trauma-list Digest, Vol 50, Issue 12
czuehlke at frontiernet.net
czuehlke at frontiernet.net
Mon Aug 6 13:51:26 BST 2007
It works
Carol Eisenbrandt BSN ER nurse
Quoting trauma-list-request at trauma.org:
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> Today's Topics:
>
> 1. Re: TEST - Integrated Collaborative TRAUMA/Disaster Network
> (Juan Anzieta Neumann)
> 2. pressors in trauma, wasn't the world once flat? (Mike Smertka)
> 3. Why are crystalloids better > pressors ? (IVAN HRONEK)
> 4. Re: Why are crystalloids better > pressors ?= NEITHER
> (KMATTOX at aol.com)
> 5. Re: Why are crystalloids better > pressors ?= NEITHER
> (Alex Garbino)
> 6. Bullet Removal (Andrew J Bowman)
>
>
> ----------------------------------------------------------------------
>
> Message: 1
> Date: Sun, 5 Aug 2007 19:32:57 -0400
> From: "Juan Anzieta Neumann" <janzieta at telsur.cl>
> Subject: Re: TEST - Integrated Collaborative TRAUMA/Disaster Network
> To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
> Message-ID: <006501c7d7b8$f45cdf70$0401010a at Personal2>
> Content-Type: text/plain; format=flowed; charset="iso-8859-1";
> reply-type=original
>
>
> ----- Original Message -----
> From: "AMAT ROCA, MIGUEL" <19505mar at comb.es>
> To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
> Sent: Saturday, July 14, 2007 5:30 AM
> Subject: Re: TEST - Integrated Collaborative TRAUMA/Disaster Network
>
>
>> Test works
>>
>> ---------- Original Message ----------------------------------
>> De: "Pedro Gustavo Teixeira" <pedrogus at gmail.com>
>> Respondre a: "Trauma & Critical Care mailing list"
>> <trauma-list at trauma.org>
>> Data: Fri, 13 Jul 2007 11:21:03 -0700
>>
>>> TEST WORKS
>>>
>>> On 7/12/07, KMATTOX at aol.com <KMATTOX at aol.com> wrote:
>>>>
>>>> My dear friends and colleagues on this list server.
>>>>
>>>> This vehicle is extremely valuable method of us clinically and
>>>> managerially
>>>> communicating with each other during time of need. We all used this
>>>> communication mechanism to great value during the Katrina/Rita
>>>> Disaster.
>>>>
>>>> It is entirely possible that sometime in the future (let us hope and
>>>> pray
>>>> that it is in the many year future) we may need to use this mechanism to
>>>> ask for
>>>> help, to signal problems and danger, and to professionally exchange
>>>> clinical
>>>> information. Such a need could also be within the week.
>>>>
>>>> I would ask EACH OF YOU to merely hit the reply button and state,
>>>> TEST WORKS
>>>> to document that you are in and are part of this INTEGRATED
>>>> COLLABORATIVE
>>>> NETWORK. If it works during a TEST, then it will work during times
>>>> of
>>>> need.
>>>>
>>>>
>>>> Please - this is like a disaster drill. Let us check our ability to
>>>> LINK..............
>>>>
>>>> Kenneth L. Mattox, MD
>>>> Houston
>>>>
>>>>
>>>>
>>>> ************************************** Get a sneak peak of the all-new
>>>> AOL
>>>> at
>>>> http://discover.aol.com/memed/aolcom30tour
>>>> --
>>>> trauma-list : TRAUMA.ORG
>>>> To change your settings or unsubscribe visit:
>>>> http://www.trauma.org/index.php?/community/
>>>>
>>>
>>>
>>>
>>> --
>>> Pedro Teixeira, MD
>>> Research Fellow
>>> University of Southern California - Keck School of Medicine
>>> Department of Surgery - Division of Trauma and Surgical Critical Care
>>> 1200 North State Street, Room 10-750
>>> Los Angeles, California 90033-4525
>>>
>>> Tel: (323) 226-8112
>>> Fax: (323) 226-8116
>>> --
>>> trauma-list : TRAUMA.ORG
>>> To change your settings or unsubscribe visit:
>>> http://www.trauma.org/index.php?/community/
>>>
>>
>>
>
>
> ------------------------------
>
> Message: 2
> Date: Sun, 5 Aug 2007 17:56:32 -0700 (PDT)
> From: Mike Smertka <medic0947969 at yahoo.com>
> Subject: pressors in trauma, wasn't the world once flat?
> To: "Trauma &, Critical Care mailing list" <trauma-list at trauma.org>
> Message-ID: <797191.10692.qm at web61119.mail.yahoo.com>
> Content-Type: text/plain; charset=iso-8859-1
>
> Thanks everyone for the replies to my earlier questions on
> theraputically reduced SBP.
>
> Prior to signing up for this list I raised the question about
> using pressors in trauma and to say I was met with resistence would
> be a kind understatement. But here is my madness.
>
> Pressors are used all the time in trauma, but nobody realizes it.
> How often in the OR or while sutering is epi used to constrict
> vasculature to help control bleeding? It seems to me, all the time.
> I would stipulate that cutting or suturing causes trauma. Maybe a
> controlled trauma or over a small area. But still a pressor used for
> bleeding control. (not to raise CVP)
>
> Now it was brought up on this list to use vasopressin. Stepping
> away from the TBI for a second, from cardiogenic shock of
> nontraumatic origin to spinal trauma, pressors are indicated; If not
> to aid in perfusion, then for what? I understand the dogma of no
> pressors comes from the idea that the pressor does not help CVP and
> therefore is contraindicated because the increase in BP gives a
> false impression of tissue perfusion. But from a common sense point
> of view, back to TBI, you are not trying to raise CVP, you are
> trying to raise MAP. So why would the pressor not work? Unfortunatly
> I don't know the answers to the following questions. Please can
> anyone tell me:
>
> Which pressor? Why vasopresson over levofed or any other?
> Obviously some work differently than others, but I do not know why
> the focus is on Vasopressin.
>
> What doses are being considered and why? It seems to me using 40
> units of vasopressin might be too much on a pt with a pulse, but
> what is the reasoning for the dose being used or is it titrated to
> effect?
>
> The other side of the coin is by raising MAP with a pressor do you
> impact CVP? Are any other organs or systems negatively impacted?
> i.e. the kidneys?
>
> Does this idea simply come from the idea that in a cold,
> diaphoretic patient we might look at the BP reading and forget we
> treat patients not monitors?
>
> Thanks for taking time to consider this.
>
> Mike
>
> KMATTOX at aol.com wrote:
>
> In a message dated 8/5/2007 4:30:51 P.M. Central Daylight Time, ih7 at msn.com
> writes:
>
> if the ICP is increased, you need to keep the MAP 60 mm higher so the blood
> flows forward through the brain
>
>
> I would agree with that, but would plead that it is NOT crystalloid fluids
> which should be used to achieve that MAP. Remember that most of the studies
> of the past 30-40 yrs were in patients that had 3 liters (or more) challenge
> of crystalloid prior to any surgeon, especially neurosurgeon, seeing them.
> The ICP increase is a complex compartment syndrome and much of our
> traditional urban legend therapy actually iatrogenicly contributed
> to the spiraling
> increase in ICP.
>
> I am delighted to see the direction of the discussions on this web site, and
> do believe that it is going to lead to a whole new wave of research.
>
> k
>
>
>
> ************************************** Get a sneak peek of the all-new AOL at
> http://discover.aol.com/memed/aolcom30tour
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
>
> ---------------------------------
> Be a better Heartthrob. Get better relationship answers from someone
> who knows.
> Yahoo! Answers - Check it out.
>
> ------------------------------
>
> Message: 3
> Date: Sun, 5 Aug 2007 19:08:53 -0700
> From: IVAN HRONEK <ih7 at msn.com>
> Subject: Why are crystalloids better > pressors ?
> To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
> Message-ID: <BAY141-W9B241682FAA22DC089692F3E50 at phx.gbl>
> Content-Type: text/plain; charset="iso-8859-1"
>
> Let me try to reply to keep the ball rolling:
>
> The way I look at it is the pressors would save administration of
> crystalloid, espec. beneficial in TBI e.g.
> You're right, in some of the animal studies they did decrease
> perfusion/cardiac output. The idea is to follow the "delayed
> resuscitation philosophy" with keeping the crystalloid volume low
> prior to control of bleeding.
>
> Which pressor: again, you're right: one animal study compared
> phenylephrine to vasopressine and got similar results. Levophed also
> did similar job. One difference is the effect on the heart -
> Levophed has some beta 1 effect and may cause more tachycardia than
> appropriate. Phenylephrine and Vasopressine are pure
> vasoconstrictors and so fulfil this role best. A lot of studies have
> been done with Vasopressine and so it is better known and can be
> used in follow-up human studies easier.
>
> Vasopressin dose: 40 U is the CPR dose, right. I agree with you
> Mike, again, I can't see myself shooting a big blous dose to a
> patient without starting with smaller doses and yes, I think
> titration to effect is best, definitely, as with perhaps any drug.
>
> CVP: yes, most vasoconstrictors also squeeze the large veins, but I
> think this would be a transient effect.
> The kidneys are more affected by hypotension as GF is entirely
> dependent on the filtration pressure. Once you raise the BP, urine
> stats flowing again, like it has been shown with Levophed before. We
> are talking short-time use here, prior to control of bleeding and
> transfusion, which are the definitive therapy. A more common
> complication is skin ischemia, I saw digital ischemia in a pt. who
> was on it for > 7 days, splanchnic ischemia has also been shown to
> exist in the animal studies.
>
> Where the idea comes from: I think saving crystalloids, when I see
> myself giving > 10 L of crystalloid and see the anasarca hapenning
> in front of my eyes, I start hating myself. I agree with you once
> again - the BP is not a good diagnostic endpoint, CO is better, SvO2
> better still, as is acidosis or lactate, however people say these
> all are general and not regional (e.g. brain or kidney ischemia)
> monitors. If you mean to say that pts. with an OK BP can be in deep
> trouble, I agree.
>
> I think here we would be trying to temporize and hope the kidneys,
> the muscles, skin and the splanchnic organs can take some temporary
> ischemia from the vasoconstriction due to the hemorr. shock as well
> as to that due to the vasopressor and we would keep perfusing the
> brain and the heart, that's what the body does by itself in these
> situations anyway.
>
> What I don't understand is why crystalloids help - they do not
> increase oxygen delivery meaningfully..
> but they keep the BP and CO, - is that useful for the body ?? Why ?
>
> What if we just keep up the BP and not the CO - by using pressors ??
> (now I am questioning the dogma).
> Would patients become more acidotic and have low SvO2 more than with
> crystalloids ?
>
> Thanks also for considering my question, yours, Ivan
>
>
>
>
>> Date: Sun, 5 Aug 2007 17:56:32 -0700> From: medic0947969 at yahoo.com>
>> To: trauma-list at trauma.org> Subject: pressors in trauma, wasn't
>> the world once flat?> > Thanks everyone for the replies to my
>> earlier questions on theraputically reduced SBP.> > Prior to
>> signing up for this list I raised the question about using
>> pressors in trauma and to say I was met with resistence would be a
>> kind understatement. But here is my madness.> > Pressors are used
>> all the time in trauma, but nobody realizes it. How often in the
>> OR or while sutering is epi used to constrict vasculature to help
>> control bleeding? It seems to me, all the time. I would stipulate
>> that cutting or suturing causes trauma. Maybe a controlled trauma
>> or over a small area. But still a pressor used for bleeding
>> control. (not to raise CVP)> > Now it was brought up on this list
>> to use vasopressin. Stepping away from the TBI for a second, from
>> cardiogenic shock of nontraumatic origin to spinal trauma, pressors
>> are indicated; If
> not to aid in perfusion, then for what? I understand the dogma of
> no pressors comes from the idea that the pressor does not help CVP
> and therefore is contraindicated because the increase in BP gives a
> false impression of tissue perfusion. But from a common sense point
> of view, back to TBI, you are not trying to raise CVP, you are
> trying to raise MAP. So why would the pressor not work? Unfortunatly
> I don't know the answers to the following questions. Please can
> anyone tell me: > > Which pressor? Why vasopresson over levofed or
> any other? Obviously some work differently than others, but I do not
> know why the focus is on Vasopressin.> > What doses are being
> considered and why? It seems to me using 40 units of vasopressin
> might be too much on a pt with a pulse, but what is the reasoning
> for the dose being used or is it titrated to effect? > > The other
> side of the coin is by raising MAP with a pressor do you impact CVP?
> Are any other organs or systems negatively impacted? i.e. t
> he kidneys?> > Does this idea simply come from the idea that in a
> cold, diaphoretic patient we might look at the BP reading and forget
> we treat patients not monitors?> > Thanks for taking time to
> consider this.> > Mike> > KMATTOX at aol.com wrote:> > In a message
> dated 8/5/2007 4:30:51 P.M. Central Daylight Time, ih7 at msn.com >
> writes:> > if the ICP is increased, you need to keep the MAP 60 mm
> higher so the blood > flows forward through the brain> > > I would
> agree with that, but would plead that it is NOT crystalloid fluids >
> which should be used to achieve that MAP. Remember that most of the
> studies > of the past 30-40 yrs were in patients that had 3 liters
> (or more) challenge > of crystalloid prior to any surgeon,
> especially neurosurgeon, seeing them. > The ICP increase is a
> complex compartment syndrome and much of our > traditional urban
> legend therapy actually iatrogenicly contributed to the spiraling >
> increase in ICP. > > I am delighted to see the direction of the
> discuss
> ions on this web site, and > do believe that it is going to lead to
> a whole new wave of research. > > k> > > >
> ************************************** Get a sneak peek of the
> all-new AOL at > http://discover.aol.com/memed/aolcom30tour> -->
> trauma-list : TRAUMA.ORG> To change your settings or unsubscribe
> visit:> http://www.trauma.org/index.php?/community/> > > >
> ---------------------------------> Be a better Heartthrob. Get
> better relationship answers from someone who knows.> Yahoo! Answers
> - Check it out. > --> trauma-list : TRAUMA.ORG> To change your
> settings or unsubscribe visit:>
> http://www.trauma.org/index.php?/community/
>
> ------------------------------
>
> Message: 4
> Date: Sun, 5 Aug 2007 22:21:25 EDT
> From: KMATTOX at aol.com
> Subject: Re: Why are crystalloids better > pressors ?= NEITHER
> To: trauma-list at trauma.org
> Message-ID: <c42.1765ab53.33e7dfa5 at aol.com>
> Content-Type: text/plain; charset="US-ASCII"
>
>
> In a message dated 8/5/2007 9:12:31 P.M. Central Daylight Time, ih7 at msn.com
> writes:
>
> What I don't understand is why crystalloids help - they do not increase
> oxygen delivery meaningfully..
> but they keep the BP and CO, - is that useful for the body ?? Why ?
>
> What if we just keep up the BP and not the CO - by using pressors ?? (now I
> am questioning the dogma).
> Would patients become more acidotic and have low SvO2 more than with
> crystalloids ?
>
>
>
>
> The BIG fallacy here is that we continue to assume that CO and BP are our
> objective of resuscitation. WRONG. Whether it be brain, kidney,
> gut, or big
> toe preservation, it is perfusion and oxygen extraction that is essential,
> with variables of temperature, pH, etc. altering the exchange.
> That is why
> NIR would be much better than the BP cuff. Whether it is MAST, drugs,
> crystalloids, or position, any attempt to resuscitate based on BP as an end
> point simply is living in the 1960s and not the 21st century. Get your
> head out of the past and into current thinking. You need to go no
> further than
> Karim Brohi's trauma.org pages to get an excellent review of this subject.
>
> k
>
>
>
> ************************************** Get a sneak peek of the all-new AOL at
> http://discover.aol.com/memed/aolcom30tour
>
>
> ------------------------------
>
> Message: 5
> Date: Sun, 5 Aug 2007 22:28:45 -0500
> From: "Alex Garbino" <agarbino at gmail.com>
> Subject: Re: Why are crystalloids better > pressors ?= NEITHER
> To: "Trauma &, Critical Care mailing list" <trauma-list at trauma.org>
> Message-ID:
> <4cf37ad00708052028v5cbe794v6f3edbd5300b2f24 at mail.gmail.com>
> Content-Type: text/plain; charset=ISO-8859-1
>
> As you look at the new techniques to monitor perfusion (NIR instead of BP,
> etc), I would also look at some of the new work regarding slow reperfusion
> protocols. Remember that it's not so much the lack of oxygen as much as the
> sudden onrush of oxygen after deprivation that causes cell death (mostly via
> free radicals, etc). These protocols are being intensely researched in
> cardiovascular events, etc.; but I think this would apply to trauma, TBIs,
> and any other state where tissue is exposed to hypoxia. Maybe in the future
> patients will undergo permissive hypotension and slow reperfusion as opposed
> to today's immediate massive reperfusion, 100% O2 masks, etc.
>
> Alex Garbino
>
> On 8/5/07, KMATTOX at aol.com <KMATTOX at aol.com> wrote:
>>
>>
>> In a message dated 8/5/2007 9:12:31 P.M. Central Daylight Time,
>> ih7 at msn.com
>> writes:
>>
>> What I don't understand is why crystalloids help - they do not increase
>> oxygen delivery meaningfully..
>> but they keep the BP and CO, - is that useful for the body ?? Why ?
>>
>> What if we just keep up the BP and not the CO - by using pressors
>> ?? (now I
>> am questioning the dogma).
>> Would patients become more acidotic and have low SvO2 more than with
>> crystalloids ?
>>
>>
>>
>>
>> The BIG fallacy here is that we continue to assume that CO and BP are our
>> objective of resuscitation. WRONG. Whether it be brain, kidney, gut,
>> or big
>> toe preservation, it is perfusion and oxygen extraction that is
>> essential,
>> with variables of temperature, pH, etc. altering the exchange. That
>> is why
>> NIR would be much better than the BP cuff. Whether it is MAST, drugs,
>> crystalloids, or position, any attempt to resuscitate based on BP as an
>> end
>> point simply is living in the 1960s and not the 21st
>> century. Get your
>> head out of the past and into current thinking. You need to go no
>> further than
>> Karim Brohi's trauma.org pages to get an excellent review of this
>> subject.
>>
>> k
>>
>>
>>
>> ************************************** Get a sneak peek of the all-new AOL
>> at
>> http://discover.aol.com/memed/aolcom30tour
>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.php?/community/
>>
>
>
> ------------------------------
>
> Message: 6
> Date: Mon, 6 Aug 2007 01:31:23 -0400
> From: "Andrew J Bowman" <andrewj.bowman at gmail.com>
> Subject: Bullet Removal
> To: "Trauma &, Critical Care mailing list" <trauma-list at trauma.org>
> Message-ID:
> <dfe364720708052231g36ac1a70saa1c2b21933ed92e at mail.gmail.com>
> Content-Type: text/plain; charset=ISO-8859-1
>
> I was reading some of the recent postings at trauma.org website.
>
> There was one posting about the retro-aortic bullet that was left in place.
>
> Is there ever a concern about eventual erosion of the bullet into the nearby
> vascular structures?
>
> I had a patient in my past who had suffered a GSW in his youth. He presented
> to my ER late at night with abdominal pain and hypotension. CT showed
> massive hemoperitoneum.
>
> OR showed that bullet had eroded into the IVC.
>
> Thanks,
>
> Andrew Bowman
>
>
> ------------------------------
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
> End of trauma-list Digest, Vol 50, Issue 12
> *******************************************
>
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