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Mon, 16 Jun 2003 10:03:47 +1000

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This is issue is easily resolved if we resort to first principles.

In coronary occlusion cardiac arrest, the only hope of survival is to
reperfuse the myocardium.  Hence chest compressions attempt to create a
circulatory output and adrenaline is given  to peripherally vasoconstrict
and centralise whatever blood flow is achieved.  The fundamental idea is to
get some blood circulating, hopefully to the myocardium itself.

In major penetrating trauma the OPPOSITE is the case.  The only hope of
survival is repairing the hole(s) in the circulation.  The LAST thing you
want in this circumstance is increase blood flow prior to surgery.  Hence
CPR is totally inappropriate in penetrating trauma.

There is still a perception that it is important to perfuse the brain.  But
there is NO point in trying to perfuse the brain if doing so will hasten the
patient's demise.  Bleeding sufficient to cause cardiac arrest is to all
extent and purposes lethal.  When you think about it, if the patient has
haemorrhaged enough to lead to cardiac arrest, there is no blood left in the
circulation to perfuse anything anyhow.

So CPR in trauma is not only useless and lethal - it's fundamentally
illogical !

John

Dr John L Holmes
Director Emergency Medicine
Mater Health Services
Brisbane,  Australia 

-----Original Message-----
From: DocRickFry@aol.com [mailto:DocRickFry@aol.com]
Sent: Monday, 16 June 2003 5:48
To: trauma-list@trauma.org
Subject: Re: Penetrating Chest trauma

In a message dated 6/15/2003 8:27:12 AM Eastern Daylight Time,
Narani.Sivayoham@stgeorges.nhs.uk writes:

On arrival in hospital, he had a left thoracotomy done which revealed large
amount of blood in his left chest and a incision through his left ventricle.

Narani Sivayoham 

Narani--
Knowing now the nature of the injuries, which are entirely predictable, it
should be obvious that closed chest massage would have been of absolutely no
value
ERF

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<div class=3DSection1>

<p class=3DMsoNormal><span class=3DEmailStyle15><font size=3D3 =
color=3Dmaroon
face=3DArial FAMILY=3DSANSSERIF><span =
style=3D'font-size:12.0pt;font-family:Arial'>This
is issue is easily resolved if we resort to first =
principles.<o:p></o:p></span></font></span></p>

<p class=3DMsoNormal><span class=3DEmailStyle15><font size=3D3 =
color=3Dmaroon
face=3DArial><span style=3D'font-size:12.0pt;font-family:Arial'><![if =
!supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></font></span></p>=

In =
coronary occlusion
cardiac arrest, the only hope of survival is to reperfuse the =
myocardium. &nbsp;Hence chest compressions =
attempt to create
a circulatory output and adrenaline is given &nbsp;to peripherally vasoconstrict and centralise whatever =
blood flow
is achieved. &nbsp;The =
fundamental idea is
to get some blood circulating, hopefully to the myocardium =
itself.<o:p></o:p>

<p class=3DMsoNormal><span class=3DEmailStyle15><font size=3D3 =
color=3Dmaroon
face=3DArial><span style=3D'font-size:12.0pt;font-family:Arial'><![if =
!supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></font></span></p>=

In =
major penetrating
trauma the OPPOSITE is the case. &nbsp;The
only hope of survival is repairing the hole(s) in the circulation. =
&nbsp;The LAST thing you want in =
this circumstance
is increase blood flow prior to surgery. &nbsp;Hence CPR is totally inappropriate in penetrating =
trauma.<o:p></o:p>

<p class=3DMsoNormal><span class=3DEmailStyle15><font size=3D3 =
color=3Dmaroon
face=3DArial><span style=3D'font-size:12.0pt;font-family:Arial'><![if =
!supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></font></span></p>=

There =
is still a perception
that it is important to perfuse the brain. &nbsp;But there is NO point in trying to perfuse the brain =
if doing
so will hasten the patient&#8217;s demise. &nbsp;Bleeding sufficient to cause cardiac arrest is to all =
extent and
purposes lethal. &nbsp;When =
you think about
it, if the patient has haemorrhaged enough to lead to cardiac arrest, =
there is no
blood left in the circulation to perfuse anything =
anyhow.<o:p></o:p>

<p class=3DMsoNormal><span class=3DEmailStyle15><font size=3D3 =
color=3Dmaroon
face=3DArial><span style=3D'font-size:12.0pt;font-family:Arial'><![if =
!supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></font></span></p>=

<p class=3DMsoNormal><span class=3DEmailStyle15><font size=3D3 =
color=3Dmaroon
face=3DArial><span style=3D'font-size:12.0pt;font-family:Arial'>So CPR =
in trauma is
not only useless and lethal &#8211; it&#8217;s fundamentally illogical =
!<o:p></o:p></span></font></span></p>

<p class=3DMsoNormal><span class=3DEmailStyle15><font size=3D3 =
color=3Dmaroon
face=3DArial><span style=3D'font-size:12.0pt;font-family:Arial'><![if =
!supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></font></span></p>=

<p class=3DMsoNormal><span class=3DEmailStyle15><font size=3D3 =
color=3Dmaroon
face=3DArial><span =
style=3D'font-size:12.0pt;font-family:Arial'>John<o:p></o:p></span></fon=
t></span></p>

<p class=3DMsoNormal><span class=3DEmailStyle15><font size=3D3 =
color=3Dmaroon
face=3DArial><span style=3D'font-size:12.0pt;font-family:Arial'><![if =
!supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></font></span></p>=

<p class=3DMsoNormal><span class=3DEmailStyle15><font size=3D3 =
color=3Dmaroon
face=3DArial><span style=3D'font-size:12.0pt;font-family:Arial'><![if =
!supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></font></span></p>=

<p class=3DMsoAutoSig><!--[if supportFields]><span =
class=3DEmailStyle15><font=20
color=3Dmaroon face=3DArial><span style=3D'font-family:Arial'><span =
style=3D'mso-element:
field-begin'></span><span style=3D"mso-spacerun: =
yes">&nbsp;</span>AUTOTEXTLIST=20
\s &quot;E-mail Signature&quot; <span =
style=3D'mso-element:field-separator'></span></span></font></span><![end=
if]--><b><font
color=3Dblue face=3DArial><span =
style=3D'font-family:Arial;color:blue;font-weight:
bold'>Dr John L Holmes<o:p></o:p></span></font></b></p>

<p class=3DMsoAutoSig><font size=3D3 color=3Dblue face=3DArial><span =
style=3D'font-size:
12.0pt;font-family:Arial;color:blue'>Director Emergency =
Medicine<o:p></o:p></span></font></p>

<p class=3DMsoAutoSig><font size=3D3 color=3Dblue face=3DArial><span =
style=3D'font-size:
12.0pt;font-family:Arial;color:blue'>Mater Health =
Services<o:p></o:p></span></font></p>

<p class=3DMsoAutoSig><font size=3D3 color=3Dblue face=3DArial><span =
style=3D'font-size:
12.0pt;font-family:Arial;color:blue'>Brisbane,<span =
style=3D"mso-spacerun:
yes">&nbsp; </span>Australia <o:p></o:p></span></font></p>

<p class=3DMsoNormal><!--[if supportFields]><span =
class=3DEmailStyle15><font=20
color=3Dmaroon face=3DArial><span style=3D'font-family:Arial'><span =
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class=3DEmailStyle15><font
color=3Dmaroon face=3DArial><span style=3D'font-family:Arial'><![if =
!supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></font></span></p>=

<p class=3DMsoNormal style=3D'margin-left:36.0pt'><font size=3D2 =
color=3Dblack
face=3DTahoma><span =
style=3D'font-size:10.0pt;font-family:Tahoma;color:black'>-----Original
Message-----<br>
<b><span style=3D'font-weight:bold'>From:</span></b> DocRickFry@aol.com
[mailto:DocRickFry@aol.com]<br>
<b><span style=3D'font-weight:bold'>Sent:</span></b> Monday, 16 June =
2003 5:48<br>
<b><span style=3D'font-weight:bold'>To:</span></b> =
trauma-list@trauma.org<br>
<b><span style=3D'font-weight:bold'>Subject:</span></b> Re: Penetrating =
Chest
trauma</span></font></p>

<p class=3DMsoNormal style=3D'margin-left:36.0pt'><font size=3D3
face=3D"Times New Roman"><span style=3D'font-size:12.0pt'><![if =
!supportEmptyParas]>&nbsp;<![endif]><o:p></o:p></span></font></p>

<p class=3DMsoNormal style=3D'margin-left:36.0pt'><font size=3D2 =
color=3Dblack
face=3DArial><span =
style=3D'font-size:10.0pt;font-family:Arial;color:black'>In a
message dated 6/15/2003 8:27:12 AM Eastern Daylight Time,
Narani.Sivayoham@stgeorges.nhs.uk writes:<br>
<br style=3D'mso-special-character:line-break'>
<![if !supportLineBreakNewLine]><br =
style=3D'mso-special-character:line-break'>
<![endif]></span></font><font size=3D2 color=3Dblack face=3DArial><span
style=3D'font-size:10.0pt;font-family:Arial;color:black;mso-color-alt:wi=
ndowtext'><o:p></o:p></span></font></p>

<div style=3D'border:none;border-left:solid blue 1.5pt;padding:0mm 0mm =
0mm 4.0pt'>

<p class=3DMsoNormal =
style=3D'mso-margin-top-alt:auto;margin-bottom:12.0pt;
margin-left:39.75pt;border:none;mso-border-left-alt:solid blue 1.5pt;
padding:0mm;mso-padding-alt:0mm 0mm 0mm 4.0pt'><font size=3D2 =
color=3Dblack
face=3DArial><span =
style=3D'font-size:10.0pt;font-family:Arial;color:black'>On
arrival in hospital, he had a left thoracotomy done which revealed =
large amount
of blood in his left chest and a incision through his left =
ventricle.</span></font><font
color=3Dblack face=3DArial FAMILY=3DSANSSERIF><span =
style=3D'font-family:Arial;
color:black;background:white'><br>
<br>
</span></font><font size=3D2 color=3Dblack face=3DArial =
FAMILY=3DSANSSERIF><span
style=3D'font-size:10.0pt;font-family:Arial;color:black;background:white=
'>Narani
Sivayoham</span></font><font color=3Dblack face=3DArial =
FAMILY=3DSANSSERIF><span
style=3D'font-family:Arial;color:black;background:white'> =
<o:p></o:p></span></font></p>

</div>

<p class=3DMsoNormal style=3D'margin-left:36.0pt'><font size=3D3 =
color=3Dblack
face=3DArial><span =
style=3D'font-size:12.0pt;font-family:Arial;color:black;
background:white'><br>
</span></font><font size=3D2 color=3Dblack face=3DArial =
FAMILY=3DSANSSERIF><span
style=3D'font-size:10.0pt;font-family:Arial;color:black;background:white=
'><br>
Narani--<br>
Knowing now the nature of the injuries, which are entirely predictable, =
it
should be obvious that closed chest massage would have been of =
absolutely no
value<br>
ERF</span></font><font color=3Dblack><span =
style=3D'color:black;mso-color-alt:windowtext'><o:p></o:p></span></font>=
</p>

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Penetrating Chest trauma