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Tue Aug 7 11:16:19 BST 2007

test works

-----Original Message-----
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Sent: Mon, 6 Aug 2007 4:00 am
Subject: trauma-list Digest, Vol 50, Issue 12

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Today's Topics:

   1. Re: TEST - Integrated Collaborative TRAUMA/Disaster Network
      (Juan Anzieta Neumann)
   2. pressors in trauma, wasn't the world once flat? (Mike Smertka)
   3. Why are crystalloids better > pressors ? (IVAN HRONEK)
   4. Re: Why are crystalloids better > pressors ?= NEITHER
      (KMATTOX at aol.com)
   5. Re: Why are crystalloids better > pressors ?= NEITHER
      (Alex Garbino)
   6. Bullet Removal (Andrew J Bowman)

Attached Message

From:

Juan Anzieta Neumann <janzieta at telsur.cl>

To:

Trauma &amp; Critical Care mailing list <trauma-list at trauma.org>

Subject:

Re: TEST - Integrated Collaborative TRAUMA/Disaster Network

Date:

Sun, 5 Aug 2007 19:32:57 -0400

----- Original Message ----- From: "AMAT ROCA, MIGUEL" <19505mar at comb.es>?
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>?
Sent: Saturday, July 14, 2007 5:30 AM?
Subject: Re: TEST - Integrated Collaborative TRAUMA/Disaster Network?
?
> Test works?
>?
> ---------- Original Message ----------------------------------?
> De: "Pedro Gustavo Teixeira" <pedrogus at gmail.com>?
> Respondre a: "Trauma & Critical Care mailing list" > <trauma-list at trauma.org>?
> Data: Fri, 13 Jul 2007 11:21:03 -0700?
>?
>>TEST WORKS?
>>?
>>On 7/12/07, KMATTOX at aol.com <KMATTOX at aol.com> wrote:?
>>>?
>>> My dear friends and colleagues on this list server.?
>>>?
>>> This vehicle is extremely valuable method of us clinically and?
>>> managerially?
>>> communicating with each other during time of need. We all used this?
>>> communication mechanism to great value during the Katrina/Rita >>> Disaster.?
>>>?
>>> It is entirely possible that sometime in the future (let us hope and >>> pray?
>>> that it is in the many year future) we may need to use this mechanism to?
>>> ask for?
>>> help, to signal problems and danger, and to professionally exchange?
>>> clinical?
>>> information. Such a need could also be within the week.?
>>>?
>>> I would ask EACH OF YOU to merely hit the reply button and state,?
>>> TEST WORKS?
>>> to document that you are in and are part of this INTEGRATED >>> COLLABORATIVE?
>>> NETWORK. If it works during a TEST, then it will work during times >>> of?
>>> need.?
>>>?
>>>?
>>> Please - this is like a disaster drill. Let us check our ability to?
>>> LINK..............?
>>>?
>>> Kenneth L. Mattox, MD?
>>> Houston?
>>>?
>>>?
>>>?
>>> ************************************** Get a sneak peak of the all-new >>> AOL?
>>> at?
>>> http://discover.aol.com/memed/aolcom30tour?
>>> --?
>>> trauma-list : TRAUMA.ORG?
>>> To change your settings or unsubscribe visit:?
>>> http://www.trauma.org/index.php?/community/?
>>>?
>>?
>>?
>>?
>>-- >>Pedro Teixeira, MD?
>>Research Fellow?
>>University of Southern California - Keck School of Medicine?
>>Department of Surgery - Division of Trauma and Surgical Critical Care?
>>1200 North State Street, Room 10-750?
>>Los Angeles, California 90033-4525?
>>?
>>Tel: (323) 226-8112?
>>Fax: (323) 226-8116?
>>--?
>>trauma-list : TRAUMA.ORG?
>>To change your settings or unsubscribe visit:?
>>http://www.trauma.org/index.php?/community/?
>>?
>?
> ?

Attached Message

From:

Mike Smertka <medic0947969 at yahoo.com>

To:

Trauma &amp, Critical Care mailing list <trauma-list at trauma.org>

Subject:

pressors in trauma, wasn't the world once flat?

Date:

Sun, 5 Aug 2007 17:56:32 -0700 (PDT)

Thanks everyone for the replies to my earlier questions on theraputically 
reduced SBP.

  Prior to signing up for this list I raised the question about using pressors 
in trauma and to say I was met with resistence would be a kind understatement. 
But here is my madness.

  Pressors are used all the time in trauma, but nobody realizes it. How often in 
the OR or while sutering is epi used to constrict vasculature to help control 
bleeding? It seems to me, all the time. I would stipulate that cutting or 
suturing causes trauma. Maybe a controlled trauma or over a small area. But 
still a pressor used for bleeding control. (not to raise CVP)

  Now it was brought up on this list to use vasopressin. Stepping away from the 
TBI for a second, from cardiogenic shock of nontraumatic origin to spinal 
trauma, pressors are indicated; If not to aid in perfusion, then for what? I 
understand the dogma of no pressors comes from the idea that the pressor does 
not help CVP and therefore is contraindicated because the increase in BP gives a 
false impression of tissue perfusion. But from a common sense point of view, 
back to TBI, you are not trying to raise CVP, you are trying to raise MAP. So 
why would the pressor not work? Unfortunatly I don't know the answers to the 
following questions. Please can anyone tell me: 

  Which pressor? Why vasopresson over levofed or any other? Obviously some work 
differently than others, but I do not know why the focus is on Vasopressin.

  What doses are being considered and why? It seems to me using 40 units of 
vasopressin might be too much on a pt with a pulse, but what is the reasoning 
for the dose being used or is it titrated to effect?  

  The other side of the coin is by raising MAP with a pressor do you impact CVP? 
Are any other organs or systems negatively impacted? i.e. the kidneys?

  Does this idea simply come from the idea that in a cold, diaphoretic patient 
we might look at the BP reading and forget we treat patients not monitors?

  Thanks for taking time to consider this.

  Mike

KMATTOX at aol.com wrote:

In a message dated 8/5/2007 4:30:51 P.M. Central Daylight Time, ih7 at msn.com 
writes:

if the ICP is increased, you need to keep the MAP 60 mm higher so the blood 
flows forward through the brain

I would agree with that, but would plead that it is NOT crystalloid fluids 
which should be used to achieve that MAP. Remember that most of the studies 
of the past 30-40 yrs were in patients that had 3 liters (or more) challenge 
of crystalloid prior to any surgeon, especially neurosurgeon, seeing them. 
The ICP increase is a complex compartment syndrome and much of our 
traditional urban legend therapy actually iatrogenicly contributed to the 
spiraling 
increase in ICP. 

I am delighted to see the direction of the discussions on this web site, and 
do believe that it is going to lead to a whole new wave of research. 

k

************************************** Get a sneak peek of the all-new AOL at 
http://discover.aol.com/memed/aolcom30tour
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trauma-list : TRAUMA.ORG
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---------------------------------
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Attached Message

From:

IVAN HRONEK <ih7 at msn.com>

To:

Trauma &amp; Critical Care mailing list <trauma-list at trauma.org>

Subject:

Why are crystalloids better > pressors ?

Date:

Sun, 5 Aug 2007 19:08:53 -0700

Let me try to reply to keep the ball rolling:

The way I look at it is the pressors would save administration of crystalloid, 
espec. beneficial in TBI e.g.
You're right, in some of the animal studies they did decrease perfusion/cardiac 
output. The idea is to follow the "delayed resuscitation philosophy" with 
keeping the crystalloid volume low prior to control of bleeding. 

Which pressor: again, you're right: one animal study compared phenylephrine to 
vasopressine and got similar results. Levophed also did similar job. One 
difference is the effect on the heart - Levophed has some beta 1 effect and may 
cause more tachycardia than appropriate. Phenylephrine and Vasopressine are pure 
vasoconstrictors and so fulfil this role best. A lot of studies have been done 
with Vasopressine and so it is better known and can be used in follow-up human 
studies easier.

Vasopressin dose: 40 U is the CPR dose, right. I agree with you Mike, again, I 
can't see myself shooting a big blous dose to a patient without starting with 
smaller doses and yes, I think titration to effect is best, definitely, as with 
perhaps any drug.

CVP: yes, most vasoconstrictors also squeeze the large veins, but I think this 
would be a transient effect.
The kidneys are more affected by hypotension as GF is entirely dependent on the 
filtration pressure. Once you raise the BP, urine stats flowing again, like it 
has been shown with Levophed before. We are talking short-time use here, prior 
to control of bleeding and transfusion, which are the definitive therapy. A more 
common complication is skin ischemia, I saw digital ischemia in a pt. who was on 
it for > 7 days, splanchnic ischemia has also been shown to exist in the animal 
studies.

Where the idea comes from: I think saving crystalloids, when I see myself giving 
> 10 L of crystalloid and see the anasarca hapenning in front of my eyes, I 
start hating myself.  I agree with you once again - the BP is not a good 
diagnostic endpoint, CO is better, SvO2 better still, as is acidosis or lactate, 
however people say these all are general and not regional (e.g. brain or kidney 
ischemia) monitors. If you mean to say that pts. with an OK BP can be in deep 
trouble, I agree. 

I think here we would be trying to temporize and hope the kidneys, the muscles, 
skin and the splanchnic organs can take some temporary ischemia from the 
vasoconstriction due to the hemorr. shock as well as to that due to the 
vasopressor and we would keep perfusing the brain and the heart, that's what the 
body does by itself in these situations anyway.

What I don't understand is why crystalloids help - they do not increase oxygen 
delivery meaningfully..
but they keep the BP and CO, - is that useful for the body ?? Why ?

What if we just keep up the BP and not the CO - by using pressors ??  (now I am 
questioning the dogma).
Would patients become more acidotic and have low SvO2 more than with 
crystalloids ?

Thanks also for considering my question, yours, Ivan

> Date: Sun, 5 Aug 2007 17:56:32 -0700> From: medic0947969 at yahoo.com> To: 
trauma-list at trauma.org> Subject: pressors in trauma, wasn't the world once 
flat?> > Thanks everyone for the replies to my earlier questions on 
theraputically reduced SBP.> > Prior to signing up for this list I raised the 
question about using pressors in trauma and to say I was met with resistence 
would be a kind understatement. But here is my madness.> > Pressors are used all 
the time in trauma, but nobody realizes it. How often in the OR or while 
sutering is epi used to constrict vasculature to help control bleeding? It seems 
to me, all the time. I would stipulate that cutting or suturing causes trauma. 
Maybe a controlled trauma or over a small area. But still a pressor used for 
bleeding control. (not to raise CVP)> > Now it was brought up on this list to 
use vasopressin. Stepping away from the TBI for a second, from cardiogenic shock 
of nontraumatic origin to spinal trauma, pressors are indicated; If not to aid 
in perfusion, then for what? I understand the dogma of no pressors comes from 
the idea that the pressor does not help CVP and therefore is contraindicated 
because the increase in BP gives a false impression of tissue perfusion. But 
from a common sense point of view, back to TBI, you are not trying to raise CVP, 
you are trying to raise MAP. So why would the pressor not work? Unfortunatly I 
don't know the answers to the following questions. Please can anyone tell me: > 
> Which pressor? Why vasopresson over levofed or any other? Obviously some work 
differently than others, but I do not know why the focus is on Vasopressin.> > 
What doses are being considered and why? It seems to me using 40 units of 
vasopressin might be too much on a pt with a pulse, but what is the reasoning 
for the dose being used or is it titrated to effect? > > The other side of the 
coin is by raising MAP with a pressor do you impact CVP? Are any other organs or 
systems negatively impacted? i.e. the kidneys?> > Does this idea simply come 
from the idea that in a cold, diaphoretic patient we might look at the BP 
reading and forget we treat patients not monitors?> > Thanks for taking time to 
consider this.> > Mike> > KMATTOX at aol.com wrote:> > In a message dated 8/5/2007 
4:30:51 P.M. Central Daylight Time, ih7 at msn.com > writes:> > if the ICP is 
increased, you need to keep the MAP 60 mm higher so the blood > flows forward 
through the brain> > > I would agree with that, but would plead that it is NOT 
crystalloid fluids > which should be used to achieve that MAP. Remember that 
most of the studies > of the past 30-40 yrs were in patients that had 3 liters 
(or more) challenge > of crystalloid prior to any surgeon, especially 
neurosurgeon, seeing them. > The ICP increase is a complex compartment syndrome 
and much of our > traditional urban legend therapy actually iatrogenicly 
contributed to the spiraling > increase in ICP. > > I am delighted to see the 
direction of the discussions on this web site, and > do believe that it is going 
to lead to a whole new wave of research. > > k> > > > ************************************** 
Get a sneak peek of the all-new AOL at > http://discover.aol.com/memed/aolcom30tour> 
--> trauma-list : TRAUMA.ORG> To change your settings or unsubscribe visit:> 
http://www.trauma.org/index.php?/community/> > > > ---------------------------------> 
Be a better Heartthrob. Get better relationship answers from someone who knows.> 
Yahoo! Answers - Check it out. > --> trauma-list : TRAUMA.ORG> To change your 
settings or unsubscribe visit:> http://www.trauma.org/index.php?/community/

Attached Message

From:

KMATTOX at aol.com

To:

trauma-list at trauma.org

Subject:

Re: Why are crystalloids better > pressors ?= NEITHER

Date:

Sun, 5 Aug 2007 22:21:25 EDT

In a message dated 8/5/2007 9:12:31 P.M. Central Daylight Time, ih7 at msn.com  
writes:

What I  don't understand is why crystalloids help - they do not increase 
oxygen  delivery meaningfully..
but they keep the BP and CO, - is that useful for  the body ?? Why ?

What if we just keep up the BP and not the CO - by  using pressors ??  (now I 
am questioning the dogma).
Would patients  become more acidotic and have low SvO2 more than with 
crystalloids  ?

The BIG fallacy here is that we continue to assume that CO and BP are our  
objective of resuscitation.   WRONG.   Whether it be brain,  kidney, gut, or big 

toe preservation, it is perfusion and oxygen extraction that  is essential, 
with variables of temperature, pH, etc. altering the  exchange.     That is why 
NIR would be much better than the  BP cuff.     Whether it is MAST, drugs, 
crystalloids, or  position, any attempt to resuscitate based on BP as an end 
point simply is  living in the 1960s and not the 21st century.      Get  your 
head out of the past and into current thinking.   You need to go  no further 
than 
Karim Brohi's trauma.org pages to get an excellent review of  this subject.  

k

************************************** Get a sneak peek of the all-new AOL at 
http://discover.aol.com/memed/aolcom30tour

Attached Message

From:

Alex Garbino <agarbino at gmail.com>

To:

Trauma &amp, Critical Care mailing list <trauma-list at trauma.org>

Subject:

Re: Why are crystalloids better > pressors ?= NEITHER

Date:

Sun, 5 Aug 2007 22:28:45 -0500

As you look at the new techniques to monitor perfusion (NIR instead of BP,
etc), I would also look at some of the new work regarding slow reperfusion
protocols. Remember that it's not so much the lack of oxygen as much as the
sudden onrush of oxygen after deprivation that causes cell death (mostly via
free radicals, etc). These protocols are being intensely researched in
cardiovascular events, etc.; but I think this would apply to trauma, TBIs,
and any other state where tissue is exposed to hypoxia. Maybe in the future
patients will undergo permissive hypotension and slow reperfusion as opposed
to today's immediate massive reperfusion, 100% O2 masks,  etc.

Alex Garbino

On 8/5/07, KMATTOX at aol.com <KMATTOX at aol.com> wrote:
>
>
> In a message dated 8/5/2007 9:12:31 P.M. Central Daylight Time,
> ih7 at msn.com
> writes:
>
> What I  don't understand is why crystalloids help - they do not increase
> oxygen  delivery meaningfully..
> but they keep the BP and CO, - is that useful for  the body ?? Why ?
>
> What if we just keep up the BP and not the CO - by  using pressors
> ??  (now I
> am questioning the dogma).
> Would patients  become more acidotic and have low SvO2 more than with
> crystalloids  ?
>
>
>
>
> The BIG fallacy here is that we continue to assume that CO and BP are our
> objective of resuscitation.   WRONG.   Whether it be brain,  kidney, gut,
> or big
> toe preservation, it is perfusion and oxygen extraction that  is
> essential,
> with variables of temperature, pH, etc. altering the  exchange.     That
> is why
> NIR would be much better than the  BP cuff.     Whether it is MAST, drugs,
> crystalloids, or  position, any attempt to resuscitate based on BP as an
> end
> point simply is  living in the 1960s and not the 21st
> century.      Get  your
> head out of the past and into current thinking.   You need to go  no
> further than
> Karim Brohi's trauma.org pages to get an excellent review of  this
> subject.
>
> k
>
>
>
> ************************************** Get a sneak peek of the all-new AOL
> at
> http://discover.aol.com/memed/aolcom30tour
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>

Attached Message

From:

Andrew J Bowman <andrewj.bowman at gmail.com>

To:

Trauma &amp, Critical Care mailing list <trauma-list at trauma.org>

Subject:

Bullet Removal

Date:

Mon, 6 Aug 2007 01:31:23 -0400

I was reading some of the recent postings at trauma.org website.

There was one posting about the retro-aortic bullet that was left in place.

Is there ever a concern about eventual erosion of the bullet into the nearby
vascular structures?

I had a patient in my past who had suffered a GSW in his youth. He presented
to my ER late at night with abdominal pain and hypotension. CT showed
massive hemoperitoneum.

OR showed that bullet had eroded into the IVC.

Thanks,

Andrew Bowman

--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/

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