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Wed Nov 4 11:06:08 GMT 2009

I'm looking forward to reading the paper!

ck

In a message dated 11/4/2009 03:26:22 Central Standard Time,  
Ronald.Gross at baystatehealth.org writes:

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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Mechanical ventilation and flail chest