BIG, FAST 1

[Richard Wigle MD FACS]

As I noted previously, the reason the cut down is taught is
not that it is the "recommended" approach but rather
because it can be adapted to almost any circumstances with
whatever supplies are available. Although its' principles
are fairly universally accepted and it provides a treatment
framework with which teams can work in cohesion, ATLS is
not primarily intended for folks in major centers but for
the fellow who is out there in impoverished circumstances 

R Wigle MD FACS
--- Matthew Reeds <mgreeds at reeds.uk.com> wrote:

> I must say that I don't believe cut-downs should be
> taught in ATLS for a
> number of reasons:-
> 
>  
> 
> 1)     Although, as you quite rightly say, saphenous vein
> cut-down works,
> there are however much simpler and quicker methods for
> gaining access (I
> have had a BIG in a patient in the A+E resus room trauma
> bay [ED] and
> aspirated marrow before one of my colleagues [with no
> experience of BIG I
> might add] even had all the kit ready to do a saphenous
> cut-down.) This
> patient had been in a prolonged entrapment RTA in the
> freezing cold with no
> venous access. He was an IVDA and so his veins were shot
> and there was no
> hope of gaining venous access there and then;
> 
>  
> 
> 2)     There is a risk of damaging the saphenous nerve
> for those who make
> the cut-down too high up. You and I would probably never
> do that but I have
> seen it happen by the more inexperienced medics!;
> 
>  
> 
> 3)     If one needs to infuse fluids (notwithstanding the
> role for
> permissive hypotension) you can subsequently achieve
> venous access with less
> urgency (using either venflons, central lines
> [subclavian, internal jugular
> or femoral etc.]) As you rightly say, it is rare for
> venous access using
> Seldinger method to fail and these other methods (BIG,
> FAST 1 and IO etc.
> are interim measures); and,
> 
>  
> 
> 4)     I myself would be perfectly happy to do a venous
> cut-down for venous
> access but can't remember the last time I did in trauma
> (I am not that old
> honestly!) I have done many for elective surgery reasons
> and in fact the
> last one that I happened to do was approx 6 weeks ago
> (great saphenous vein
> harvest for CABG as the radial artery was unsuitable for
> grafting.) I am
> used to harvesting upto the saphenovenous junction so
> (presumably like you)
> I am happy with my anatomy and surgical technique but I
> still wouldn't use
> one in trauma (there are better options out there!!)
> 
>  
> 
>  
> 
> I agree that ATLS is a worldwide accepted standard and
> has tremendously
> improved the standard of care from trauma since its
> inception.  The problem
> with ATLS is the time period it takes to update on
> techniques. Our local
> course (major U.K. city) as indeed everywhere else is
> still teaching 2L
> fluid STAT for EVERYONE! This goes against the permissive
> hypotension
> phenomenon and I gave up counting a long time ago the
> number of times I have
> seen trauma patients' conditions worsen through cyclical
> fluid
> resuscitation, whilst ignoring and making the surgical
> bleeding worse. This
> is because people follow protocols (which should be
> banned) rather than
> using clinical acumen and judgment and accepting that
> each situation is
> different. For those that are unsure, we can accept
> guidelines (which
> suggest a course of action for the clinician to follow if
> need be) but never
> one which dictates that the clinician must ignore common
> sense and act
> against his/her better judgment on the patient's
> condition in front of
> him/her.
> 
>  
> 
>  
> 
> Matthew Reeds
> 
> Surgery
> 
> U.K.
> 
>  
> 
>  
> 
>  
> 
> -----Original Message-----
> From: bensonblues at comcast.net
> [mailto:bensonblues at comcast.net] 
> Sent: 18 March 2007 17:38
> To: trauma-list at trauma.org
> Subject: IO's, ad nauseum
> 
>  
> 
> Matt from the UK:
> 
>  
> 
> Do you really think cut downs should not be taught in
> ATLS?  In selected
> patients, I still believe that there is a role for the
> (saphenous v.) cut
> down, especially kids. It is unsusal for the Seldinger
> method to fail us in
> our trauma bay, except in IVDA patients. But if it does,
> venous cut down
> remains a good option: less trauma, more
> reliable/definitive, and less pain
> if infiltrative anesthesia is used. If I am wrong here, I
> now know I am
> getting old.
> 
>  
> 
> DB from the US
> 
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