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blunt traumatic arrest pharmacotherapy

mike mike.smyth at blueyonder.co.uk
Tue Dec 15 12:54:22 GMT 2009

Hi Mark

I would argue that specifically trained fire fighters and tactical 
medics are not laypersons (who are the only group for whom 
unresponsive+abnormal breathing=CPR). Your 'group' have a duty to 
respond, are trained as such, will be judged as such and consequently 
should practice as 'professionals'. They have no basis for their 
argument in my opinion.


Mark Forrest wrote:
> Thanks Mike and I agree with all that u say. For a paramedic or doc we can assess the situation along ALS/ATLS lines and make a therApeutic decision. However, I am dealing with fire and rescue, firearms and other medics who are not aiming to attain paramedic status. I still believe that they are a significant level above BLS but there is currently no level for this standard as ILS is simply BLS plus defib. It would have been better as Intermmediate life support lying genuinely half way between BLS and ALS as my guys skills do!
> I guess we just need to dig our heels in and make a stand on a contoversial issue again...... It can be a lonely place out there!!
> Thanks for your comments
> Mark F
> Uk 
> Sent from my iPhone
> On 14 Dec 2009, at 17:19, mike <mike.smyth at blueyonder.co.uk> wrote:
> Hi Mark
> Your first statement is misleading - the initiation of CPR in the unresponsive patient with abnormal breathing is applicable only to laypersons, not healthcare professionals. Paramedics should be practising in a manner more consistent with in-hospital resuscitation including pulse checks - they are where I work. The JRCALC guidelines (followed by UK paramedics) do differentiate between medical and traumatic arrest the latter of which has 'management' pathways for blunt and penetrating traumatic arrest. Pasted below is the opening passage to the traumatic cardiac arrest guideline;
> "Traumatic cardiac arrest is a very different condition
> from the more usual cardiac arrest which is often
> related to ischaemic heart disease. Management of
> traumatic cardiac arrest must be directed toward
> identifying and treating the underlying cause of the
> arrest or resuscitation is unlikely to be successful.
> Traumatic cardiac arrest may develop as a result of:
> 1. Hypoxia caused by manageable issues such as
> obstruction of the airway (e.g. facial injury or
> decreased level of consciousness) or breathing
> problems (e.g. pneumo/haemothorax).
> 2. Hypoperfusion caused by compromise of the heart
> (e.g. stab wound causing cardiac tamponade) or
> hypovolaemia (either occult or revealed haemorrhage)."
> Subsequent management pathways are directed to reversing the above, and where they fail, indicate that further resuscitation is likely to be futile. Paramedic reviewers of your manual should not be responding in the manner that you indicate. I do however agree that the ERC and UK guidelines make no concession to the futility of chest compressions in cases of traumatic arrest; to the best of my knowledge this is no different in the AHA guidelines, or other international flavours thereof.
> regards
> Mike
> (UK paramedic)
> Mark Forrest wrote:
> Hi Ron
> This is exactly the problem that we face at the moment 'unresponsive' and 'abnormal breathing' casualties autmotically get CPR in our current Uk/ERC BLS guidelines. My firefighters and tac medics will see far more trauma than cardiac arrests so this pratice just doesn't fit but our book/ course reviewers from the ambulance services continually state that pulse checks, supporting respiration and more thorough casualty assessment is outside BLS/ resus guidelines. This sort of knee jerk blinkered view is very frustrating.
> Getting such comments from yourself, Tim and Gideon, who all seem to agree with our Faculty view, reinforces our stand that such practice does not fit practioners managing trauma
> Cheers
> Mark F
> UK
> Sent from my iPhone
> On 14 Dec 2009, at 14:15, "Gross, Ronald" <Ronald.Gross at baystatehealth.org> wrote:
> Mark,
> I am confused (OK, so my wife would say that is a normal state for me).....since when does "abnormal breathing" beget immediate chest compressions?  The only people that are going to qualify for chest compressions are those who are pulseless after trauma, and they will be bagged (or tubed) because most likely they will be "breath-less" as well!  To me it is that simple.  It appears that your field guys are indeed trying to equate the trauma patient to the medical patient and that is not going to bode well.  If I did CPR on every unresponsive patient, I would have a whole lot of drunks and "underdoses" (cynicism at its best!!) who will be waking up with very sore chests!
> Ron
> Ronald I. Gross, MD, FACS
> Chief of Trauma & Emergency Surgery
> Baystate Medical Center
> 759 Chestnut Street
> Springfield, MA  01199
> 413-794-4022  phone
> 413-794-0142  fax
> ronald.gross at baystatehealth.org
> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of MARK FORREST
> Sent: Friday, December 11, 2009 5:57 PM
> To: Trauma-List [TRAUMA.ORG]
> Subject: Re: blunt traumatic arrest pharmacotherapy
> Hi Ron
> I have been following this with great interest as we have recently been having a real dilemma with a new training manual for UK firefighters and firearms officers. 90% of their work will be trauma related, however they may still attend some cardiac arrests. We have tried to produce a manual and treatment algorithm that brings together trauma and cardiac care into one simple process but whilst this has been fairly straight forward to sell to our trauma care providers and medical Faculty, the UK paramedics that have reviewed the manual just cannot get ALS out of there head and will not accept pulse checks, supportive ventilation for resp rates less than 8 and worst of all, they expect all 'unresponsive' patients or with abnormal breathing to get immediate chest compressions, as thats what BLS says!
> We want to ignore this and to reach our guys to assess the casualty further in terms of conscious level, pulses,  CRT etc but the 'cardiac ALS' guys just wont have it and say that this introduces delays and does not fit ERC guidelines.
> They also insist that ALS includes trauma!!! God knows why we all do ATLS, ATACC etc if that is the case!!!
> How do we resolve this for these guys.....do we just accept CPR in every unresponsive victim??
> Regards
> Mark
> Dr Mark Forrest
> Consultant in Anaesthetics & Critical Care
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