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Fri Aug 26 06:45:07 BST 2011

"so we can sit them up and reduce ICP and the risk of ventilator associated pneumonia"

Euh ! ? ?

Can you not get the same result
Without "Sitting them up"
By inclining the bed XX degrees  ?

Is there a engineering hurdle to this ?

Curious ?

Charles
From: Kmattox <kmattox at aol.com>
To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
Cc: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>; "trauma-list at trauma.org" <trauma-list at trauma.org>
Sent: Friday, August 26, 2011 12:19 AM
Subject: Re: VOMIT and ER workup of a MAJOR trauma patient

Julie has made a good point. 

Sent from my iPhone

On 2011-08-25, at 7:49 PM, Julie Miller <jamiller444 at yahoo.com> wrote:

> We also like the pan scan in major multitrauma patients. In addition to identifying injuries to the head and torso, it also allows reconstruction views of the spine, allowing us to discontinue spinal precautions rapidly in most patients so we can sit them up and reduce ICP and the risk of ventilator associated pneumonia. 
> 
> Julie Miller
> 
> Sent from my iphone
> 
> On 26/08/2011, at 5:46 AM, jjsurgmd at aol.com wrote:
> 
>> 
>> 
>> Sent from my iPhone
>> 
>> On Aug 25, 2011, at 9:27 AM, KMATTOX at aol.com wrote:
>> 
>>> Dr. Ursic:      
>>> 
>>> As described, the patient is clearly a surgical patient that has a head  
>>> injury, a possible hemomediastium, and a possible "something" in the abdomen ( 
>>> positive FAST for fluid), but apparently BP and pulse stable. 
>>> 
>>> 
>>> As presented, this patient has an apparent abnormal screen on his chest  
>>> X-ray, so the next test is a diagnostic, not another SCREENING test to 
>>> evaluate  the mediastinum.    That test is an aortogram, as one needs to  evaluate 
>>> the innominate artery, the ascending aorta, the aortic arch and the  distal 
>>> thoracic aorta.    A C.T does NOT evaluate these locations  as virtually the 
>>> entire radiographic, trauma, and vascular literature for the  past decade 
>>> have focused only on the proximal descending thoracic  aorta.  SO your 
>>> recommendation for a CT of the chest is unfounded,  although often done because 
>>> radiologists do not often like to get up at night to  do aortograms.      
>>> 
>>> Second, you said NOTHING about use of afterload reduction  agents.  The 
>>> very second that you suspect a thoracic vascular injury,  one should start 
>>> afterload reduction to decrease the shear factor on the aortic  wall.    
>>> 
>>> Third:  There is NO indication to start two large bore  IVs.  NONE in the 
>>> case as presented.  To start one small  bore IV I have no argument, but if 
>>> one starts a large bore IV, then lots of  crystalloid ALWAYS goes in.  One 
>>> could give a LONG LIST of reasons  why ANY CRYSTALLOID of the clinicians 
>>> choice has an unfavorable impact on the  patient, creation of clotting 
>>> problems, turning on inflammatory mediators (bad  humors), etc. etc. etc.      The 
>>> examiners on the ABS  mostly now know these lists and would be looking for 
>>> crystalloid prevention in  the patient as presented.    
>>> 
>>> Fourth:  As presented, this patient would require a CT of the  head and 
>>> neck soon after arrival in the ER, say within the first 10  minutes.    As 
>>> presented the priority in this patient is to  do something to his head injury, 
>>> directed by the head CT.  
>>> 
>>> Fifth:    There is NO reason as presented for a FAST of the  heart and 
>>> pericardium, and I have heard many more lectures and papers than I  wish to 
>>> count anymore on the misleading information from a FAST of the  abdomen.    Many 
>>> trauma centers have abandoned the abdominal  FAST.    I see PROBLEMS every 
>>> week from over reading and mis  reading of ultrasounds in the ER by 
>>> emergency physicians, in patients that had  no reasons for an ultrasound in the 
>>> first place.  I would hate to  teach students and residents a dependency and 
>>> use of a test which has almost no  impact on treatment and decision making, 
>>> and then most often a NEGATIVE  impact.  
>>> 
>>> Sixth:  I still do not have a good impression of the PHYSICAL  EXAMINATION 
>>> of the abdomen or pelvis at any time in this patient.    Are there any 
>>> physical findings suggestive of an injury in either of these  locations.    If 
>>> there is and you have intubated the patient, I  could make a case for a CT of 
>>> the abdomen prior to the crainiotomy or admission  to the Neurosurgery  
>>> ICU.    
>>> 
>>> My greatest concerns with your suggested treatment of the patient was the  
>>> reliance on abdominal FAST, the starting of two large bore IVs, and the 
>>> Chest  CT.      It is long overdue time for us to put these  tests and 
>>> treatments into their proper perspective.  I would suspect  that both you and the 
>>> examiners on the American Board of Surgery would have some  element of 
>>> agreement.      
>>> 
>>> The time this patient should remain in the ER should be very very short and 
>>> it is essential that you do not over treat him.  Many members of the  ABS 
>>> are concerned that we are training a group of young surgeons who are  
>>> infatuated with technology, and have forgotten judgment, physical examination  
>>> and perspective.    
>>> 
>>> k
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VOMIT and ER workup of a MAJOR trauma patient