trauma-list Digest, Vol 38, Issue 13

Wed Aug 9 13:23:23 BST 2006

We have had long discussion about NSAID's in our department. ketorolac is associated with the worst side effect profile and Ibuprofen has the least amount of side effects, hence we have stopped buying Ketoroalc for the department.

regards

Dr Prasad
Consultant Anaesthetist
Birmingham UK

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Subject: trauma-list Digest, Vol 38, Issue 13

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Today's Topics:

   1. RE: Ketorolac (ARUNI SEN)
   2. RE: Ketorolac (Hardcastle, Tim, Dr <tch at sun.ac.za>)
   3. RE: Ketorolac (Black, John)
   4. RE: Ketorolac (Lorick Fox, PA-C)
   5. Re: SGW to Femoral triangle - Synthetic vs "autogenous"
      (meredith mcbride)
   6. Re: SGW to Femoral triangle - Synthetic vs "autogenous"
      (Ronald Gross)
   7. Re: Ketorolac (Guy Jackson)
   8. RE: Ketorolac or is it DICLOFENAC
      (Hardcastle, Tim, Dr <tch at sun.ac.za>)
   9. RE: Ketorolac (Hardcastle, Tim, Dr <tch at sun.ac.za>)
  10. RE: Ketorolac or is it DICLOFENAC (Lorick Fox, PA-C)
  11. Lecture help (susanna mathews)
  12. Re: Lecture help (KMATTOX at aol.com)
  13. Re: SGW to Femoral triangle - Synthetic vs "autogenous"
      (meredith mcbride)
  14. Re: SGW to Femoral triangle - Synthetic vs "autogenous"
      (KMATTOX at aol.com)
  15. Re: SGW to Femoral triangle - Synthetic vs "autogenous"
      (Sohail Muzammil)
  16. Re: SGW to Femoral triangle - Synthetic vs "autogenous"
      (KMATTOX at aol.com)
  17. RE: Ketorolac (Nick Macartney)
  18. Re: SGW to Femoral triangle - Synthetic vs "autogenous"
      (Ronald Gross)
  19. Ketorolac (bensonblues at comcast.net)
  20. Re: SGW to Femoral triangle - Synthetic vs "autogenous"
      (docrickfry at aol.com)
  21. Re: SGW to Femoral triangle - Synthetic vs "autogenous"
      (docrickfry at aol.com)
  22. Re: SGW to Femoral triangle - Synthetic vs "autogenous"
      (docrickfry at aol.com)
  23. Re: Traumatic Neck Wound Further progress (navin goyal)
  24. Re: SGW to Femoral triangle - Synthetic vs "autogenous"
      (Ronald Gross)
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From: "ARUNI SEN" <ARUNI.SEN at new-tr.wales.nhs.uk>
Precedence: list
Subject: RE: Ketorolac
Date: Tue, 8 Aug 2006 13:19:59 +0100
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
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Good analgesic - bit toxic in the long run - shortest possible duration is best.

Aruni sen

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of rwolfer at aol.com
Sent: 07 August 2006 19:37
To: trauma-list at trauma.org
Subject: Re: Ketorolac

We use it for only 3 - 5 days total.  I have very good results with it. 

Rebecca Wolfer, MD, FACS, FCCP
Associate Professor, Marshall University School of Medicine
Dept of Surgery
Director Thoracic Surgery
Director, Surgical Critical Care Cabell Huntington Hospital
Director, Trauma Cabell Huntington Hospital

-----Original Message-----
From: kimrunitz at gmail.com
To: trauma-list at trauma.org
Sent: Mon, 7 Aug 2006 1:26 PM
Subject: Ketorolac

Dear List members!

I remember a recent debate on the safety of Ketorolac as postoperative 
analgesia. But now I am not able to find these references. 
Does it ring a bell with any of you? What is your policy? 

Best regards

Kim Rünitz
M.D. 
Trainee in anestesiology

Bornholmsgade 6, 3.Th
1266 Kbh K
Danmark
Telf: # 24654717
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From: "Hardcastle, Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za>
Precedence: list
Subject: RE: Ketorolac
Date: Tue, 8 Aug 2006 14:53:33 +0200
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
In-Reply-To: <001c01c6bab6$f3573230$c483258a at smd21719>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
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Guy

As long as you give it orally or rectally - the incidence of complications after IMI diclofenac is so high that the Medical Protection Society in South Africa considers this an indefencible action and the Health Professions Council of SA a reason for investigation of a doctor for negligence (Personal communication with KD Boffard of the HPCSA Disciplinary Committtee)

Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS  instructor and DSTC Cape Town Course Director
Intern program Coordinator: Surgery
Program Manager: Emergency Medicine (SU)
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Department of Surgery Room 4064
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa
e-mail: tch at sun.ac.za
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Guy Jackson
Sent: Tuesday, August 08, 2006 8:51 AM
To: Trauma &amp; Critical Care mailing list
Subject: Re: Ketorolac

Kim,

Ketoralac had its licence removed for peri-op analgesia here in the UK.
There were concerns with bleeding and renal failure. There are also concerns
regarding bone healing. In the literature to date it is clear that if you
want to stop fracture healing use ketoralac in your trial!

Personally, in the absence of contra-indications, I use short course
diclofenac. This is because the incidence of side effects is by definition
dose and duration of therapy related, and it allows patients with fractures
to get mobile and get off them. I actively limit the space on the drug chart
to ensure this.

Hope this helps,

Guy Jackson
London, UK

----- Original Message ----- 
From: "Kim Rünitz" <kimrunitz at gmail.com>
To: <trauma-list at trauma.org>
Sent: Monday, August 07, 2006 6:26 PM
Subject: Ketorolac

Dear List members!

I remember a recent debate on the safety of Ketorolac as postoperative
analgesia. But now I am not able to find these references.
Does it ring a bell with any of you? What is your policy?

Best regards

Kim Rünitz
M.D.
Trainee in anestesiology

Bornholmsgade 6, 3.Th
1266 Kbh K
Danmark
Telf: # 24654717
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From: "Black, John" <John.Black at orh.nhs.uk>
Precedence: list
Subject: RE: Ketorolac
Date: Tue, 8 Aug 2006 13:59:00 +0100 
To: "'Trauma &amp; Critical Care mailing list'" <trauma-list at trauma.org>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <F0178D21711F10428FDDEA537CF180E5028704DD at oxnetmsx02.orh.nhs.uk>
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It is also very useful in the acute setting in the Emergency Department.

John Black
Emergency Medicine
Oxford, UK

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of rwolfer at aol.com
Sent: 07 August 2006 19:37
To: trauma-list at trauma.org
Subject: Re: Ketorolac

We use it for only 3 - 5 days total.  I have very good results with it. 

Rebecca Wolfer, MD, FACS, FCCP
Associate Professor, Marshall University School of Medicine
Dept of Surgery
Director Thoracic Surgery
Director, Surgical Critical Care Cabell Huntington Hospital
Director, Trauma Cabell Huntington Hospital

-----Original Message-----
From: kimrunitz at gmail.com
To: trauma-list at trauma.org
Sent: Mon, 7 Aug 2006 1:26 PM
Subject: Ketorolac

Dear List members!

I remember a recent debate on the safety of Ketorolac as postoperative 
analgesia. But now I am not able to find these references. 
Does it ring a bell with any of you? What is your policy? 

Best regards

Kim Rünitz
M.D. 
Trainee in anestesiology

Bornholmsgade 6, 3.Th
1266 Kbh K
Danmark
Telf: # 24654717
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From: "Lorick Fox, PA-C" <Lorick at Lorick.org>
Precedence: list
Subject: RE: Ketorolac
Date: Tue, 08 Aug 2006 16:19:44 +0300
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
References: <001c01c6bab6$f3573230$c483258a at smd21719>
    <3FE6F2A76FE75C418D3E0481CD75EA1E15C7C9 at TYGEVS01.tyg.sun.ac.za>
In-Reply-To: <3FE6F2A76FE75C418D3E0481CD75EA1E15C7C9 at TYGEVS01.tyg.sun.ac .za>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <7.0.0.16.2.20060808161241.02d6a4b8 at Lorick.org>
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Message: 4
At 03:53 PM 8/8/2006, you wrote:

Guy

As long as you give it orally or rectally - the incidence of complications after IMI diclofenac is so high that the Medical Protection Society in South Africa considers this an indefencible action and the Health Professions Council of SA a reason for investigation of a doctor for negligence (Personal communication with KD Boffard of the HPCSA Disciplinary Committtee)

Tim,
That policy seemed a bit strong (based on my anecdotal experience, which is just that, but which has seen zero adverse reactions to a LOT of IM Toradol/ketorolac) so I just did a literature search and can't find any case reports of ADR's either.  We heard about a single case of acute renal failure on either list or CCM-L (not sure), but that actually is the only ADR I know of.
Can you shed any light on that reasoning of Dr. Boffard (I understand that it is not necessarily yours)?
I am a bit surprised that an everyday occurrence in the U.S. with many, many doses given is considered negligence elsewhere, just because of the numbers involved and lack of published reports (or did I miss them in my search?).

THANKS! 

Lorick

Lorick Fox, MPAS, PA-C
SEAVIN/GSC
USAF Peace Vector IV
Gianaclis Egyptian Air Force Base
Gianaclis, Egypt
+(20)3-448-2335 or FAX +(20)3-448-2339
www.lorick.org

Content-Transfer-Encoding: 8bit
From: meredith mcbride <mmcbridemd at yahoo.com>
Precedence: list
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"
Date: Tue, 8 Aug 2006 06:24:27 -0700 (PDT)
To: "Trauma &amp, Critical Care mailing list" <trauma-list at trauma.org>
In-Reply-To: <44D8350A.7FF1.00B9.0 at harthosp.org>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <20060808132427.8164.qmail at web33502.mail.mud.yahoo.com>
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There has been no report of neuromotor compromise to the limb which would contraindicate attempts at vascular reconstruction, nor is this an critically unstable patient who must be surgically abbreviated in damage control mode to preserve life.

  To go to amputation simply because you are limited to anatomic approaches due to unfamiliarity or discomfort with extra-anatomic approaches would be an clearcut breach of standard of care. A bit like taking out someone's colon because you weren't comfortable with appendectomy.

  We seem to be making a mountain out of a molehill here.

Ronald Gross <Rgross at harthosp.org> wrote:
  Sorry to say this Ken, but I think it is time to cut your loses (no pun
intended), and look to amputation. The expression "life over limb"
comes to mind, and I have thought all along, from what you described,
that the limb in question was going to be lost, I just wasn't sure
when.
Ron
>>> 8/7/2006 11:18 AM >>>
On the cases I presented last week, one developed an arterial sentinel 

bleeding episode during dressing change, which became torential the
next day. 
Arteriogram revealed a site at the proximal suture line, STENTED with

endovascular stent which stopped the bleeding. TWO days later the
same thing happened 
to the distal suture line and again a stent stopped the bleeding. NO

further bleeding, but groin is still a mess and not ready for an extra
anatomic 
bypass. 

What can we expect???
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From: "Ronald Gross" <Rgross at harthosp.org>
Precedence: list
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"
Date: Tue, 08 Aug 2006 09:42:29 -0400
To: "Critical Care mailing list Trauma &amp" <trauma-list at trauma.org>
References: <44D8350A.7FF1.00B9.0 at harthosp.org>
    <20060808132427.8164.qmail at web33502.mail.mud.yahoo.com>
In-Reply-To: <20060808132427.8164.qmail at web33502.mail.mud.yahoo.com>
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Message: 6
Meredith,

I'm still climbing.......is this limb functional. given the muscular
loss?

Ron

>>> meredith mcbride <mmcbridemd at yahoo.com> 8/8/2006 9:24 AM >>>
There has been no report of neuromotor compromise to the limb which
would contraindicate attempts at vascular reconstruction, nor is this an
critically unstable patient who must be surgically abbreviated in damage
control mode to preserve life.

  To go to amputation simply because you are limited to anatomic
approaches due to unfamiliarity or discomfort with extra-anatomic
approaches would be an clearcut breach of standard of care. A bit like
taking out someone's colon because you weren't comfortable with
appendectomy.

  We seem to be making a mountain out of a molehill here.

Ronald Gross <Rgross at harthosp.org> wrote:
  Sorry to say this Ken, but I think it is time to cut your loses (no
pun
intended), and look to amputation. The expression "life over limb"
comes to mind, and I have thought all along, from what you described,
that the limb in question was going to be lost, I just wasn't sure
when.
Ron
>>> 8/7/2006 11:18 AM >>>
On the cases I presented last week, one developed an arterial sentinel

bleeding episode during dressing change, which became torential the
next day. 
Arteriogram revealed a site at the proximal suture line, STENTED with

endovascular stent which stopped the bleeding. TWO days later the
same thing happened 
to the distal suture line and again a stent stopped the bleeding. NO

further bleeding, but groin is still a mess and not ready for an extra
anatomic 
bypass. 

What can we expect???
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From: "Guy Jackson" <r.g.m.jackson at qmul.ac.uk>
Precedence: list
Subject: Re: Ketorolac
Date: Tue, 8 Aug 2006 14:57:02 +0100
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
References: <001c01c6bab6$f3573230$c483258a at smd21719><3FE6F2A76FE75C418D3E0481CD75EA1E15C7C9 at TYGEVS01.tyg.sun.ac.za>
    <7.0.0.16.2.20060808161241.02d6a4b8 at Lorick.org>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
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Tim and Lorick,

The problem with im diclofenac is sterile abscess, which generated a number of case reports. Not nice which ever way you look at it.

I use it iv. Either in a bag of Hartman's (Ringer's Lactate) or diluted in 20 ml 0.9% saline over 20 minutes. The incidence of thrombophlebitis is less with greater dilution. A pharmacist also told me once that a little bicarb was needed if you put it in saline. This is fairly standard practice in the UK. However, the introduction of iv paracetamol into the UK has made me use this more recently.

Cheers,

Guy

  ----- Original Message ----- 
  From: Lorick Fox, PA-C 
  To: Trauma &amp; Critical Care mailing list 
  Sent: Tuesday, August 08, 2006 2:19 PM
  Subject: RE: Ketorolac

  At 03:53 PM 8/8/2006, you wrote:

    Guy

    As long as you give it orally or rectally - the incidence of complications after IMI diclofenac is so high that the Medical Protection Society in South Africa considers this an indefencible action and the Health Professions Council of SA a reason for investigation of a doctor for negligence (Personal communication with KD Boffard of the HPCSA Disciplinary Committtee)

  Tim,
  That policy seemed a bit strong (based on my anecdotal experience, which is just that, but which has seen zero adverse reactions to a LOT of IM Toradol/ketorolac) so I just did a literature search and can't find any case reports of ADR's either.  We heard about a single case of acute renal failure on either list or CCM-L (not sure), but that actually is the only ADR I know of.
  Can you shed any light on that reasoning of Dr. Boffard (I understand that it is not necessarily yours)?
  I am a bit surprised that an everyday occurrence in the U.S. with many, many doses given is considered negligence elsewhere, just because of the numbers involved and lack of published reports (or did I miss them in my search?).

  THANKS! 

  Lorick

  Lorick Fox, MPAS, PA-C
  SEAVIN/GSC
  USAF Peace Vector IV
  Gianaclis Egyptian Air Force Base
  Gianaclis, Egypt
  +(20)3-448-2335 or FAX +(20)3-448-2339
  www.lorick.org

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From: "Hardcastle, Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za>
Precedence: list
Subject: RE: Ketorolac or is it DICLOFENAC
Date: Tue, 8 Aug 2006 16:09:07 +0200
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
In-Reply-To: <7.0.0.16.2.20060808161241.02d6a4b8 at Lorick.org>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <3FE6F2A76FE75C418D3E0481CD75EA1E15C7CA at TYGEVS01.tyg.sun.ac.za>
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Lorick

This comment relates to DICLOFENAC - please rerad the original reply and the context therof.

Tim

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]On Behalf Of Lorick Fox, PA-C
Sent: Tuesday, August 08, 2006 3:20 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: Ketorolac

At 03:53 PM 8/8/2006, you wrote:

Guy

As long as you give it orally or rectally - the incidence of complications after IMI diclofenac is so high that the Medical Protection Society in South Africa considers this an indefencible action and the Health Professions Council of SA a reason for investigation of a doctor for negligence (Personal communication with KD Boffard of the HPCSA Disciplinary Committtee)

Tim,
That policy seemed a bit strong (based on my anecdotal experience, which is just that, but which has seen zero adverse reactions to a LOT of IM Toradol/ketorolac) so I just did a literature search and can't find any case reports of ADR's either.  We heard about a single case of acute renal failure on either list or CCM-L (not sure), but that actually is the only ADR I know of.
Can you shed any light on that reasoning of Dr. Boffard (I understand that it is not necessarily yours)?
I am a bit surprised that an everyday occurrence in the U.S. with many, many doses given is considered negligence elsewhere, just because of the numbers involved and lack of published reports (or did I miss them in my search?).

THANKS! 

Lorick

Lorick Fox, MPAS, PA-C
SEAVIN/GSC
USAF Peace Vector IV
Gianaclis Egyptian Air Force Base
Gianaclis, Egypt
+(20)3-448-2335 or FAX +(20)3-448-2339
www.lorick.org <http://www.lorick.org/>
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From: "Hardcastle, Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za>
Precedence: list
Subject: RE: Ketorolac
Date: Tue, 8 Aug 2006 16:11:56 +0200
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
In-Reply-To: <002401c6baf2$864c7f10$c483258a at smd21719>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <3FE6F2A76FE75C418D3E0481CD75EA1E15C7CB at TYGEVS01.tyg.sun.ac.za>
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Guy

Exactly what our anaesthesiologiests do and the complication I was aluding to; not only are sterile abscesses reported, but numerous cases of necrotising fasciitis are reported, some leading to limb loss. Remember the pH of Diclofenac (Voltaren IM) is just over 1 - like injecting pool acid into your muscles!!!!!

tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS  instructor and DSTC Cape Town Course Director
Intern program Coordinator: Surgery
Program Manager: Emergency Medicine (SU)
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Department of Surgery Room 4064
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa
e-mail: tch at sun.ac.za
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Guy Jackson
Sent: Tuesday, August 08, 2006 3:57 PM
To: Trauma &amp; Critical Care mailing list
Subject: Re: Ketorolac

Tim and Lorick,

The problem with im diclofenac is sterile abscess, which generated a number of case reports. Not nice which ever way you look at it.

I use it iv. Either in a bag of Hartman's (Ringer's Lactate) or diluted in 20 ml 0.9% saline over 20 minutes. The incidence of thrombophlebitis is less with greater dilution. A pharmacist also told me once that a little bicarb was needed if you put it in saline. This is fairly standard practice in the UK. However, the introduction of iv paracetamol into the UK has made me use this more recently.

Cheers,

Guy

  ----- Original Message ----- 
  From: Lorick Fox, PA-C 
  To: Trauma &amp; Critical Care mailing list 
  Sent: Tuesday, August 08, 2006 2:19 PM
  Subject: RE: Ketorolac

  At 03:53 PM 8/8/2006, you wrote:

    Guy

    As long as you give it orally or rectally - the incidence of complications after IMI diclofenac is so high that the Medical Protection Society in South Africa considers this an indefencible action and the Health Professions Council of SA a reason for investigation of a doctor for negligence (Personal communication with KD Boffard of the HPCSA Disciplinary Committtee)

  Tim,
  That policy seemed a bit strong (based on my anecdotal experience, which is just that, but which has seen zero adverse reactions to a LOT of IM Toradol/ketorolac) so I just did a literature search and can't find any case reports of ADR's either.  We heard about a single case of acute renal failure on either list or CCM-L (not sure), but that actually is the only ADR I know of.
  Can you shed any light on that reasoning of Dr. Boffard (I understand that it is not necessarily yours)?
  I am a bit surprised that an everyday occurrence in the U.S. with many, many doses given is considered negligence elsewhere, just because of the numbers involved and lack of published reports (or did I miss them in my search?).

  THANKS! 

  Lorick

  Lorick Fox, MPAS, PA-C
  SEAVIN/GSC
  USAF Peace Vector IV
  Gianaclis Egyptian Air Force Base
  Gianaclis, Egypt
  +(20)3-448-2335 or FAX +(20)3-448-2339
  www.lorick.org

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From: "Lorick Fox, PA-C" <Lorick at Lorick.org>
Precedence: list
Subject: RE: Ketorolac or is it DICLOFENAC
Date: Tue, 08 Aug 2006 17:17:17 +0300
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
References: <7.0.0.16.2.20060808161241.02d6a4b8 at Lorick.org>
    <3FE6F2A76FE75C418D3E0481CD75EA1E15C7CA at TYGEVS01.tyg.sun.ac.za>
In-Reply-To: <3FE6F2A76FE75C418D3E0481CD75EA1E15C7CA at TYGEVS01.tyg.sun.ac .za>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <7.0.0.16.2.20060808171508.057ede98 at Lorick.org>
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Message: 10
OOPS...sorry. Being illiterate again.
(I have to say that the Egyptian physicians I work with here use IM diclofenac like it was water, but I never see their outcomes. I will pass this around to them.)

Again, THANKS
Lorick

At 05:09 PM 8/8/2006, you wrote:

Lorick

This comment relates to DICLOFENAC - please rerad the original reply and the context therof.

Tim

-----Original Message-----
From: trauma-list-bounces at trauma.org [ mailto:trauma-list-bounces at trauma.org]On Behalf Of Lorick Fox, PA-C
Sent: Tuesday, August 08, 2006 3:20 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: Ketorolac

At 03:53 PM 8/8/2006, you wrote:

Guy

As long as you give it orally or rectally - the incidence of complications after IMI diclofenac is so high that the Medical Protection Society in South Africa considers this an indefencible action and the Health Professions Council of SA a reason for investigation of a doctor for negligence (Personal communication with KD Boffard of the HPCSA Disciplinary Committtee)

Tim,
That policy seemed a bit strong (based on my anecdotal experience, which is just that, but which has seen zero adverse reactions to a LOT of IM Toradol/ketorolac) so I just did a literature search and can't find any case reports of ADR's either.  We heard about a single case of acute renal failure on either list or CCM-L (not sure), but that actually is the only ADR I know of.
Can you shed any light on that reasoning of Dr. Boffard (I understand that it is not necessarily yours)?
I am a bit surprised that an everyday occurrence in the U.S. with many, many doses given is considered negligence elsewhere, just because of the numbers involved and lack of published reports (or did I miss them in my search?).

THANKS! 

Lorick

Lorick Fox, MPAS, PA-C
SEAVIN/GSC
USAF Peace Vector IV
Gianaclis Egyptian Air Force Base
Gianaclis, Egypt
+(20)3-448-2335 or FAX +(20)3-448-2339
www.lorick.org < http://www.lorick.org/> 

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From: "susanna mathews" <orthodiva at hotmail.com>
Precedence: list
Subject: Lecture help
Cc: 
Date: Tue, 8 Aug 2006 10:14:44 -0500
To: "trauma-l" <trauma-l at lists.aast.org>,
    "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <BAY107-DAV220FD6A4ABBCB9F39EDC0BB540 at phx.gbl>
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Message: 11
Dear list members,
     It has been requested that I prepare something for out Surgical Technology program concerning the differences between elective surgery and trauma.  Students are not being taught any critical thinking processes to deal with situations they may find themselves in after graduation, and this is stressful -to say the least- for not only the new employees but also the Surgeons, Anesthesiologists and RN's who must deal with it.  My format will be a brief lecture followed by several scenarios to illustrate what can happen and how they can anticipate and plan for the unexpected and rapidly changing course of the surgery.
     Any suggestions, resources or experiences you may be willing to share would be a great help.  You are the ones on the front lines of trauma and it is your input I believe to be most valuable.  I already have bits of "Top Knife" (with the blessing of Dr. Maddox, I hope) and the resources of trauma.org as a starting point, but I want more.  Anything you encounter with new staff that makes you crazy?  Something that we should teach but do not?  Someone at your facility who does it better and would be willing to share with me?  Anything from those with military connections?
     Someday one of my "kids" may be across the table from you.  I want them to be up to the challenge.
Thank you,
Susanna Mathews
orthodiva at hotmail.com<mailto:orthodiva at hotmail.com>
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From: KMATTOX at aol.com
Precedence: list
Subject: Re: Lecture help
Cc: 
Date: Tue, 8 Aug 2006 11:19:02 EDT
To: trauma-list at trauma.org, trauma-l at lists.aast.org
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <330.9bb6b3d.320a0566 at aol.com>
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Thank you Susanna for your comments.  We are all committed to  continuing to 
train and educate those who will be caring for the sickest of the  sick, the 
most traumatized of the trauma, and the greatest of the challenges in  
medicine.   

k
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From: meredith mcbride <mmcbridemd at yahoo.com>
Precedence: list
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"
Date: Tue, 8 Aug 2006 08:53:48 -0700 (PDT)
To: "Trauma &amp, Critical Care mailing list" <trauma-list at trauma.org>
In-Reply-To: <44D85C85.7FF1.00B9.0 at harthosp.org>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <20060808155348.50471.qmail at web33514.mail.mud.yahoo.com>
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:)

  I'm not sure either. Just going off our limited info to date.

  I agree with you and other posters that a neurologically nonfunctional limb ought not be salvaged.

Ronald Gross <Rgross at harthosp.org> wrote:
  Meredith,

I'm still climbing.......is this limb functional. given the muscular
loss?

Ron

>>> meredith mcbride 8/8/2006 9:24 AM >>>
There has been no report of neuromotor compromise to the limb which
would contraindicate attempts at vascular reconstruction, nor is this an
critically unstable patient who must be surgically abbreviated in damage
control mode to preserve life.

To go to amputation simply because you are limited to anatomic
approaches due to unfamiliarity or discomfort with extra-anatomic
approaches would be an clearcut breach of standard of care. A bit like
taking out someone's colon because you weren't comfortable with
appendectomy.

We seem to be making a mountain out of a molehill here.

Ronald Gross wrote:
Sorry to say this Ken, but I think it is time to cut your loses (no
pun
intended), and look to amputation. The expression "life over limb"
comes to mind, and I have thought all along, from what you described,
that the limb in question was going to be lost, I just wasn't sure
when.
Ron
>>> 8/7/2006 11:18 AM >>>
On the cases I presented last week, one developed an arterial sentinel

bleeding episode during dressing change, which became torential the
next day. 
Arteriogram revealed a site at the proximal suture line, STENTED with

endovascular stent which stopped the bleeding. TWO days later the
same thing happened 
to the distal suture line and again a stent stopped the bleeding. NO

further bleeding, but groin is still a mess and not ready for an extra
anatomic 
bypass. 

What can we expect???
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From: KMATTOX at aol.com
Precedence: list
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"
Date: Tue, 8 Aug 2006 11:59:49 EDT
To: trauma-list at trauma.org
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <3bd.8b3b0e8.320a0ef5 at aol.com>
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We have a new developing and progressively larger problem each day.   The leg 
is sensate, but as you recall the saphenous and femoral veins have been  
LIGATED.  Despite a fasciotomy, the leg is getting bigger and  bigger.   The 
fasciotomy site is really weeping.   I am  wondering if this HUGE leg will ever be 
functional, even if we maintain arterial  viability.   Will rehab help with 
evacuating the leg of its excess  fluid.   Will the destroyed valves at the 
groin result in a huge post  phlebetic limb?    Have we saved a leg only to watch 
it become  functionless.     

k
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From: "Sohail Muzammil" <sohailmuzammil at hotmail.com>
Precedence: list
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"
Date: Tue, 8 Aug 2006 23:44:19 +0500
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
References: <31b.5515694.3208b3e1 at aol.com>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
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Reminds me of a similar case way back in my residency days. In a mess such
as you describe the vessels will bleed; mostly catastrophic and always at
odd hours of the night. The time has come to counsel the patient and
amputate (or ablate as Dr. Mattox puts it).

Regards
S Muzammil, FRCS
----- Original Message -----
From: <KMATTOX at aol.com>
To: <trauma-list at trauma.org>
Sent: Monday, 07 August, 2006 8:18 PM
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"

> On the cases I presented last week, one developed an arterial sentinel
> bleeding episode during dressing change, which became torential the next
day.
> Arteriogram revealed a site at the proximal suture line,  STENTED with
> endovascular stent which stopped the bleeding.  TWO days later  the same
thing happened
> to the distal suture line and again a stent stopped the  bleeding.  NO
> further bleeding, but groin is still a mess and not ready for  an extra
anatomic
> bypass.
>
> What can we expect???
>
>
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From: KMATTOX at aol.com
Precedence: list
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"
Date: Tue, 8 Aug 2006 15:25:04 EDT
To: trauma-list at trauma.org
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <458.6e07d600.320a3f10 at aol.com>
Content-Type: text/plain; charset="US-ASCII"
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Message: 16
In a message dated 8/8/2006 1:45:34 P.M. Central Standard Time,  
sohailmuzammil at hotmail.com writes:

The time  has come to counsel the patient and
amputate (or ablate as Dr. Mattox puts  it).

Regards
S Muzammil, FRCS

This suggestion was also mentioned in our group, by me.   It has  caused a 
great deal of ethical, moral, and scientific polarization.    The leg is still 
viable.   The man is a construction worker and wants  to keep his leg.   

k
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From: "Nick Macartney" <nick at macartney.org>
Precedence: list
Subject: RE: Ketorolac
Date: Tue, 8 Aug 2006 20:36:16 +0100
To: "'Trauma &amp; Critical Care mailing list'" <trauma-list at trauma.org>
In-Reply-To: <20060807190158.12469.qmail at web83004.mail.mud.yahoo.com>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <007101c6bb21$ebc3a420$152ca8c0 at Topfloor>
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Message: 17
Great drug. In the UK contraindicated for perioperative use - see
www.bnf.org for the UK formulary.
Nick 

> -----Original Message-----
> From: trauma-list-bounces at trauma.org 
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Maureen Canavan
> Sent: 07 August 2006 20:02
> To: Trauma &amp, Critical Care mailing list
> Subject: Re: Ketorolac
> 
> Our hospital is use 3 to 5 days with a 24 hour post op wait 
> when the patient has had ortho surgery..
> 
> rwolfer at aol.com wrote:  We use it for only 3 - 5 days total. 
> I have very good results with it. 
> 
> Rebecca Wolfer, MD, FACS, FCCP
> Associate Professor, Marshall University School of Medicine 
> Dept of Surgery Director Thoracic Surgery Director, Surgical 
> Critical Care Cabell Huntington Hospital Director, Trauma 
> Cabell Huntington Hospital
> 
> 
> -----Original Message-----
> From: kimrunitz at gmail.com
> To: trauma-list at trauma.org
> Sent: Mon, 7 Aug 2006 1:26 PM
> Subject: Ketorolac
> 
> 
> Dear List members!
> 
> I remember a recent debate on the safety of Ketorolac as 
> postoperative analgesia. But now I am not able to find these 
> references. 
> Does it ring a bell with any of you? What is your policy? 
> 
> Best regards
> 
> Kim Rünitz
> M.D. 
> Trainee in anestesiology
> 
> 
> Bornholmsgade 6, 3.Th
> 1266 Kbh K
> Danmark
> Telf: # 24654717
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From: "Ronald Gross" <rgross at harthosp.org>
Precedence: list
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"
Date: Tue, 08 Aug 2006 15:50:17 -0400
To: <trauma-list at trauma.org>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <44D8B2B9020000B900003A02 at hcnwgwds01.hh.chs>
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Message: 18
Ken,
While the leg might be viable, is it or might it still be FUNCTIONAL. 
As I try to envision the destruction to the groin and upper thigh as
described, a wonder if there will be any FUNCTION or if he will instead
be dragging a viable, non-functional appendage, much as a sailboat would
drag her anchor in a storm.......
My guess is, knowing Dr. Mattox, that the leg will not be functional,
and the debate now raging is more (understandably) emotional than
ethical, or scientific.  
Amputation now will enable emotional and physical rehab in the very near
future.  Delay, with months of futile surgical heroism will delay and
perhaps eliminate eventual emotional rehab, regardless of the physical
outcome.
I will shut up now.
Ron

>>> <KMATTOX at aol.com> 08/08/06 3:25 PM >>>

In a message dated 8/8/2006 1:45:34 P.M. Central Standard Time,  
sohailmuzammil at hotmail.com writes:

The time  has come to counsel the patient and
amputate (or ablate as Dr. Mattox puts  it).

Regards
S Muzammil, FRCS

This suggestion was also mentioned in our group, by me.   It has  caused
a 
great deal of ethical, moral, and scientific polarization.    The leg is
still 
viable.   The man is a construction worker and wants  to keep his leg.  

k
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From: bensonblues at comcast.net
Precedence: list
Subject: Ketorolac
Date: Tue, 08 Aug 2006 20:24:37 +0000
To: trauma-list at trauma.org
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <080820062024.4081.44D8F3050001792800000FF122028887449C0A9A040D02019C020A0D at comcast.net>
Content-Type: text/plain
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Message: 19
Kim,

The Physician's Desk Reference (USA) outlines contraindications for the use of ketorolac (bleeding or taking anticoagulants, suspected ICH, need for operation, hypovolemia, renal insufficiency, etc. Based upon its theoretic antiplatelet effects, negative effects on wound healing, and its well known renal effects, I see no role for ketorolac in any preop, postop, periop patient. The "Guy" from the UK is right on - they seem to be on the ball over there. I don't give it at all in my busy 90K visit ED, but my colleagues will argue that it is useful in renal colic because it decreaes ureteral peristalsis and renal blood flow. I say that giving ketorolac for renal colic is like giving a tocolytic to treat labor pains. This is a drug looking for an indication...

DB
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From: docrickfry at aol.com
Precedence: list
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"
Date: Tue, 08 Aug 2006 18:32:12 -0400
To: trauma-list at trauma.org
References: <458.6e07d600.320a3f10 at aol.com>
In-Reply-To: <458.6e07d600.320a3f10 at aol.com>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <8C88951A09D7AEC-8F0-8D10 at MBLK-M29.sysops.aol.com>
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For the leg swelling that was mentioned, one maneuver that has worked and been described is to elevate the leg and wrap it with ace bandages to promote drainage--obviously there has been compromise of venous drainage, but it is highly difficult and unusial to fully ablate all venous drainage from the leg.  Restoration of venous outflow may be considered if this does not work with a temporary conduit or shunt.
ERF 

-----Original Message-----
From: KMATTOX at aol.com
To: trauma-list at trauma.org
Sent: Tue, 8 Aug 2006 3:25 PM
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"

In a message dated 8/8/2006 1:45:34 P.M. Central Standard Time,  
sohailmuzammil at hotmail.com writes:

The time  has come to counsel the patient and
amputate (or ablate as Dr. Mattox puts  it).

Regards
S Muzammil, FRCS

This suggestion was also mentioned in our group, by me.   It has  caused a 
great deal of ethical, moral, and scientific polarization.    The leg is still 
viable.   The man is a construction worker and wants  to keep his leg.   

k
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From: docrickfry at aol.com
Precedence: list
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"
Date: Tue, 08 Aug 2006 18:32:16 -0400
To: trauma-list at trauma.org
References: <458.6e07d600.320a3f10 at aol.com>
In-Reply-To: <458.6e07d600.320a3f10 at aol.com>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <8C88951A2EF1EA0-8F0-8D11 at MBLK-M29.sysops.aol.com>
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Message: 21
For the leg swelling that was mentioned, one maneuver that has worked and been described is to elevate the leg and wrap it with ace bandages to promote drainage--obviously there has been compromise of venous drainage, but it is highly difficult and unusial to fully ablate all venous drainage from the leg.  Restoration of venous outflow may be considered if this does not work with a temporary conduit or shunt.
ERF 

-----Original Message-----
From: KMATTOX at aol.com
To: trauma-list at trauma.org
Sent: Tue, 8 Aug 2006 3:25 PM
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"

In a message dated 8/8/2006 1:45:34 P.M. Central Standard Time,  
sohailmuzammil at hotmail.com writes:

The time  has come to counsel the patient and
amputate (or ablate as Dr. Mattox puts  it).

Regards
S Muzammil, FRCS

This suggestion was also mentioned in our group, by me.   It has  caused a 
great deal of ethical, moral, and scientific polarization.    The leg is still 
viable.   The man is a construction worker and wants  to keep his leg.   

k
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From: docrickfry at aol.com
Precedence: list
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"
Date: Tue, 08 Aug 2006 18:38:41 -0400
To: trauma-list at trauma.org
References: <44D8B2B9020000B900003A02 at hcnwgwds01.hh.chs>
In-Reply-To: <44D8B2B9020000B900003A02 at hcnwgwds01.hh.chs>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
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Message: 22
I agree with this and am very sensitive about removing a doomed limb at the earliest time, but right now we are just days, not weeks and months, into it, and there is really no indication of inevitable doom just yet.  The LEAP study published in several installments in the NEJM has clearly shown that some of the old maxims guiding the need for early amputation have fallen by the wayside as data drives by--i.e. loss of plantar sensation, Gustilo III-C injuries, severe venous insufficiency, etc etc have all shown surprisingly good salvage of reasonably functional limbs with present technology.  In view of the patient's wishes to continue, and no overriding reason to amputate at present, I think it is reasonable to give the wounds a chance to heal and attempt an extra-anatomic bypass within a few days if at all feasible.
ERF 

-----Original Message-----
From: rgross at harthosp.org
To: trauma-list at trauma.org
Sent: Tue, 8 Aug 2006 3:50 PM
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"

Ken,
While the leg might be viable, is it or might it still be FUNCTIONAL. 
As I try to envision the destruction to the groin and upper thigh as
described, a wonder if there will be any FUNCTION or if he will instead
be dragging a viable, non-functional appendage, much as a sailboat would
drag her anchor in a storm.......
My guess is, knowing Dr. Mattox, that the leg will not be functional,
and the debate now raging is more (understandably) emotional than
ethical, or scientific.  
Amputation now will enable emotional and physical rehab in the very near
future.  Delay, with months of futile surgical heroism will delay and
perhaps eliminate eventual emotional rehab, regardless of the physical
outcome.
I will shut up now.
Ron

>>> <KMATTOX at aol.com> 08/08/06 3:25 PM >>>

In a message dated 8/8/2006 1:45:34 P.M. Central Standard Time,  
sohailmuzammil at hotmail.com writes:

The time  has come to counsel the patient and
amputate (or ablate as Dr. Mattox puts  it).

Regards
S Muzammil, FRCS

This suggestion was also mentioned in our group, by me.   It has  caused
a 
great deal of ethical, moral, and scientific polarization.    The leg is
still 
viable.   The man is a construction worker and wants  to keep his leg.  

k
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From: navin goyal <drnavingoyal at yahoo.co.in>
Precedence: list
Subject: Re: Traumatic Neck Wound Further progress
Date: Wed, 9 Aug 2006 10:58:42 +0100 (BST)
To: trauma-list at trauma.org
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <20060809095842.15382.qmail at web8415.mail.in.yahoo.com>
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Message: 23
The patient with traumatic neck wound is doing fine. The chest are still there with no bubbling . CT scan with virtual bronchoscpy and barium swallow was done at the time of admission to locate the injury site and to rule out any esophageal injury. CT films showed no injury to the esophagus .

  Dr. Navin Goyal 
  Trauma Fellow,
  LTM Medical College, 
  Mumbai. INDIA

---------------------------------
Heres a new way to find what you're looking for - Yahoo! Answers
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From: "Ronald Gross" <Rgross at harthosp.org>
Precedence: list
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"
Date: Wed, 09 Aug 2006 06:50:12 -0400
To: <trauma-list at trauma.org>
References: <44D8B2B9020000B900003A02 at hcnwgwds01.hh.chs>
    <8C8895288AC5724-8F0-8D67 at MBLK-M29.sysops.aol.com>
In-Reply-To: <8C8895288AC5724-8F0-8D67 at MBLK-M29.sysops.aol.com>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <44D985A4.7FF1.00B9.0 at harthosp.org>
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Message: 24
Rick,
I am in complete agreement with all you have said.  My only problem in
THIS case is that by the description Ken gave us, I can see the
groin/entire anterior upper thigh gone, leaving very little in the way
of muscular support/function to the limb.  I too am incredibly sensitive
to the gentleman's desire to keep his leg - Christ, I would be
unreasonable in my desire to do the same, I am sure - but I really would
love to see exactly what is left that would make this a FUNCTIONAL lower
extremity.  
Be well,
Ron

>>> <docrickfry at aol.com> 8/8/2006 6:38 PM >>>
I agree with this and am very sensitive about removing a doomed limb at
the earliest time, but right now we are just days, not weeks and months,
into it, and there is really no indication of inevitable doom just yet. 
The LEAP study published in several installments in the NEJM has clearly
shown that some of the old maxims guiding the need for early amputation
have fallen by the wayside as data drives by--i.e. loss of plantar
sensation, Gustilo III-C injuries, severe venous insufficiency, etc etc
have all shown surprisingly good salvage of reasonably functional limbs
with present technology.  In view of the patient's wishes to continue,
and no overriding reason to amputate at present, I think it is
reasonable to give the wounds a chance to heal and attempt an
extra-anatomic bypass within a few days if at all feasible.
ERF 

-----Original Message-----
From: rgross at harthosp.org 
To: trauma-list at trauma.org 
Sent: Tue, 8 Aug 2006 3:50 PM
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"

Ken,
While the leg might be viable, is it or might it still be FUNCTIONAL. 
As I try to envision the destruction to the groin and upper thigh as
described, a wonder if there will be any FUNCTION or if he will
instead
be dragging a viable, non-functional appendage, much as a sailboat
would
drag her anchor in a storm.......
My guess is, knowing Dr. Mattox, that the leg will not be functional,
and the debate now raging is more (understandably) emotional than
ethical, or scientific.  
Amputation now will enable emotional and physical rehab in the very
near
future.  Delay, with months of futile surgical heroism will delay and
perhaps eliminate eventual emotional rehab, regardless of the physical
outcome.
I will shut up now.
Ron

>>> <KMATTOX at aol.com> 08/08/06 3:25 PM >>>

In a message dated 8/8/2006 1:45:34 P.M. Central Standard Time,  
sohailmuzammil at hotmail.com writes:

The time  has come to counsel the patient and
amputate (or ablate as Dr. Mattox puts  it).

Regards
S Muzammil, FRCS

This suggestion was also mentioned in our group, by me.   It has 
caused
a 
great deal of ethical, moral, and scientific polarization.    The leg
is
still 
viable.   The man is a construction worker and wants  to keep his leg. 

k
--
trauma-list : TRAUMA.ORG
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http://www.trauma.org/traumalist.html 

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