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Wed Dec 22 17:37:44 GMT 2010

No problem at all, but my major target WAS and IS NS and  
LR.......................One of my surgical colleagues (not in Houston) has  stated that one 
way to wipe out a civilization is to give overdoses of normal  saline.    

k

In a message dated 12/22/2010 11:24:59 A.M. Central Standard Time,  
sohailmuzammil at gmail.com writes:

Dear Dr.  Mattox,

Very succinct; though regulating the use of N Saline/Ringers  is
admittedly a rather extreme suggestion! I hope you wouldn't mind if  I
were to forward your email to some colleagues not on this  mailing
list.

Regards
S  Muzammil

==============================================
From:  KMATTOX at aol.com
To: trauma-list at trauma.org
Date: Wed, 22 Dec 2010  09:49:59 EST
Subject: MTP, VIIa, and OTHER thoughts
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
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MTP, VIIa, and OTHER thoughts