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Mon Dec 18 17:39:38 GMT 2006

Tim
I was born in Uganda, studied in Kenya and have been working in many african
countries, homes of all three mambas and the different cobras, since 1979.
I'm not saying that a tourniguet should not be used in rare circumstances
you mentioned, but I'm worried that the message reaches people who know
little of snakes, but have heard of the use of tourniquets in snake bites
and apply them for any snake bite. This could cause a lot of problems!!
Peter

-----Messaggio originale-----
Da: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
Per conto di Hardcastle, Tim, Dr <tch at sun.ac.za>
Inviato: lunedì 18 dicembre 2006 6.05
A: Trauma &amp; Critical Care mailing list
Oggetto: RE: tourniquets

Peter

Your opening statement is correct. However when it comes to the Cape Cobra
and the Mamba's (including Jameson's) a tourniquet is advised even before
signs of envenomation if anti-venin is more than an hour away.

Unless you have actually worked with such snakebites - as I have (I live in
South Africa where these snakes primarily occur) then check the facts before
commenting; the national recommendations of the SAIMR are for low threshold
for tourniquet in the situation described.

Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS  instructor and DSTC Cape Town Course Director
Intern program Coordinator: Surgery
M.Med (Emergency Medicine) Executive Committee member
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Division of Surgery (General) Room 4064
Department of Surgical Sciences
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa
e-mail: tch at sun.ac.za
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of peter
Sent: Saturday, December 16, 2006 4:12 PM
To: 'Trauma &amp; Critical Care mailing list'
Subject: R: tourniquets

Many bites from venemous snakes don't necessarily inject venom, so one has
to be cautious on the use of a tourniquet. There is a lot of ignorance on
snakes and if the message reaches lay people that tourniquet could help, we
will get a lot of patients bitten by black snakes with them on! The black
mamba is not black but it is a common error to think so. 
Peter 

-----Messaggio originale-----
Da: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
Per conto di oded private
Inviato: giovedì 14 dicembre 2006 19.06
A: trauma-list at trauma.org
Oggetto: RE: tourniquets

1) Traumatic amputation with active haemorrhage - (rare, since most such 
stumps will spasm and tamponade anyway)

Most system practice this- but if we claim to practice evidence based 
medicine as well, we should pay good attention to jhon pillgram's work. I've

seen no further work examaning his approach.
Anyone cares to enlight me?

>3) Bite from a Cape Cobra (Naja nivea) or Black Mamba (Dendroaspis 
>polylepis) if more than 1 hour to definitive care and no antivenin 
>available

I think that this can be limited to use only by physicians or under 
permition by medical control.

>From: "Hardcastle, Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za>
>Reply-To: "Trauma &amp; Critical Care mailing list" 
><trauma-list at trauma.org>
>To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
>Subject: RE: tourniquets
>Date: Thu, 14 Dec 2006 14:55:19 +0200
>
>Guys
>
>(Pret, Ron and Karim - this is in support of all you have said thus far!)
>
>There are some indications for tourniquets:
>1) Traumatic amputation with active haemorrhage - (rare, since most such 
>stumps will spasm and tamponade anyway)
>2) Blast injury in warfare, with active bleeding, particularly where there 
>is major tissue loss
>3) Bite from a Cape Cobra (Naja nivea) or Black Mamba (Dendroaspis 
>polylepis) if more than 1 hour to definitive care and no antivenin 
>available
>
>They should in any event be released every 30 minutes for a minute or so 
>and then re-applied to the point of abse nt blood-flow / no pulse. They 
>should be removed with adequate myoglobinuria prophylaxis on board.
>
>tim
>Dr T C Hardcastle
>M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
>Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
>ATLS  instructor and DSTC Cape Town Course Director
>Intern program Coordinator: Surgery
>M.Med (Emergency Medicine) Executive Committee member
>Clinical Head (Director): Diana Princess of Wales Trauma Unit
>Division of Surgery (General) Room 4064
>Department of Surgical Sciences
>Tygerberg Hospital / University of Stellenbosch
>PO Box 19063
>Tygerberg 7505
>Western Cape
>South Africa
>e-mail: tch at sun.ac.za
>Cell: +27824681615
>Office: +27219389281 or 4911 pager 0302
>
>
>
>-----Original Message-----
>From: trauma-list-bounces at trauma.org
>[mailto:trauma-list-bounces at trauma.org]On Behalf Of Ronald Gross
>Sent: Thursday, December 14, 2006 2:01 PM
>To: trauma-list at trauma.org
>Subject: Re: tourniquets
>
>
>I ain't young, but may be able to speak with some authority,
>unfortunately having cared for many of the very same injuries you
>discussed - and you are absolutely correct in your assessment!
>Happy Holidays,
>Ron
>
> >>> <bensonblues at comcast.net> 12/14/2006 2:47 AM >>>
>Pret had something with his "compare Baghdad to Baltimore" statement.
>I'll take the liberty to compare Da Nang (circa '69) to Detroit: The
>homeboys in Detroit 1) can't shoot straight (thank God), and 2)
>(usually) use low velocity weapons (thank God again). Low-velocity GSWs
>tend to crush tissue, and bleeding from an extremity is usually
>adequately controlled with direct pressure.  Wounds produced by
>high-velocity rounds, however, such as the 7.62 x 39 mm (AK-47) produce
>considerable soft tissue injury and sometimes near-amputation of an
>extremity. Bleeding from these injuries can be difficult to control with
>direct pressure, and in many situations using a tourniquet may be all
>that a corpsman can do to keep his Marine from bleeding to death. I
>doubt that much has changed in terms of GSWs in Bahgdad - the AK-47 is
>still a favorite killing tool. Likewise, wounds produced by "Bouncing
>Bettys" (a creative VC modification of the Claymore mine) or the
>contemporary IEDs are likely t
>  o prod
>uce extremity wounds in which hemorrrhage is difficult to control with
>available hands, thus necessitating a tourniquet. Any young combat
>medics out there with input?
>
>DB
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R: tourniquets