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Clamp the the chest tube?

oded private tangentcarrot at hotmail.com
Sun Apr 9 21:10:17 BST 2006


I love the sentence-

"Trauma is time sensitive. The question is- which interventions are more 
important than time?"

Is your answer "NO intervention is more important than ANY amount of time, 
for ANY trauma paitent"?


>From: docrickfry at aol.com
>Reply-To: "Trauma & Critical Care mailing list" 
><trauma-list at trauma.org>
>To: trauma-list at trauma.org
>Subject: Re: Clamp the the chest tube?
>Date: Sun, 09 Apr 2006 16:00:38 -0400
>
>In that case you in New York are quite out of touch with the current 
>published standards--see PHTLS and Norm McSwain's Scudder Oration in Truama 
>from 3 years ago--although there is room for a variety of prehospital 
>interventions, none of these should ever delay the rapid transport of a 
>patient to the nearest appropriate hospital, which remains the most 
>important principle of prehospital trauma management.  There is no place 
>for any time in the field for an injured patient except extrication
>ERF
>
>-----Original Message-----
>From: J.A. Terranson <measl at mfn.org>
>To: Trauma &amp; Critical Care mailing list <trauma-list at trauma.org>
>Sent: Sun, 9 Apr 2006 14:14:59 -0500 (CDT)
>Subject: Re: Clamp the the chest tube?
>
>
>
>On Sat, 8 Apr 2006 docrickfry at aol.com wrote:
>
> > Please refresh--when did we ever leave it?
>
>While i can't speak to your neck of the woods, in New York we left this
>behind in the late '80s.  In fact, until the NYFD borged our EMS, our
>EMT-Ps (and often our "EMTPYs" [awful emts] were pretty close to actually
>practicing independent medicine.  Where are *you* that scoop and run is
>still the norm?
>
>
> > ERF
> >
> > -----Original Message-----
> > From: J.A. Terranson <measl at mfn.org>
> > To: Trauma & Critical Care mailing list <trauma-list at trauma.org>
> > Sent: Sat, 8 Apr 2006 12:56:50 -0500 (CDT)
> > Subject: Re: Clamp the the chest tube?
> >
> >
> >
> > So, are you proposing we go back to "Scoop and Run"?
> >
> >
> > On Sat, 8 Apr 2006 docrickfry at aol.com wrote:
> >
> > > Ahhhh...this argument always manages to rear its ugly head at some
> > > point-- "Well, you know, evidence is fine, data-based medicine is 
>fine,
> > > until, that is, that is fails to support something that I just want to
> > > do--then....MY own imagination and what I think sounds logical 
>prevails"
> > > Remember just 250 years ago this same argument was used for
> > > bloodletting--perfectly logical to everybody, lets out the evil 
>humors,
> > > plenty of anecdotal cases of how people suddenly felt better, etc--who
> > > needs data for such OBVIOUSLY beneficial intervention?  Then the data
> > > came out, and guess what--not only no benefit, but it KILLED!  Same 
>with
> > > electro-shock Rx, frontal lobotomy--without a QA process applied, any
> > > interventio is DANGEROUS until PROVEN otherwisw--why?  Because THAT, 
>not
> > > the opposite, is what is SAFEST for the patient. And we think witch
> > > doctors were only a thing of the past..... ERF
> > >
> > > -----Original Message-----
> > > From: Mike MacKinnon <mmackinnon at cox.net>
> > > To: Trauma & Critical Care mailing list <trauma-list at trauma.org>
> > > Sent: Fri, 7 Apr 2006 20:25:42 -0700
> > > Subject: Re: Clamp the the chest tube?
> > >
> > >
> > > Hey Dr. KM
> > >
> > >
> > >
> > > No data to my knowledge. However, just because something hasn't been 
>studied
> > > doesn't mean it has no empirical benefit (i.e.: the classic parachute
> > > example).
> > >
> > >
> > >
> > > The procedure is utilized in air med for the same reasons (more 
>stringent I
> > > would suggest) as in the trauma room. Patient in extremis with clear 
>chest
> > > tube indication and long transport times. I can tell you, no more than 
>1-2
> > > of these are done a year at my service and everything done is reviewed 
>by
> > > our 4 med directors and the receiving trauma surgeon. While there is 
>no data
> > >  I would suggest that with those two groups in agreement that the 
>patient
> > > needed a chest tube and it was justified that there is oversight and 
>control
> > > in regards to such a high risk procedure.
> > >
> > >
> > >
> > > Really, are you suggesting you need a peer reviewed study to show 
>indication
> > > for a procedure that is a "no brainer" and clinically driven in the 
>trauma
> > > room? The indications for air med are few and far between for chest 
>tubes
> > > (much less than in the trauma room).
> > >
> > >
> > >
> > > In anycase, here are three studies which I found after a quick search.
> > >
> > >
> > >
> > > Prehosp Emerg Care. 2005 Apr-Jun;9(2):191-7.
> > >
> > >
> > >
> > >
> > >
> > > The safety and efficacy of prehospital needle and tube thoracostomy by
> > > aeromedical personnel.
> > >
> > >
> > >
> > > Davis DP, Pettit K, Rom CD, Poste JC, Sise MJ, Hoyt DB, Vilke GM.
> > >
> > >
> > >
> > > Department of Emergency Medicine, UCSD, San Diego, CA 92103, USA.
> > > davismd at cox.net
> > >
> > >
> > >
> > > BACKGROUND: Aeromedical crews routinely use needle thoracostomy (NT) 
>and
> > > tube thoracostomy (TT) to treat major trauma victims (MTVs) with 
>potential
> > > tension pneumothorax; however, the efficacy of prehospital NT and TT 
>is
> > > unclear. OBJECTIVES: To explore the efficacy of aeromedical NT and TT 
>in
> > > MTVs. METHODS: A retrospective chart review was performed using 
>prehospital
> > > medical records and the county trauma registry over a seven-year 
>period. All
> > > MTVs undergoing placement of NT or TT by aeromedical personnel were 
>included
> > >  patients with incomplete data were excluded. Descriptive statistics 
>were
> > > used to report the incidence of air release, clinical improvement 
>(improved
> > > breath sounds or compliance if intubated, decreased dyspnea if 
>nonintubated)
> > >  and vital signs improvements (systolic blood pressure [SBP] increase 
>to =90
> > > mm Hg or increase by 5 mm Hg if < 90 mm Hg; heart rate improvement to 
>60-100
> > > beats/min, increase by 10 beats/min if < 60 BPM, or decrease by 10 
>beats/min
> > > if > 100 beats/min; oxygen saturation increase if < 95%) for both NT 
>and TT
> > > as documented in prehospital medical records. Survival and improvement 
>in
> > > SBP based on trauma registry data were recorded for patients 
>stratified by
> > > initial SBP. RESULTS: A total of 136 procedures (89 NTs and 47 TTs) in 
>81
> > > patients were identified using prehospital medical records over a 
>four-year
> > > period. Response rates to NT (60% overall, 32% vital signs) and TT 
>(75%
> > > overall, 60% vital signs) were high. Vital signs improvements were 
>observed
> > > more often in patients with a pulse and in nonintubated patients. A 
>total of
> > > 168 patients were identified in the trauma registry over the 
>seven-year
> > > study period. Normalization of SBP was observed in two-thirds of 
>patients
> > > with a field SBP = 90 mm Hg and one-third of patients in whom field 
>SBP
> > > could not be obtained. A small but significant proportion of patients
> > > undergoing prehospital NT and TT, including some with prehospital
> > > hypotension and high injury severity, survived to hospital discharge. 
>The
> > > incidence of complications was low. CONCLUSIONS: Aeromedical crews 
>appear to
> > > appropriately select MTVs to undergo field NT or TT. A low incidence 
>of
> > > complications and a small but significant group of unexpected 
>survivors
> > > support continued use of this procedure by aeromedical personnel.
> > >
> > >
> > >
> > > J Emerg Med. 1995 Mar-Apr;13(2):155-63.
> > >
> > >
> > >
> > >
> > >
> > > Prehospital needle aspiration and tube thoracostomy in trauma victims: 
>a
> > > six-year experience with aeromedical crews.
> > >
> > >
> > >
> > > Barton ED, Epperson M, Hoyt DB, Fortlage D, Rosen P.
> > >
> > >
> > >
> > > Department of Emergency Medicine, University of California, San Diego
> > > Medical Center 92013-8676, USA.
> > >
> > >
> > >
> > > The use of prehospital tube thoracostomy (TT) for the treatment of 
>suspected
> > > tension pneumothorax (TPtx) in trauma patients is controversial. A 
>study is
> > > presented that reviews a 6-year experience with the use of needle 
>catheter
> > > aspiration (NA) and chest tubes performed in the field by air medical
> > > personnel. Prehospital flight charts and hospital records from 207 
>trauma
> > > patients who underwent one or both of these procedures in the field 
>were
> > > retrospectively reviewed. The clinical indications used to determine
> > > treatment are presented for both procedures. Improvement in clinical 
>status
> > > of patients observed by flight personnel were similar for both 
>treatment
> > > groups (54% for NA, 61% for TT). Thirty-two (38%) of the TT patients 
>had
> > > failed NA attempts prior to chest tube placement. Average time on 
>scene (T.O
> > > S.) was significantly greater for the TT group (25.7 min versus 20.3 
>min for
> > > NA group). Fewer patients were pronounced dead on arrival (D.O.A.) 
>with TT
> > > treatment compared to NA alone (7% versus 19%, respectively). Injury
> > > severity scores, number of hospital complications, length of stay 
>(L.O.S.),
> > > and total hospital costs were not different between the two groups. 
>There
> > > were no cases of lung damage or empyema formation associated with
> > > prehospital TT treatment. Overall mortality was similar for both 
>groups.
> > > >From these data, we conclude that NA is a relatively rapid 
>intervention in
> > > the treatment of suspected TPtx in the prehospital setting; however, 
>TT is
> > > an effective adjunct for definitive care without increasing morbidity 
>or
> > > mortality. A better understanding of the physiology of intrapleural 
>air
> > > masses is needed to determine the most effective decompression 
>requirements
> > > prior to aeromedical transport.
> > >
> > >
> > >
> > > J Trauma. 2005 Jul;59(1):96-101.
> > >
> > >
> > >
> > > Prehospital chest tube thoracostomy: effective treatment or additional
> > > trauma?
> > >
> > >
> > >
> > > Spanjersberg WR, Ringburg AN, Bergs EA, Krijen P, Schipper IB.
> > >
> > >
> > >
> > > Department of General Surgery and Traumatology, University of 
>Rotterdam,
> > > Erasmus Medical Center, The Netherlands.
> > >
> > >
> > >
> > > BACKGROUND: The use of prehospital chest tube thoracostomy (TT) 
>remains
> > > controversial because of presumed increased complication risks. This 
>study
> > > analyzed infectious complication rates for physician-performed 
>prehospital
> > > and emergency department (ED) TT. METHODS: Over a 40-month period, all
> > > consecutive trauma patients with TT performed by the flight physician 
>at the
> > > accident scene were compared with all patients with TT performed in 
>the
> > > emergency department. Bacterial cultures, blood samples, and thoracic
> > > radiographs were reviewed for TT-related infections. RESULTS: 
>Twenty-two
> > > patients received prehospital TTs and 101 patients received ED TTs. 
>Infected
> > > hemithoraces related to TTs were found in 9% of those performed in the
> > > prehospital setting and 12% of ED-performed TTs (not significant).
> > > CONCLUSION: The prehospital chest tube thoracostomy is a safe and 
>lifesaving
> > > intervention, providing added value to prehospital trauma care when
> > > performed by a qualified physician. The infection rate for prehospital 
>TT
> > > does not differ from ED TT.
> > >
> > >
> > >
> > > Mike M.
> > >
> > >
> > >
> > > -------Original Message-------
> > >
> > >
> > >
> > > From: KMATTOX at aol.com
> > >
> > > Date: 04/07/06 20:02:20
> > >
> > > To: trauma-list at trauma.org
> > >
> > > Subject: Re: Clamp the the chest tube?
> > >
> > >
> > >
> > >
> > >
> > > In a message dated 4/7/2006 10:00:15 P.M. Central Standard Time,
> > >
> > > mmackinnon at cox.net writes:
> > >
> > >
> > >
> > >
> > >
> > > Happens all the time Dr. Mattox. Long transport times where  patients 
>are
> > >
> > > severly injured and need a completely justifiable chest  tube.
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > > True true and unrelated.    Show me the  data.   I know of no good 
>data
> > > which
> > >
> > > has been peer reviewed by the  Trauma service in critique of flight 
>services
> > >
> > >
> > >   Flight services  procedures are among the most out of control of any 
>in
> > >
> > > medicine.
> > >
> > >
> > >
> > > k
> > >
> > > --
> > >
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> > >
> >
> >
>
>--
>Yours,
>
>J.A. Terranson
>sysadmin at mfn.org
>0xBD4A95BF
>
>
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