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Wed, 18 Jun 2003 14:15:43 +0100

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Thanks Rick/Ken/Pret/Barry - I will try and clarify and apologies for not
being more explicit for the reasons for exploring this issue in the first
instance - I was hoping to obtain a broad feel for the general issues
(through discussion) before focusing in on the specifics - as well as taking
the risk of being controversial!

Our local ambulance services are currently reviewing operational protocols
delivered by field paramedics/technicians and ambulance control room staff
for penetrating chest trauma for this relatively rare scenario - although
sadly an increasing problem in our inner cities in the UK. I am also acutely
aware of a lack of robust evidence for virtually all pre-hospital clinical
interventions (and indeed much of hospital based clinical practice!). I am
very much aware of the enormous challenge (and in my view the almost
impossible task) of obtaining irrefutable class 1 evidence (or indeed any
level of evidence) for much of prehospital clinical care because of the size
of the studies required to demonstrate any significant effect because of so
many confounding variables - we will always be dependent on lower levels of
evidence for certain types of injury patterns in specific contexts. Lack of
evidence demonstrating an effect is in itself is not a reason for not
questioning current clinical practice and reviewing clinical
guidelines..........

When I referred to a 'lifeless patient' in the original post I meant to
refer specifically to the 'apparently clinically lifeless' patient with
recent loss of vital signs, organized cardiac electrical activity and a
retained weapon in the chest, who may or may not have an underlying
survivable penetrating cardiac/pulmonary injury pattern.

The surgical principle of "not removing the knife" in patients with vital
signs until you are set up to do this under direct vision is a principle
that I do not question in the operating theatre or indeed the Emergency
Department. I am questioning its validity when applied to the pre-hospital
phase of the patient's care in this particular context, when because of
circumstances the patient cannot access resuscitation/operating room
interventional skills in an acceptable time frame.

Cardiac tamponade, and possibly tension pneumothorax, are the only potential
salvageable injuries that could potentially be partially relieved by knife
removal followed by CPR (only a relatively small amount of blood/clot would
need to be evacuated from the pericardium to potentially restore a perfusing
rhythm) and thoracocentesis on the side of injury. Catastrophic haemorrhage
does not always complicate penetrating cardiac wounds or knife removal. If
hypovolaemia is the underlying cause of the arrest, the situation is clearly
not salvageable but cannot be made worse. Survival will ultimately depend
whether such patients can be 'bridged' to timely definitive care. 

Does this simple approach have any merit at all or should the towel be
thrown in and admit defeat admitted in the field on every occasion? We
already know what the outcome is for this subset of patients when delivered
to hospital under existing protocols.

Regarding ambulance control room operational protocols, the decision (to
remove the knife) on the basis of telephone information from bystanders is
clearly fraught with difficulty and I suspect existing advice (leave knife
in situ) should stand. 

John Black

-----Original Message-----
From: DocRickFry@aol.com [mailto:DocRickFry@aol.com] 
Sent: 17 June 2003 18:18
To: trauma-list@trauma.org
Subject: Re: Remove the knife!

In a message dated 6/17/2003 10:22:15 AM Eastern Daylight Time,
John.Black@orh.nhs.uk writes:

Could someone try and explain to me (again) how a lifeless patient benefits
from current advice of leaving the knife in situ and not performing CPR if
they are more than a say 5-10 minutes from hospital? 

John--
I'm not sure of the point of your question given you answered it in spades
yourself in the first part of your post--I must be missing something.  First
off, a lifeless patient by definition is dead--does this really need
explaining?  A lifeless patient at the scene should be pronounced dead--all
experts, texts, etc agree on this.  Especially if "more than 5-10 minutes "
from a hospital. 
If there are signs of life (which is not what you are asking) then of course
there could be no indication anyway for CPR (because there ARE signs of
life), CPR is useless anyway as it cannot at all help the underlying
problem, and cannot at all do anything to perfuse the body in this setting.
The only thing that can be done of any value if resuscitation is deemed to
not be futile is to rapidly transport to a definitive care center for rapid
thoracotomy.  Removing an impaled object can only worsen, cannot improve,
the problem.  Like you say, there is the explanation--again!
ERF

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<div class=3DSection1>

<p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial =
FAMILY=3DSERIF><span
style=3D'font-size:10.0pt;font-family:Arial;color:navy'>Thanks =
Rick/Ken</span></font><font
size=3D2 color=3Dnavy face=3DArial><span lang=3DEN-GB =
style=3D'font-size:10.0pt;
font-family:Arial;color:navy;mso-ansi-language:EN-GB'>/Pret</span></font=
><font
size=3D2 color=3Dnavy face=3DArial><span =
style=3D'font-size:10.0pt;font-family:Arial;
color:navy'>/Barry - I will try and clarify and apologies for not being =
more
explicit for the reasons for exploring this issue in the first instance =
-
I was hoping to obtain a broad feel for the general issues (through =
discussion)
before focusing in on the specifics - as well as taking the risk of =
being
controversial!<o:p></o:p></span></font></p>

<p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
style=3D'font-size:
10.0pt;font-family:Arial;color:navy'><o:p>&nbsp;</o:p></span></font></p>=

Our local ambulance services are =
currently
reviewing operational protocols delivered by field =
paramedics/technicians and
ambulance control room staff for penetrating chest trauma for this =
relatively
rare scenario - although sadly an increasing problem in our inner =
cities
in the <st1:country-region><st1:place>UK=
</st1:place></st1:country-region>. I am also acutely aware of a lack of robust evidence for
virtually all pre-hospital clinical interventions (and indeed much of =
hospital
based clinical practice!). I am very much aware of =
the enormous
challenge (and in my view the almost impossible task) of obtaining =
irrefutable class
1 evidence (or indeed any level of evidence) for much of prehospital =
clinical
care because of the size of the studies required to demonstrate any =
significant
effect because of so many confounding variables - we will always be
dependent on lower levels of evidence for certain types of injury =
patterns in
specific contexts. Lack of evidence demonstrating an effect is =
in itself
is not a reason for not questioning current clinical practice and =
reviewing
clinical guidelines..........<o:p></o:p>

<p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
style=3D'font-size:
10.0pt;font-family:Arial;color:navy'><o:p>&nbsp;</o:p></span></font></p>=

<p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
style=3D'font-size:
10.0pt;font-family:Arial;color:navy'>When I referred to a 'lifeless
patient' in the original post I meant to refer specifically to the =
'apparently
clinically lifeless' patient with recent loss of vital signs, organized =
cardiac
electrical activity and a retained weapon in the chest, who may or may =
not have
an underlying survivable penetrating cardiac/pulmonary injury =
pattern.<o:p></o:p></span></font></p>

<p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
style=3D'font-size:
10.0pt;font-family:Arial;color:navy'><o:p>&nbsp;</o:p></span></font></p>=

The surgical principle of "not
removing the knife" in patients with vital signs until you are set up =
to
do this under direct vision is a principle that I do not question in =
the operating
theatre
or =
indeed the Emergency Department. I am questioning its =
validity when
applied to the pre-hospital phase of the patient's care in this =
particular
context, when because of circumstances the patient cannot access =
resuscitation/operating
room interventional skills in an acceptable time =
frame.<o:p></o:p>

<p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
style=3D'font-size:
10.0pt;font-family:Arial;color:navy'><o:p>&nbsp;</o:p></span></font></p>=

Cardiac tamponade, and possibly =
tension
pneumothorax, are the only potential salvageable injuries that could
potentially be partially relieved by knife removal followed by CPR =
(only a
relatively small amount of blood/clot would need to be evacuated
from the pericardium to potentially restore a perfusing rhythm) and
thoracocentesis on the side of injury. Catastrophic haemorrhage does =
not always
complicate penetrating cardiac wounds or knife removal. If
hypovolaemia is the underlying cause of the arrest, the situation is =
clearly
not salvageable but cannot be made worse. Survival will ultimately =
depend whether
such patients can be 'bridged' to timely definitive care. =
<o:p></o:p>

<p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
style=3D'font-size:
10.0pt;font-family:Arial;color:navy'><o:p>&nbsp;</o:p></span></font></p>=

Does this simple approach
have any merit at all or should the towel be thrown in and admit =
defeat
admitted in the field on every occasion? We already know what the =
outcome is
for this subset of patients when delivered to hospital under existing
protocols.<o:p></o:p>

<p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
style=3D'font-size:
10.0pt;font-family:Arial;color:navy'><o:p>&nbsp;</o:p></span></font></p>=

Regarding ambulance control room =
operational
protocols, the decision (to remove the knife) on =
the basis of
telephone information from bystanders is clearly fraught with =
difficulty and I
suspect existing advice (leave knife in situ) should stand. =
<o:p></o:p>

<p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
style=3D'font-size:
10.0pt;font-family:Arial;color:navy'><o:p>&nbsp;</o:p></span></font></p>=

<p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
style=3D'font-size:
10.0pt;font-family:Arial;color:navy'>John =
Black<o:p></o:p></span></font></p>

<p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
style=3D'font-size:
10.0pt;font-family:Arial;color:navy'><o:p>&nbsp;</o:p></span></font></p>=

<p class=3DMsoNormal><font size=3D2 color=3Dnavy face=3DArial><span =
style=3D'font-size:
10.0pt;font-family:Arial;color:navy'><span
style=3D'mso-spacerun:yes'>&nbsp;</span><o:p></o:p></span></font></p>

<p class=3DMsoNormal style=3D'margin-left:36.0pt'><font size=3D2 =
face=3DTahoma><span
style=3D'font-size:10.0pt;font-family:Tahoma'>-----Original =
Message-----<br>
<b><span style=3D'font-weight:bold'>From:</span></b> DocRickFry@aol.com
[mailto:DocRickFry@aol.com<span class=3DGramE>] <br>
<b><span style=3D'font-weight:bold'>Sent</span></b></span><b><span
style=3D'font-weight:bold'>:</span></b> </span></font><st1:date =
Month=3D"6" Day=3D"17"
Year=3D"2003"><font size=3D2 face=3DTahoma><span =
style=3D'font-size:10.0pt;font-family:
 Tahoma'>17 June 2003</span></font></st1:date><font size=3D2 =
face=3DTahoma><span
style=3D'font-size:10.0pt;font-family:Tahoma'> </span></font><st1:time =
Hour=3D"18"
Minute=3D"18"><font size=3D2 face=3DTahoma><span =
style=3D'font-size:10.0pt;font-family:
 Tahoma'>18:18</span></font></st1:time><font size=3D2 =
face=3DTahoma><span
style=3D'font-size:10.0pt;font-family:Tahoma'><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: Remove the =
knife!</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'><o:p>&nbsp;</o:p></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'>In a message =
dated
6/17/2003 10:22:15 AM Eastern Daylight Time, John.Black@orh.nhs.uk =
writes:<br>
<br style=3D'mso-special-character:line-break'>
<![if !supportLineBreakNewLine]><br =
style=3D'mso-special-character:line-break'>
<![endif]><o:p></o:p></span></font></p>

<p class=3DMsoNormal =
style=3D'mso-margin-top-alt:0cm;margin-right:0cm;margin-bottom:
12.0pt;margin-left:36.0pt'><font size=3D2 color=3Dnavy =
face=3DArial><span
style=3D'font-size:10.0pt;font-family:Arial;color:navy;background:white'=
>Could
someone try and explain to me (again) how a lifeless patient benefits =
from
current advice of leaving the knife in situ and not performing CPR if =
they are
more than a say 5-10 minutes from hospital? </span></font><font =
color=3Dblack
face=3DArial><span =
style=3D'font-family:Arial;color:black;background:white'><o:p></o:p></sp=
an></font></p>

John-- 
I'm not sure of the point of your question given you answered it in =
spades
yourself in the first part of your post--I must be missing =
something.&nbsp;
First off, a lifeless patient by definition is dead--does this really =
need
explaining?&nbsp; A lifeless patient at the scene should be pronounced
dead--all experts, texts, etc agree on this.&nbsp; Especially if =
&quot;more
than 5-10 minutes &quot; from a hospital. 
If there are signs of life (which is not what you are asking) then of =
course
there could be no indication anyway for CPR (because there ARE signs of =
life),
CPR is useless anyway as it cannot at all help the underlying problem, =
and
cannot at all do anything to perfuse the body in this setting.&nbsp; =
The only
thing that can be done of any value if resuscitation is deemed to not =
be futile
is to rapidly transport to a definitive care center for rapid
thoracotomy.&nbsp; Removing an impaled object can only worsen, cannot =
improve,
the problem.&nbsp; Like you say, there is the explanation--again! 
ERF<o:p></o:p>

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