Volume resus & hypothermia

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In a message dated 23-Feb-02 13:55:57 Central Standard Time, KMATTOX@aol.com 
writes:

> First the IVs.  It is now widely accepted from both clinical and 
>  experimental models of large animal hemorrhage, that the "urban legend" of 
>  two large bore IVs wide open and the 3cc crystalloid replacement to the 
1cc 
>  estimated blood loss, is now considered to be a dangerous strategy.  One 
>  "pops the clot" at about 80/- to 85/- and the more crystalloid one gives 
the 
>  greater the dilution of coagulation factors and the greater the logrithmic 
>  turn on of cytokines.   

As another consideration, it's tough to keep the fluids warm in the ED, much 
less in the field, and cold fluids will drop the core temp, further 
depressing the clotting cascade.

>  Second:  There is not a single controlled study which demonstrates the 
>  benefit of field decompression of hemothorax.  I can point out individual 
>  cases where the death was caused from an iatrogenic puncture of the heart, 
a 
>  lung, or a major vessel, including intercostal vessels.   Without 
question, 
>  this practice can contribute to systemic air embolism, a much greater 
cause 
>  of death than most on this list would like to openly admit.   
>  
>  Should you have presented this case to our M&M, you as an OVERTREATING
>  field personnel, would have had an opportunity for considerable attitude 
>  adjustment.   I would hope that you, in your own quality review, make a 
real 
>  assessment as to just why you are doing some of the things you listed that 
>  you did.    
>  
>  k
>  

OK...having literally just finished ATLS, I'll note that the full 2 liter 
fluid bolus, 100 plus mmHg systolic pressure and "3 for 1" crystalloid for 
blood replacement is still advocated (the 1997 book is still in use). In 
addition, early needle decompression (in the ED) is still being advocated if 
there is evidence of a tension Pneumothorax (and no significant caveats 
reference air embolism among other things). Another interesting point that 
was brought out is that DPL, at least at the sponsoring institution, is 
rarely done, with FAST (done in coordination with the radiology department) 
and rapid CT scan (done in the ED), being preferred.

I was informed that there was a new edition of ATLS coming out in May...has 
the COS addressed the issues that you bring up here? If so, I think I'll wait 
a couple of months before I take the instructor's course, so that I'll have a 
chance to learn it the "right way" this time...BTW, I did bring up the idea 
of permissive hypotension, and the senior instructors just smiled, and said 
that they had to go by the "current" book, and the junior instructors had no 
real idea of what I was talking about...


ck
Charles S. Krin, DO

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