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Wed Dec 20 13:42:07 GMT 2006

Mark,

I would release the first tourniquet in the field ensuring
that I had defib pads on the patient and some calcium
chloride to give, which I would give on the basis of ECG
changes on the defib monitor.  We carry a v. compact iSTAT
machine (more for secondary retrievals than primaries but
with kit) which allows to get ABGs and electrolytes from
about 2mls of blood, so could get a K+ off that in the
field but more inclined to treat on the clinical
picture/ECG changes.

Suspension trauma is a tricky one.  I have not had to
actively manage this, but have thought a little (emphasis
on the little) about my approach to how I would mange it.
If we consider that the person lost consciousness due to
decreased venous return hence decreased cardiac output
hence decreased perfusion to the brain, it doesn't make a
lot of sense to me to keep the patient upright, thereby
continuing to limit the blood supply to the organ that
passing out is supposed to protect.

So I think my approach would be, keep the harness tight
initially.  Put the patient in a recumbent position.  Be
prepared to protect airway if no rapid return of
consciousness.  Ensure well volume loaded for initail
relative hypovolaemia and ensueing renal failure problems.
Once recumbent, with defib pads in place, adequate fluid
load and calcium at the ready, loosen one leg, monitor
reaction, then loosen the other.

I suppose similar approach to the crush scenario
previously considered.  Interested to hear others take on
this rare but challenging type of trauma.

Not sure about the modified pulse oximeter idea, you will
need to expand on it for a luddite like myself.

Haven't heard any opinions/thoughts on the use of calcium
chloride prophylactically just prior to Crush or
tourniquet release.

Cheers
Stefan

Dr Stefan Mazur
Emergency Physician/Retrieval Fellow
Adelaide
Australia

On Tue, 19 Dec 2006 20:26:09 +0000
  "Mark Hellaby" <hellaby at hotmail.com> wrote:
> 
> 
> 
>  
> 
> Anthony , it was more the treatment / initial management 
>of crush and control of metabolittes etc i was getting 
>at, i presume that tourniquets would have no benifficial 
>effects on compartment syndrome in fact would make it 
>worse  Stefan cheers for your reply,  
> A couple of questions for you , would you (presumeing 
>you were able to apply tourniquets in the field ) release 
>them there after extrication or wait until the patiend was 
>at a definitive care facility with blood gas analysis on 
>site.  Has anyone ever considered whether it would be 
>possible 
>to look at tissue perfusion with such cases using a 
>modified pulse oximeter to look at tissue saturation and 
>not arterial ....just something i was wondering about 
> Think it is also intersting to note that although the 
>initial rescue may be succesful the underlying renal 
>damage maybe catasphoic , as has been born out following 
>research after earthquake rescues I am interested whether 
>you feel these guidelines could 
>be used for patients suffering from suspension trauma, a 
>combination of orthostatic shock and a pseudo type crush 
>syndrome with similar metabolic build up and the potential 
>for catastrophic cardiac collapse following release, the 
>management of these cases is frought with questions and 
>difficulties, current suggestions are to keep the harness 
>under tension durring transfer to hospital (??!!!) and 
>maintaining patient in an upright or semi recumbant 
>position (!!)    
> Regards
> 
>    Mark Hellaby 
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