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Thu Mar 22 09:08:36 GMT 2007

I must say that I don't believe cut-downs should be taught in ATLS for a
number of reasons:-

1)     Although, as you quite rightly say, saphenous vein cut-down works,
there are however much simpler and quicker methods for gaining access (I
have had a BIG in a patient in the A+E resus room trauma bay [ED] and
aspirated marrow before one of my colleagues [with no experience of BIG I
might add] even had all the kit ready to do a saphenous cut-down.) This
patient had been in a prolonged entrapment RTA in the freezing cold with no
venous access. He was an IVDA and so his veins were shot and there was no
hope of gaining venous access there and then;

2)     There is a risk of damaging the saphenous nerve for those who make
the cut-down too high up. You and I would probably never do that but I have
seen it happen by the more inexperienced medics!;

3)     If one needs to infuse fluids (notwithstanding the role for
permissive hypotension) you can subsequently achieve venous access with less
urgency (using either venflons, central lines [subclavian, internal jugular
or femoral etc.]) As you rightly say, it is rare for venous access using
Seldinger method to fail and these other methods (BIG, FAST 1 and IO etc.
are interim measures); and,

4)     I myself would be perfectly happy to do a venous cut-down for venous
access but can't remember the last time I did in trauma (I am not that old
honestly!) I have done many for elective surgery reasons and in fact the
last one that I happened to do was approx 6 weeks ago (great saphenous vein
harvest for CABG as the radial artery was unsuitable for grafting.) I am
used to harvesting upto the saphenovenous junction so (presumably like you)
I am happy with my anatomy and surgical technique but I still wouldn't use
one in trauma (there are better options out there!!)

I agree that ATLS is a worldwide accepted standard and has tremendously
improved the standard of care from trauma since its inception.  The problem
with ATLS is the time period it takes to update on techniques. Our local
course (major U.K. city) as indeed everywhere else is still teaching 2L
fluid STAT for EVERYONE! This goes against the permissive hypotension
phenomenon and I gave up counting a long time ago the number of times I have
seen trauma patients' conditions worsen through cyclical fluid
resuscitation, whilst ignoring and making the surgical bleeding worse. This
is because people follow protocols (which should be banned) rather than
using clinical acumen and judgment and accepting that each situation is
different. For those that are unsure, we can accept guidelines (which
suggest a course of action for the clinician to follow if need be) but never
one which dictates that the clinician must ignore common sense and act
against his/her better judgment on the patient's condition in front of
him/her.

Matthew Reeds

Surgery

U.K.

-----Original Message-----
From: bensonblues at comcast.net [mailto:bensonblues at comcast.net] 
Sent: 18 March 2007 17:38
To: trauma-list at trauma.org
Subject: IO's, ad nauseum

Matt from the UK:

Do you really think cut downs should not be taught in ATLS?  In selected
patients, I still believe that there is a role for the (saphenous v.) cut
down, especially kids. It is unsusal for the Seldinger method to fail us in
our trauma bay, except in IVDA patients. But if it does, venous cut down
remains a good option: less trauma, more reliable/definitive, and less pain
if infiltrative anesthesia is used. If I am wrong here, I now know I am
getting old.

DB from the US

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