List Archives

Fri Aug 6 07:05:56 BST 2010

Rebecca

One caveat for lung contusion:
For the first three to eight hours try to recruit the lung with slightly
higher Vt - 8ml/kg, before doing the lung-protective stuff.

People are unduly scared of PEEP - I use PEEP = 1/5 of FiO2 with good
results.
Agree - ignore the pCO2 unless the pH drops - but I have not yet found it
necessary to use Bicarb if the PEEP is adjusted to response.

We also use a lot of PSV rather than SIMV now, with shorted vent times -
patients prefer to adjust the vent to their needs, rather than have the
vent fight them. We accept sats >90% in the previously healthy.

Oh and Kieth - I agree: use early not as a rescue therapy! (We don't have
Resp Tech in South Africa - the trauma surgeons and intensivists do the
ventilating ourselves)

Tim
Dr T C Hardcastle
M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
Principal Specialist Trauma Surgeon /
Honorary Senior Lecturer UKZN Dept Surgery
Deputy Director - IALCH Trauma Service
Durban, South Africa

We do not prone!
> What u do is try not to beat up the lungs to much UAE low pressure and low
> peep and accept some degree of hypoxia.  Sats.  88 are ok as there are
> plenty of copders and kids with congenital heart disease walking around
> with lower sats and use permissive hypercapnia.   I had one or with co2.
> 110. And sats 85.  He huffed propane.  He was this way for over a week
> survived with no deficits.    It is hard Ro get peole to do this.   If ph
> gets to low.  Give bicarb
> Sent from my iPhone
>
> On Aug 5, 2010, at 5:40 PM, Ante Ä†oriÄ‡ <ante.coric85 at gmail.com> wrote:
>
>> Well, l'm not sure how much proning is real helpful in longterm, besides
>> clearing hypoxaemia better intially, no survival benefit is reported, as
>> to
>> my notice.
>> If my patient has a lung contusions, l would start him/her on long
>> protecitve strategy, or atleast a modification of it, not waiting for
>> bad
>> gas analysis to kick in.
>>
>> cheers,
>>
>> Ante
>>
>> 2010/8/1 Keith Lamb <lambrrt at gmail.com>
>>
>>> Does anyone use any of the "lung injury score systems" to help identify
>>> patients who you anticipate will get "sicker", and use that info as
>>> part of
>>> their management strategy?
>>>
>>> Example: Lets say you have a trauma patient s/p MVC, multiple system
>>> involvement. Lets say your patient had exp. lap, splenectomy, and liver
>>> lac.
>>> In addition your patient had some blunt chest trauma, including sternal
>>> fracture, rib fractures, and unilateral pulmonary contusion.
>>>
>>> No significant gas exchange abnormality.
>>>
>>> Lets say you calculate your lung injury score, and then again 24 hours
>>> later
>>> and it is worse, BUT you still have no significant gas exchange
>>> abnormalities.
>>>
>>> Doesn't it make sense to "prophylactically" institute a strategy that
>>> is as
>>> lung protective as possible? Example: more PEEP, less tidal volume,
>>> maybe
>>> even HFOV?
>>>
>>> Some times it a hard sell to institute these type of things before
>>> there is
>>> significant hypoxemia/respiratory failure.
>>>
>>> My experience has been that we tend to use such strategies (HFOV,
>>> proning,
>>> NO, etc.) as rescue therapies and tend to implement them in a last
>>> ditch
>>> effort to salvage the unsalvageable. Then we swear up and down that
>>> these
>>> therapies "don't work", because we have unfavorable outcomes.
>>>
>>> If you do use a scoring system, which one?
>>>
>>> Keith
>>>
>>> Keith D. Lamb RCP, RRT
>>> Christiana Care Health System
>>> Newark, DE
>>> 302.983.6178
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