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Tue Jun 26 05:08:49 BST 2012

Sorry  but one cannot restart a heart that has no oxygen delivery.
Hypovolemic from blood loss trumps all the rest

Norman

Norman McSwain MD, FACS
Professor of Surgery, Tulane University
Trauma director, Spirit of Charity Trauma Center, ILH
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Brandon Oto
Sent: Monday, June 25, 2012 10:20 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: CPR and Drugs for Blunt Traumatic Arrest (Prehospital
Perspective)

One could also argue, perhaps not convincingly but at least coherently,
that hypoxia or other causes might induce fibrillation prior to the
point where death from the underlying cause is irreversible. In other
words, although the etiology is obviously traumatic, and prognosis
undoubtedly dismal, perhaps they simply got "unlucky" and entered VF
whole minutes before an inevitable PEA or asystolic end-game. If you can
shock them back out you may still have a little more time to fix the
problem.

It's a stretch, and certainly senseless if no attempt is made to correct
the underlying cause, but I agree that automatically calling VF a
terminal rhythm may be premature. PEA/asystole would be a more plausible
"give up" condition...

Brandon

***
http://degreesofclarity.com/
http://emsbasics.com/

On Jun 25, 2012, at 2:59 PM, Stephen Richey wrote:

> Which pretty much negates the major supposed benefit of helicopters, 
> but let's not get too far off course.
> 
> The way I look at it is that if you've done what you can to "fix" the 
> problem, then trying to convert the rhythm is the next step since VF 
> isn't exactly something that can be relied upon to spontaneously 
> convert.  Also, given the rate of medical issues causing crashes 
> resulting in serious trauma, it could be argued from that perspective.

> I'm not saying it's a definitely good idea, but it is something to at 
> least discuss and debate as an academic discussion.
> 
> On Mon, Jun 25, 2012 at 2:40 PM, <daniel.gerard at comcast.net> wrote:
> 
>> Yes we were forbidden, but if we made telemetry contact, the doc 
>> answering could over-ride that. Now at UMDNJ they use emergency 
>> medicine docs to take telemetry, but when I first started as a 
>> paramedic, a surgeon got on if it was a trauma and an internal 
>> medicine doc (or family practice, or emergency medicine doc) got on 
>> if it was medical...NO we didn't use the above the waist/below the 
>> waist criteria...Keep in mind in that urban setting, we had short 
>> transport times, so sometimes when we made contact we were literally
>> 3-4 minutes out. Generally our first radio contact with our dispatch 
>> was to do a trauma notification.
>> 
>> 
>> Now the helicopter may have had a different set of rules, but they 
>> had longer scene and transport times.
>> 
>> 
>> Daniel R. Gerard, MS, RN, NREMT-P
>> Secretary - International Association of Emergency Medical Services 
>> Chief's (2009 - 2011)
>> 
>> http://www.linkedin.com/in/dangerard
>> 
>> http://www.iaemsc.org/index.html
>> 
>> ----- Original Message -----
>> From: "Stephen Richey" <stephen.richey at gmail.com>
>> To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
>> Sent: Monday, June 25, 2012 11:32:13 AM
>> Subject: Re: CPR and Drugs for Blunt Traumatic Arrest (Prehospital
>> Perspective)
>> 
>> Here's my question about that approach (don't touch the defib): what 
>> about after you've done what you can to correct the potentially
"reversible"
>> underlying causes of arrest? Were you still prohibited from trying to

>> convert the VF?
>> 
>> 
>> On Mon, Jun 25, 2012 at 2:18 PM, <daniel.gerard at comcast.net> wrote:
>> 
>>> Just my thoughts and past experience here folks.
>>> 
>>> 
>>> Years ago (1980/1981), when I first started as an EMT in Newark, NJ,

>>> and they were doing some basic analysis of trauma patients out of 
>>> their registry there, Ken Swan ALWAYS told us that less was more. 
>>> HIS WORDS...Traumatic arrest You MUST correct the underlying problem

>>> (tension pneumo, control hemorrhage, etc.). You shouldn't touch a 
>>> drug or defib, EVER for the traumatic arrest patient, and that IF 
>>> you were going to
>> start
>>> CPR, it should be for a patient who had an identifiable underlying 
>>> issue that could be resolved (tension pneumo, etc.). During his 
>>> analysis of the trauma patients in Newark, at that time (early 
>>> 1980's) NONE of the
>> patients
>>> who received pre-hospital epi 1:10000, atropine, NaHCO3 survived.
>>> 
>>> 
>>> So I had a saying, that got adopted by most of the people there, 
>>> 'you CANNOT have good ALS without GOOD BLS'. You couldn't do an ALS 
>>> procedure until you took care of all the critical BLS procedures... 
>>> White lights
>> and
>>> cold steel was what saved trauma patients, this is no lie . We were
>> DRILLED
>>> not to spend time on scene. IV's and advanced airways HAD TO BE DONE

>>> IN
>> THE
>>> BACK OF THE AMBULANCE ON THE WAY TO THE TRAUMA CENTER. NO ALS ON
SCENE.
>> Dr.
>>> Swan would would crazy over the on scene time, and he would get on 
>>> our medical director Clayton Griffin's back during trauma review if 
>>> there was an ALS unit on scene over 10 minutes. Bartholomew 
>>> Tortella, who was our associate medical director (I know two trauma 
>>> surgeons leading EMS as medical directors...it was a hospital for 
>>> surgeons, what can I say), drilled us that we could NEVER EVER 
>>> infuse fluid unless the patients BP
>> was
>>> less than 80, and then only to bring the BP back up to 80-90. Most 
>>> of our IV's were large bore (16 or 14 gauge) that once we connected 
>>> the ringers (which we hung with blood tubing), we would flush the 
>>> blood out of the line (about 10 or 20 cc's) and shut off.
>>> And NEVER EVER any drugs.
>>> 
>>> 
>>> The first words, after we updated them on any changes/ treatment/ 
>>> particulars from the last telemetry report via radio when we got to 
>>> the trauma center was 'how long were you on scene', followed by, 
>>> 'how long
>> did
>>> it take for you to get here'.
>>> 
>>> 
>>> We didn't work a lot of traumatic arrests (blunt or penetrating), 
>>> but
>> when
>>> we did they were the right ones.
>>> 
>>> 
>>> Daniel
>>> 
>>> 
>>> Daniel R. Gerard, MS, RN, NREMT-P
>>> Secretary - International Association of Emergency Medical Services 
>>> Chief's (2009 - 2011)
>>> 
>>> http://www.linkedin.com/in/dangerard
>>> 
>>> http://www.iaemsc.org/index.html
>>> 
>>> ----- Original Message -----
>>> From: KMATTOX at aol.com
>>> To: trauma-list at trauma.org
>>> Sent: Monday, June 25, 2012 8:00:28 AM
>>> Subject: Re: CPR and Drugs for Blunt Traumatic Arrest
>>> 
>>> Prehospital Cardiac Arrest following blunt trauma. Pronounce dead 
>>> unless part of an ongoing protocol with tight review.
>>> 
>>> Blunt trauma and arrest in the EC. If EKG does nota have a tight 
>>> rhythm , pronounce dead, unless there is a surgical protocol
>>> 
>>> Blunt trauma and arrest anywhere. NO External cardiac compression, 
>>> NO ATLS drugs. Will be ineffective. If there is to be a reversal it 
>>> will be something surgical such as pericardial herniation, 
>>> hemopericardium, ruptured right artium, etc.
>>> 
>>> Any CPR and ACLS will only make the situation WORSE, and should 
>>> prompt a peer review and education of those who propose such an
action.
>>> 
>>> MANY MANY articles have been written on this subject and appear in 
>>> the trauma literature.
>>> 
>>> k
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> In a message dated 6/24/2012 6:33:59 P.M. Central Daylight Time, 
>>> edcritcare at gmail.com writes:
>>> 
>>> Hi Folks,
>>> 
>>> I have been a long-term lurker on this list.
>>> 
>>> I do a podcast called the EMCrit Podcast, which covers 
>>> Resuscitation, Trauma, and Critical Care topics. [http://emcrit.org]

>>> It gets >100,000 downloads per month from EM, anesthesia, critical 
>>> care, and trauma practitioners.
>>> 
>>> One of my listeners can't convince her attendings that giving CPR 
>>> and
>> ACLS
>>> medications to a blunt traumatic arrest is not sound resuscitation. 
>>> On literature search, there's not much evidence. Physiologically, 
>>> these interventions make no sense.
>>> 
>>> My own practice is to perform bilateral finger thoracosotomies 
>>> (chest
>> tube
>>> placement without actually placing the tube unless there is air or 
>>> blood
>>> return) and echo the heart for tamponade. If those two don't reveal 
>>> a reversible cause, we call the code.
>>> 
>>> I think this mirrors the practice of most of my trauma colleagues.
>>> 
>>> But since there is not great evidence, your expert opinion is the 
>>> next
>> best
>>> thing.
>>> 
>>> If you have a minute and you have an opinion on this topic, call the

>>> podcast voiceline at 1-781-436-2748 and leave a voice message with 
>>> your feelings. I will compile them all and release them as a 
>>> podcast. Make
>> sure
>>> you state who you are and where you work when leaving the message.
>>> 
>>> If you are shy or would rather stick with the written word, reply to

>>> this post and I'll give voice to your thoughts.
>>> 
>>> I know this topic has been discussed on the list before and on 
>>> trauma.orgas well, so I will definitely discuss those opinions from 
>>> the archives as well.
>>> 
>>> Much thanks,
>>> 
>>> Scott
>>> 
>>> --
>>> Scott Weingart <http://scottweingart.com>, MD
>>> 
>>> Associate Professor
>>> 
>>> Director of ED Critical Care
>>> 
>>> Mount Sinai School of Medicine
>>> 
>>> New York, NY
>>> ED Critical Care Blog & Podcast <http://blog.emcrit.org>
>>> [image: YouTube] <http://youtube.com/emcrit> [image:
>>> Facebook]<http://facebook.com/emcrit> [image:
>>> Google Plus Page] <https://plus.google.com/b/101796437135386808424/>
>>> [image:
>>> Twitter] <http://twitter.com/emcrit>
>>> --
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>>> 
>> 
>> 
>> 
>> --
>> Stephen Richey
>> Founder and Chief Researcher/Designer Kolibri Aviation Safety 
>> Research 5174-B Winterberry Circle Indianapolis, IN 46254
>> 317-985-4740
>> 
>> "I think the best thing, and the only thing in our infinite 
>> inadequacy in making up for the loss of life, is to say something we 
>> have been able to say in a lot of other accidents to grieving 
>> families. That is 'Those deaths will not be in vain. We will not let 
>> them be in vain. Every one of those lives will be made to count in 
>> terms of making sure that three, four, five or ten other people do 
>> not die."- John J. Nance
>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.php?/community/
>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.php?/community/
>> 
> 
> 
> 
> --
> Stephen Richey
> Founder and Chief Researcher/Designer
> Kolibri Aviation Safety Research
> 5174-B Winterberry Circle
> Indianapolis, IN 46254
> 317-985-4740
> 
> "I think the best thing, and the only thing in our infinite inadequacy

> in making up for the loss of life, is to say something we have been 
> able to say in a lot of other accidents to grieving families.  That is

> 'Those deaths will not be in vain. We will not let them be in vain. 
> Every one of those lives will be made to count in terms of making sure

> that three, four, five or ten other people do not die."- John J. Nance
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
> 

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