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Mechanical ventilation and flail chest

Gross, Ronald Ronald.Gross at baystatehealth.org
Wed Nov 4 09:25:34 GMT 2009


Well as Mark already knowns I will trach within 7 days and fix multiply distracted fractures/flails at or just after that 7 day mark.
Ron

PS - thanks, Mark!
Typed (poorly) with my thumbs on my Blackberry!

----- Original Message -----
From: trauma-list-bounces at trauma.org <trauma-list-bounces at trauma.org>
To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
Sent: Wed Nov 04 03:42:54 2009
Subject: Re: Mechanical ventilation and flail chest

I agree with Ian. When I said 'early' I meant within the first few days!
Mark F
Uk

Sent from my iPhone

On 4 Nov 2009, at 05:26, Ian Seppelt <seppelt at med.usyd.edu.au> wrote:

Or even earlier. If the patient is clearly going to need more than a week or two ventilation then the sooner the trache is done the better.
Ian

Ante C'oric' wrote:
what about time limit? do you trach after 2 or 3 weeks? l've heard someone
doing it after only 1 week? Do you keep ETT longer in children?
Ante

2009/11/3 Mark Forrest <atacc.doc at btinternet.com>

 
Simple solution.... Tracheostomy! The question is when, early or late?!
We tend to go early, and once the FiO2 is 0.6 or less. Then sedation off.
I wait to be convinced that we are wrong in our timing!
Regards
Mark F
UK
Ps next question, who if anyone is surgically fixing flails and when? Great
presentation on this by Ron at the weekend.

Sent from my iPhone

On 1 Nov 2009, at 05:20, parthasarathi goswami <parthasarathi013 at yahoo.com>
wrote:

TO ALL LIST MEMBERS,

LET US REMEMBER THAT BEING INTUBATED IS ONE OF THE MOST PAINFUL PROCEDURES
THAT HAPPENS IN THE ICU..ALTHOUGH NO BLOOD IS LET OR ANY NEEDLE OR SCALPEL
IS USED INTIBATION INCREASES THE STRESS OF THE PATIENTS AND MANY RECOLLECT
THAT AS ONE OF THE MOST PAINFUL MEMORIES OF THEIR ICU STAY..ALL PATIENTS ON
THE VENT OR INTUBATED MUST RECCIEVE SOME SEDATION AND ANXIOLYSYIS.(
DEXMEDETOMIDIDNE PROBABLY FITS THE BILL NICE AND SQUARE)...IT HELPS CALM
FRAYED NERVES..MAY ALSO HELP US WEAN PATIENTS FASTER ..AFTER ALL NO ONE
WANTS TO GO HOME WITH A NORMAL PHYSIOLOGY BUT A PAINFUL THROAT.AND A BAG OF
BAD MEMORIES.

DR PARTHASARATHI GOSWAMI
CHIEF ICU COORDINATOR
WOODLANDS HOSPITAL, KOLKATA , INDIA

--- On Sun, 11/1/09, Krin135 at aol.com <Krin135 at aol.com> wrote:


From: Krin135 at aol.com <Krin135 at aol.com>
Subject: Re: Mechanical ventilation and flail chest
To: trauma-list at trauma.org
Date: Sunday, November 1, 2009, 12:45 AM


Dr. Duchesne:

having run into the problem in the past, I modestly recommend that we
change "paralyzed and sedated" to "sedated and paralyzed," to indicate that
the
sedation/analgesia is the more important phase of the treatment. I've seen
a  more than few cases (both medical and trauma) of patients on the vent
who
were unstable (tachycardia, labile blood pressure, lousy blood  gases)
until we increased their sedation. These patients were fully  paralyzed at
the
time. Most of them were lost to my follow up, so I had no way  to ask them
if they remembered any of the painful procedures (chest tubes,  Foleys)
that
they received while intubated.

I have had more than a few patients in the last 35 years who could relate
*interesting* anecdotes from the discussions going on during their general
anesthesia...can be very embarrassing for the docs and nurses  involved!

I've also seen many well sedated patients that did not need paralysis to
tolerate even painful ventilation.

ck


In a message dated 10/31/2009 11:44:56 Central Standard Time,
jduchesn at tulane.edu writes:

Dear  Matthieu:
I have my own bias on what works for lung contusion with severe  chest wall
injury (flail chest) and ARDS net is not the answer.
I like to  use damage control ventilation using pressure control at low
rate with a 1 to  1 I:E ratioa. This works great in opening your FRC. I
identify the best PEEP  and then add Pressure above PEEP to give you a
Plateau at
33. For this  maneuver the patient needs to be paralyzed and sedated in
order
to achieve the  best recruitment.
I use this damage control ventilation mode for the first  72 hours and
although I don't have our own data yet the CXR difference is  dramatic.
Good Luck
Duchesne
CharityOne-New Orleans
Sent via  BlackBerry by AT&T

-----Original Message-----
From: Matthieu G.  <mat.genz at gmail.com>
Date: Sat, 31 Oct 2009 18:13:49
To:  Trauma-List [TRAUMA.ORG]<trauma-list at trauma.org>
Subject: Mechanical  ventilation and flail chest

Dear list members,

do you use a  specific mechanical ventilation strategy for patient with
flail  chest and underlying lung contusions, besides the lung
protective  approach for patient with ALI/ARDS? For example, Moore's
Trauma  textbook advocates the use of volume controlled over pressure-
supported  mode, the rationale being that even the modest negative
pressures  needed to trigger the ventilator cycle may destabilize the
chest  wall.

Thank you for your input.

Matthieu  Gensburger

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