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Fri, 17 May 2002 08:42:28 +0930

Mark wrote:

Message: 11 
From: "MARK FORREST" <atacc.doc@virgin.net> 
To: <trauma-list@trauma.org> 
Subject: Re: Trauma management scenario 
Date: Thu, 16 May 2002 01:19:05 +0100 
Reply-To: trauma-list@trauma.org 

Dear Chris, 
You ask about Rowley's concerns over permissive hypotension in blunt trauma.

Without wanting to steal his glory, I believe that he has several worries. 
Firstly, the evidence base for partial resuscitation is largely based in 
penetrating rather than blunt trauma. Secondly, a large question mark hangs 
over the value of radial pulse presence as an indicator of 'adequate' 
perfusion. 

Personally, I am with Ken and John and the other list members who limit 
resuscitation in blunt or penetrating trauma and accept that our patient who

is GCS 14 and has a radial pulse and CRT <2 secs is 'adequately' perfused. 
Head injury victims are the only other controversial group since hypotension

has been sited as the greatest cause of secondary brain injury. However, 
this is not an excuse for excessive fluid replacement as the concept of 
'small volume resuscitation' can still be applied using hypertonic fluids 
for example and some of these have even been suggested to potentially halve 
mortality in hypotensive brain injured patients (Wade et al, J Trauma 42: 
S61-S65). 

As for RSI, what is the indication in our hypothetical case? If the GCS was 
falling rapidly then yes, but with a GCS of 14 there is no current 
indication. 
Remember to intubate you will also need a muscle relaxant (SUX) and adequate

sedation afterwards (Benzos such as midazolam may be useful here) eg 
propofol infusion 

Other drugs: I'm with the morphine or diamorphine brigade. Easily titrated 
analgesia with a degree of sedation and anxiolysis. Like to have ketamine 
with me for very unstable cases or the odd case where morphine just doesn't 
cover pain without excessive sedation, but not for the inexperienced when 
you have to start considering benzos etc. Use it alone if necessary 
pre-hospital and appreciate that it does not guarantee a secure airway and 
no drop in BP. 

Long-board favourite for extrication, but anyone go for a vac-mat? 
Where do we go from here Chris?! 

Regards 
Mark F 
Cons UK 

----- Original Message ----- 
From: "Cotton, Chris (SAAS)" <cotton.chris@saambulance.com.au> 
To: <trauma-list@trauma.org> 
Sent: Thursday, May 16, 2002 12:20 AM 
Subject: Pain management scenario 

> From: "Rowley Cottingham" <rowley@cix.co.uk> 
> To: <trauma-list@trauma.org> 
> Subject: RE: Initial trauma management in RTC entrapment - Chris Cotton's 
> scenario. 
> Date: Tue, 14 May 2002 15:59:46 +0100 
> Reply-To: trauma-list@trauma.org 
> 
> Please do not give midazolam with ketamine in an entrapment. There lies a 
> huge risk. If you must, give some in the emergency unit when you can 
recover 
> 
> the situation. Intubation in a vehicle is likewise very dangerous, I quite

> agree. Remember, there is no evidence to show that hypotensive 
resuscitation 
> 
> is safe in blunt trauma and quite a lot to show that losing the radial 
pulse 
> 
> is not a safe endpoint for perfusion adequacy. 
> 
> 
> Yes Nick, the speed is probably light on for such an impact and injuries. 
> This is a fictitious (?!) scenario, but not (apart from a conservative 
speed 
> estimate POSSIBLY) at all unrealistic, and i'm sure most of us could 
relate 
> a similar accident without too much thought. What this scenario was 
designed 
> to do was to get a range of different minds discussing an incident that 
> confronts paramedics and then emergency room staff on a regular basis. 
> 
> One major area i am keen to focus on is best practise for this patient. 
> Regardless of what different services allow their paramedics to do on the 
> roadside for a patient, i am keen to see what the consensus for a 
benchmark 
> of this patient (as an example!) might be. Take ALL of the qualification 
and 
> knowledge gaps out of the equation for all of us - what is best practise? 
> Then, once we have more or less a consensus on scene management and pain 
> management, etc.., and extrication, i hope one of the ED doctors who 
writes 
> to the list can then continue the scenario to hospital and carry on the 
> scenario with the nurses and surgeons who can offer their perspectives on 
> further management (x-ray, etc..,) from the best practise perspective. Put

a 
> few twists on it if you need to illustrate a point that tests best 
practise. 
> 
> Okay, this style may be a little different, but let's play with the 
scenario 
> as it is and see where it takes us? In the mean time i would like to ask 
> Rowley to expand on the issue of hypovolaemic resuscitation, losing radial

> pulse and perfusion inadequacy in blunt trauma - without getting bogged 
> down, this is a different end point perhaps to what ken mattox would 
> advocate. Or is it? How does this relate to the patient described here? 
This 
> is the hub of a question I would like some progress on. 
> 
> Nick, once the legs are freed, what sort of extrication would you perform?

> Inline with a longboard, or something else? If a choice had to be made at 
> the roadside, would RSI be performed or not? Is there a role for benzo's 
in 
> this situation? 
> 
> ...just askin' the questions. Expanding my mind reading the responses ;o) 
> Thankyou for continuing to be involved - hopefully all disciplines who 
> subscribe can benefit from this one, particularly if someone picks it up 
and 
> runs with the hospital perspective too. 
> 
> Regards, 
> Chris Cotton 
> Intensive Care Paramedic 
> South Australia. 

... and from me ...

Thanks all once again for the replies. I listen with interest to different
points of view on subjects like RSI, pain management &  extrication. Unlike
some people who DO know it all, I don't. That's why i'm here. I am trying to
listen to balanced argument so i can make up my mind as to what is best
practise - or atleast which direction i should be looking in! Once i get a
feel for what is "more or less" consensus from some very good opinions on
this list, that'll give me some areas to look at for my own, and maybe my
colleagues consideration. I am starting to realise that just because we
currently do, or don't use a particular procedure doesn't mean we shouldn't
ask questions regarding its continued relevance to emergency medicine.

Points in question that affect me on the roadside regularly are volume
resuscitation end points. I still need to evaluate the journal articles
either way on this.

Hypertonic saline is a topic that is building its case for head injury and
resuscitaion. Darren Mcinerney, jump in here any time you see fit!

RSI is a topic that is controversial it seems, with most advocating its
benefits in appropriately trained and skilled hands. My thoughts are that if
there IS clear benefit (?studies) for a certain subset of patients, then the
procedure should be used by those who are appropriately trained and skilled.
The study that Tim Coats did on pre-hospital intubation showed clearly that
those that we intubate as a result of trauma WITHOUT drugs have abysmal
outcomes - not suprising, but it NEEDED to be proved and then said. I openly
state that i am not currently trained or authorised to use this procedure -
but does that mean i should never do it? I state once again that if
something is proved to have a demonstrable improvement to patient outcomes,
than it is my right as a professional to seek that for the patient. I don't
care if it is me who (once appropriately trained) does it, or whether
someone else who has more experience (eg. anaesthesiologist) does it.
However, IF studies show that a procedure is more beneficial for patient
outcomes when instituted earlier in a total scene management plan, then i
think we should be targeting our care at providing what works best. No egos,
just getting in and getting it done. If i'm "johnny on the spot" and my
patient benefits ... give me the necessary knowledge and skills to safely
and wisely make decisions about what will improve outcomes...and when, and
when NOT to use them!

John, i see now what you were getting at with the extrication plan and
timings. Good point, and i will take that back for consideration with my
local team and rescue unit for discussion and comment. Feel free to e-mail
me off line if you have a specific package i could use please.

Okay ... where to from here? I would like to see the volume resuscitation
issues (including choice of fluid) expanded on if we think we can do so in
an educational way. Then, i would like to hand this patient over to the
hospital. For the nurses and ED staff out there - are there any new advances
on WHAT information you want to receive about this patient - or just the
standard, professional notification you would normally expect from your
paramedics? What are you going to set up? Best practise? Once again, the
floor noble brethren is yours... ;o)

Regards,
Chris Cotton,
Intensive Care Paramedic
South Australia.

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