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From: <I>trauma-list-request@trauma.org</I><BR>Reply-To:
<I>trauma-list@trauma.org</I><BR>To:
<I>trauma-list@trauma.org</I><BR>Subject: <I>trauma-list Digest, Vol 42,
Issue 23</I><BR>Date: <I>Thu, 21 Dec 2006 12:00:17 +0000 (GMT)</I><BR>Send
trauma-list mailing list submissions to<BR>trauma-list@trauma.org<BR><BR>To
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please edit your Subject line so it is more specific<BR>than "Re: Contents
of trauma-list digest..."<BR>
<P>Today's Topics:<BR><BR>1. Crush and tourniquets (Jason Van der
Velde)<BR>2. RE: Crush and tourniquets (Hardcastle, Tim, Dr
<tch@sun.ac.za>)<BR>3. RE: Crush and tourniquets (Hardcastle, Tim, Dr
<tch@sun.ac.za>)<BR>4. Re: Crush and tourniquets (Stefan Mark
Mazur)<BR>5. Northfield Hits Blood-Test Hurdle (S Schecter)<BR>6. Re: Crush
and tourniquets (Krin135@aol.com)<BR>7. RECOA I - 1st International Course
of Osteo-Articular<BR>Reconstruction (Nuno Lopes)<BR>8. Head Injury -
Termination of Resuscitative Efforts<BR>(bensonblues@comcast.net)<BR>9. RE:
Crush and tourniquets (Anthony Caruso)<BR>10. Re: head injury- termi ation
of resuscitative efforts<BR>(oded private)<BR>11. RE: head injury- termi
ation of resuscitative efforts<BR>(oded private)<BR>12. Lay person's trauma
training (oded private)<BR>
<P>
<HR color=#a0c6e5 SIZE=1>
From: <I>"Jason Van der Velde"
<rescue@doctors.org.uk></I><BR>Reply-To: <I>"Trauma &amp;
Critical Care mailing list" <trauma-list@trauma.org></I><BR>To:
<I>trauma-list@trauma.org</I><BR>Subject: <I>Crush and
tourniquets</I><BR>Date: <I>Tue, 19 Dec 2006 15:05:33 +0000</I><BR>You
probably knew Karim that I would eventually resist no more and rise to your
initial posting!!! Time to stop lurking in this fascinating tourniquet
debate!!<BR>Apologies for the lengthily reply, but particularly in light of
Dr. Mazur insightful comments, this is not a simple topic and needs space
to be addressed properly. I believe I write with reasonable authority as
apart from my clinical work, I lecture extensively on the systemic sequalea
of muscle damage. It is the subject of my masters thesis, and in more
detail my envisaged PhD work.<BR>1st an observation: We are a large
multidisciplinary discussion group. Equally trauma is NOT the remit of only
one specialty or professional group. Predictably we all are approaching
what is essentially THE SAME kinematics and pathophysiological process from
different angles, which is not necessary a bad thing, but may I suggest
that we all need to “think out of the box?that is our "individual
specialties". This is particularly important for the patient, who’s journey
is a lifetime, and not the 15min in the ambulance or 2 hours on the
operating table. Crush syndrome kills or seriously disables:<BR>1) on or
shortly after extrication (Cardiac Arrhythmias/thromboembolic)<BR>2) In a
few days or weeks (Acute Renal Failure/Cardiac
Arrhythmias/thromboembolic)<BR>3) In a number of years, which as acute
clinicians we frequently forget! (Chronic Renal Failure)<BR>Crush syndrome
is a true systemic insult. Apart from the well know renal complications of
muscle damage, prehospital deaths post extrication secondary to cardiac
arrhythmia, are frequently misdiagnosed as hypovolaemic arrests and could
hold a key to making a significant dent in post extrication mortality
statistics, ie. Peak 1 of either the Scottish Trauma Audit[i] or
Trunkey's[ii] curve. Hence this is an important subject that requires a
roadside to critical care approach to management.<BR>Electrolyte
abnormalities occur frequently in patients with crush-related acute renal
failure.[iii] We have known about such disturbances for some time now,
particularly the tremendous potential for hyperkalaemia and consequent
fatal cardiac arrhythmias.[iv] What we have not fully appreciated until
quite recently is the staggering percentage of patients who have died
either on scene or en-route to hospital, as a result of electrolyte
abnormalities during or shortly post extrication.<BR>Important autopsy
findings from 111 deaths in the 1999 Athens earthquake have only recently
been made public.[v] Although this study’s main purpose was to audit
emergency response as a whole, it begins to give us the first real evidence
to support a long held belief of the adverse effects of extrication on
cardiac function. Researches from the University of Athens General Hospital
evaluated and combined demographic data, circumstances of death, rescue
time, mechanisms of injury, causes of death, Abbreviated Injury Scale (AIS
90) and Injury Severity Score (ISS) values, vital functions and
co-morbidity in a study seeking to identify preventable deaths in Trunkey’s
first group. Their findings attributed a staggering 46.6 % of post
extrication earthquake deaths directly to cardiac complications.<BR>It is
hypothesised that this pathophysiological process is far more common than
we think in every day trauma practice and if this is so, it is clear that
we have to drastically alter our current practices, particularly our
prehospital practices, if we are to make any headway in addressing
mortality/morbidity.<BR>Dr. Mazur has certainly presented this list with a
very logical approach to management. Perhaps I can add to his comments by
providing some additional points as well as some evidence to back his
management strategies up. The goals are prevention and protection. There is
more than sufficient data to warrant an initial aggressive approach to
preventing fatal cardiac arrhythmias, whilst at the same time initiating
early, renal protective strategies. I am more than happy to discuss this
data further, in depth, off list.<BR>EARLY identification of at risk
patients and assigning them to a crush protocol is the key. Crush protocols
are not new. We’ve been studying them and using them since the 1st world
war![vi] Now I can safely make the comment that by the time you have
biochemical diagnosis (ie. Serum CK) of a crush syndrome, it is too late.
The decision to initiate preventative and protective strategies should be a
balanced, educated decision weighing up kinematics, degree and time of
entrapment, environmental influences and premorbid health against the need
for circulating volume preservation and haemorrhage control. The early use
of myoglobin specific urinary dipstick appears to be a sensible tool in
aiding such an early management decision.[vii].<BR>I believe that the key
is proper training and experience in identifying at risk patients by the
kinematics of insult alone?How this is done is a whole discussion on its
own. It is also a contentious issue at the heart of how we manage our
prehospital emergency services. But what is NOT contentious is the
overwhelming evidence:<BR>Early aggressive intervention,[viii],[ix],[x]
prior to extrication[xi], has been shown to benefit long term outcome in
entrapped casualties at risk of Crush Syndrome.<BR>WHY prior to
extrication??<BR>A NORMOvolaemic, NORMOtensive, NORMOthermic, NORMOetc.
etc. etc. system handles the “ischemic soup?that is bolused from a released
limb far better than one that is in haemodynamic crisis... If we are going
to remove a crushing force or remove a tourniquet, the body has to be in
shape to handle it! I speak from an anaesthetic perspective where I manage
tourniquet release post operatively on a weekly basis both electively and
as an emergency. Maintaining systemic normality is standard perioperative
management in orthopaedic, vascular, plastics etc. etc. surgery. Can you
all put hand on heart and say you release that “ischaemic soup?into a
haemodynamically stable circulation each and every time?? Is this why we
get away with it in theatre and not in the emergency room? I’m not by any
means implying that each and every time we take someone to theatre and put
a tourniquet that we don’t have a problem, of course not! But it is a
no-brainer that a haemodynamically stable patient has a better
chance...<BR>WHY prophylactic tourniquets are good??<BR>There should be no
ambiguity, that circulation preservation strategies, i.e. permissive
hypotension until definitive surgical or interventional radiological
management of the haemorrhage, takes precedence over any crush syndrome
protocol. Just thought I’d make that statement 1st! I do believe in the
DDIT approach with tourniquets as a useful adjunct in the right
circumstances in haemorrhage control?but may I add once again to the
argument? WITH SYSTEMIC PREOPTIMISATION PRIOR TO RELEASE !<BR>Do you want a
rescuer managing a cardiac arrhythmia during the extrication? Do want to
manage it in an ambulance? Or do you want SOME control over when it is
going to occur? That is why we teach our rescue personnel to put
tourniquets on, prior to release and call an appropriately qualified person
who is able to start a crush protocol to go some way to restore systemic
normality.<BR>Tourniquets should remain in place until the patient is in a
safer environment, ideally in a hospital resuscitation bay or theatre, with
full cardiovascular monitoring, but as a sensible compromise, in cases
where there is potentially a long delay to definitive care or a difficult
extrication, the stage release protocol could be used earlier.<BR>Once in a
place of safety, with appropriate monitoring, appropriate preoptimisation,
a staged release of tourniquets is an entirely logical next approach. This
is currently lacking a clinical effectiveness audit, something which I aim
to tackle as part of a PhD.<BR>The goal is to do a controlled “infusion?as
opposed to “bolus?the inevitable ischemic washout. Tourniquets should be
individually released for a period of thirty seconds, whilst monitoring the
casualty’s condition closely and then reapplied for a period of 3 minutes.
After reapplication, wait for 3 minutes. If the casualty is stable, release
the other tourniquet (if present) for 30 seconds. Repeat this procedure
with each tourniquet being released 3 times until finally being left off.
During this time a large CO2 and therefore acid load will return to the
main circulation. Ventilated patients should be hyperventilated. Adverse
responses can be managed with further fluid, pressors, calcium and sodium
bicarbonate.<BR>To answer Dr. Mazur’s question, there is good evidence in
support of the early use of potassium binders such as sodium polystyrene
sulfonate (Sodium or Calcium Resonium) orally or rectally before patients
are extricated and transferred to hospital.[xii] Should Calcium be used
prophylacticly? Well again, no evidence, but very logical. I am looking
into the possibility of a study in a particularly earthquake prone
country?will let the list know the results. But I am about to publish one
very good case example where we used such agents periarrest in the face of
massive hyperkalaemia with discharge home 4 days later!<BR>I leave you with
one thought: It can be argued that we have inadvertently been efficiently
managing a huge bulk of patients at risk of crush syndrome through our
traditionally liberal approach to fluid resuscitation, throughout the
trauma patient journey. With today’s more conservative approach to the use
of fluids in trauma, could we now begin to see a shift away from such
problems as fluid overload and ARDS to those of a crush
syndrome?<BR><BR>Dr. Jason van der Velde (EMDM-A, MBChB, BAA)<BR>Disaster
Response Coordinator<BR>UN/OCHA Liaison<BR>Anaesthesia Trauma and Critical
Care Team<BR>atacc.co.uk<BR><BR>[i] Jonathan Wyatt, Diana Beard, Alasdair
Gray, Anthony Busuttil, and Colin Robertson. The time of death after
trauma. BMJ 1995; 310: 1502<BR>[ii] Trunkey DD. Trauma. Sci Am
1983;249(2):20-7<BR>[iii] Sever MS, Erek E, Vanholder R, et al. The Marmara
earthquake: admission laboratory features of patients with nephrological
problems. Nephrol Dial Transplant 2002;17:1025-1031.<BR>[iv] James PB.
Cardiac arrest after crush injury. Br Med J (Clin Res Ed). 1983 Sep
17;287(6395):839.<BR>[v] Papadopoulos IN, Kanakaris N, Triantafillidis A,
et. al. Autopsy findings from 111 deaths in the 1999 Athens earthquake as a
basis for auditing the emergency response. Br J Surg. 2004
Dec;91(12):1633-40<BR>[vi] Frankenthal L. Lieber Verschuettungen. Virchows
Archives 1916;22:332-45 (in German).<BR>[vii] Apple, F.S., Y. Hellsten, and
P.M. Clarkson. Early detection of skeletal muscle injury by assay of
creatine kinase MM isoforms in serum after acute exercise. Clin. Chem.
34(6): 1102-1104, 1988.<BR>[viii] Better OS. The crush syndrome revisited
(1940-1990). Nephron 1990;55:97-103.<BR>[ix] Better OS, Rubinstein I, Reis
ND. Muscle crush compartment syndrome: fulminant local oedema with
threatening systemic effects. Kid Int 2003;63:1155-7.<BR>[x] Malinoski DJ,
Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care Clin.
2004 Jan;20(1):171-92<BR>[xi] Gunal AI, Celiker H, Dogukan A, et. al. Early
and vigorous fluid resuscitation prevents acute renal failure in the crush
victims of catastrophic earthquakes. J Am Soc Nephrol. 2004
Jul;15(7):1862-7<BR>[xii] Sever MS, Vanholder R, Lameire N. Management of
crush-related injuries after disasters. N Engl J Med. 2006 Mar
9;354(10):1052-63.<BR><BR><BR>This message has been scanned for viruses by
BlackSpider MailControl - www.blackspider.com<BR><BR>
<P>
<P>
<HR color=#a0c6e5 SIZE=1>
From: <I>"Hardcastle, Tim, Dr <tch@sun.ac.za>"
<tch@sun.ac.za></I><BR>Reply-To: <I>"Trauma &amp; Critical Care
mailing list" <trauma-list@trauma.org></I><BR>To: <I>"Trauma
&amp; Critical Care mailing list"
<trauma-list@trauma.org></I><BR>Subject: <I>RE: Crush and
tourniquets</I><BR>Date: <I>Wed, 20 Dec 2006 16:25:11
+0200</I><BR>Jason<BR><BR>Good to see you contribute and appreciate your
views. Is there any evidence regarding time of entrapment and extent of
entrapment (eg complete limb under wall vs body caught in crashed car, with
minimal pressure on limbs) in terms of severity and treatment protocols.
You did not mention Carlos Brown's work from LAC. They showed that for CK
<15000 the incidence of renal failure was <6% and that bicarb and
mannitol had no advantage over saline flush alone. This is my experience
here in South Africa too; one of my registrars is writing up our series of
close to 500 cases of crush over a two year period at the moment for his
M.Med dissertation.<BR><BR>I agree on the exchange resins though, although
this effect seems related to longer term rather than acute lowering of the
potassium.<BR><BR>The majority of crush injury I see comes from
interpersonal violence (locally called kangaroo-court and sjambok assault,
you may remember) and from vascular injury reperfusion. Is the effect and
outcome different?<BR><BR>The incidence of chronic renal dysfunction in
this group is surprisingly small from what my renal unit colleagues, who
follow these patients longterm, tell me. If they reverse the renal
dysfunction (usually within around three weeks) they seem to have good
functional outcomes with a small group having persistant hypertension at
five years. the trick is to not let them get dehydrated during the
inevitable polyuric phase of recovery.<BR><BR>Regards<BR>Tim<BR>Dr T C
Hardcastle<BR>M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)<BR>Senior Surgeon /
Senior Lecturer: Surgery (Trauma and ICU)<BR>ATLS instructor and DSTC Cape
Town Course Director<BR>Intern program Coordinator: Surgery<BR>M.Med
(Emergency Medicine) Executive Committee member<BR>Clinical Head
(Director): Diana Princess of Wales Trauma Unit<BR>Division of Surgery
(General) Room 4064<BR>Department of Surgical Sciences<BR>Tygerberg
Hospital / University of Stellenbosch<BR>PO Box 19063<BR>Tygerberg
7505<BR>Western Cape<BR>South Africa<BR>e-mail: tch@sun.ac.za<BR>Cell:
+27824681615<BR>Office: +27219389281 or 4911 pager
0302<BR><BR><BR><BR>-----Original Message-----<BR>From:
trauma-list-bounces@trauma.org<BR>[mailto:trauma-list-bounces@trauma.org]On
Behalf Of Jason Van der Velde<BR>Sent: Tuesday, December 19, 2006 5:06
PM<BR>To: trauma-list@trauma.org<BR>Subject: Crush and
tourniquets<BR><BR><BR>You probably knew Karim that I would eventually
resist no<BR>more and rise to your initial posting!!! Time to
stop<BR>lurking in this fascinating tourniquet debate!!<BR><BR>Apologies
for the lengthily reply, but particularly in<BR>light of Dr. Mazur
insightful comments, this is not a<BR>simple topic and needs space to be
addressed properly. I<BR>believe I write with reasonable authority as apart
from my<BR>clinical work, I lecture extensively on the systemic<BR>sequalea
of muscle damage. It is the subject of my masters<BR>thesis, and in more
detail my envisaged PhD work.<BR><BR>1st an observation: We are a large
multidisciplinary<BR>discussion group. Equally trauma is NOT the remit of
only<BR>one specialty or professional group. Predictably we all<BR>are
approaching what is essentially THE SAME kinematics<BR>and
pathophysiological process from different angles,<BR>which is not necessary
a bad thing, but may I suggest that<BR>we all need to "think out of the
box" that is our<BR>"individual specialties". This is particularly
important<BR>for the patient, who's journey is a lifetime, and not
the<BR>15min in the ambulance or 2 hours on the operating table.<BR>Crush
syndrome kills or seriously disables:<BR>1) on or shortly after extrication
(Cardiac<BR>Arrhythmias/thromboembolic)<BR>2) In a few days or weeks (Acute
Renal<BR>Failure/Cardiac Arrhythmias/thromboembolic)<BR>3) In a number of
years, which as acute clinicians we<BR>frequently forget! (Chronic Renal
Failure)<BR><BR>Crush syndrome is a true systemic insult. Apart from
the<BR>well know renal complications of muscle damage,<BR>prehospital
deaths post extrication secondary to cardiac<BR>arrhythmia, are frequently
misdiagnosed as hypovolaemic<BR>arrests and could hold a key to making a
significant dent<BR>in post extrication mortality statistics, ie. Peak 1
of<BR>either the Scottish Trauma Audit[i] or Trunkey's[ii]<BR>curve. Hence
this is an important subject that requires a<BR>roadside to critical care
approach to management.<BR><BR>Electrolyte abnormalities occur frequently
in patients<BR>with crush-related acute renal failure.[iii] We have
known<BR>about such disturbances for some time now, particularly<BR>the
tremendous potential for hyperkalaemia and consequent<BR>fatal cardiac
arrhythmias.[iv] What we have not fully<BR>appreciated until quite recently
is the staggering<BR>percentage of patients who have died either on scene
or<BR>en-route to hospital, as a result of electrolyte<BR>abnormalities
during or shortly post extrication.<BR><BR>Important autopsy findings from
111 deaths in the 1999<BR>Athens earthquake have only recently been made
public.[v]<BR>Although this study's main purpose was to audit
emergency<BR>response as a whole, it begins to give us the first
real<BR>evidence to support a long held belief of the adverse<BR>effects of
extrication on cardiac function. Researches<BR>from the University of
Athens General Hospital evaluated<BR>and combined demographic data,
circumstances of death,<BR>rescue time, mechanisms of injury, causes of
death,<BR>Abbreviated Injury Scale (AIS 90) and Injury Severity<BR>Score
(ISS) values, vital functions and co-morbidity in a<BR>study seeking to
identify preventable deaths in Trunkey's<BR>first group. Their findings
attributed a staggering 46.6 %<BR>of post extrication earthquake deaths
directly to cardiac<BR>complications.<BR><BR>It is hypothesised that this
pathophysiological process is<BR>far more common than we think in every day
trauma practice<BR>and if this is so, it is clear that we have to
drastically<BR>alter our current practices, particularly our
prehospital<BR>practices, if we are to make any headway in
addressing<BR>mortality/morbidity.<BR><BR>Dr. Mazur has certainly presented
this list with a very<BR>logical approach to management. Perhaps I can add
to his<BR>comments by providing some additional points as well as<BR>some
evidence to back his management strategies up. The<BR>goals are prevention
and protection. There is more than<BR>sufficient data to warrant an initial
aggressive approach<BR>to preventing fatal cardiac arrhythmias, whilst at
the<BR>same time initiating early, renal protective strategies. I<BR>am
more than happy to discuss this data further, in depth,<BR>off
list.<BR><BR>EARLY identification of at risk patients and assigning<BR>them
to a crush protocol is the key. Crush protocols are<BR>not new. We've been
studying them and using them since the<BR>1st world war![vi] Now I can
safely make the comment that<BR>by the time you have biochemical diagnosis
(ie. Serum CK)<BR>of a crush syndrome, it is too late. The decision
to<BR>initiate preventative and protective strategies should be<BR>a
balanced, educated decision weighing up kinematics,<BR>degree and time of
entrapment, environmental influences<BR>and premorbid health against the
need for circulating<BR>volume preservation and haemorrhage control. The
early<BR>use of myoglobin specific urinary dipstick appears to be
a<BR>sensible tool in aiding such an early
management<BR>decision.[vii].<BR><BR>I believe that the key is proper
training and experience<BR>in identifying at risk patients by the
kinematics of<BR>insult alone... How this is done is a whole discussion
on<BR>its own. It is also a contentious issue at the heart of<BR>how we
manage our prehospital emergency services. But what<BR>is NOT contentious
is the overwhelming evidence:<BR><BR>Early aggressive
intervention,[viii],[ix],[x] prior to<BR>extrication[xi], has been shown to
benefit long term<BR>outcome in entrapped casualties at risk of Crush
Syndrome.<BR><BR>WHY prior to extrication??<BR>A NORMOvolaemic,
NORMOtensive, NORMOthermic, NORMOetc.<BR>etc. etc. system handles the
"ischemic soup" that is<BR>bolused from a released limb far better than one
that is<BR>in haemodynamic crisis... If we are going to remove
a<BR>crushing force or remove a tourniquet, the body has to be<BR>in shape
to handle it! I speak from an anaesthetic<BR>perspective where I manage
tourniquet release post<BR>operatively on a weekly basis both electively
and as an<BR>emergency. Maintaining systemic normality is
standard<BR>perioperative management in orthopaedic, vascular,<BR>plastics
etc. etc. surgery. Can you all put hand on heart<BR>and say you release
that "ischaemic soup" into a<BR>haemodynamically stable circulation each
and every time??<BR>Is this why we get away with it in theatre and not in
the<BR>emergency room? I'm not by any means implying that each<BR>and every
time we take someone to theatre and put a<BR>tourniquet that we don't have
a problem, of course not!<BR>But it is a no-brainer that a haemodynamically
stable<BR>patient has a better chance...<BR><BR>WHY prophylactic
tourniquets are good??<BR>There should be no ambiguity, that
circulation<BR>preservation strategies, i.e. permissive hypotension
until<BR>definitive surgical or interventional radiological<BR>management
of the haemorrhage, takes precedence over any<BR>crush syndrome protocol.
Just thought I'd make that<BR>statement 1st! I do believe in the DDIT
approach with<BR>tourniquets as a useful adjunct in the right
circumstances<BR>in haemorrhage control... but may I add once again to
the<BR>argument.... WITH SYSTEMIC PREOPTIMISATION PRIOR TO
RELEASE<BR>!<BR><BR>Do you want a rescuer managing a cardiac arrhythmia
during<BR>the extrication? Do want to manage it in an ambulance? Or<BR>do
you want SOME control over when it is going to occur?<BR>That is why we
teach our rescue personnel to put<BR>tourniquets on, prior to release and
call an appropriately<BR>qualified person who is able to start a crush
protocol to<BR>go some way to restore systemic
normality.<BR><BR>Tourniquets should remain in place until the patient is
in<BR>a safer environment, ideally in a hospital resuscitation<BR>bay or
theatre, with full cardiovascular monitoring, but<BR>as a sensible
compromise, in cases where there is<BR>potentially a long delay to
definitive care or a difficult<BR>extrication, the stage release protocol
could be used<BR>earlier.<BR><BR>Once in a place of safety, with
appropriate monitoring,<BR>appropriate preoptimisation, a staged release
of<BR>tourniquets is an entirely logical next approach. This
is<BR>currently lacking a clinical effectiveness audit,<BR>something which
I aim to tackle as part of a PhD.<BR><BR>The goal is to do a controlled
"infusion" as opposed to<BR>"bolus" the inevitable ischemic washout.
Tourniquets<BR>should be individually released for a period of
thirty<BR>seconds, whilst monitoring the casualty's condition<BR>closely
and then reapplied for a period of 3 minutes.<BR>After reapplication, wait
for 3 minutes. If the casualty<BR>is stable, release the other tourniquet
(if present) for<BR>30 seconds. Repeat this procedure with each
tourniquet<BR>being released 3 times until finally being left
off.<BR>During this time a large CO2 and therefore acid load will<BR>return
to the main circulation. Ventilated patients should<BR>be hyperventilated.
Adverse responses can be managed with<BR>further fluid, pressors, calcium
and sodium bicarbonate.<BR><BR>To answer Dr. Mazur's question, there is
good evidence in<BR>support of the early use of potassium binders such
as<BR>sodium polystyrene sulfonate (Sodium or Calcium Resonium)<BR>orally
or rectally before patients are extricated and<BR>transferred to
hospital.[xii] Should Calcium be used<BR>prophylacticly? Well again, no
evidence, but very logical.<BR>I am looking into the possibility of a study
in a<BR>particularly earthquake prone country... will let the list<BR>know
the results. But I am about to publish one very good<BR>case example where
we used such agents periarrest in the<BR>face of massive hyperkalaemia with
discharge home 4 days<BR>later!<BR><BR>I leave you with one thought: It can
be argued that we<BR>have inadvertently been efficiently managing a huge
bulk<BR>of patients at risk of crush syndrome through our<BR>traditionally
liberal approach to fluid resuscitation,<BR>throughout the trauma patient
journey. With today's more<BR>conservative approach to the use of fluids in
trauma,<BR>could we now begin to see a shift away from such problems<BR>as
fluid overload and ARDS to those of a crush syndrome?<BR><BR>Dr. Jason van
der Velde (EMDM-A, MBChB, BAA)<BR>Disaster Response Coordinator<BR>UN/OCHA
Liaison<BR>Anaesthesia Trauma and Critical Care
Team<BR>atacc.co.uk<BR><BR>[i] Jonathan Wyatt, Diana Beard, Alasdair Gray,
Anthony<BR>Busuttil, and Colin Robertson. The time of death
after<BR>trauma. BMJ 1995; 310: 1502<BR>[ii] Trunkey DD. Trauma. Sci Am
1983;249(2):20-7<BR>[iii] Sever MS, Erek E, Vanholder R, et al. The
Marmara<BR>earthquake: admission laboratory features of patients
with<BR>nephrological problems. Nephrol Dial
Transplant<BR>2002;17:1025-1031.<BR>[iv] James PB. Cardiac arrest after
crush injury. Br Med J<BR>(Clin Res Ed). 1983 Sep 17;287(6395):839.<BR>[v]
Papadopoulos IN, Kanakaris N, Triantafillidis A, et.<BR>al. Autopsy
findings from 111 deaths in the 1999 Athens<BR>earthquake as a basis for
auditing the emergency response.<BR>Br J Surg. 2004
Dec;91(12):1633-40<BR>[vi] Frankenthal L. Lieber Verschuettungen.
Virchows<BR>Archives 1916;22:332-45 (in German).<BR>[vii] Apple, F.S., Y.
Hellsten, and P.M. Clarkson. Early<BR>detection of skeletal muscle injury
by assay of creatine<BR>kinase MM isoforms in serum after acute exercise.
Clin.<BR>Chem. 34(6): 1102-1104, 1988.<BR>[viii] Better OS. The crush
syndrome revisited<BR>(1940-1990). Nephron 1990;55:97-103.<BR>[ix] Better
OS, Rubinstein I, Reis ND. Muscle crush<BR>compartment syndrome: fulminant
local oedema with<BR>threatening systemic effects. Kid Int
2003;63:1155-7.<BR>[x] Malinoski DJ, Slater MS, Mullins RJ. Crush injury
and<BR>rhabdomyolysis. Crit Care Clin. 2004 Jan;20(1):171-92<BR>[xi] Gunal
AI, Celiker H, Dogukan A, et. al. Early and<BR>vigorous fluid resuscitation
prevents acute renal failure<BR>in the crush victims of catastrophic
earthquakes. J Am<BR>Soc Nephrol. 2004 Jul;15(7):1862-7<BR>[xii] Sever MS,
Vanholder R, Lameire N. Management of<BR>crush-related injuries after
disasters. N Engl J Med. 2006<BR>Mar 9;354(10):1052-63.<BR><BR><BR>This
message has been scanned for viruses by BlackSpider MailControl -
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From: <I>"Hardcastle, Tim, Dr <tch@sun.ac.za>"
<tch@sun.ac.za></I><BR>Reply-To: <I>"Trauma &amp; Critical Care
mailing list" <trauma-list@trauma.org></I><BR>To: <I>"Trauma
&amp; Critical Care mailing list"
<trauma-list@trauma.org></I><BR>Subject: <I>RE: Crush and
tourniquets</I><BR>Date: <I>Wed, 20 Dec 2006 07:40:24
+0200</I><BR>Stephan<BR><BR>I do give Calcium only if clinically indicated
- it does have side-effects IV, notably bradycardia if unapposed by some
potassium. My problem with the crush arguement is a simple one - the tissue
ischaemia and reperfusion injury usually happen only with prolonged
(>1hour) entrapment and most civilian extrications are performed in less
time than that. So what I'm saying is that there may be a place for this
type of "controlled release" in the prolonged entrapment case or where you
are doing an extrication amputation, but otherwise the risk may outway the
benefit.<BR><BR>Fluid - fluid - fluid is the way to go: no permissive
hypotension here! There is also no conclusive evidence that the Soda-bic /
Mannitol regime has a better outcome for the kidneys then fluid alone in
the early phase (See the Carlos Brown article in J Trauma) unless you have
a CK value over about 15000, which implies the patient must be in a
hospital to check the level.<BR><BR>Just my thoughts<BR>Tim<BR>Dr T C
Hardcastle<BR>M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)<BR>Senior Surgeon /
Senior Lecturer: Surgery (Trauma and ICU)<BR>ATLS instructor and DSTC Cape
Town Course Director<BR>Intern program Coordinator: Surgery<BR>M.Med
(Emergency Medicine) Executive Committee member<BR>Clinical Head
(Director): Diana Princess of Wales Trauma Unit<BR>Division of Surgery
(General) Room 4064<BR>Department of Surgical Sciences<BR>Tygerberg
Hospital / University of Stellenbosch<BR>PO Box 19063<BR>Tygerberg
7505<BR>Western Cape<BR>South Africa<BR>e-mail: tch@sun.ac.za<BR>Cell:
+27824681615<BR>Office: +27219389281 or 4911 pager
0302<BR><BR><BR><BR>-----Original Message-----<BR>From:
trauma-list-bounces@trauma.org<BR>[mailto:trauma-list-bounces@trauma.org]On
Behalf Of Stefan Mark Mazur<BR>Sent: Tuesday, December 19, 2006 1:09
PM<BR>To: Trauma &amp; Critical Care mailing list<BR>Subject: Re: Crush
and tourniquets<BR><BR><BR>O.K. I'll play.<BR><BR>In order to promote
discussion, some thoughts on the<BR>subject.<BR><BR>We know that the
problems that ensue in crush are due to<BR>diminished limb perfusion,
usually due to venous<BR>obstruction but possibly arterial as well.
The<BR>consequence of this is obviously cellular anaerobic<BR>metabolism,
build up of cellular waste products esp<BR>lactate, cellular swelling
progressing to cellular death.<BR>Resultant metabolic abnormalities coupled
with this<BR>include potassium, CK and myoglobin release. So all
this<BR>sits in the limbs until the compressive force is released<BR>and
allowed back into the general circulation.<BR><BR>From a long term
management point of view the big issue<BR>is the resultant renal failure
secondary to rhabdomyolysis<BR>coupled with the trauma to the limb and
compartment<BR>syndrome risks. From the prehospital point of view
the<BR>issue is the sudden release of potassium and lactae into<BR>the
general circulation, coupled with the resultant<BR>hypovolaemia from
suddenely decreased<BR>vascular resistance and its effect on the
organs<BR>principally the heart, which tends to react badly to<BR>acidosis
and large potasium loads, i.e. significant<BR>arrhythmias.<BR><BR>We manage
these prehospial then by giving adequate fluid<BR>load to maintain adequate
renal perfusion and protect from<BR>effects of hypovolaemia. The addition
of sodium<BR>bicarbonate to every second or third bag makes sense in
an<BR>attempt to maintain a urinary pH above 6.5 which decreases<BR>the
risks of renal failure caused by
myoglobbin<BR>preciptitation/casts/gel/gunk clogging up the
renal<BR>tubules/collecting system. But what about the acidemia<BR>and
potassium load on the heart?<BR><BR>My approach to this is to ensure that I
have defibrillator<BR>pads attached to the patient prior to release
(if<BR>possible, access permiting) and that I have an ampoule of<BR>calcium
chloride ready to give at the first sign of ECG<BR>changes looking like
hyperkalaemia (i.e peaked T waves, no<BR>p waves widening QRS etc).
Obviously not to be given in<BR>the same line as the bicarb, limestone
formation is<BR>unlikely to help anyone.<BR><BR>If we consider that when
people are pinned such that crush<BR>injury is a factor, it is usually by
the lower limbs and<BR>usually bilateral then applying tourniquets to both
limbs<BR>(if possible, often not, or only one limb accessible)
just<BR>proir to patient release would seem to make theoretical<BR>sense.
Then once patient released, releasing one<BR>tourniquet would allow a
measured release of acid and<BR>potassium, the effect of this could judged
on the basis of<BR>ECG changes, if problem treat and wait until
treatment<BR>(i.e calcium, defibrillation, insulin/dextrose) has
been<BR>implemented and successful until subjecting heart to a<BR>second
insult before releasing the second tourniquet. If<BR>no effect upon
releasing the first tourniquet, then<BR>release the second and be ready to
treat again. This<BR>would seem to be similar to the process of unclamping
the<BR>iliacs one at a time and monitoring the effects that<BR>occurs in
aortic surgery.<BR><BR>So my thoughts, but I have a question as well to add
to<BR>the discussion.<BR><BR>Would/do people give calcium prophlactically
pre-release<BR>or are people more inclined to have ready and treat on
the<BR>basis of clinical/ECG changes?<BR><BR>Looking forward to thers
thoughts/discussion on this.<BR><BR>Cheers,<BR>Stefan<BR><BR>Dr Stefan
Mazur<BR>Emergency Physician/Retrieval
Fellow<BR>Adelaide<BR>Australia<BR><BR><BR>On Mon, 18 Dec 2006 23:51:59
+0000<BR>"Mark Hellaby" <hellaby@hotmail.com>
wrote:<BR>><BR>><BR>><BR>><BR>> Much the talk so far has
surrounded major bleeds and<BR>>snakes !<BR>> There has been nothing
about the use of touniquets to<BR>>isolate a crushed limb from
circulatory system prior to<BR>>release to allow rehydration, acid base
analysis /<BR>>correction etc and then following this a
controlled<BR>>staged release in a managed environment....I would
be<BR>>interested in peoples thoughts on this aspect of
touniquet<BR>>use aswell regards<BR>><BR>><BR>> Mark Hellaby
BSc (Hons), RODP<BR>> Think you're a film buff? Play the Movie Mogul
quiz<BR>> for a chance to win fantastic prizes<BR>><BR>><BR>>
Click here to report this email as spam.<BR><BR><BR>This message has been
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From: <I>"Stefan Mark Mazur"
<stefmazur@ausdoctors.net></I><BR>Reply-To: <I>"Trauma &amp;
Critical Care mailing list" <trauma-list@trauma.org></I><BR>To:
<I>"Trauma &amp; Critical Care mailing list"
<trauma-list@trauma.org></I><BR>Subject: <I>Re: Crush and
tourniquets</I><BR>Date: <I>Wed, 20 Dec 2006 13:42:07
+0000</I><BR>Mark,<BR><BR>I would release the first tourniquet in the field
ensuring<BR>that I had defib pads on the patient and some
calcium<BR>chloride to give, which I would give on the basis of
ECG<BR>changes on the defib monitor. We carry a v. compact iSTAT<BR>machine
(more for secondary retrievals than primaries but<BR>with kit) which allows
to get ABGs and electrolytes from<BR>about 2mls of blood, so could get a K+
off that in the<BR>field but more inclined to treat on the
clinical<BR>picture/ECG changes.<BR><BR>Suspension trauma is a tricky one.
I have not had to<BR>actively manage this, but have thought a little
(emphasis<BR>on the little) about my approach to how I would mange
it.<BR>If we consider that the person lost consciousness due
to<BR>decreased venous return hence decreased cardiac output<BR>hence
decreased perfusion to the brain, it doesn't make a<BR>lot of sense to me
to keep the patient upright, thereby<BR>continuing to limit the blood
supply to the organ that<BR>passing out is supposed to protect.<BR><BR>So I
think my approach would be, keep the harness tight<BR>initially. Put the
patient in a recumbent position. Be<BR>prepared to protect airway if no
rapid return of<BR>consciousness. Ensure well volume loaded for
initail<BR>relative hypovolaemia and ensueing renal failure
problems.<BR>Once recumbent, with defib pads in place, adequate
fluid<BR>load and calcium at the ready, loosen one leg,
monitor<BR>reaction, then loosen the other.<BR><BR>I suppose similar
approach to the crush scenario<BR>previously considered. Interested to hear
others take on<BR>this rare but challenging type of trauma.<BR><BR>Not sure
about the modified pulse oximeter idea, you will<BR>need to expand on it
for a luddite like myself.<BR><BR>Haven't heard any opinions/thoughts on
the use of calcium<BR>chloride prophylactically just prior to Crush
or<BR>tourniquet release.<BR><BR>Cheers<BR>Stefan<BR><BR>Dr Stefan
Mazur<BR>Emergency Physician/Retrieval
Fellow<BR>Adelaide<BR>Australia<BR><BR><BR>On Tue, 19 Dec 2006 20:26:09
+0000<BR>"Mark Hellaby" <hellaby@hotmail.com>
wrote:<BR>><BR>><BR>><BR>><BR>><BR>>Anthony , it was more
the treatment / initial management of crush <BR>>and control of
metabolittes etc i was getting at, i presume that <BR>>tourniquets would
have no benifficial effects on compartment <BR>>syndrome in fact would
make it worse Stefan cheers for your reply, <BR>>A couple of questions
for you , would you (presumeing you were able <BR>>to apply tourniquets
in the field ) release them there after <BR>>extrication or wait until
the patiend was at a definitive care <BR>>facility with blood gas
analysis on site. Has anyone ever <BR>>considered whether it would be
possible to look at tissue perfusion <BR>>with such cases using a
modified pulse oximeter to look at tissue <BR>>saturation and not
arterial ....just something i was wondering about <BR>>Think it is also
intersting to note that although the initial rescue <BR>>may be
succesful the underlying renal damage maybe catasphoic , as <BR>>has
been born out following research after earthquake rescues I am
<BR>>interested whether you feel these guidelines could be used for
<BR>>patients suffering from suspension trauma, a combination of
<BR>>orthostatic shock and a pseudo type crush syndrome with similar
<BR>>metabolic build up and the potential for catastrophic cardiac
<BR>>collapse following release, the management of these cases is
frought <BR>>with questions and difficulties, current suggestions are to
keep the <BR>>harness under tension durring transfer to hospital (??!!!)
and <BR>>maintaining patient in an upright or semi recumbant position
(!!) <BR>>Regards<BR>><BR>> Mark Hellaby Think you're a film buff?
Play the Movie Mogul <BR>>quiz for a chance to win fantastic
prizes<BR>><BR>> Click here to report this email as
spam.<BR><BR><BR><BR>This message has been scanned for viruses by
BlackSpider MailControl - www.blackspider.com<BR><BR>
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From: <I>"S Schecter" <schecters@gmail.com></I><BR>Reply-To:
<I>"Trauma &amp; Critical Care mailing list"
<trauma-list@trauma.org></I><BR>To: <I>"Trauma &amp, Critical
Care mailing list" <trauma-list@trauma.org></I><BR>Subject:
<I>Northfield Hits Blood-Test Hurdle</I><BR>Date: <I>Wed, 20 Dec 2006
11:48:36 -0500</I><BR>'Preliminary' Findings<BR>Of PolyHeme Death
Rate<BR>Suggest Approval Setback<BR>By *THOMAS M. BURTON*<BR>December 19,
2006 11:54 p.m.; Page A10<BR><BR><BR>Northfield
Laboratories<BR><http://online.wsj.com/quotes/main.html?type=djn&symbol=NFLD>Inc.,
seeking<BR>to be first to market with a blood substitute, said that 46
patients died<BR>after being giving its blood substitute, PolyHeme, in a
study of trauma<BR>patients, compared with 35 who died under standard
treatment.<BR><BR>The findings -- of death rates 30 days after severe
injuries -- appear to be<BR>a major setback for the Evanston, Ill., company
and for the overall effort<BR>to get federal approval for a blood
substitute.<BR><BR>Northfield said there were "discrepancies" in the data
from the trauma study<BR>and that it plans to further evaluate them. Thus,
it said, it considers the<BR>findings announced yesterday to be
"preliminary." Moreover, Chief Executive<BR>Steven A. Gould said in a
conference call that the death-rate findings<BR>weren't statistically
significant.<BR><BR>He said the company plans to "continue to move forward
toward submission" of<BR>the data to the Food and Drug
Administration.<BR><BR>The test results were announced after the close of
regular trading. As of 4<BR>p.m. composite trading on the Nasdaq Stock
Market, the stock was at $11.42,<BR>down $2.90, or 20%. In after-hours
trading, it was quoted at $5.54, off 51%<BR>from the 4 p.m.
level.<BR><BR>After hearing the conference call, William D. Hoffman, chief
of<BR>cardiac-surgery critical care at Massachusetts General Hospital and
former<BR>medical director of another blood-substitute company, said, "In
my opinion,<BR>it would be irresponsible and unprecedented to grant an
approval for<BR>PolyHeme based on these data."<BR><BR>He said that "a 5%
absolute difference in mortality in favor of the control<BR>arm of the
study is too great" for the findings to be considered<BR>"noninferior" to
standard care.<BR><BR>The study was designed to evaluate whether the blood
substitute was either<BR>superior to, or not worse than, standard therapy.
The announcement of<BR>preliminary data doesn't definitely answer that
question, but the raw<BR>numbers would appear to be a big problem for
Northfield.<BR><BR>In the study, badly hemorrhaging trauma patients were
randomly assigned to<BR>PolyHeme, or to standard therapy, which is saline
solution in the ambulance<BR>and donor blood in the hospital. The company
said there were a total of 722<BR>patients originally in the study, with
349 patients ultimately receiving the<BR>blood substitute and 363 getting
standard treatment. However, it said it has<BR>found data errors in the
preliminary findings and that it plans to provide<BR>full results as soon
as possible.<BR><BR>Dr. Gould said that in the 586 patients for whom there
were no data errors,<BR>there were 30 deaths in the PolyHeme group and 28
in the standard-therapy<BR>group. Dr. Gould said that, in the 586 patients,
PolyHeme did achieve<BR>statistical "noninferiority" in the
study.<BR><BR>The results would appear to leave the FDA with a quandary:
Can the agency<BR>approve a blood substitute that may still be worse than
standard therapy?<BR><BR>The way the study was set up, PolyHeme can be
found "noninferior" to saline<BR>and donor blood, and still not be "the
same as" saline and blood. Instead,<BR>it means that, statistically, the
product hasn't been proven better or<BR>worse.<BR><BR>That seemingly
technical distinction makes a big difference, as seen in the<BR>trauma
study's protocol, or methodological plan, which was made available
to<BR>The Wall Street Journal. This document shows that PolyHeme could be
deemed<BR>"noninferior" and -- because of the way the term is defined and
the<BR>relatively small size of the study -- still be potentially as much
as nearly<BR>7% worse than blood and saline in terms of patients'
deaths.<BR><BR>In the vast majority of clinical trials, a company is
required to show that<BR>its drug is better than something else, either a
placebo or the standard<BR>therapy for an illness. In the Northfield study,
its blood substitute can<BR>either be superior, inferior or -- the middle
ground -- noninferior.<BR><BR>The design of the Northfield trauma study has
drawn criticism in part<BR>because of an earlier Northfield study. In that
surgery trial, 10 of 81<BR>patients on Northfield's PolyHeme had heart
attacks, of whom two people<BR>died. None of the 71 patients getting donor
blood had a heart attack in that<BR>earlier study. Northfield quietly shut
down that trial and didn't publicly<BR>disclose the results, saying only in
a 2001 federal filing that the study<BR>was taking too long to complete.
The company has since, in interviews with<BR>the Journal, said the heart
attacks may have not been caused by the blood<BR>substitute.<BR><BR>The
current Northfield study in trauma patients finished enrolling the
last<BR>of its U.S. patients this summer.<BR><BR>
<P>
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From: <I>Krin135@aol.com</I><BR>Reply-To: <I>"Trauma &amp; Critical
Care mailing list" <trauma-list@trauma.org></I><BR>To:
<I>trauma-list@trauma.org</I><BR>Subject: <I>Re: Crush and
tourniquets</I><BR>Date: <I>Wed, 20 Dec 2006 13:22:26 EST</I><BR><BR>In a
message dated 12/20/2006 8:26:23 AM Central Standard Time,<BR>tch@sun.ac.za
writes:<BR><BR>The incidence of chronic renal dysfunction in this group is
surprisingly<BR>small from what my renal unit colleagues, who follow these
patients longterm,<BR>tell me. If they reverse the renal dysfunction
(usually within around three<BR>weeks) they seem to have good functional
outcomes with a small group having<BR>persistant hypertension at five
years. the trick is to not let them get<BR>dehydrated during the inevitable
polyuric phase of recovery.<BR><BR><BR>Tim:<BR><BR>What protocol do your
renal chaps use to keep up with the polyuria? While my<BR>experience with
post traumatic/post crush polyuria is a bit limited, I did<BR>train long
enough ago that we had frequent episodes of acute post bladder
neck<BR>obstruction polyuria, something that we don't see as much any more
here in<BR>the States, due to a combination of more aggressive
catheterization, new<BR>medications to reduce prostate size and a long
history of aggressive prostate<BR>surgery.<BR><BR>Our technique 'back in
the day' was to do hourly outputs, and replace 60 to<BR>70% of the last
hour's output with 0.2% saline, with associated dextrose
and<BR>electrolytes (usually D5 1/4 NS with 10 mEq K as citrate or bicarb)
over and<BR>above any needs that the patient otherwise
required.<BR><BR>ck<BR>Charles S. Krin, DO FAAFP<BR><BR>
<P>
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<HR color=#a0c6e5 SIZE=1>
From: <I>"Nuno Lopes" <nuno.lopes@netvisao.pt></I><BR>Reply-To:
<I>"Trauma &amp; Critical Care mailing list"
<trauma-list@trauma.org></I><BR>To:
<I>trauma-list@trauma.org</I><BR>Subject: <I>RECOA I - 1st International
Course of Osteo-Articular Reconstruction</I><BR>Date: <I>Wed, 20 Dec 2006
18:27:48 -0000</I><BR>Dear Colleagues,<BR><BR>I have the pleasure to invite
you for the 1st International Course of Osteo-Articular Reconstruction
(RECOA I) under the subject - Reconstruction in the Fractures of the
Inferior Extremity, that goes to have place in Viseu, Portugal, 25-28 of
April, 2007.<BR><BR>Official languages will include those of Latin origin
and English, with translation available.<BR><BR>Colleagues from all over
the world will be welcomed Online or Onsite. You can accede more
information and make the pre-register in http://www.recoa.org/<BR><BR>We
intend to offer to the participants an innovative and different meeting,
allowing associating scientific, cultural activity and sport, adapted to
each one and joining doctors, nurses and therapists.<BR><BR>This will be
first of a series of courses on Osteo-Articular Reconstruction, forming a
cycle that will have the duration of 5 years and annual regularity and that
it will give right to a Diploma of Osteo-Articular
Reconstruction.<BR><BR>The scientific activity will have one component
"online", the base of all the scientific information of the Course, with
formative purpose and final test of aptitude. The participation in this
virtual component of the Course will be gratuitous and universal and will
have place through the web page. You can do the pre register at
http://www.recoa.org/pages/registo.aspx<BR><BR>The component "Onsite" of
the Course, will have place in the Montebelo Hotel close to Viseu, in the
north zone of Portugal, with the mountain of Estrela and Caramulo in the
horizon, landscape to cut the breath. The scientific sessions will have
place in the morning, with the presentation of the conferences chosen for
the course, and in the afternoon, workshops will have place on
reconstruction procedures.<BR><BR>But the scientific activity does not go
to be the only one in this meeting. We prepared a cultural program to
present part of Portugal to the participants: Leaving Lisbon in day 25, we
will go to cover some of the places most interesting of the interior of
Portugal until arrive at Viseu, in comfortable auto Pullman, and in the
return, in day 28, we will travel in the coast of Portugal.<BR><BR>Finally,
we programmed some activities in the outdoors that will have place in the
afternoon of days 26 and 27.<BR><BR>We therefore anticipate a meeting with
an interesting scientific program, exchanges of experience, conviviality
and establishment of solid friendships.<BR><BR>Best regards,<BR>Nuno
Craveiro Lopes<BR>Course Web page: www.recoa.org<BR><BR><BR>
<P>
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From: <I>bensonblues@comcast.net</I><BR>Reply-To: <I>"Trauma &amp;
Critical Care mailing list" <trauma-list@trauma.org></I><BR>To:
<I>trauma-list@trauma.org</I><BR>Subject: <I>Head Injury - Termination of
Resuscitative Efforts</I><BR>Date: <I>Wed, 20 Dec 2006 08:43:22
+0000</I><BR>oded private,<BR><BR>First of all, I must tell you that I love
your name. You would never get lost in America with a name like oded
private. Sounds like a rock star's name.<BR><BR>Resuscitating a person who
may/is likely to have brain damage is the most challenging decision for the
resuscitologist. I like to look at problems logically, and put myself in
the place of the victim. Here are some of the possible situations if you
successfully resuscitate me. First, let's assume that I'm resuscitated,
spend a week in ICU, a week on Step-Down, 1 to 2 weeks on the floor,
then...1) I go home to my family, return to work, and enjoy intelligent
interaction with humanity until something else gets me 30 years later, or
2) I go home to my family, can't return to work, drains the family estate
to the point of financial ruin until something gets me 20 years later, or
3) I go to the rehabilitation center, return home to my family, can't work,
drains the family estate, and die of alcoholism 10 years later, or 4) I go
to the rehabilitation center, get a feeding tube in my belly, drains the
family estate, and die of pulmpnary embolism 5 years later (I really hate
all of h<BR>umanit<BR>y by now), or, if there is a God and I am deserving
of his attention: 5) I died from my injuries. The physician decides that
quality life was no longer possible for me, based upon my injuries, and
thus terminated resuscitative efforts. My family, with the benefit of what
I left for them in terms of my estate, continues to educate themselves and
find productive lives.<BR><BR>All of these scenarios are potential outcomes
for your patient. Your job is to decide which of these scenarios is
statistically the most likely, and to make a humane decision when
resuscitating. It ain't easy, my brother.<BR><BR>To oded (and all): Have a
good holiday season. People who take care of people are special people. I
hope that peace and prosperity finds you from now to
eternity.<BR><BR>DB<BR>
<P>
<P>
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From: <I>"Anthony Caruso" <Medic541@hotmail.com></I><BR>Reply-To:
<I>"Trauma &amp; Critical Care mailing list"
<trauma-list@trauma.org></I><BR>To: <I>"'Trauma &amp; Critical
Care mailing list'" <trauma-list@trauma.org></I><BR>Subject: <I>RE:
Crush and tourniquets</I><BR>Date: <I>Wed, 20 Dec 2006 16:00:35
-0500</I><BR>Yeah Mark, that's what I meant. For any type of pre hospital
benefit of<BR>using one.<BR>Thanks'.<BR><BR>-----Original
Message-----<BR>From: trauma-list-bounces@trauma.org
[mailto:trauma-list-bounces@trauma.org]<BR>On Behalf Of Mark
Hellaby<BR>Sent: Tuesday, December 19, 2006 3:26 PM<BR>To:
trauma-list@trauma.org<BR>Subject: Crush and
tourniquets<BR><BR><BR><BR><BR><BR><BR><BR><BR>Anthony , it was more the
treatment / initial management of crush and<BR>control of metabolittes etc
i was getting at, i presume that tourniquets<BR>would have no benifficial
effects on compartment syndrome in fact would make<BR>it
worse<BR><BR>Stefan cheers for your reply,<BR><BR>A couple of questions for
you , would you (presumeing you were able to apply<BR>tourniquets in the
field ) release them there after extrication or wait<BR>until the patiend
was at a definitive care facility with blood gas analysis<BR>on
site.<BR><BR>Has anyone ever considered whether it would be possible to
look at tissue<BR>perfusion with such cases using a modified pulse oximeter
to look at tissue<BR>saturation and not arterial ....just something i was
wondering about<BR><BR>Think it is also intersting to note that although
the initial rescue may be<BR>succesful the underlying renal damage maybe
catasphoic , as has been born<BR>out following research after earthquake
rescues<BR><BR>I am interested whether you feel these guidelines could be
used for patients<BR>suffering from suspension trauma, a combination of
orthostatic shock and a<BR>pseudo type crush syndrome with similar
metabolic build up and the potential<BR>for catastrophic cardiac collapse
following release, the management of these<BR>cases is frought with
questions and difficulties, current suggestions are to<BR>keep the harness
under tension durring transfer to hospital (??!!!) and<BR>maintaining
patient in an upright or semi recumbant position
(!!)<BR><BR><BR><BR>Regards<BR><BR><BR><BR><BR>Mark
Hellaby<BR><BR>_____<BR><BR>Think you're a film buff? Play the Movie Mogul
quiz<BR><http://g.msn.com/8HMBENUK/2752??PS=47575> for a chance to
win fantastic<BR>prizes<BR><BR><BR>
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From: <I>"oded private" <tangentcarrot@hotmail.com></I><BR>Reply-To:
<I>"Trauma &amp; Critical Care mailing list"
<trauma-list@trauma.org></I><BR>To:
<I>trauma-list@trauma.org</I><BR>Subject: <I>Re: head injury- termi ation
of resuscitative efforts</I><BR>Date: <I>Thu, 21 Dec 2006 10:46:12
+0200</I><BR>I was talking about a patient arresting in the ED. But we can
talk about the option of prehospital or en route arrest as
well<BR><BR><BR>>From: "Ronald Gross"
<Rgross@harthosp.org><BR>>Reply-To: "Trauma &amp; Critical
Care mailing list" <BR>><trauma-list@trauma.org><BR>>To:
<trauma-list@trauma.org><BR>>Subject: Re: head injury- termi ation
of resuscitative efforts<BR>>Date: Tue, 19 Dec 2006 14:38:28
-0500<BR>><BR>>As I recall, the patient had a cardiac arrest s/p TBI.
The patient<BR>>arrived without an airway and in PEA. If you want to do
CPR <BR>>(assuming<BR>>that someone was doing so en route without ET
intubation) then <BR>>continue.<BR>> Bag in the guise of
"preoxygenation", place leads and do an <BR>>epigastric<BR>>FAST
view. If there is no cardiac activity, stop, and proceed where
<BR>>I<BR>>left off on my last e-mail......take care of the family,
etc.<BR>><BR>> >>> <rwolfer@aol.com> 12/19/2006 1:20
PM >>><BR>>I would do a code. Nothing heroic. I agree about
organ donation. I<BR>>have actually gotten a couple of donations because
of this. The <BR>>family<BR>>always seems to "feel better" that
everything was done and donation<BR>>occurred. They state " atleast
something good will come of it"<BR>><BR>>Rebecca Wolfer, MD, FACS,
FCCP<BR>>Associate Professor, Marshall University School of
Medicine<BR>>Dept of Surgery<BR>>Director Thoracic
Surgery<BR>>Director, Surgical Critical Care Cabell Huntington
Hospital<BR>>Director, Trauma Cabell Huntington
Hospital<BR>><BR>><BR>>-----Original Message-----<BR>>From:
Rgross@harthosp.org<BR>>To: trauma-list@trauma.org<BR>>Sent: Tue, 19
Dec 2006 12:18 PM<BR>>Subject: Re: head injury- termi ation of
resuscitative efforts<BR>><BR>><BR>>I treat the family. The
patient is dead, and will stay dead,<BR>>regardless<BR>>of what you
do. Now is the time to help the family honor
the<BR>>patient's<BR>>wishes, if known, and to call the organ
donation service in your<BR>>region.<BR>> Lastly, thoracotomy IS
indicated - to procure the heart and lungs
<BR>>for<BR>>transplantation. (so there - I did come forward and
admit it!)<BR>><BR>>Take care,<BR>>Ron<BR>> >>> "oded
private" <tangentcarrot@hotmail.com> 12/19/2006 11:47 AM <BR>>
>>><BR>>Hello list<BR>><BR>>I'd like to hear your opinion
about deciding to terminate treatment<BR>>for<BR>><BR>>isolated
TBI resulting in cardiac arrest.<BR>><BR>>What if the pateint is
still in PEA? Will you attempt to defibrilate<BR>>VF, if<BR>>it
happened for some reason?<BR>><BR>>If you do treat him- what will you
do? ET intubation and <BR>>ventilation<BR>>alone?<BR>>CPR? Does
anybody here practice thoractomy in the scenario and
is<BR>>ready<BR>>to<BR>>"come forward" and admit to
it?<BR>><BR>>_________________________________________________________________<BR>>Express
yourself instantly with MSN Messenger! Download today
it's<BR>>FREE!<BR>>http://messenger.msn.click-url.com/go/onm00200471ave/direct/01/<BR>><BR>>--<BR>>trauma-list
: TRAUMA.ORG<BR>>To change your settings or unsubscribe
visit:<BR>>http://www.trauma.org/traumalist.html<BR>><BR>>Confidentiality
Notice<BR>><BR>>This e-mail message, including any attachments, is
for the sole use <BR>>of<BR>>the intended recipient(s) and may
contain confidential or <BR>>proprietary<BR>>information which is
legally privileged. Any unauthorized review,<BR>>use,<BR>>disclosure,
or distribution is prohibited. If you are not
the<BR>>intended<BR>>recipient, please promptly contact the sender by
reply e-mail and<BR>>destroy all copies of the original
message.<BR>>--<BR>>trauma-list : TRAUMA.ORG<BR>>To change your
settings or unsubscribe
visit:<BR>>http://www.trauma.org/traumalist.html<BR>>________________________________________________________________________<BR>>Check
out the new AOL. Most comprehensive set of free safety and<BR>>security
tools, free access to millions of high-quality videos from<BR>>across
the web, free AOL Mail and more.<BR>>--<BR>>trauma-list :
TRAUMA.ORG<BR>>To change your settings or unsubscribe
visit:<BR>>http://www.trauma.org/traumalist.html<BR>><BR>>Confidentiality
Notice<BR>><BR>>This e-mail message, including any attachments, is
for the sole use <BR>>of<BR>>the intended recipient(s) and may
contain confidential or <BR>>proprietary<BR>>information which is
legally privileged. Any unauthorized review,
<BR>>use,<BR>>disclosure, or distribution is prohibited. If you are
not the <BR>>intended<BR>>recipient, please promptly contact the
sender by reply e-mail and<BR>>destroy all copies of the original
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From: <I>"oded private" <tangentcarrot@hotmail.com></I><BR>Reply-To:
<I>"Trauma &amp; Critical Care mailing list"
<trauma-list@trauma.org></I><BR>To:
<I>trauma-list@trauma.org</I><BR>Subject: <I>RE: head injury- termi ation
of resuscitative efforts</I><BR>Date: <I>Thu, 21 Dec 2006 10:47:55
+0200</I><BR><BR>Oh, I know that. I googled it the minute I saw the
mail<BR><BR>>From: "Hardcastle, Tim, Dr <tch@sun.ac.za>"
<tch@sun.ac.za><BR>>Reply-To: "Trauma &amp; Critical Care
mailing list" <BR>><trauma-list@trauma.org><BR>>To: "Trauma
&amp; Critical Care mailing list"
<BR>><trauma-list@trauma.org><BR>>Subject: RE: head injury-
termi ation of resuscitative efforts<BR>>Date: Wed, 20 Dec 2006 07:31:01
+0200<BR>><BR>>Oded<BR>><BR>>FCCP - Fellowship of Critical Care
Physicians or Fellow or College <BR>>of Chest Physicians, depending on
country of origin.<BR>><BR>>Tim<BR>><BR>>-----Original
Message-----<BR>>From:
trauma-list-bounces@trauma.org<BR>>[mailto:trauma-list-bounces@trauma.org]On
Behalf Of oded private<BR>>Sent: Tuesday, December 19, 2006 8:55
PM<BR>>To: trauma-list@trauma.org<BR>>Subject: Re: head injury- termi
ation of resuscitative efforts<BR>><BR>><BR>><BR>><BR>>Hi
Rebecca<BR>>You made teach myself something new today- what's
"FCCP"<BR>><BR>>I'm not sure I understand you- you say you'd call a
code just so the <BR>>family<BR>>will be more likely to agree on
donation?<BR>><BR>> >From: rwolfer@aol.com<BR>> >Reply-To:
"Trauma &amp; Critical Care mailing list"<BR>>
><trauma-list@trauma.org><BR>> >To:
trauma-list@trauma.org<BR>> >Subject: Re: head injury- termi ation of
resuscitative efforts<BR>> >Date: Tue, 19 Dec 2006 13:20:58
-0500<BR>> ><BR>> >I would do a code. Nothing heroic. I agree
about organ donation. <BR>>I have<BR>> >actually gotten a couple
of donations because of this. The family <BR>>always<BR>> >seems
to "feel better" that everything was done and donation
<BR>>occurred.<BR>> >They state " atleast something good will come
of it"<BR>> ><BR>> >Rebecca Wolfer, MD, FACS, FCCP<BR>>
>Associate Professor, Marshall University School of Medicine<BR>>
>Dept of Surgery<BR>> >Director Thoracic Surgery<BR>>
>Director, Surgical Critical Care Cabell Huntington Hospital<BR>>
>Director, Trauma Cabell Huntington Hospital<BR>> ><BR>>
><BR>> >-----Original Message-----<BR>> >From:
Rgross@harthosp.org<BR>> >To: trauma-list@trauma.org<BR>>
>Sent: Tue, 19 Dec 2006 12:18 PM<BR>> >Subject: Re: head injury-
termi ation of resuscitative efforts<BR>> ><BR>> ><BR>>
>I treat the family. The patient is dead, and will stay dead,
<BR>>regardless<BR>> >of what you do. Now is the time to help the
family honor the <BR>>patient's<BR>> >wishes, if known, and to
call the organ donation service in your <BR>>region.<BR>> >
Lastly, thoracotomy IS indicated - to procure the heart and <BR>>lungs
for<BR>> >transplantation. (so there - I did come forward and admit
it!)<BR>> ><BR>> >Take care,<BR>> >Ron<BR>> >
>>> "oded private" <tangentcarrot@hotmail.com> 12/19/2006
11:47 <BR>>AM >>><BR>> >Hello list<BR>> ><BR>>
>I'd like to hear your opinion about deciding to terminate
<BR>>treatment for<BR>> ><BR>> >isolated TBI resulting in
cardiac arrest.<BR>> ><BR>> >What if the pateint is still in
PEA? Will you attempt to <BR>>defibrilate<BR>> >VF, if<BR>>
>it happened for some reason?<BR>> ><BR>> >If you do treat
him- what will you do? ET intubation and <BR>>ventilation<BR>>
>alone?<BR>> >CPR? Does anybody here practice thoractomy in the
scenario and is <BR>>ready<BR>> >to<BR>> >"come forward" and
admit to it?<BR>> ><BR>>
>_________________________________________________________________<BR>>
>Express yourself instantly with MSN Messenger! Download today
it's<BR>> >FREE!<BR>>
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><BR>> >--<BR>> >trauma-list : TRAUMA.ORG<BR>> >To
change your settings or unsubscribe visit:<BR>>
>http://www.trauma.org/traumalist.html<BR>> ><BR>>
>Confidentiality Notice<BR>> ><BR>> >This e-mail message,
including any attachments, is for the sole <BR>>use of<BR>> >the
intended recipient(s) and may contain confidential or
<BR>>proprietary<BR>> >information which is legally privileged.
Any unauthorized review, <BR>>use,<BR>> >disclosure, or
distribution is prohibited. If you are not the <BR>>intended<BR>>
>recipient, please promptly contact the sender by reply e-mail
and<BR>> >destroy all copies of the original message.<BR>>
>--<BR>> >trauma-list : TRAUMA.ORG<BR>> >To change your
settings or unsubscribe visit:<BR>>
>http://www.trauma.org/traumalist.html<BR>>
>________________________________________________________________________<BR>>
>Check out the new AOL. Most comprehensive set of free safety and
<BR>>security<BR>> >tools, free access to millions of high-quality
videos from across <BR>>the web,<BR>> >free AOL Mail and
more.<BR>> >--<BR>> >trauma-list : TRAUMA.ORG<BR>> >To
change your settings or unsubscribe visit:<BR>>
>http://www.trauma.org/traumalist.html<BR>><BR>>_________________________________________________________________<BR>>Express
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From: <I>"oded private" <tangentcarrot@hotmail.com></I><BR>Reply-To:
<I>"Trauma &amp; Critical Care mailing list"
<trauma-list@trauma.org></I><BR>To:
<I>trauma-list@trauma.org</I><BR>Subject: <I>Lay person's trauma
training</I><BR>Date: <I>Thu, 21 Dec 2006 11:02:54 +0200</I><BR>Since the
subject has come up during the tourniquets debate, I'd like to discuss it
furthet.<BR><BR>What kind of training for lay rescures is available in your
community?<BR>What do you teach them?<BR>Do you teach diffrent ABC's for
trauma care? (no CPR?)<BR>What do you say about spinal immobalization
during airway managment?<BR>How do you manage myths?<BR><BR>I myself open
trauma care class for lays with a writing on the board taken from the ATLS
7th edition<BR>(I hope it's fine with you all you FACS's)-<BR>"The main
principle of trauma care is to do no further harm"<BR>and I ask them wehre
do they think it's from. When they are told it's from a course book for
physicians, they already know the answers to questions like "if he can't
breath after I open the airway, shouldn't I open his wind pipe?" "or what
if I think he is bleeding internally and gonna die? shouldn't I at least
try to do something?"<BR>(They actually asked those and more before I
started using that
pharse)<BR><BR>_________________________________________________________________<BR>Express
yourself instantly with MSN Messenger! Download today it's FREE!
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