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Mon Mar 5 02:11:31 GMT 2012

Thank you with much respect

Ray Staggs, RN
Performance Improvement Patient Safety Coordinator
Trauma Services
816-271-6707
Fax: 816-271-7637
ray.staggs at heartland-health.com

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-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Krin135 at aol.com
Sent: Sunday, March 04, 2012 8:47 AM
To: trauma-list at trauma.org
Subject: Re: CVC for subclavian access in major haemorrhage

Ray:

as a retired FM/EM doc, I can only point out that in the ED, by definition,  we are limited in what we can do....and smaller hospitals (where I spent most of  my career) are even more limited than recognized Trauma Centers.

Based on almost 2 decades on this list, and a fair amount of reading and experience outside the list....here's what I have distilled to maintain an acceptable (which depends on the amount of damage AND the presence or absence of  closed head trauma) Central Perfusion Pressure pending arrival in the OR to plug  the leaks:

1: Basics save lives....you have already covered those, including stopping the bleeding you can by applying direct pressure or a tourniquet, and splinting the obvious broken bones (including sheet wraps for a fractured pelvis). I've seen many cases (some to my shame) where some of these factors were NOT cared for in the ED in the rush to get the patient to the OR....and in  several cases, where there was a negative impact on patient recovery due to  those missed opportunities.

2: From least to most preferable infusions to maintain blood pressure:
inotropes; crystalloid IVF; colloidal IVF (including Hetspan et al); Low titer
0  neg blood and AB pos FFP; type specific but uncrossmatched blood products ;  typed and matched  blood products.

3: in your example, the MAP would be (46 + ((76-40)/3))= 58....very close to the minimum 60 MAP in non TBI patients with no co morbidities....(surprised?)....I'd shoot for just enough fluid to bring the HR  down to about 120....and would re assess the level of consciousness to make sure  that there is not a situation where the patient is paralyzed but not fully  sedated...or under treated for pain....either of which can have a major impact  on how well the patient does in the post op period.

My point? There is no 'best' recipe....only a continuum of treatment that begins with the first contact the patient has with the system and only ends when  the patient is discharged from rehab. Check out the Trauma.org's excellent web  site, review the back files from this list (and others, in particular EMED-L and  CCM-L), and talk to your surgeons and ED docs.

Also, are you on the MARC.org and Missouri Time Critical Diagnosis mailing lists?

if not, contact me off list and I'll see about pointing you towards those valuable resources.

ck

In a message dated 03/04/12 08:21:23 Central Standard Time, Ray.Staggs at heartland-health.com writes:

I have  read and heard from Dr. Mattox as well as others to bypass the ED and head  straight to the OR if the patient is bleeding.  If I am among the other  level II,III trauma centers waiting for the OR to be available and I am  assisting the ED provider and ED nurses for the 20-30 minutes while we wait.  HR 140's BP 76/40 RR Intubated and bagging Temp 35.6, Uncrossed matched blood in the cooler and ready to infuse 2:1:1 Ratio RBC, FFP,  Platelets, do I recommend a CVC large enough to handle large volume ensuring  the
systolic bp is =>90, do we infuse IVF's or do we wait.   Keep  in minds it will
take 10-15 minutes before the cooler of blood products is  ready and at the
bed side, so I am stuck waiting with a fading patient.   What is best?

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CVC for subclavian access in major haemorrhage