trauma-list digest, Vol 1 #1662 - 22 msgs

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I'd say a good reason for not using hetastarch (or indeed any colloid) is
that they are ineffective. I accept that absence of evidence is not the same
thing as evidence of absence; but there is a sufficient body of good quality
research on the crystalloid/ coloid debate showing no evidence of benefit
from colloid that I think we can pretty much close the debate. Despite
possible arguments for why colloids should work for volume replacement, they
don't. Any colloid, any circumstance, If you want to fiddle about saying
paediatric cases with a combinination of head injury and septic shock have
not been studied, then fine- consider colloids an experimental treatment in
such cases. But as part of routine clinical practice, they have had their
day.

BTW, while I personally agree with the concept of permissive hypotension, I
disagree with Dr Mattox on the strength of evidence. As far as I'm aware,
that stands at different interpretations of pathophysiology and conflicting
animal studies and computer models with the only study showing benefit in
patients being confined to penetrating thoracic trauma. The evidence is not
there one way or the other and extrapolation from this one study to raise
implications for all forms of trauma is not warranted.

> If they are going to such lengths to preserve the orthodoxy 
> that they will
> disbar anyone who questions it, how long before the system 
> becomes ossified
> (if it hasn't already) and what should be done about it?


It ossified several years ago. there are sufficient vested interests in
maintaining the status quo. A major weakness of ATLS, ALS etc. is the policy
of not recommending for instructor status those candidates who question the
orthodoxy. As much of what is within these courses goes against the
available evidence, this ensures that instructors are either ignorant of
recent advances in the area they are supposed to be teaching; or teaching
what they do not practice.

Unfortunately, difficult to change from within the advanced life support
circle. Easier to work from outside (but very much within the broader
medical community)- continue to emphasise the importance of evidence based
medicine and working to individual competence over didactic teaching and
'badge collecting'. Challenge the orthodoxy and support your juniors who do
the same.

Matt Dunn
Warwick


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