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MTP, VIIa, and OTHER thoughts

Robert Smith rfsmithmd at comcast.net
Wed Dec 22 15:52:11 GMT 2010


Dr. Mattox,

I had a question. When your patients go directly to the OR from the ambulance, how do they get registered and processed into the system so that they may receive blood, drugs and imaging? Do you have trauma pseudonym patient registrations already set up or processed and/or clerical staff in the OR to facilitate whatever you do?

Rob Smith

PS, I love the use of the Royal "We"


On Dec 22, 2010, at 8:49 AM, KMATTOX at aol.com wrote:

> No.
> 
> The simple short answer is still no.    
> 
> (Read on only if you have an open scientific mind)
> 
> Over the many years VIIa has been researched, we have evaluated every paper 
> very carefully, looking for appropriate controls and comparisons.   We  
> have listened to the presentations at national and international  meetings.    
> Even when testimonials state that the bleeding  was slowed down or stopped 
> with VIIa or use of other such factors (including  IX), other things were 
> done as well and one could not have attributed the change  solely to VIIa.    
> The controls in all of the studies were  not good.   Coagulation profiles 
> for immediate evaluation (such as TEG  and Rapid TEG) were not uniformly 
> performed.     
> 
> Over the many years that VIIa has been used by our neighbors and colleagues 
> across Texas and the world, we have probably used no more than a total of 
> 5  vials.    I would dare say that we have not used more blood and  had a 
> greater mortality than other trauma centers that routinely use  VIIa.     
> 
> Furthermore, if one limits crystalloid use in the EMS, EC, and OR, and uses 
> the freshest blood possible, and uses TEG directed component therapy, 
> including  plasma and platelets, then one does not see the watery coagulopathy 
> which is  very often iatrogenic, occurring in the OR after several liters of 
> crystalloid,  and due to that factor, not the "coagulopathy of trauma" 
> (whatever that  is).    
> 
> I have yet to find any controlled study in trauma which demonstrated any  
> survival advantage to using VIIa.   I can find many studies which show  a 
> survival advantage by keeping the patient hypotensive, limiting crystalloid,  
> not using MAST, etc.      
> 
> It is far past time when we need to focus on what is really now known about 
> coagulopathy seen following major trauma:   
> 
> 1.     If FDA, and others would regulate the DOSING of  crystalloid fluids 
> (especially Ringers Lactate and Normal Saline), like FDA  regulates the 
> dosing of other drugs and devices, and uses what is known from  many many 
> controlled laboratory and human studies, the majority of post injury  coagulopathy 
> would simply go away and we would not really need all of the  expensive 
> biologics, devices, and drugs to reverse the iatrogenic  coagulopathy.    
> Instead of looking for a magic bullet after "the  horse is out of the barn,"  
> keep the barn from burning in the first place,  by doing what has been learned 
> in many civilian and military trauma experiences,  FOR OVER 100 YEARS.  
> 
> 2.   DO NOT POP THE CLOT (fresh soft clots), by raising the BP by  many 
> different means as has been documented in various modes for over 8000  years, 
> including the Bible, Shakespeare, Imhotep, Walter Cannon, Shaftan,  Sondeen, 
> Rhee, etc. etc. etc. 
> 
> 3.   For the kind of patients who will need operative control of  
> hemorrhage, take them to a trauma facility with surgeons present and merely go  
> directly from the ambulance bay to the OR, using the ED to wave to the patient  
> as they head for the elevator.     For this group of  patients, there is 
> nothing good which can be gained in the ED, that cannot be  done better in the 
> OR, FOR A LONG LENGTH OF REASONS.  
> 
> 4.   Consider eliminating the use of LR and NS completely, unless  it is in 
> small amounts of no more than 25 ml. at a time
> 
> 5.    FINALLY bite the bullet and correct and rewrite the  ATLS manual and 
> course to correctly reflect what is known, and has been shown in  the recent 
> wars and civilian trauma experience.     
> 
> 6.    Use TEG and Rapid TEG in the ED, OR, ICU, instead  of the long list 
> of other less functional coagulation  profiles.    
> 
> 7.    Do not be mislead by the many incompletely evaluated  topical 
> clotting aids
> 
> 8.    Recognize that "...we have met the enemy and he is  us." (Pogo)
> 
> k
> 
> 
> 
> In a message dated 12/22/2010 1:10:59 A.M. Central Standard Time,  
> tshepherdmd at hotmail.com writes:
> 
> 
> Has  anyone found it advantageous to add factor seven or factor nine to 
> their  MTP?
> 
> 
> NOTHING  SPLENDID Has Ever Been Achieved Except By Those  Who DARED BELIEVE 
> THAT SOMETHING INSIDE THEM  Was Superior to  CIRCUMSTANCE
> 
> 
> 
> 
> 
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