp;&nbsp; =
&lt;A=20
    title=3D3Datacc.doc@virgin.net=20
    =
=3D<BR>href=3D3D"mailto:atacc.doc@virgin.net"&gt;MARK=3D20<BR>&nbsp;&nbsp=
;&nbsp;=20
    FORREST&lt;/A&gt; &lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp; &lt;DIV =
style=3D3D"FONT:=20
    10pt arial"&gt;&lt;B&gt;To:&lt;/B&gt; &lt;A=20
    =3D<BR>title=3D3Dtrauma-list@trauma.org=3D20<BR>&nbsp;&nbsp;&nbsp;=20
    =
href=3D3D"mailto:trauma-list@trauma.org"&gt;trauma-list@trauma.org&lt;/A&=
gt;=20
    =3D<BR>&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp; &lt;DIV style=3D3D"FONT: =
10pt=20
    arial"&gt;&lt;B&gt;Sent:&lt;/B&gt; Tuesday, February 12, =3D<BR>2002 =

    5:08=3D20<BR>&nbsp;&nbsp;&nbsp; PM&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp; =
&lt;DIV=20
    style=3D3D"FONT: 10pt arial"&gt;&lt;B&gt;Subject:&lt;/B&gt; Re: =
PANCREATIC=20
    =3D<BR>TRAUMA - What=3D20<BR>&nbsp;&nbsp;&nbsp; are we=20
    missing?&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;&lt;BR&gt;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp; =
&lt;DIV&gt;&lt;FONT=20
    face=3D3DArial size=3D3D2&gt;Dear=20
    Alster,&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp; =
&lt;DIV&gt;&lt;FONT=20
    face=3D3DArial size=3D3D2&gt;Any more information for the=20
    =3D<BR>non-surgical=3D20<BR>&nbsp;&nbsp;&nbsp; members.=20
    &lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp; &lt;DIV&gt;&lt;FONT=20
    face=3D3DArial size=3D3D2&gt;Very interested in the amount and =
=3D<BR>type of=20
    fluid=3D20<BR>&nbsp;&nbsp;&nbsp; given during resuscitation and =
inevitable=20
    SIRS period after=3D20<BR>&nbsp;&nbsp;&nbsp;=20
    surgery.&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp; =
&lt;DIV&gt;&lt;FONT=20
    face=3D3DArial=20
    =
size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial size=3D3D2&gt;Surprised that =
deteriorations=20
    were =3D<BR>so rapid as=3D20<BR>&nbsp;&nbsp;&nbsp; although surgical =
conditions=20
    can develop rapidly, the ARDS picture =3D<BR>is =
far=3D20<BR>&nbsp;&nbsp;&nbsp;=20
    more likely to have been developing over several=20
    days.&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp; =
&lt;DIV&gt;&lt;FONT=20
    face=3D3DArial=20
    =
size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial size=3D3D2&gt;Any ABGs, CRPs, =
lactates prior=20
    to=3D20<BR>&nbsp;&nbsp;&nbsp;=20
    deterioration?&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial=20
    =
size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial size=3D3D2&gt;Mark F=20
    &lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp; &lt;DIV&gt;&lt;FONT=20
    face=3D3DArial size=3D3D2&gt;ITU=20
    Cons,UK&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp; =
&lt;BLOCKQUOTE=20
    dir=3D3Dltr=3D20<BR>&nbsp;&nbsp;&nbsp; style=3D3D"PADDING-RIGHT: =
0px;=20
    PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =3D<BR>BORDER-LEFT: #000000 2px =
solid;=20
    MARGIN-RIGHT: 0px"&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &lt;DIV=20
    style=3D3D"FONT: 10pt arial"&gt;----- Original Message -----=20
    =3D<BR>&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    &lt;DIV=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; =
style=3D3D"BACKGROUND: #e4e4e4;=20
    FONT: 10pt arial; font-color:=20
    =
=3D<BR>black"&gt;&lt;B&gt;From:&lt;/B&gt;=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp=
;&nbsp;=20
    &lt;A title=3D3Dalster@usp.br=20
    href=3D3D"mailto:alster@usp.br"&gt;alster&lt;/A&gt;=20
    =3D<BR>&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &lt;DIV =
style=3D3D"FONT:=20
    10pt arial"&gt;&lt;B&gt;To:&lt;/B&gt; &lt;A=20
    =
=3D<BR>title=3D3Dtrauma-list@trauma.org=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;=20
    =
href=3D3D"mailto:trauma-list@trauma.org"&gt;trauma-list@trauma.org&lt;/A&=
gt;=20
    =3D<BR>&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &lt;DIV =
style=3D3D"FONT:=20
    10pt arial"&gt;&lt;B&gt;Sent:&lt;/B&gt; Monday, February 11, =
=3D<BR>2002=20
    10:35=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    PM&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &lt;DIV =
style=3D3D"FONT: 10pt=20
    arial"&gt;&lt;B&gt;Subject:&lt;/B&gt; PANCREATIC TRAUMA =3D<BR>- =
What=20
    are=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; we=20
    missing?&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; =
&lt;DIV&gt;&lt;FONT=20
    face=3D3DArial=20
    =
size=3D3D2&gt;&lt;/FONT&gt;&lt;BR&gt;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&n=
bsp;&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial size=3D3D2&gt;Hello List!=20
    &lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial size=3D3D2&gt;Where do we go from =

    =
=3D<BR>here?&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial=20
    =
size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&n=
bsp;&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial size=3D3D2&gt;26 Y/O white latin =
male was=20
    =3D<BR>victim of a=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; gunshot =
wound in the=20
    RUQ exiting&amp;nbsp;on the back=20
    =
=3D<BR>(lumbar&amp;nbsp;level).=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    &lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial size=3D3D2&gt;Trauma to the =
pancreas (Grade=20
    III =3D<BR>- caudal=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; =
pancreatectomy=20
    performed), Stomach (Grade II - sutured), Spleen=20
    =3D<BR>(nothing=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; done -Grade =
I), Diaphragm=20
    (sutured) and mesentery (sutured).=20
    =3D<BR>Pancreatic=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; fistula =
(400ml/day from=20
    day 5 till 10th Post Op day). U/S showed=20
    =3D<BR>no=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; collections =
elsewhere. No=20
    fever.&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial size=3D3D2&gt;Suddenly, at the =
12th POp day=20
    he =3D<BR>was in=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; abdominal=20
    pain&amp;nbsp;with no relief to analgesics. Plus there was a=20
    =3D<BR><BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; leucocytosis 15.000 =
(B=3D3D7%=20
    =
S=3D3D70%).&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial size=3D3D2&gt;We ordered a CT but =
12h later=20
    he =3D<BR>had to be=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; admitted =
to ICU=20
    because of ARDS. His oxymetry saturation reached =3D<BR>30%=20
    at=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; best with FiO2=3D3D100%. =
He died in 4=20
    hours.&lt;/FONT&gt;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial=20
    =
size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&n=
bsp;&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial size=3D3D2&gt;19Y/O white latin =
female was=20
    also =3D<BR>victim of a=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; =
gunshot wound on=20
    the back exiting at epigastric level. She got a =3D<BR>ride=20
    from=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; her boyfriend who was =
driving=20
    a&amp;nbsp;motorcycle&amp;nbsp;when 2 other =3D<BR>guys=20
    in=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; a car tried to rob him. As =
soon as=20
    he accelerated, trying to run =3D<BR>away,=20
    his=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; girlfriend was shot on =
the back and=20
    he suffered only scratches in =
=3D<BR>his=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    right arm. There was a trauma to the tail of the pancreas as=20
    =3D<BR>showed=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    =
bellow:&lt;/FONT&gt;&lt;/DIV&gt;&lt;IMG=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;=20
    alt=3D3D"Will you operated on this pt based on CT findings?"=20
    =3D<BR>hspace=3D3D0=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    src=3D3D"cid:009a01c1bb38$44ee11a0$70d1fc3e@oemcomputer"=20
    =
=3D<BR>border=3D3D0&gt;&amp;nbsp;&lt;IMG=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;=
&nbsp;=20
    alt=3D3D"What about this one?" =
hspace=3D3D0=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    src=3D3D"cid:009b01c1bb38$453a5ce0$70d1fc3e@oemcomputer" =
border=3D3D0&gt;=20
    =3D<BR><BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &lt;DIV&gt;&lt;FONT =
face=3D3DArial=20
    =
size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&n=
bsp;&nbsp;=20
    &lt;DIV&gt;That trauma was only diagnosed by CT and because amylase=20
    =3D<BR>levels=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; reached=20
    549.&amp;nbsp;Besides that,&amp;nbsp;pt was doing fine. Still=20
    in=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; noradrenalin =
but&amp;nbsp;going=20
    down&amp;nbsp;with=20
    0,15mcg/Kg/min.&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;Based on CT findings and because there was no ERCP =
available=20
    =3D<BR>during=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; weekends she =
was taken to=20
    the OR and a distal pancreatectomy =
plus=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    spenectomy was&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;performed. No intraop cholangiography was done. She did =
well=20
    =3D<BR>till the=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 10th POp day=20
    when&amp;nbsp;both lungs got WHITE and she developed=20
    =3D<BR>ARDS.=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Amylase levels=20
    diminished&amp;nbsp;to normal levels. Then, hepatic and=20
    =3D<BR>renal=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; insufficiency. =
Her pulse=20
    oxymetry at best was 40% with FiO2=3D3D100%=20
    =3D<BR>(last=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Friday) getting =
better when=20
    TGI was instituted (80% at best). =
Our=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    hemofiltration machine was broken. Several U/S was done showing no=20
    =3D<BR><BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; collection besides 18ml =
around the=20
    pancreas. As she was unstable =3D<BR>no=20
    post=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; op ct was =
done.&amp;nbsp;She had=20
    no fever.&amp;nbsp;Nothing.She died at =3D<BR>the=20
    23=3D20<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Post Op day (Saturday).=20
    &lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;What are we=20
    missing?&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=20
    &lt;DIV&gt;CAlster, MD&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; =

    &lt;DIV&gt;&lt;FONT face=3D3DArial=20
    =
size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&n=
bsp;&nbsp;=20
    &lt;DIV&gt;&lt;FONT face=3D3DArial=20
    =
size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;<BR>&nbsp;&nbsp;&nbsp;&n=
bsp;&nbsp;=20
    &lt;DIV&gt;&lt;FONT=20
    =
face=3D3DArial=3D20<BR>size=3D3D2&gt;&lt;/FONT&gt;&amp;nbsp;&lt;/DIV&gt;&=
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/V+vTGgRXrpMSA/r0hmdN39O+gRn6f79GBg9OvfTEbD+nlpjBNPt0DA8elfjpC<BR>P//Z<BR=
><BR>------=3D_NextPart_000_009C_01C1BB38.454B25C0--<BR><BR><BR><BR>--__-=
-__--<BR><BR>Message:=20
    7<BR>From: "Nick Nudell" &lt;nick@glacierems.com&gt;<BR>To:=20
    &lt;trauma-list@trauma.org&gt;<BR>Subject: Re: v-fib =
seizure<BR>Date: Thu,=20
    21 Feb 2002 17:58:37 -0700<BR>Organization: Glacier County =
EMS<BR>Reply-To:=20
    trauma-list@trauma.org<BR><BR>I think there is more then one =
plausible=20
    explanation.... try yours in<BR>reverse!<BR><BR>Like =
this:<BR>Seizure=20
    activity &gt; Anoxia &gt; Cardiac ischemia &gt; V-fib<BR><BR>In =
addition,=20
    reading V-fib on a monitor during seizure activity can =
be<BR>dangerous.=20
    Treating your patient (meaning check for pulses) is probably=20
    more<BR>critical then reading the monitor.<BR><BR>Turn this into a =
further=20
    discussion by asking, at times finding a pulse may<BR>be difficult =
during=20
    seizure activity, so would you first give a med (benzo<BR>or other =
relaxant)=20
    and intubate or would you jump to ACLS and Shock =
Shock<BR>Shock?<BR><BR>Take=20
    care.<BR>Nick<BR><BR>P.S. Your right, this is not really a trauma=20
    discussion, other then what if<BR>the seizure was caused by head =
injury=20
    leading to this crashing spiral?<BR><BR>____<BR>Nick Nudell,=20
    NREMT-P<BR>Glacier County EMS<BR>www.glacierems.com<BR>Northern =
Rockies=20
    Medical Center<BR>Cut Bank, =
MT<BR>nick@glacierems.com<BR><BR><BR><BR>-----=20
    Original Message -----<BR>From: &lt;Nappio@aol.com&gt;<BR>To:=20
    &lt;trauma-list@trauma.org&gt;<BR>Sent: Thursday, February 21, 2002 =
4:38=20
    PM<BR>Subject: Re: v-fib seizure<BR><BR><BR>&gt; =
ATTENTION:<BR>&gt;<BR>&gt;=20
    V-fib&nbsp; &gt;&nbsp;&nbsp;&nbsp; Anoxia&nbsp;&nbsp; =
&gt;&nbsp;&nbsp;=20
    Ischemic brain hit&nbsp;&nbsp;&nbsp; &gt;&nbsp;&nbsp;&nbsp; seizure=20
    activity<BR>&gt;<BR>&gt; Mr. Ramstrom,&nbsp; Mr. Clopp asked the =
rhetorical=20
    "stupid question" if you<BR>will,<BR>&gt; and stated the truth about =
his=20
    knowledge deficit,,but at least he stepped<BR>&gt; forth&nbsp; and =
asked the=20
    question so he wouldnt be just a cook book ambulance<BR>&gt; =
driver.If you=20
    want to eliminate the negative attitudes you speak of =
you<BR>have<BR>&gt; to=20
    accept the fact that there are cook book ambulance drivers who need=20
    to<BR>be<BR>&gt; educated.<BR>&gt; DN<BR>&gt;<BR>&gt; --<BR>&gt; =
trauma-list=20
    : TRAUMA.ORG<BR>&gt; To change your settings or unsubscribe =
visit:<BR>&gt;=20
    =
http://www.trauma.org/traumalist.html<BR>&gt;<BR><BR><BR><BR>--__--__--<B=
R><BR>Message:=20
    8<BR>Date: Fri, 22 Feb 2002 14:21:09 +1100<BR>From: "Ian Seppelt"=20
    &lt;SeppelI@wahs.nsw.gov.au&gt;<BR>To:=20
    &lt;trauma-list@trauma.org&gt;<BR>Subject: Re: v-fib =
seizure<BR>Reply-To:=20
    trauma-list@trauma.org<BR><BR>"v-fib seizure" - never heard of =
it.<BR>These=20
    patients had a primary cardiac arrest and then a secondary hypoxic=20
    =3D<BR>seizure - treatment is just as you indicated with =
defibrillation and=20
    oxyg=3D<BR>en.<BR><BR>Cheers, Ian<BR><BR>Ian Seppelt<BR>Nepean =
Hospital,=20
    Sydney.<BR><BR>&gt;&gt;&gt; CrnbryEMT@aol.com 02/22/02 06:35am=20
    &gt;&gt;&gt;<BR>Many apologies for tossing this to a tramua list=20
    ...<BR><BR>Does anyone have information on such a thing as a "v-fib=20
    seizure"? In my =3D<BR>short experience I have been called to at =
least one=20
    patient that had seiz=3D<BR>ure activity followed by cardiac arrest =
(initial=20
    rhythm: v-fib) with no s=3D<BR>eizure history. I've been told by =
many that the=20
    person must have had a "v=3D<BR>-fib seizure".<BR><BR>Is this a =
seizure that=20
    precipitates v-fib? V-vib that initially causes so=3D<BR>me sort of =
hypoxic=20
    seizure? As a Paramedic my treatment is ultimately =
the=3D<BR>=3D20same: CPR and=20
    ACLS appropriate to the presenting rhythm ... I just go =3D<BR>up a =
tree when=20
    I don't know "why".<BR><BR>Thanks.<BR><BR>-Greg Clopp,=20
    MICP<BR><BR>--<BR>trauma-list : TRAUMA.ORG<BR>To change your =
settings or=20
    unsubscribe=20
    =
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    this message are=3D20<BR>those of the individual sender, and are not =

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    10<BR>From: "Ian Cross" &lt;ian_ff@hotmail.com&gt;<BR>To:=20
    trauma-list@trauma.org<BR>Subject: Tension Pneumothorax<BR>Date: =
Fri, 22 Feb=20
    2002 14:32:49 +0000<BR>Reply-To: trauma-list@trauma.org<BR><BR>I'm a =

    fire-fighter working in a very rural community.&nbsp; We don't see=20
    that<BR>much trauma, but on occasions the country roads have a habit =
of=20
    exposing<BR>some nasty injuries.<BR><BR>We have just been through =
the=20
    trapped occupant/tension pneumothorax<BR>experience.<BR><BR>having =
read as=20
    much as I can on this subject, (with the small amount =
of<BR>literature I=20
    have available).<BR><BR>The signs of a developing T.P. are well =
described=20
    and the procedure of<BR>needle decompression is also<BR>well=20
    described.<BR><BR>However it is mentioned by those in the emergency =
services=20
    (paramedics who<BR>we occasionally get to chat with).<BR><BR>Needle=20
    decompression is only successful in about 40% of cases, - fat =
cells<BR>are=20
    jammed into the cannula<BR>In needle decompression the 'classical =
hiss of=20
    air being released' is often<BR>not present.<BR>In T.P. the lung =
will not=20
    re-inflate once the tension has been relieved.<BR><BR>Is all the =
above=20
    correct ?<BR><BR>If so how would one know that the decompression has =
worked=20
    ?<BR><BR>Does the increasing respiratory rate, slow down, does the=20
    respiratory rate<BR>decrease ?<BR><BR>The the patients anxiety and =
distress=20
    reduce ?<BR><BR>i can find no literaturew that describes the outcome =
of=20
    successful<BR>decompression and as yet no one to answer my=20
    questions.<BR><BR>Can someone please help.&nbsp; Not that we would =
be in a=20
    position to provide this<BR>procedure for a patient, it is just a =
question=20
    that I find very interesting<BR>and cannot find an =
answer.<BR><BR>Ian=20
    Greaves, Fire-fighter, The highlands of=20
    =
Scotland<BR><BR><BR><BR>_________________________________________________=
________________<BR>MSN=20
    Photos is the easiest way to share and print your=20
    =
photos:<BR>http://photos.msn.com/support/worldwide.aspx<BR><BR><BR><BR>--=
__--__--<BR><BR>Message:=20
    11<BR>From: FtLaudALSTeam@aol.com<BR>Date: Fri, 22 Feb 2002 15:50:37 =

    EST<BR>Subject: Re: v-fib seizure<BR>To: =
trauma-list@trauma.org<BR>Reply-To:=20
    =
trauma-list@trauma.org<BR><BR><BR>--part1_51.1989bd8a.29a8091d_boundary<B=
R>Content-Type:=20
    text/plain; charset=3D"US-ASCII"<BR>Content-Transfer-Encoding:=20
    7bit<BR><BR><BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Mr. Ramstrom, =
your=20
    apology is well taken and I admire you for<BR>responding and the way =
you=20
    responded. It is well taken. Have a good day.<BR><BR>Jorge Aguiar=20
    FF/PM<BR>Ft. Lauderdale=20
    =
Fire/Rescue<BR><BR>--part1_51.1989bd8a.29a8091d_boundary<BR>Content-Type:=
=20
    text/html; charset=3D"US-ASCII"<BR>Content-Transfer-Encoding:=20
    7bit<BR><BR>&lt;HTML&gt;&lt;FONT =
FACE=3Darial,helvetica&gt;&lt;FONT&nbsp;=20
    COLOR=3D"#0000ff" SIZE=3D2 FAMILY=3D"SANSSERIF" FACE=3D"Century =
Gothic"=20
    =
LANG=3D"0"&gt;&lt;BR&gt;<BR>&amp;nbsp;&amp;nbsp;&amp;nbsp;&amp;nbsp;&amp;=
nbsp;&amp;nbsp;=20
    Mr. Ramstrom, your apology is well taken and I admire you for =
responding and=20
    the way you responded. It is well taken. Have a good=20
    day.&lt;BR&gt;<BR>&lt;BR&gt;<BR>Jorge Aguiar FF/PM&lt;BR&gt;<BR>Ft.=20
    Lauderdale=20
    =
Fire/Rescue&lt;/FONT&gt;&lt;/HTML&gt;<BR><BR>--part1_51.1989bd8a.29a8091d=
_boundary--<BR><BR><BR>--__--__--<BR><BR>Message:=20
    12<BR>From: "Bjorn, Pret" &lt;pbjorn@emh.org&gt;<BR>To:=20
    "'trauma-list@trauma.org'" =
&lt;trauma-list@trauma.org&gt;<BR>Subject: RE:=20
    v-fib seizure<BR>Date: Fri, 22 Feb 2002 15:59:04 -0500<BR>Reply-To:=20
    trauma-list@trauma.org<BR><BR>Nick,<BR><BR>Absolutely possible, but =
uncommon=20
    and unlikely.&nbsp; Anoxia most frequently<BR>leads to bradycardia, =
not=20
    VF.&nbsp; And although I agree that you should treat<BR>the patient, =
not the=20
    monitor, I can recall at least one case of a teenage<BR>girl with =
Long QT=20
    who was treated for several minutes as a seizure before<BR>anyone =
checked=20
    her pulse OR rhythm (Torsades).&nbsp; Leaves a bad taste.<BR><BR>I =
think=20
    that most folks who have witnessed a conscious patient=20
    suffering<BR>sudden-onset VF would agree that the physical =
manifestations=20
    could fairly be<BR>mistaken for seizure activity.&nbsp; This more =
clearly=20
    speaks to the original<BR>post: sudden death is rarely =
subtle.<BR><BR>Best=20
    Regards,<BR><BR>Pret<BR><BR>-----Original Message-----<BR>From: Nick =
Nudell=20
    [mailto:nick@glacierems.com]<BR>Sent: Thursday, February 21, 2002 =
7:59=20
    PM<BR>To: trauma-list@trauma.org<BR>Subject: Re: v-fib =
seizure<BR><BR><BR>I=20
    think there is more then one plausible explanation.... try yours=20
    in<BR>reverse!<BR><BR>Like this:<BR>Seizure activity &gt; Anoxia =
&gt;=20
    Cardiac ischemia &gt; V-fib<BR><BR>In addition, reading V-fib on a =
monitor=20
    during seizure activity can be<BR>dangerous. Treating your patient =
(meaning=20
    check for pulses) is probably more<BR>critical then reading the=20
    monitor.<BR><BR>Turn this into a further discussion by asking, at =
times=20
    finding a pulse may<BR>be difficult during seizure activity, so =
would you=20
    first give a med (benzo<BR>or other relaxant) and intubate or would =
you jump=20
    to ACLS and Shock Shock<BR>Shock?<BR><BR>Take =
care.<BR>Nick<BR><BR>P.S. Your=20
    right, this is not really a trauma discussion, other then what =
if<BR>the=20
    seizure was caused by head injury leading to this crashing=20
    spiral?<BR><BR>____<BR>Nick Nudell, NREMT-P<BR>Glacier County=20
    EMS<BR>www.glacierems.com<BR>Northern Rockies Medical Center<BR>Cut =
Bank,=20
    MT<BR>nick@glacierems.com<BR><BR><BR><BR>----- Original Message=20
    -----<BR>From: &lt;Nappio@aol.com&gt;<BR>To:=20
    &lt;trauma-list@trauma.org&gt;<BR>Sent: Thursday, February 21, 2002 =
4:38=20
    PM<BR>Subject: Re: v-fib seizure<BR><BR><BR>&gt; =
ATTENTION:<BR>&gt;<BR>&gt;=20
    V-fib&nbsp; &gt;&nbsp;&nbsp;&nbsp; Anoxia&nbsp;&nbsp; =
&gt;&nbsp;&nbsp;=20
    Ischemic brain hit&nbsp;&nbsp;&nbsp; &gt;&nbsp;&nbsp;&nbsp; seizure=20
    activity<BR>&gt;<BR>&gt; Mr. Ramstrom,&nbsp; Mr. Clopp asked the =
rhetorical=20
    "stupid question" if you<BR>will,<BR>&gt; and stated the truth about =
his=20
    knowledge deficit,,but at least he stepped<BR>&gt; forth&nbsp; and =
asked the=20
    question so he wouldnt be just a cook book ambulance<BR>&gt; =
driver.If you=20
    want to eliminate the negative attitudes you speak of =
you<BR>have<BR>&gt; to=20
    accept the fact that there are cook book ambulance drivers who need=20
    to<BR>be<BR>&gt; educated.<BR>&gt; DN<BR>&gt;<BR>&gt; --<BR>&gt; =
trauma-list=20
    : TRAUMA.ORG<BR>&gt; To change your settings or unsubscribe =
visit:<BR>&gt;=20
    =
http://www.trauma.org/traumalist.html<BR>&gt;<BR><BR><BR>--<BR>trauma-lis=
t :=20
    TRAUMA.ORG<BR>To change your settings or unsubscribe=20
    =
visit:<BR>http://www.trauma.org/traumalist.html<BR><BR><BR>--__--__--<BR>=
<BR>Message:=20
    13<BR>From: FtLaudALSTeam@aol.com<BR>Date: Fri, 22 Feb 2002 16:01:01 =

    EST<BR>Subject: Re:v-fib<BR>To: trauma-list@trauma.org<BR>Reply-To:=20
    =
trauma-list@trauma.org<BR><BR><BR>--part1_185.407c643.29a80b8d_boundary<B=
R>Content-Type:=20
    text/plain; charset=3D"US-ASCII"<BR>Content-Transfer-Encoding:=20
    7bit<BR><BR><BR>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; I work with =
cook book=20
    Paramedics and have to compensate for them<BR>sometimes. =
Nonetheless, there=20
    is no need to slam someone when he or she has<BR>the guts to go =
online in a=20
    forum where there are physicians and others with<BR>an acknowledged =
higher=20
    education and ask a question. That is just showing<BR>lack of class, =
tact=20
    and decency. We do not know if he is a cook book<BR>medic....all he =
did was=20
    ask a question. Take=20
    care.<BR><BR>--part1_185.407c643.29a80b8d_boundary<BR>Content-Type:=20
    text/html; charset=3D"US-ASCII"<BR>Content-Transfer-Encoding:=20
    7bit<BR><BR>&lt;HTML&gt;&lt;FONT =
FACE=3Darial,helvetica&gt;&lt;FONT&nbsp;=20
    COLOR=3D"#0000ff" SIZE=3D2 FAMILY=3D"SANSSERIF" FACE=3D"Century =
Gothic"=20
    =
LANG=3D"0"&gt;&lt;BR&gt;<BR>&amp;nbsp;&amp;nbsp;&amp;nbsp;&amp;nbsp;&amp;=
nbsp;&amp;nbsp;=20
    I work with cook book Paramedics and have to compensate for them =
sometimes.=20
    Nonetheless, there is no need to slam someone when he or she has the =
guts to=20
    go online in a forum where there are physicians and others with an=20
    acknowledged higher education and ask a question. That is just =
showing lack=20
    of class, tact and decency. We do not know if he is a cook book =
medic....all=20
    he did was ask a question. Take care.=20
    =
&lt;/FONT&gt;&lt;/HTML&gt;<BR><BR>--part1_185.407c643.29a80b8d_boundary--=
<BR><BR><BR><BR>--__--__--<BR><BR>--<BR>trauma-list=20
    : TRAUMA.ORG<BR>To change your settings or unsubscribe=20
    visit:<BR>http://www.trauma.org/traumalist.html<BR><BR>End of =
trauma-list=20
    Digest<BR></BLOCKQUOTE><BR clear=3Dall>
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