# Why not shock a trauma code?



## snaps10 (Feb 12, 2012)

This "discussion" has been going around the office lately. To shock, or not to shock a trauma code. Protocols here dictate that we do not shock arrest as te result of trauma. How do we know the trauma wasn't caused by arrest?
What harm is there in placing an AED on a patient and seeing if there's shockable rhythm?  I've searched google and can't find a reason for the protocols, only that it's there. 
Opinions?


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## TheGodfather (Feb 12, 2012)

it wont do anything if you shock a traumatic arrest... there is nothing wrong with the heart (unless there was direct cardiac injury) and even in that case, electrical therapy is not what is needed. the problem is blood loss. 

studies show there is almost a *zero percent* success rate in the traumatic arrest resuscitation in the prehospital setting (without blood products). i can find these studies if anyone feels the need to challenge it.

EDIT: if you suspect the arrest was not due to the traumatic insult itself, then yes - follow ACLS guidelines. IE; car runs into wall at 5mph, etc etc. this all comes down to good history taking and a good size up


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## DrankTheKoolaid (Feb 12, 2012)

There are exceptions to the no shocking trauma rules.  A direct blow to the chest comes to mind.  Precordial thump is the principal behind this... If a blow to the chest has the possibility of converting someone out of a lethal rhythm, the opposite also rings true.  So if a blow to the chest IE a sternal punch, softball, steering wheel causes the lethal insult then shocking it would be appropriate.


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## TheGodfather (Feb 12, 2012)

Corky said:


> There are exceptions to the no shocking trauma rules.  A direct blow to the chest comes to mind.  Precordial thump is the principal behind this... If a blow to the chest has the possibility of converting someone out of a lethal rhythm, the opposite also rings true.  So if a blow to the chest IE a sternal punch, softball, steering wheel causes the lethal insult then shocking it would be appropriate.



agreed!


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## VFlutter (Feb 12, 2012)

Listen to this EMCRIT podcast, it is full of great information about traumatic arrests 

http://emcrit.org/podcasts/traumatic-arrest/


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## JPINFV (Feb 12, 2012)

Corky said:


> There are exceptions to the no shocking trauma rules.  A direct blow to the chest comes to mind.  Precordial thump is the principal behind this... If a blow to the chest has the possibility of converting someone out of a lethal rhythm, the opposite also rings true.  So if a blow to the chest IE a sternal punch, softball, steering wheel causes the lethal insult then shocking it would be appropriate.




Commotio cordis.

http://emedicine.medscape.com/article/902504-overview


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## DrankTheKoolaid (Feb 12, 2012)

That would bed it, thanks!


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## DrankTheKoolaid (Feb 12, 2012)

Sigh. Be it i mean...  Cant seem to edit with tapatalk.........


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## zmedic (Feb 12, 2012)

I think when most people talk about "trauma arrest" they are talking about big trauma. Car crash. Person fall off building. Hit by bus. If they person doesn't have a pulse it probably isn't because of R on T. I agree if someone had a "trauma" by being kicked in the chest or hit with a baseball you should put the pads on them. (Hopefully someone has been doing CPR while you were on the way because otherwise chances are slim of bringing them back.) 

As to not putting the paddles on trauma arrests. I don't know about BLS protocols, but when I was on ALS if we were not going to work a code we put them on the monitor to document asystole. And that included traumatic arrests. So if we did that and saw vfib we would work it. From the BLS perspective I would say unless you are sure (decapitation, shot in the head with brain matter and no pulses, smooshed by bus and not much left) I would work it unless ALS got there. But that's a good question for your medical director. 

Again I'd look at the patient. If crashed his car but not much damage and they are in arrest, I'd probably work it assuming the arrest caused the crash. 

Interesting question though.


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## the_negro_puppy (Feb 13, 2012)

Most pulse-less trauma patients present as a PEA or asystole arrest. rather than the shockable rhythms of VF of pulseless VT.

If you look at the pathophysiology behind traumatic arrests usually from (hypovolemic shock, head injury, tension pneumothorax or pericardial tomponade) you can understand why resus attempts in the field are almost futile.


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## snaps10 (Feb 13, 2012)

the_negro_puppy said:


> Most pulse-less trauma patients present as a PEA or asystole arrest. rather than the shockable rhythms of VF of pulseless VT.
> 
> If you look at the pathophysiology behind traumatic arrests usually from (hypovolemic shock, head injury, tension pneumothorax or pericardial tomponade) you can understand why resus attempts in the field are almost futile.



Almost is the key word. Am I going to get sued for attaching an aed (30 seconds max) and getting a "shock not advised" or possible get sued for attaching an aed getting a shockable rhythm and delivering a shock, potentially with a positive outcome. Why would the protocols say not to shok a trauma code?  Is there some negative that could possibly come of it?  I can't think of any.


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## JPINFV (Feb 13, 2012)

snaps10 said:


> Almost is the key word. Am I going to get sued for attaching an aed (30 seconds max) and getting a "shock not advised" or possible get sued for attaching an aed getting a shockable rhythm and delivering a shock, potentially with a positive outcome. Why would the protocols say not to shok a trauma code?  Is there some negative that could possibly come of it?  I can't think of any.



Depends, is the next step anything besides "stop resuscitation" for a blunt trauma? If it's a penetrating trauma, then the downside is a loss of 30 seconds from potentially definitive interventions (e.g. chest tube, pericardiocentesis<->pericardectomy continuum, etc). Also, at what time do you consider resuscitation futile, given the totality of the circumstances?


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## systemet (Feb 13, 2012)

snaps10 said:


> Almost is the key word. Am I going to get sued for attaching an aed (30 seconds max) and getting a "shock not advised" or possible get sued for attaching an aed getting a shockable rhythm and delivering a shock, potentially with a positive outcome.



Well, you can get sued for anything, including doing your job possibly.  The question is whether you'd get successfully sued.  If you're following the protocols written by your medical director or medical advisory committee, they're unlikely to find you culpable.



> Why would the protocols say not to shok a trauma code?  Is there some negative that could possibly come of it?  I can't think of any.



If the cause of the arrest is hemorrhagic hypovolemia, and you haven't corrected this, the defibrillation isn't likely to fix the code.

Alternatively, if you've opened an obstructed airway, made a surgical airway, decompressed a pneumothorax, or done a pericardialcentesis, things might be different.  

Are there negatives per se?  I doubt that's been shown prehospitally.  As pointed out by an earlier poster, the survival here is very low.  There's discussion that defibrillation may cause cardiac injury, that was part of the impetus behind moving from monophasic to biphasic defibrillation (the higher first shock success being the more significant reason).  

The stars have to line up for these sorts of patients to survive.  You basically have to be transporting a patient with surgically correctable injuries to a real hospital that can open their chest in the ER and has access to blood products in a timely fashion, or you have to be very lucky and decompress a pneumo that caused the arrest.  This isn't a reality for most rural providers.


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## systemet (Feb 13, 2012)

JPINFV said:


> Also, at what time do you consider resuscitation futile, given the totality of the circumstances?



If you can see the mitral valve.


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## tacitblue (Feb 13, 2012)

I can answer this question pretty narrowly by saying that in any arrest situation, use electrical therapy when you have a shockable rhythm per ECC guidelines.

That said, VF/VT is not usually associated with traumatic arrest; PEA and asystole are going to be your presenting rhythms. Therefor shocks are more than likely not indicated. If you do happen to be on a TC with minor MOI and have a patient in VF/VT, suspect medical eitology and start standard ACLS


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## HMartinho (Feb 13, 2012)

tacitblue said:


> I can answer this question pretty narrowly by saying that in any arrest situation, use electrical therapy when you have a shockable rhythm per ECC guidelines.
> 
> That said, VF/VT is not usually associated with traumatic arrest; PEA and asystole are going to be your presenting rhythms. Therefor shocks are more than likely not indicated. If you do happen to be on a TC with minor MOI and have a patient in VF/VT, suspect medical eitology and start standard ACLS




Hypoxia in trauma patients can provoke V-fib. So in this cases, you should shock him/her.


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## Veneficus (Feb 13, 2012)

*I should charge for this stuff.*

Defibrillation as the recommendation of therapy for VF/pulseless VT is from observation of patients suffering the most common side effect of an MI. (SCD from vfib secondary to MI is listed by multiple sources as near 70%)

This occlusion interrupts the delivery of oxygen to the heart resulting in anaerobic metabolism and eventually myocardial failure.

During this occlusion, the normal conduction mechanisms of the cells are disrupted in an easily correctable way.

There are also physiologic mechanisms for clot resolution allowing some level of delivery of o2. 

In this case, the heart cannot be reperfused without specific medical or surgical intervention. In this case continued CPR is required to maintain central perfusion in the absense of a working pump.

This lack of delivery of o2 correction after a successful defibrillation is one of the main mechanisms of recurrent vfib. (basically since the heart cannot reperfuse itself to sufficent level, it falls victim to the exact same circumstance as before)

In the case of trauma, the most common mechanism for arrest is hypovolemia. There is just no oxygen being delivered to the heart and it fails in a predictable way. (often with PEA, but occasionally the pulseless vtach-vfib-PEA-asystole path) 

If you witness this v-fib in hypovolemia, and you shock it, even if a "normal" rhthym returns, there is still no delivery of o2 and the situation will repeat itself.

CPR becomes ineffective as there is nothing to circulate.

Without prompt surgical and intensive resuscitation, there is nothing that can be done to correct this.     

Outside of this hypovolemia, there are specific instances when the injury disrupts this delivery of o2 in a correctable way. R on T phenomenon from a direct blow, cardiac tamponade, pneumothorax, hemothorax, etc. 

In these cases it is treatment of the direct insulting pathology that is key. Only in the first one will defibrillation be the treatment. (and I will mention it is an extremely rare phenomenon and you will likely know it when you see it.)

There are even cases where no therapy will help, like massive cardiac contusion or gross aortic dissection. (most aortic dissections discovered in live trauma patients are subclinical and while they require surgical or vascular correction, are not always the priority injury for repair. Compensation lasting on average 48 hours)

Defibrillating V-fib in a traumatic cardiac arrest is playing extremely long odds that one specific rare pathology is present.

If you are truly believe the patient to be viable in some way, they need to be transported without delay to a place with people capable of intervention of the specific pathologies causing the arrest.

If you think the patient is not viable and you are expending resources on them (including time preventing them from reaching definitive intervention) then you are just playing with a corpse.

In order to save any arrest patient, you must be able to preserve vital function until pathology specific interventions can restore normal physiology. 

In the traumatic arrest patient, it is extremely rare that field providers or non dedicated facilties have the tools or abilities to do this.

In the medical arrest patient, EMS probably has the ability to maintain central perfusion. (in the form of IV therapy, CPR, etc.)

In a class III (or iv) shock patient, with an ongoing hemorrhage or (self)hemostasis unless you have blood and surgical intervention, EMS is not able to support or correct these people in the field.

The help for them is at the hospital. Do not delay them.


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## snaps10 (Feb 13, 2012)

So I guess what it comes down to is that there is no real medical reason for protocols to say "Do not use an AED on a trauma patient"


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## Veneficus (Feb 13, 2012)

snaps10 said:


> So I guess what it comes down to is that there is no real medical reason for protocols to say "Do not use an AED on a trauma patient"



Apparently the page I typed on it is lost time.


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## snaps10 (Feb 13, 2012)

I'm sorry I came across that way. In no way was it my intention to disrespect your very well written and knowledgeable response. (no excuse, but I'm going on three long nights and an 8 day old daughter when I'm at home, sleepless week)
I guess where this all stemmed from was a conversation I had with a partner on the walk to the office the other day. After a white cloud week, which seemed to go by very, very slow, I mentioned that a good trauma call would sure make the time go by faster. He one upped me by saying a trauma code would as well. Next thing you know we've got 3 people saying they're putting an AED on a trauma code, and 2 (including one supervisor) saying no way, no how. Protocol says no AED for trauma. I'm new to the company, so I'm still feeling some of the people out and honestly am on the fence regarding what I feel the correct treatment would be and what my Supervisor the company wants us to do. 
Again, I apologize for my quick, smart-assed reply. The protocols don't mention any different options, other than do nor use an AED on a trauma patient.


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## Veneficus (Feb 13, 2012)

snaps10 said:


> I'm sorry I came across that way. In no way was it my intention to disrespect your very well written and knowledgeable response. (no excuse, but I'm going on three long nights and an 8 day old daughter when I'm at home, sleepless week)
> I guess where this all stemmed from was a conversation I had with a partner on the walk to the office the other day. After a white cloud week, which seemed to go by very, very slow, I mentioned that a good trauma call would sure make the time go by faster. He one upped me by saying a trauma code would as well. Next thing you know we've got 3 people saying they're putting an AED on a trauma code, and 2 (including one supervisor) saying no way, no how. Protocol says no AED for trauma. I'm new to the company, so I'm still feeling some of the people out and honestly am on the fence regarding what I feel the correct treatment would be and what my Supervisor the company wants us to do.
> Again, I apologize for my quick, smart-assed reply. The protocols don't mention any different options, other than do nor use an AED on a trauma patient.



I didn't think you were being smart.

I thought you were not getting that there is basically only two causes of traumatic arrest where defib will help.

That pathology is so rare, it is only worth consideration if somebody takes a direct blow to the chest at considerable velocity or mass or the patient did not have an airway.  (if they arrested from lack of airway, the prognosis is rather questionable)

If you think the patient is worth trying to save, you do it by getting to the trauma center without delay for anything else.


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## snaps10 (Feb 13, 2012)

10-4 I get where you're coming from.


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## systemet (Feb 13, 2012)

snaps10 said:


> (no excuse, but I'm going on three long nights and an 8 day old daughter when I'm at home, sleepless week)



Congratulations on the new daughter!


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## snaps10 (Feb 13, 2012)

Thanks.


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## FlightMedicHunter (Feb 13, 2012)

Regardless of the pathophysiology involved, I cannot possibly think of a reason that it would be acceptable to see a shockable rhythm on the monitor and not defib it.

I cannot imagine saying "well, that probably will not help soooooo let's just continue CPR until we get to the hospital."

The standard of care for a shockable rhythm is to shock it.  I am not saying to be a cookbook medic but with the tools available in the field I cannot see how anyone could make a decision to not shock a shockable rhythm......unless of course you have a protocol that says so or medical direction has given you the order to withhold defibrillation.  

There is no doubt that there is some valuable science that points to some defibrillation scenarios being futile but that is a serious risk that you take in withholding defib without orders....


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## RocketMedic (Feb 13, 2012)

FlightMedicHunter said:


> Regardless of the pathophysiology involved, I cannot possibly think of a reason that it would be acceptable to see a shockable rhythm on the monitor and not defib it.
> 
> I cannot imagine saying "well, that probably will not help soooooo let's just continue CPR until we get to the hospital."
> 
> ...



Not to sound uneducated, but on those lines, it literally can't hurt this patient to defibrillate.


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## Handsome Robb (Feb 13, 2012)

FlightMedicHunter said:


> Regardless of the pathophysiology involved, I cannot possibly think of a reason that it would be acceptable to see a shockable rhythm on the monitor and not defib it.
> 
> I cannot imagine saying "well, that probably will not help soooooo let's just continue CPR until we get to the hospital."
> 
> ...



A little off topic but we only defibrillate hypothermic arrests <86 F once after determining their temp. 

All hypothermic arrests get transported.


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## Veneficus (Feb 14, 2012)

FlightMedicHunter said:


> Regardless of the pathophysiology involved, I cannot possibly think of a reason that it would be acceptable to see a shockable rhythm on the monitor and not defib it.



Traumatic arrest is not good enough?



FlightMedicHunter said:


> I cannot imagine saying "well, that probably will not help soooooo let's just continue CPR until we get to the hospital.".



Why not?


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## FlightMedicHunter (Feb 14, 2012)

Veneficus said:


> Traumatic arrest is not good enough?
> 
> 
> 
> Why not?



Because there are simply too many variables in place for a field clinician to make this sort of decision.  The heart is in vfib/vtach because it is hypoxic and/or is slowly infarcting.  Obviously, there are many reasons that could have caused this like you already said: blood loss, trauma to the heart, AMI, etc etc.

Yes, some have mentioned situations where it might be more obvious i.e. traumatic arrest in a 5mph crash (high likelihood that an AMI came first)....but you guys make it sound like someone cannot have an AMI and then have a serious accident that results in blood loss.  

The standard of care for prehospital cardiac arrest in America is to follow ACLS guidelines (unless protocol deviates).  ACLS guidelines are to work the algorithm you are in while searching for and treating possible causes.  

I completely understand the argument that defibrillating a PT who has CLEARLY arrested due to blood loss may be futile.  I just would never take that risk myself nor would I ever teach my students to take that risk.  

Families of deceased sue all the time.  If they get a hold of the monitor and find out that their 50 year-old father was in vfib for 24 minutes and was never defibrillated there is going to be a problem.  I don't think it would be very difficult to find an expert witness to testify what the standard of care is and that the crew clearly deviated from the standard of care AND that the PT could have lived if the crew only defibrillated the PT.  

I am not disagreeing that you have a point Veneficus.  I am simply saying that the risks of withholding defibrillation far outweigh the risks of taking 4 seconds to actually defibrillate a PT who may not need it. You're pausing already every 2 min to verify rhythm.  Charge the darn monitor,shock, and move on. No harm no foul.  Futile?  Possibly,,,,,but who cares?


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## Veneficus (Feb 14, 2012)

The point of my asking was to see your thought process.




FlightMedicHunter said:


> Because there are simply too many variables in place for a field clinician to make this sort of decision.



I would stipulate it is not always possible, but I think an astute clinician can probably figure it out more often than seems postulated here.  



FlightMedicHunter said:


> .but you guys make it sound like someone cannot have an AMI and then have a serious accident that results in blood loss.



MI with uncontrolled/serious hemorrhage?

That sounds like really bad news.



FlightMedicHunter said:


> The standard of care for prehospital cardiac arrest in America is to follow ACLS guidelines (unless protocol deviates).  ACLS guidelines are to work the algorithm you are in while searching for and treating possible causes.



I am familiar with the guidlines. I also understand enough to know it was basically a consensus of saying nothing. If you read the actual AHA website on it, it basically says "we recommend doing this" and then it goes on to say how it likely isn't going to work.

That is like saying "go through the motions because the outcome is likely fatal."

Perhaps it is just my personality, but why do something you know will not work? What kind of medicine is that?

"I will prescribe and charge you for a therapy I know will not work."

I would be embarassed to sign my name to such a recommendation, much less write it.

In fact I find it insulting to not only providers with any level of knowledge but also to patients who actually will be paying for this garbage. 



FlightMedicHunter said:


> I completely understand the argument that defibrillating a PT who has CLEARLY arrested due to blood loss may be futile.  I just would never take that risk myself nor would I ever teach my students to take that risk.



If we do not talk about it and debate it, the recommendations will never change.

But there are conflicting directives.

1. take trauma patient to hospital without delay
2. work cardiac arrest on scene untill temrination of efforts
3. do not take time to treat onscene ( example: IV onscene for volume resuscitation, despite volume depletion is the likely cause) 
4. If patient is arrested, apply and use an AED. (per AHA)
5. assume in a medical arrest early defib is the key
6. assume in trauma volume depletion is the cause

That alone demonstrates these AHA "experts" clearly didn't put a lot of thought into this recommendation. 



FlightMedicHunter said:


> Families of deceased sue all the time.  If they get a hold of the monitor and find out that their 50 year-old father was in vfib for 24 minutes and was never defibrillated there is going to be a problem.  I don't think it would be very difficult to find an expert witness to testify what the standard of care is and that the crew clearly deviated from the standard of care AND that the PT could have lived if the crew only defibrillated the PT.



So are you going to be sued for deviating from the AHA guidline on traumatic arrest or the NTSB guidline and standard of care of not delaying the transport of a critical trauma patient?

Because both are recognized standards of care. You can find an expert to testify to either.

Trying to avoid getting sued does not justify questionable medical practice. There is no magic algorythm to follow in order to do what is best for all patients that will limit your liability and help the patient.



FlightMedicHunter said:


> I am not disagreeing that you have a point Veneficus.  I am simply saying that the risks of withholding defibrillation far outweigh the risks of taking 4 seconds to actually defibrillate a PT who may not need it. You're pausing already every 2 min to verify rhythm.  Charge the darn monitor,shock, and move on. No harm no foul.  Futile?  Possibly,,,,,but who cares?



It is not about agreeing or disagreeing. It is about finding the best practice. 

If an ALS provider wants to shock a patient  on the way to the ED, fine. As you said, it takes a few seconds. But, before we can say "who cares," we must first figure out if in the trauma population this has a detrimental effect. 

We are assuming "no effect."

The OP refered specifically to using an AED. Which takes more time than a manual defibrillator.

Which brings into question again of whether you are going to stay and play on a potentially viable trauma patient or if you are going to initiate rapid transport.

In ATLS and in every part of surgical educational I have, in trauma, the mantra of a decompensated patient is that it is blood loss until proven otherwise. 

So you are going to have to make a decision. A real clinical decision, not which algorythm to use.

Are you going to stay and play with trying to fix delivery of o2 to tissue in a trauma patient by restoring an organized electrical rhythm to a non functional pump?

or

Are you going to rapidly transport the trauma patient with a more conservative treatment approach in order to give this patient the best chance with delivery of o2 restored by surgical hemostasis and blood volume resuscitation?

We do not know if defibrillation will have a negative impact on hybernating cardiac tissue in the trauma population. But what we do know points towards it.

We cannot quantify how much neural tissue is lost until the point of initial EMS contact in an arrest patient. But we do know that the brain fails prior to the heart. So, we are left with the reality that this patient may not benefit from transport at all.

Since there are multiple possibilities of the cause of arrest, a decision will beyond doubt be determined by the individual patient presentation, not by an algorythmic guidline.

Finally let us consider the operation aspect. 

If this patient is a traumatic arrest, or suspected of such, If found on scene in vfib, with the likelyhood of a fatal outcome, does a lights and sirens transport with providers at risk of injury or death, justify this transport at all?

Now who says paramedics do not Dx or practice medicine?


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## FlightMedicHunter (Feb 14, 2012)

Your logic makes perfect sense..............for those that actually have the ability to utilize serious critical thinking skills.  

Unfortunately, there are a few hundred thousand (guessing) paramedics out there in America and while we must be progressive in how we teach, we also must cater to the lowest common denominator sometimes.

I could think of many reasons to deviate from the standard of care and I'd like to think (knock on wood) that I would have the knowledge of pathophysiology and disease processes to fully explain my actions to anyone.  Veneficus, you seem the same way.  However, this method of critical thinking is grossly lacking in EMS.  If we want to move forward and start teaching students to this level we have to start with changing the guidelines and the standard of care that we operate within.  In cardiac arrest, that standard of care is ACLS who, again unfortunately, caters to the lowest common denominator i.e. dental offices, etc.  

My main point here is.....I forget.........oh yeah.........is that we have difficulty getting the majority of EMS providers to properly provide regular BLS/ALS care.  Crews screw up regular CPR.  They don't push fast enough, they don't push hard enough, they take patients to the wrong hospital, the cannot differentiate between COPD and CHF, they staf on scene too long with trauma patients, they fly patients who could have walked to the ED, etc etc etc.  


Before we raise the bar, we need to bring all of these other providers above the bar that we already have,,,,which is set insanely low.  

Teaching students and/or regular street crews that it may be acceptable to withhold defibrillation boggles the mind considering they cannot even do proper compressions.....


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## Veneficus (Feb 14, 2012)

FlightMedicHunter said:


> Your logic makes perfect sense..............for those that actually have the ability to utilize serious critical thinking skills.
> 
> Unfortunately, there are a few hundred thousand (guessing) paramedics out there in America and while we must be progressive in how we teach, we also must cater to the lowest common denominator sometimes.
> 
> ...



You teach street crews not to delay transport in trauma.

You are also teaching to defib a traumatic arrest patient.

In your earlier statement, you suggest that the experts on medical cardiac care take precedent over the experts on trauma.

I see it as 6 of 1 or 1/2 dozen of another.

You might as well flip a coin. If the family is hell bent on suing, they will be arguing against you the opposite of what you did no matter what your choice.

Both of which are curriculum, both of are recognized standards by expert bodies, both apply to this same patient.

No matter what level of EMS provider you are teaching, you cannot possibly say one of these takes precedent over the other in an authoritive way. Certainly neither protect you from being sued using the other.

Personally, if I were to have to make a blanket decision, I would go with rapid transport without defib as there is evidence rapid transport improves outcome in serious trauma. 

There is no evidence defib or any other ACLS guidline helps in traumatic arrest and their very statement says it is unlikely to help.

For your students and your patients, it is a decision you will have to address in the way you decide.

Strangely enough, this is probably one of the most important issues I have ever seen discussed here.


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## FlightMedicHunter (Feb 14, 2012)

Yes, absolutely there are all kinds of conflicts of interest WITHIN the standard of care i.e. Give nitro/don't give nitro,  treat the rate/treat the rhythm, intubate/don't intubate........but shock a shockable rhythm/don't shock??

Withholding defibrillation is nowhere within the standard of care.  Again, that doesn't mean that I am disagreeing with the logic of withholding defibrillation.  It only means that when we stray outside the standard of care we are taking a risk.  

I am simply saying that this risk seems unnecessary


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## Veneficus (Feb 14, 2012)

But the guidelines do state that in trauma volume insufficency is the assumed cause until proven otherwise.

Defib is not the treatment for hypovolemia.

The cardiac rhythm is not stipulated.

In the ACLS guidlines and in medicine, reversible causes take precedent over algoryhtmic treatments.

As for the risk, the risk of what?

Like I said, no matter the course you choose, you have the same risk. Basically 50%.


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## FlightMedicHunter (Feb 14, 2012)

Veneficus said:


> Like I said, no matter the course you choose, you have the same risk. Basically 50%.



I think I could find a medical director or two who might disagree and say that withholding defibrillation in any scenario would be placing everyone involved at a higher risk of liability, unless of course it is written in the protocol or orders have been given.  

I think we can agree that critical thinking will progress this profession and lead to better paramedics.  

I think we'll have to agree to disagree on the point that just because you can justify something that somehow the risk is the same.  We have all been questioned and reprimanded for "using our heads" in situations far less intense as withholding defibrillation.  I agree with your thinking, my friend, but the majority of medical direction and the legal world probably would disagree.


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## Veneficus (Feb 14, 2012)

FlightMedicHunter said:


> I think I could find a medical director or two who might disagree and say that withholding defibrillation in any scenario would be placing everyone involved at a higher risk of liability



I know a handful personally who would agree in the hypovolemic arrest, it wouldn't matter.  



FlightMedicHunter said:


> I think we can agree that critical thinking will progress this profession and lead to better paramedics.



I agree, but teaching paramedics to make decisions from fear of legal action doesn't develop critical thinking. Nor does "just following orders." 



FlightMedicHunter said:


> We have all been questioned and reprimanded for "using our heads" in situations far less intense as withholding defibrillation.



Questioned and reprimanded is not the same thing. 

I cannot ever recall being reprimanded by any physician for using my head. 

There has been the occasional ignorant FTO in the past though. (including one that didn't think you could use a 12 lead to analyze the right side of the heart.) 



FlightMedicHunter said:


> I agree with your thinking, my friend, but the majority of medical direction



A majority of medical direction is of no consequence. 

Best practice in traumatic/surgical resuscitation concerns me. (takes up most of my day actually.) 



FlightMedicHunter said:


> and the legal world probably would disagree.



The role of a lawyer is to win. They don't actually have to believe in what they represent.

Forming and delivering the most persuasive/compelling argument is what they do.

"Just following orders" is a really weak defense. I wouldn't risk trying it. (especially considering the rather historically magnificent ways in which it has failed.) If a lawyer can manipulate the heart strings of a jury or the logic of a judge, your protcol doesn't stand a chance of a finding in your favor.


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## FlightMedicHunter (Feb 14, 2012)

We are getting way off base here.  There is something that is worth pointing out here though.  There are many progressive EMS folks out there who preach about critical thinking and understanding pathophysiology.  I am one of those folks.  Veneficus, you also sound like one of those folks.  

However, there also seems to be a group out there who wants medics to be freelancers and operate however they see fit....as long as they can justify it.  I find a major fundamental flaw in this argument:  We are not physicians.  As much as we want to learn and move ahead we are simply not physicians and therefore cannot act outside of standing orders or medical direction.  Yes, we must teach critical thinking but just teaching somebody critical thinking does not forfeit the fact that we operate under a physician's license.  

As much as you and I hate it, we DO have to teach how to protect yourself from legal action.  We do it all the time.  Yes, CYA is a part of EMS.  Legal knowledge is part of all EMS curricula.  Any instructor who teaches that it is okay to withhold defibrillation without having a protocol or orders is doing the student a disservice.  

How many times have you given nitro to someone that you knew was not having cardiac ischemia?  Everyone has.  Even though they knew it wouldn't help.  They did it to cover their ***.  

You sound like you work in an ED or trauma environment.  Maybe you work on the street as well.  But you have to remember that this is a big nation of paramedics and 99% of the time, if someone is going to get roasted, it is going to be the paramedic.  If liability arises, most agencies will search for a reason to blame the paramedic for what went wrong.  The worker bees are always the scapegoats.  When was the last time you read the headline "Doctor gets fired for writing crappy protocol!" or "Doctor gets sued and fired for giving crazy medical orders over the radio!"??  The answer is never.

But how many times have you seen a paramedic get fired for going outside their scope of practice or breaking the rules?  It happens every day.  The trick is to meander your treatment around within the protocols to protect yourself.  

Again, we can agree to disagree.  I have taken risks myself just as you say you would if you had a hypovolemic traumatic arrest.  But, we cannot teach others that this is acceptable when in the end they will be the ones who will get thrown under the bus.


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## FlightMedicHunter (Feb 14, 2012)

I am going to take a non scientific pole of EMS physicians.  The question will simply read (without any other background):

What would your thoughts be on a ground paramedic who showed up in your emergency room with a traumatic arrest?  This patient has been in vfib for the past 27 minutes and there have been zero defibrillations.  The paramedic states that he thinks the patient is hypovolemic and his reasoning for withholding the shocks was that electrical therapy would be futile and the only care that would save the patient's life would be fluid and blood replacement.



Nothing more.  Nothing less.


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## Veneficus (Feb 14, 2012)

FlightMedicHunter said:


> I am going to take a non scientific pole of EMS physicians.  The question will simply read (without any other background):
> 
> What would your thoughts be on a ground paramedic who showed up in your emergency room with a traumatic arrest?  This patient has been in vfib for the past 27 minutes and there have been zero defibrillations.  The paramedic states that he thinks the patient is hypovolemic and his reasoning for withholding the shocks was that electrical therapy would be futile and the only care that would save the patient's life would be fluid and blood replacement.
> 
> ...



That is a loaded question, who is in vfib for 27 minutes in a traumatic arrest?

Furthermore, would the opinion be different if it was a doctor?


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## firetender (Feb 14, 2012)

Let me go out on a limb here, knowing that Vene and FMH are living this stuff and I haven't in years. I've read the arguments pro and con, but am stumbling over the issue of priorities.

My first (possibly naive) thought is,  if  come across a trumatic incident where my patient presents in V-fib, that calls into question whether what I'm seeing is the result of trauma or electrical dysfunction. 

At that point I would have to ask myself "Even though there's trauma here, I might be missing something."

If it's electrical, and I'm not sure why, that is potentially immediately fixable through de-fib. That, at least, is something to work with and it doesn't take much time to do. Naturally you're going to want to stave off blood loss, but in the absence of a functioning heart, it's a moot point, there's nothing to stave.

NOT treating a fibrillating heart guarantees there will be no recovery, period. 

All the rest is about time management.  

(Please file under "Dinosaur logic, irrespective of litigation fears"!).


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## FlightMedicHunter (Feb 14, 2012)

Veneficus said:


> That is a loaded question, who is in vfib for 27 minutes in a traumatic arrest?
> 
> Furthermore, would the opinion be different if it was a doctor?



The argument is not whether a physician can safely make this decision.  It is whether a paramedic on an ambulance can make the decision on his own without a protocol or written orders directly saying to withhold defibrillation.  Your argument is that if they were hypovolemic that you would withhold shocking and do rapid transport with fluid resuscitation.  You said you would do this because shocking would be futile as a normal heart rhythm would not be perfusing anyway due to the hypovolemia. 

I will make an honest attempt to get impartial opinions from ED physicians as well as my school medical director and several medical directors on the state board.  I will update this thread when I get their opinions.  

Don't go running from you argument now.....


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## Veneficus (Feb 14, 2012)

FlightMedicHunter said:


> We are getting way off base here.  There is something that is worth pointing out here though.  There are many progressive EMS folks out there who preach about critical thinking and understanding pathophysiology.  I am one of those folks.  Veneficus, you also sound like one of those folks.



Yea, I see a bit of value in pathophys 

I don't think we are off base at all.

The OP specifically stated his protocols direct traumatic arrests should not be defibrillated.

He then asked why. 

After explaining it to him there is an ongoing debate on the value. 



FlightMedicHunter said:


> However, there also seems to be a group out there who wants medics to be freelancers and operate however they see fit....as long as they can justify it.  I find a major fundamental flaw in this argument:



I don't find this to be the case. I think there are people out there who rightfully require liberal enough guidlines so that the treatments available to EMS providers can be more appropriately selected for a given patient.

I have coined the term "surgical resuscitation" to more accurately describe it. Specifically selected therapy for specific conditions and presentations.

I think it is a bit overreaching to call that similar to paramedics doing whatever they want. There are still finite therapies available to them.

In the case of defibrillation of traumatic arrest, withholding treatments based on presentation has been a part of EMS for as long as I can remember. (which is a long time)

A simple example is medication allergy. You wouldn't give a medication to a patient who claimed an allergy would you? Why? You could just predose him with some epi and benadryl and get the desired effect anyway.

You don't do it, because at that point the complexity of the therapy and the amount of side effects outweigh the benefit derived from the original medication.

So you or any reasonable paramedic would select another available and indicated treatment or forgo treatment entirely if that option didn't exist.  



FlightMedicHunter said:


> We are not physicians.  As much as we want to learn and move ahead we are simply not physicians and therefore cannot act outside of standing orders or medical direction.



You are not a physician, got it. 

But I am not suggesting acting outside of medical direction. I do suggest that medical direction needs to be more than simple an if:then statement. Such rigidity simply doesn't function well in medicine.

a good example is compartment syndrome of the lower extremity secondary to edema in dialysis patients. 

If you have clinical signs and symptoms of compartment syndrome in the lower extremity, the indicated surgical treatment is 4 compartment fasciotomy. 

Here is where if:then breaks down. If you have an elderly, heart failure, diabetic, renal failure patient like many in this population, when you cut their legs open, those wounds may never heal. Creating complications, decreasing quality of life, increasing costs.

It may be better to try increased dialysis first. Which is not indicated medically in the treatment of compartment syndrome.

Granted, this is more of a surgical/nephro debate, but if I think about it long enough I could probably find an EMS example. 




FlightMedicHunter said:


> Yes, we must teach critical thinking but just teaching somebody critical thinking does not forfeit the fact that we operate under a physician's license.



Didn't ay it did.  



FlightMedicHunter said:


> As much as you and I hate it, we DO have to teach how to protect yourself from legal action.  We do it all the time.  Yes, CYA is a part of EMS.  Legal knowledge is part of all EMS curricula.



You can teach legal aspects of EMS without invoking fear from the constant threat of litigation.

litigation is part of modern medicine, it is not really a question of if somebody brings legal action, but when. Anytime gettng sued takes precedent in your mind over doing the right thing, it might be time to find another career or get some medication for anxiety or other relevant psychosis. 

Education should remove fear, not install it. That is what seperates it from indoctrination or brainwashing.



FlightMedicHunter said:


> Any instructor who teaches that it is okay to withhold defibrillation without having a protocol or orders is doing the student a disservice.



I beg to differ. 

What if there is no protocol addressing defibrillation in traumaic arrest?



FlightMedicHunter said:


> How many times have you given nitro to someone that you knew was not having cardiac ischemia?  Everyone has.  Even though they knew it wouldn't help.  They did it to cover their ***.



They didn't do it as a diagnostic procedure to help differentiate a more specific diagnosis of ACS?

If they did it to cover there ***, they administered an unindicated medication to a patient. That is a medical error. 

Are you suggesting that it is ok to knowingly perform a medical error on somebody to help you avoid getting sued?

You know as an instructor you can be held liable for erroneous teaching. Teaching somebody to give a medication "to cover their ***" as the indication would certainly not be a good idea.



FlightMedicHunter said:


> You sound like you work in an ED or trauma environment.  Maybe you work on the street as well.  But you have to remember that this is a big nation of paramedics and 99% of the time, if someone is going to get roasted, it is going to be the paramedic.  If liability arises, most agencies will search for a reason to blame the paramedic for what went wrong.  The worker bees are always the scapegoats.



Do you really think if something goes wrong, that the :censored::censored::censored::censored: is going to roll in a direction other than down? You seem way too smart for that. Even if you don't get fired from your agency, the work environment will likely become so hostile you'll quit.

The benefit to the physician in the current way EMS is set up in the US, is they do not bear direct responsibility. If they did, there would be a lot less paper medical directors and absentee medical directors.

The agency with the deepest pockets will be sued, and some little guy will take the fall.

Always.  



FlightMedicHunter said:


> But how many times have you seen a paramedic get fired for going outside their scope of practice or breaking the rules?  It happens every day.



Really? Everyday?

I have seen it happen to 1 EMT-B for administering epi outside her scope in my whole career now spanning 5 countries and starting in 89.

Who told you it happens everyday? 



FlightMedicHunter said:


> just as you say you would if you had a hypovolemic traumatic arrest.



This is not a risk, it is decision backed by expert recommendation and more than a few scientific studies on the outcome of traumatic arrest.

I am far more likely to be congratulated for my clinical accumen and medical knowledge than I am for any potential negative consequence of performing a futile treatment on a corpse. 

Unless this guy is moments away from a trauma center, his injuries caused by a penetrating mechanism, and all the stars lining up just right for him, he is dead. (Not because he wasn't defirbillated)


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## Veneficus (Feb 14, 2012)

FlightMedicHunter said:


> Your argument is that if they were hypovolemic that you would withhold shocking and do rapid transport with fluid resuscitation.  You said you would do this because shocking would be futile as a normal heart rhythm would not be perfusing anyway due to the hypovolemia.



Sorry, i didn't read this properly the first time.

I would also withhold fluid if it was a penetrating mechanism.



FlightMedicHunter said:


> I will make an honest attempt to get impartial opinions from ED physicians as well as my school medical director and several medical directors on the state board.  I will update this thread when I get their opinions.
> 
> Don't go running from you argument now.....



I will never run from this argument. 

Before you do that though, I don't usually boast my credentials, but in addition to being a paramedic and paramedic instructor, I am 120 days away from my joint MD/PhD degree. My PhD is in pathophysiology and my dissertation and original research are on the pathophysiology of shock.

I would be happy to speak with any physician who would like to debate the matter.


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## Veneficus (Feb 14, 2012)

firetender said:


> Let me go out on a limb here, knowing that Vene and FMH are living this stuff and I haven't in years. I've read the arguments pro and con, but am stumbling over the issue of priorities.
> 
> My first (possibly naive) thought is,  if  come across a trumatic incident where my patient presents in V-fib, that calls into question whether what I'm seeing is the result of trauma or electrical dysfunction.
> 
> ...



It is not dinosaur logic.

In penetrating trauma, if the downtime is not long and aggresive surgical intervention and resuscitation are available, there is a small possibility of restoring enough physiologic function for defib to work.

The key there is restoring physiologic function. It is a similar (not exact) mechanism to having to defib the heart from vtach (usually) or vfib secondary to cardioplegia in various on pump cardio surgeries. You must first restore normal working order.

If you hang around trying to defib, the likely (almost promised) outcome is refractory vfib. 

The unknown factor is, we don't know if defib will detract from other therapies.

Hanging around on scene will detract. 

What it comes down to is the provider on scene is going to have to make a choice. 

As I pointed out, there are even conflicting recommendations. 

In the end, the decision will come down to clinical proficency (and as part of that experience) of the provider to determine the best course.

If you think it is vfib secondary to hypovolemia in a penetrating arrest, you need to beat feet defib will not help.

If you think it is vfib secondary to a coronary condition with trauma, you will need to defib.

If it is traumatic arrest due to blunt mechanism, doesn't matter what you do, it's already over.


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## TheGodfather (Feb 14, 2012)

Veneficus said:


> If you think it is vfib secondary to hypovolemia in a penetrating arrest, you need to beat feet defib will not help.
> 
> If you think it is vfib secondary to a coronary condition with trauma, you will need to defib.
> 
> If it is traumatic arrest due to blunt mechanism, doesn't matter what you do, it's already over.



can i get a hallelujah?! amen!


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## Brandon O (Feb 14, 2012)

One brief thought, playing devil's advocate for a moment.

Even cardiac failure due to clearly traumatic etiologies, such as hypovolemia, may deteriorate into VF due to irritability, _prior_ to the point where it becomes totally non-pumping due to asystole or PEA. In that case, if defibrillation could return a circulating rhythm (which is admittedly far from certain), you would be restoring some amount of perfusion for some amount of time. Even if the output is poor and brief it would almost certainly be vastly better than compressions and could potentially temporize until the underlying cause could be fixed.

Furthermore, if a traumatic cause does precipitate VF, and you correct an underlying cause, you may still need to shock to restore sinus rhythm.

This is all a stretch and I'm not suggesting it changes the basic concept that arrest due to squishing is generally a lost cause. But if you're asking why could it ever help, there's a theoretical example.


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## Aidey (Feb 14, 2012)

Vene (or anyone else)

Wasn't there someone doing a study on withholding defib in certain types of arrest in favor for continued CPR until the cause of the arrest could be fixed?


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## Veneficus (Feb 15, 2012)

Brandon Oto said:


> One brief thought, playing devil's advocate for a moment.
> 
> Even cardiac failure due to clearly traumatic etiologies, such as hypovolemia, may deteriorate into VF due to irritability, _prior_ to the point where it becomes totally non-pumping due to asystole or PEA. In that case, if defibrillation could return a circulating rhythm (which is admittedly far from certain), you would be restoring some amount of perfusion for some amount of time. Even if the output is poor and brief it would almost certainly be vastly better than compressions and could potentially temporize until the underlying cause could be fixed.



I think you are overlooking something very important in this theory.

In an MI arrest, a part of the heart is affected by ischemia, there is still working and perfusing parts.

In the hypovolemic arrest, the entire myocardium has failed. It begins in the compensating phase when endogenous endophine constricts endocardial capilary beds in order to shunt more blood to the epicardial arteries. 

When delivery of o2 is so inadequete, eventually you have anaerobic metabolism. The tissue is trying to sustain itself, not work properly. (contract)

If it has already reached a level of vfib, (irritability) then the cellular level metabolism is insufficent. (caused by lack of oxygenation of the total heart) At this rather small moment in time, a couple of minutes, if you were to defib, and the heart were to return to an organized rhythm, it will still be unable to carry out any function.(contraction from ATP depletion, required for muscle contraction) The atp production in anaerobic metabolism cannot hope to make up for the loss of beta oxidation or even aeorbic glucose metabolism.

Since you cannot deliver what is needed (oxygen) to return normal metabolism, because part of either the hematocrit, circulatory volume, or both are depleted, there still will not be contractility. 

So your clinical outcomes are only going to be recurrent vfib, pea, or aystole. 

This is witnessed after cardioplegia in cardiac surgery. When sufficent circulating volume is restored, the vtach, vfib is defibrillated and a perfusing rhythm returns. 

When the circulating volume is still insufficent, the rhythm does not convert.  After waiting a few minutes, it is attempted again, with the idea that bypass rig returned more volume with sufficent circulation and gas exchange occured to allow return to normal metabolism. (there is also some time for return of more normalized temperatures when hypothermia is used) After this second attempt, volume resuscitation is increased prior to yet another defib attempt. 

This last step is then repeated until it works. (I have not seen or heard of it failing) 

But in this setting you can actually watch how the whole volume resuscitation concept works. Not only on the EKG, but directly observing the heart. 



Brandon Oto said:


> Furthermore, if a traumatic cause does precipitate VF, and you correct an underlying cause, you may still need to shock to restore sinus rhythm..



Yes you will. But this restoration of underlying cause is going to require either surgical hemostasis,and/or restoration of circulating volume and hematocrit. In class 3-4 shock, when arrest happens, the pt is unresponsive to crystaloid. Which means there is nothing EMS brings to the party that helps except a ride.

But the unknown quantity is, would restoration of a normal looking rhythm via defibrillation force an attempt at function, which likely would increase acidosis and cause cellular failure in the entire organ?

Would the electrical current cause direct cell injury to the already long struggling cells?

Even an injured cell can go into an apoptosis cascade.

What are you willing to bet on no damage?



Brandon Oto said:


> This is all a stretch and I'm not suggesting it changes the basic concept that arrest due to squishing is generally a lost cause. But if you're asking why could it ever help, there's a theoretical example.



too oversimplified.


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## systemet (Feb 15, 2012)

As a devil's advocate (actually, I'm not sure which side of the argument I'd have to be on to be a devil's advocate here), what about the idea that pulseless VF /VT represents a state where cellular energy demand isn't met by cellular metabolism and high-energy phosphate / glycogen stores are being depleted, and the development of lactic acidosis / metabolite accumulation is occuring at an accelerated rate.

I wonder if it's possible that having the hear in pseudo-PEA, true PEA, or asystole might be better from a cellular metabolism standpoint?

[I do agree with the futility of defibrillating someone who has no volume and no hematocrit, if we're talking about producing a beating heart with decent hemodynamics.] 

Just wondering what the opinions were about this from a physiology / pathophysiology standpoint.


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## Veneficus (Feb 15, 2012)

systemet said:


> As a devil's advocate (actually, I'm not sure which side of the argument I'd have to be on to be a devil's advocate here), what about the idea that pulseless VF /VT represents a state where cellular energy demand isn't met by cellular metabolism and high-energy phosphate / glycogen stores are being depleted, and the development of lactic acidosis / metabolite accumulation is occuring at an accelerated rate.
> 
> I wonder if it's possible that having the hear in pseudo-PEA, true PEA, or asystole might be better from a cellular metabolism standpoint?
> 
> ...



I don't understand what you are asking sorry


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## Veneficus (Feb 15, 2012)

*2nd look*



systemet said:


> As a devil's advocate (actually, I'm not sure which side of the argument I'd have to be on to be a devil's advocate here), what about the idea that pulseless VF /VT represents a state where cellular energy demand isn't met by cellular metabolism and high-energy phosphate / glycogen stores are being depleted, and the development of lactic acidosis / metabolite accumulation is occuring at an accelerated rate.



I am still not sure if there is a question in here or what you are trying to say?



systemet said:


> I wonder if it's possible that having the heart in pseudo-PEA, true PEA, or asystole might be better from a cellular metabolism standpoint?



That is what is happening. Cells go into "hybernation" as they try to use the ATP generated to preserve cell integrity. 

At some point this integrety is compomised by membrane permiability (multiple mechanisms)

If proper intervention (like restoration of circulation) is undertaken while still in time for the cell to recover from the insult, the acute arrest pathology is corrected and homeostasis can return. 

But keep in mind, the inflammatory response to shock has alread been initiated, and there will be a longer term sequele to that. (like delayed cell killing)

Not all cells are affected equally either, so some will die and some will return to function. How many makes a big difference. 

If proper and timely intervention is not undertaken, there is a point where injury triggers the apoptosis cascade in a cell. That is irreversible and is largely recognized to take up to 10 days to manifest with clinical signs. (the average being around 4 in the heart)

Hypothermia is the reversible treatment to slow down cell metabolism.

While focusing on the heart in this discussion, let us not lose sight of the insult to other organs. The heart is the very last organ to be affected. So the damage to the rest of the body is already substantial.

I would liken defirbrillating a hypovolemic arrest to kicking a dying animal and expecting that will help.


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## systemet (Feb 15, 2012)

Veneficus said:


> I am still not sure if there is a question in here or what you are trying to say?



Sorry.  Question: "Is it better to be in a PEA / low perfusion state or asystole for the individual cardiomyocyte, compared with high frequency stimulation during VF/VT?".

Just wondering as a thought experiment.  Sorry for the lack of clarity.



> That is what is happening. Cells go into "hybernation" as they try to use the ATP generated to preserve cell integrity.
> 
> At some point this integrety is compomised by membrane permiability (multiple mechanisms)
> 
> ...



Agreed / accepted.



> If proper and timely intervention is not undertaken, there is a point where injury triggers the apoptosis cascade in a cell. That is irreversible and is largely recognized to take up to 10 days to manifest with clinical signs. (the average being around 4 in the heart)



And this is related to loss of membrane potential (i.e. depolarisation), Ca2+ entry, caspase activation, and loss of mitochondrial membrane potential, and MPTP formation.  I'm just wondering if VF/VT accelerates this.



> Hypothermia is the reversible treatment to slow down cell metabolism.
> 
> While focusing on the heart in this discussion, let us not lose sight of the insult to other organs. The heart is the very last organ to be affected. So the damage to the rest of the body is already substantial.



It's interesting that much of the discussion in the literature has been so focused on the neurological effects of hypothermia, versus any CV effects.  Granted, the neurological outcome is critical, but it's also important to avoid sudden arrhythmic death, especially in the first 24 hours, and have hemodynamic stability.



> I would liken defirbrillating a hypovolemic arrest to kicking a dying animal and expecting that will help.



I think you're right, but the discussion got me thinking about the energetic state of the myocardium during VF.


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## Veneficus (Feb 15, 2012)

systemet said:


> Sorry.  Question: "Is it better to be in a PEA / low perfusion state or asystole for the individual cardiomyocyte, compared with high frequency stimulation during VF/VT?".



I don't think it matters. With the membrane permiability, it will be in asystole soon enough.



systemet said:


> And this is related to loss of membrane potential (i.e. depolarisation), Ca2+ entry, caspase activation, and loss of mitochondrial membrane potential, and MPTP formation.  I'm just wondering if VF/VT accelerates this



I would say VF is a variant manifestation of the above considering PEA and asystole are more common in hypovolemic arrest.

Sort of a "last hurrah" for the heart with the energy it has before it can't go on. 

From what I know about hypovolemic arrest, I would also suggest that this course of VF is going to be measured in a few short minutes.


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## zmedic (Feb 15, 2012)

The other way to look at all this is to say "forget about what's logical, what should work, what actually happens when there is a prehospital cardiac arrest due to blunt trauma?" 

The data I've seen so far say if someone is in arrest from blunt trauma they all die. Doesn't matter if you defib them, do CPR, give fluids, MAST pants, whatever. They all die. 

So if I was writing a protocol for what my medics should do if they show up at a blunt trauma cardiac arrest, I'd say don't start CPR. That it doesn't matter how logical it is to defib the patient, that vfib could have caused the crash. If no one is surviving, clearly it doesn't make sense to bring these patients to the hospital. 

Old study:
http://ukpmc.ac.uk/abstract/MED/8371308/reload=0;jsessionid=oC2kHQOVkge8WF82wCSU.143

Study from Japan, with agressive treatment including open heart CPR, 3/477 patients who suffered blunt cardic arrest survived to discharge with good neurological outcome. Everyone else died or lived in a vegitative state. 

http://www.springerlink.com/content/p634xg356l860q07/fulltext.pdf


Now the last study had a few survivors, but it's hard to tell how well that system translates to a US system. 

Now I think there are times when it makes sense to go outside the protocol.  I think I would work a 8 year old who was hit by a car, or someone who was talking when I got on scene and coded in front of me after a trauma. But I know that they aren't coming back. I think the best protocols allow some discretion. 

I would also point out that the brain's need for oxygen is similar regardless of if the cause of cardiac arrest is trauma or medical. So if the patient isn't getting bystander CPR in a traumatic arrest they have a much lower chance of being saved. I'd guess (though I have no data) that there is less bystander CPR in trauma because the patient is often stuck in the car/under the train/ under the collapsed building or whatever caused the trauma.


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## Brandon O (Feb 15, 2012)

Veneficus said:


> ... So your clinical outcomes are only going to be recurrent vfib, pea, or aystole.



I suppose my point is that if there's any possibility of a later reversal, "recurrent vfib" may be our best bet. Even if the intervening rhythm is agonal and poor, with weak, poorly synchronous contractions, and even if we go into VF ten times, that cycle is still better than no rhythm at all, and once in a blue moon this might make the difference between salvageable vs. non-salvageable.



> ... But this restoration of underlying cause is going to require either surgical hemostasis,and/or restoration of circulating volume and hematocrit. In class 3-4 shock, when arrest happens, the pt is unresponsive to crystaloid. Which means there is nothing EMS brings to the party that helps except a ride.



I was thinking a little more about other causes, particularly since penetrating trauma is perhaps the one situation where traumatic arrests still have the most potential for survival. For instance, maybe we've corrected a tension pneumothorax, or maybe there was a primarily hypoxic arrest due to obstructed airway or respiratory depression. (Actually, that last is probably our best bet.) These are things we can remedy.



> But the unknown quantity is, would restoration of a normal looking rhythm via defibrillation force an attempt at function, which likely would increase acidosis and cause cellular failure in the entire organ?



I think there is little question that an active heart will have greater metabolic demand. But a non-pumping heart means our window for correction has become truly tiny -- that's clear enough -- so I don't think that "letting it twitch" is ever going to yield the better supply/demand balance. (Unless we come up with a way of really inducing hibernation, such as rapid hypothermia... or hydrogen sulfide, hey.)



> Would the electrical current cause direct cell injury to the already long struggling cells?



Although electrocution is probably not exactly organic granola, so far the literature seems to increasingly find that cardiac damage from defibrillation is minimal...


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## FlightMedicHunter (Feb 16, 2012)

So, talked to several physicians today including several from the state medical board, 2 attendings from our level trauma center, and 1 attending from our pediatric ED.  I gave them the scenario exactly as it is shown from my earlier post.  

All are in agreement that there is accepted standard of care that would allow for a prehospital paramedic to make the decision to withhold defibrillation in a traumatic arrest, regardless of the situation.  

I remain in full agreement with them that it is completely unacceptable to make your own decision in the field to withhold shocking vfib/vtach.  Veneficus, I understand you are experienced and that you are working on your MD, but just as in my earlier posts I cannot agree that this would be an acceptable practice.

Defibrillating someone takes an additional 3 seconds every 2 minutes while en route to an ED.  When we see vfib/vtach, we shock it, simple as that.  

You asked earlier "who stays in vfib for 25 minutes?"  The answer is no one knows because no one in their right mind would ever sit there and watch someone remain in vfib for more than 1 round of CPR


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## Veneficus (Feb 16, 2012)

zmedic said:


> The other way to look at all this is to say "forget about what's logical, what should work, what actually happens when there is a prehospital cardiac arrest due to blunt trauma?"
> 
> The data I've seen so far say if someone is in arrest from blunt trauma they all die. Doesn't matter if you defib them, do CPR, give fluids, MAST pants, whatever. They all die.
> 
> ...



Excellent post.


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## Aidey (Feb 16, 2012)

FlightMedicHunter said:


> So, talked to several physicians today including several from the state medical board, 2 attendings from our level trauma center, and 1 attending from our pediatric ED.  I gave them the scenario exactly as it is shown from my earlier post.
> 
> All are in agreement that there is *accepted standard of care that would allow for a prehospital paramedic to make the decision to withhold defibrillation *in a traumatic arrest, regardless of the situation.
> 
> ...




Maybe I'm having a reading comprehension fail, but those two lines seem to completely disagree with each other.


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## TheGodfather (Feb 16, 2012)

Aidey said:


> Maybe I'm having a reading comprehension fail, but those two lines seem to completely disagree with each other.



I was thinking the same thing...


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## FlightMedicHunter (Feb 16, 2012)

FlightMedicHunter said:


> All are in agreement that there is accepted standard of care that would allow for a prehospital paramedic to make the decision to withhold defibrillation in a traumatic arrest, regardless of the situation.




Oops....this clearly should say:

All are in agreement that there is *NO* accepted standard of care that would allow for a prehospital paramedic to make the decision to withhold defibrillation in a traumatic arrest, regardless of the situation


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## Veneficus (Feb 16, 2012)

FlightMedicHunter said:


> So, talked to several physicians today including several from the state medical board, 2 attendings from our level trauma center, and 1 attending from our pediatric ED.  I gave them the scenario exactly as it is shown from my earlier post.



You didn't have to type all of this out actually, I am not impressed by titles 

As I said before, you went to your people with a leading question, you got the answer you were soliciting.

I can do exactly the same thing with far more impressive titled people than that. 



FlightMedicHunter said:


> All are in agreement that there is accepted standard of care that would allow for a prehospital paramedic to make the decision to withhold defibrillation in a traumatic arrest, regardless of the situation.
> 
> I remain in full agreement with them that it is completely unacceptable to make your own decision in the field to withhold shocking vfib/vtach.



???

These are conflicting statements.

I will defer to zmedics statement. These patients will all die. No matter what you do.

If your looking for the technicality of death, No pulse equals dead in blunt traumatic arrest. Only if there is considerable things that are in the patients favor in penetrating do these same people live.



FlightMedicHunter said:


> Veneficus, I understand you are experienced and that you are working on your MD, but just as in my earlier posts I cannot agree that this would be an acceptable practice.



I don't see how you can terminate efforts or not even begin efforts in a traumatic arrest and be focused on a heart rhythm. 

In the event that you never hooked up a monitor the patient could still be in vfib. (for a few minutes before his heart cells finally shut down, not because you defibrillated him) 



FlightMedicHunter said:


> Defibrillating someone takes an additional 3 seconds every 2 minutes while en route to an ED.  When we see vfib/vtach, we shock it, simple as that.



You shock it. Don't add in "we."

"We" don't transport dead people to the ED.

Physicians here have the ability to determine the futility of efforts. Both in the hospital and outside of it.  Cardiac rhythm is only one aspect of determing that.

Also I will remind you yet again, the question here is not an ALS defibrillation that take a few seconds, it is with an AED that takes a bit longer. As I recall that wasn't part of your question.

Strong work.


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## FlightMedicHunter (Feb 16, 2012)

Veneficus said:


> You didn't have to type all of this out actually, I am not impressed by titles



Trust me, I was not trying to impress you.  I was simply disclosing who I spoke with





Veneficus said:


> ???
> 
> These are conflicting statements.



I made the correction on the previous page that they stated there is NO accepted standard of care that would allow for withholding defibrillation.



Veneficus said:


> I don't see how you can terminate efforts or not even begin efforts in a traumatic arrest and be focused on a heart rhythm.



This statement tells me that you are so far off of what is acceptable in EMS that it scares me.  The standard of care is to treat the rhythm while searching for and treating underlying causes.  No paramedics are taught that if they find the underlying cause to just go ahead and disregard the rhythm.  





Veneficus said:


> "We" don't transport dead people to the ED.
> 
> Physicians here have the ability to determine the futility of efforts. Both in the hospital and outside of it.



I don't see how this relates.  I agree that most traumatic arrests are futile and good judgment should be exercised in regards to whether or not we should even resuscitate or transport



Veneficus said:


> Also I will remind you yet again, the question here is not an ALS defibrillation that take a few seconds, it is with an AED that takes a bit longer. As I recall that wasn't part of your question.
> 
> Strong work.



This does not matter to me.  AED or manual defibrillator....if the AED is attached and advises shock, the standard of care is to shock.  If the monitor shows vfib or is in pulseless vtach, the standard of care is to shock, unless, as I've stated countless time, there is a written protocol or an MD gives orders.

I challenge you or anyone on this board (or for the country for that matter) to submit documentation showing that they worked a traumatic arrest, documented vfib/vtach on the monitor, withheld defibrillation due to any of your previously mentioned reasoning, admitted to doing this on purpose,,,,and didn't get fired.


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## usalsfyre (Feb 16, 2012)

I think the point being made is if the rhythm has deteriorated to vfib and you aren't able to intervene in a meaningful way (blood, surgery, ect) than defibrillation is pointless (but then looking back you've acknowledged that).

Keeping a job and making sense medically sometimes aren't in line together. Keeping yourself from getting sued is even trickier if not impossible. But then, how many lawsuits against EMS providers involving medical care do you really hear about?

The big takeaway is there's no reason to even start resuscitation on blunt traumatic arrest.


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## FlightMedicHunter (Feb 16, 2012)

usalsfyre said:


> The big takeaway is there's no reason to even start resuscitation on blunt traumatic arrest.




Couldn't agree more and I'm with that 110%.....however, should they choose to attempt resuscitation that doesn't give any paramedic the power to make the conscious decision to withhold defibrillation if they happen to see vfib, vtach, or hear the words 'shock advised' from an AED.


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## Handsome Robb (Feb 16, 2012)

Example:

Today in the Level 2 we had a pt come in GSWx5 in the torso, pelvis and leg. Survived to the TC on the chopper, through the ER, CT, into emergent surgery, out of surgery to the TICU where he promptly coded. 

Bradycardic in the 30s, .5 of atropine, came up to 100 then art line showed 0/0 with no waveform, PEA at 40s-50s, CPR immediately, was already intubated, bilateral chest tubes placed, 3 rounds of epi, bicarb (ph was 7.0 per labs), PRBCs running, defibbed on the second round when he presented with v-fib, back to PEA in the 40s, trauma surgeon called it after a large amount of blood showed in the ETT. Yes, he coded that fast that anesthesia and the surgeon were still present.

This was after blood products and emergent surgery. Traumatic arrests have a very low survivability, despite where the pt is.


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## Brandon O (Feb 16, 2012)

Any plasma/platelets given?


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## TheGodfather (Feb 16, 2012)

Brandon Oto said:


> Any plasma/platelets given?



if he was coming out of surgery, more than likely he already had readily available type/crossmatched blood at/near the bedside.. i cant imagine after that journey through the ED, into surgery, and out of surgery with only FFP/type O packed cells....


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## Veneficus (Feb 16, 2012)

*Normally*

I try to be rather humble and introspective.

But the stupidity of "follow the guidlines" in response to a question on "why" something is done a certain way and then running to somebody else to confirm telling people to follow the guidlines really wears on me.

Did you not understand why I said I would be happy to have this conversation with a physician? 

Because from your response and behavior here it seems beyond your mental capability to say anything other than "follow the guidlines." I could probably observe the same effect if I tried to have a calculator divide by zero.



FlightMedicHunter said:


> I made the correction on the previous page that they stated there is NO accepted standard of care that would allow for withholding defibrillation..



I think you are getting too hung up on the idea of not defibrillating as the focus of this discussion.

The standard is to withhold resuscitation attempts in traumatic arrest. 

Additionally there is a standard for rapid transport of trauma and not to increase on scene time to provide supportive intervention. (you know, like IVs, cardiac monitors, that kind of thing)

Apparently at least one doctor wrote in a protocol not to "defibrillate" as demonstrated in the OP.

I suspect that the protocol does not specifically say to "not defibrillate," but something more along the lines of not to connect an AED to the patient.

Does that not sound more reasonable to you?

After all, if you are going to take the time to hook the thing up, you might as well get some use out of it right?



FlightMedicHunter said:


> This statement tells me that you are so far off of what is acceptable in EMS that it scares me..



You ought to see me when I get warmed up. 

I have been known to cut the veins out of people's legs by myself for transplant as well as surgically resect benign tumors on eyelids in outpatient clinics among my other endeavors while disregarding physician recommendations. (actually I have more than a few well written appraisals of my skill and ability for it)

(really scared yet?)

Regardless of the service I am assigned to, I function under direct and indirect supervision of a senior physician in what one of my friends and peers calls "medical purgatory." (it best describes the transition period between paramedic and physician) the doctors here like to just say "as a physician."

As a scientist, my ability to call into question clinical standards is rather advanced. I am especially well thought of in the times when I can demonstrate the basic science principles why the treatments are not going to be effective and suggest a reasonable alternative that is clinically applicable. (Actually I have published papers on stuff like that with a couple more in the works.)

I am not perfect, but so far there are only 2 mechanisms i have undertaken that elude me. (and I'm working on them) One is NfkB as a mediator of inflammation and apoptosis, the other is why oral glutathione and N -acetylcysteine fail to reduce free radicals that cause retinopathy in neonates from long term oxygen therapy.

So please, until you acutally understand the mechanisms behind disease and treatments, kindly withhold your criticism on how scary and out of touch I am.

Any fool can provide treatments from a script, pretend they are saving lives by more than just accident, and hold onto that standard as if it were religious text. It doesn't take a healthcare provider to that.



FlightMedicHunter said:


> The standard of care is to treat the rhythm while searching for and treating underlying causes.  No paramedics are taught that if they find the underlying cause to just go ahead and disregard the rhythm.



Really?

So if you had a patient who was 70 years old and struck by car, with a heartrate of 152, instead of treating hypovolemia you would begin treatment of SVT?

Or were you teaching to delay the treatment of hypovolemia secondary to trauma to run a 12 lead to determine if it was in fact true SVT?

What if your patient, who was an olympic cross country skiing gold medalist who called EMS for general malaise after eating at her favorite restaurant? Would you teach to treat her resting heart rate of 35 as bradycardia while you determined what made her feel sick?

Perhaps you teach to call med control to ask if you can withhold treatment for "bradycardia" in this patient?

Because the above are no different from witholding resuscitation, no different from not hooking up an AED in a traumatic arrest, no different from not transporting every arrest patient to a hospital. 



FlightMedicHunter said:


> I don't see how this relates.  I agree that most traumatic arrests are futile and good judgment should be exercised in regards to whether or not we should even resuscitate or transport.



It relates because I live in a country that puts physicians on many ambulances. When you get an ambulance, you likely are going to get a doctor. Especially if the call sounds bad to the dispatcher.

The decisions made by these EMS physicians (and the students working under them) out of the hospital are every bit as protected and respected as the ones they make in the hospital. Including when to initiate, withhold, or discontinue various treatments on a given patient from their clinical judgement; as well as instituting treatment that may not be part of a guidline somewhere because in their expert professional opinion of understanding "why", it might help the patient.

My original comment in this thread started with the mechanism behind "why" the OP might have a protocol to withhold treatment. 

I later detailed what I would do and why. Which is of course subject to what I know and the level of autonomy I have. (Which is far more than any US paramedic.) 

I didn't instruct people what to do and I did my very best to ignore the simplicity of simply saying "follow the dogma" in order to have an intelligent conversation with my EMS collegues as to "why."




FlightMedicHunter said:


> This does not matter to me.  AED or manual defibrillator....if the AED is attached and advises shock, the standard of care is to shock.  If the monitor shows vfib or is in pulseless vtach, the standard of care is to shock, unless, as I've stated countless time, there is a written protocol or an MD gives orders..



Really? Why would the question about "why" a protocol said to withhold a treatment matter to you while you spouted about a standard that in the very standard it said it wasn't likely to work?

Let me guess...

Because you heard an EMS instructor one day say "when you see vfib you shock it." You probably say that same thing a lot too don't you? 

How about this one?

"Trauma is a surgical disease, trauma patients need a surgeon." (or some common variance of that) 

Please, go back to telling your students to shock vfib when they see it and give everyone 15L of oxygen with a nonrebreather. While your at it, overemphasize the importance of long spine boards to protect against secondary injury as well. Oh, and call a helicopter or med control because you don't have a clue and need a doctor to say something to cover your ignorance.

Does that put your soul at ease on my command of EMS standards?



FlightMedicHunter said:


> I challenge you or anyone on this board (or for the country for that matter) to submit documentation showing that they worked a traumatic arrest, documented vfib/vtach on the monitor, withheld defibrillation due to any of your previously mentioned reasoning, admitted to doing this on purpose,,,,and didn't get fired.



The poor creature, he doesn't know any better...

How do you document your reports? Let me just give you an example of how this gets written when you are a paramedic.

"Found victim of high speed MVA pulseless and apneic upon arrival. Withheld resuscitation based on wounds inconsistent with life."

You ever hear of anyone in the US getting fired for writing a report like that?

Let me guess, you are one of those people who think you need to write a compendium of every detail of a given call and cite the source for the treatments you administered too?

(For the mods,this is the nicest version of this reply, I think it is rather controlled)


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## Handsome Robb (Feb 16, 2012)

Brandon Oto said:


> Any plasma/platelets given?



FFP given during surgery, not sure how much. I can't remember if he got any platelets although I'm sure he did at some point and yes we did have typed and crossed blood during the resuscitation. 

After a brief talk with the Surgeon, which made the nursing students quite jealous I may add  , her thought was there was possibly some involvement with the Internal Iliac although they didn't find anything during surgery and his belly remained soft throughout resuscitation. Also hemorrhage into the lungs from the blood in the tube which was the general consensus among the docs that were present. 

A little blood came out of the chest tubes but nothing to write home about. Guy actually had 3. 2 in the left and 1 in the right. Came into the TC with the first one in the left placed then the bilateral tubes were placed during the code by the surgeon.


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## RocketMedic (Feb 17, 2012)

Personally, I wouldn't treat hypovolemia on that 70 y/o either, at least not aggressively. Load and go to a trauma center, _conservative_ fluid resuscitation with _barely_ palpable radial pulses, and watch the monitor. _Really_ wouldn't want to give pressors or much in the way of fluid, and I'd rather have them tachy than overloaded/flushing clots.


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## RocketMedic (Feb 17, 2012)

NVRob said:


> FFP given during surgery, not sure how much. I can't remember if he got any platelets although I'm sure he did at some point and yes we did have typed and crossed blood during the resuscitation.
> 
> After a brief talk with the Surgeon, which made the nursing students quite jealous I may add  , her thought was there was possibly some involvement with the Internal Iliac although they didn't find anything during surgery and his belly remained soft throughout resuscitation. Also hemorrhage into the lungs from the blood in the tube which was the general consensus among the docs that were present.
> 
> A little blood came out of the chest tubes but nothing to write home about. Guy actually had 3. 2 in the left and 1 in the right. Came into the TC with the first one in the left placed then the bilateral tubes were placed during the code by the surgeon.



Possibly a ruptured surgical repair?


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## Handsome Robb (Feb 17, 2012)

Rocketmedic40 said:


> Possibly a ruptured surgical repair?



It's very possible. I'll find out eventually after the autopsy. This guy was a mess. He took 5 rounds at relatively close range from a .40 or .45. One of thm fractured his pelvis another shattered his tibia.


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## RocketMedic (Feb 17, 2012)

NVRob said:


> It's very possible. I'll find out eventually after the autopsy. This guy was a mess. He took 5 rounds at relatively close range from a .40 or .45. One of thm fractured his pelvis another shattered his tibia.



Yep...fight's over. One of the nastiest characteristics of a lot of modern ammunition is that it's not all x-ray "easy" to detect. Not super-applicable, but a very common insurgent trick is to use heavy glass as shrapnel.


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## FlightMedicHunter (Feb 17, 2012)

Veneficus, your analogies make no sense.  

The OP said the protocol was to not even attach the AED.  First, he has a PROTOCOL!!!....and second, without attaching the AED there is no indication to shock.  

You are trying to argue 5 different things now.  This discussion has never been about whether or not to work a traumatic arrest in the first place.  

From the beginning, this discussion has been about whether or not AMERICAN paramedics will withhold defibrillation or not.  

You withheld that you are not in America which explains to me why you cannot understand my point.  I am not saying that your pathophysiological remarks do not make sense.  I am saying that in AMERICA,,,,anywhere in AMERICA, if a paramedic sees vfib on the monitor of a patient that they are working, the standard of care is to shock it.  

There is not a single EMS system in America that would allow a paramedic to keep his job if he purposely withheld defibrillation on ANY patient that they were working. 



Veneficus said:


> "Found victim of high speed MVA pulseless and apneic upon arrival. Withheld resuscitation based on wounds inconsistent with life."



This quote does not relate to our discussion. We have not been arguing whether or not to 'work' the code in the first place.  

You stated that you would be okay with a paramedic simply providing quality CPR and rapid transport all the while withhold defibrillation.  You said this.  I stated that I can understand your point pathophysiologically.....sort of...but

in America.....the standard of care is to defibrillate vfib/vtach when working an arrest and while transporting them to the hospital.  This fact is non-debatable.  This IS the standard and it would be highly malevolent of ANY paramedic to consciously withhold defibrillation in AMERICA.

If you want to debate whether this standard should be changed, then I am all ears.  If you want to talk about what studies found and how that might change the FUTURE standard, again I'm all ears.  

If all you say is true with all your big words and what not then you must be a smart man.  A smart man would know that you cannot come on a forum such as this and tell young and future that is their prerogative to withhold defibrillation for a patient that they are doing CPR on.  

There is a difference in arguing emerging medical science and simply arguing what the standard of care is.  I don't know how paramedics work where you are from.  In fact, paramedics in most other countries have much broader decision making authority than they do here.  But we are not talking about EMS on a worldwide scale.  Simply America.

I am very involved in the progression of EMS education in this country.  I agree that our system is set up so that there are many situations where the paramedic is forced to follow the guidelines and cannot make their own decisions.  Unfortunately, this is how the EMS system in America has evolved.  I don't like it any more than anyone else.  My job as an educator is to teach my students how to use their critical thinking skills so that they can make educated and informed decisions, all while remaining within the standard of care and their scope of practice.  I am very progressive in my opinions of where I would like to see EMS go.  But, the answer isn't to teach our paramedics that they can simply make decisions that blatantly go against the standard of care.  The answer is to change the standard of care.

Either way in America, while doing CPR,,,,we shock vfib.


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## FlightMedicHunter (Feb 17, 2012)

NVRob said:


> defibbed on the second round when he presented with v-fib, back to PEA in the 40s, trauma surgeon called it after a large amount of blood showed in the ETT. Yes, he coded that fast that anesthesia and the surgeon were still present.




Amazing that the trauma surgeon defibrillated this patient.....doesn't he know that the new thing to do is just let it ride??


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## Handsome Robb (Feb 17, 2012)

FlightMedicHunter said:


> Amazing that the trauma surgeon defibrillated this patient.....doesn't he know that the new thing to do is just let it ride??



Your blowing this out of proportion. 

The discussion was about traumatic arrest in the field. 

If you have a shockable rhythm you work it, I have yet to see a protocol that says otherwise. 

The key is *most* systems have it written so in the presence of a traumatic injury that the patient presents pulseless and apneic that you don't attempt resuscitation in the field which often includes not even attaching a monitor. 

The example I presented was a scenario in a Trauma Center, in a critical care unit, post surgery. The pt was already on the monitor. If we needed to and it was deemed appropriate we could have cracked his chest open again among other things that we couldn't do in the field. 

Also total time of the code I helped work today was less than 8 minutes. Not a long effort. As soon as he went back into PEA the surgeon called it.


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## systemet (Feb 17, 2012)

FlightMedicHunter said:


> From the beginning, this discussion has been about whether or not AMERICAN paramedics will withhold defibrillation or not.



I seem to remember it being a discussion about the management of traumatic cardiac arrests.  I don't see where the conversation was strictly limited to a US perspective.  Nor do I see why only people who live or are qualified as paramedics in the US have a right to comment on this topic, especially on a website with a lot of international members.

I thought we were discussing medicine.  I think this is quite an interesting discussion, and that people on a "professional" website should be able to respectfully disagree with each other and argue their points reasonably.  To me, it didn't seem like Vene was telling anyone to deliberately violate their medical control guidelines, protocols, or established local standards or practice.  

All the best.


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## Handsome Robb (Feb 17, 2012)

Flightmedichunter, here are my agencies protocols. Since you seem to feel so strongly about the topic, lets hear what you have to say.


BLUNT TRAUMA 
 Assess scene for evidence of non-trauma induced cardiac arrest. If present follow 
cardiac dysrhythmia protocols. 
 After confirming cardiac arrest due to blunt trauma and no signs of obvious death, 
begin BLS. 
 Apply cardiac monitor. If asystole or slow PEA call base physician 
for termination orders. If any other rhythm: 
□ Expedite transport to trauma center. 
□ Continue BLS. 
□ Follow appropriate cardiac dysrhythmia protocol. 
□ Provide definitive airway control. 
□ Consider bilateral needle thoracenteses, especially if any evidence of 
chest 
□ trauma. 
□ Establish 2 IV’s or IO’s at wide open rate. 

PENETRATING TRAUMA 
• After confirming cardiac arrest and no signs of obvious death, begin BLS. 
• If transport time to trauma center is greater than 10 minutes call base physician for 
termination orders. 
• If transport time to trauma center is less than or equal to 10 minutes expedite 
transport. All treatment to be done enroute: 
□ Apply cardiac monitor. 
□ Continue BLS. 
□ Follow appropriate cardiac dysrhythmia protocol. 
□ Provide definitive airway control. 
□ Consider bilateral needle thoracenteses, especially if any evidence of 
chest trauma. 
□ Establish 2 IV’s or IO’s at wide open rate.

SPECIAL CONSIDERATIONS 
• May consider transport in unusual circumstances such as: Pregnancy – especially if 
any possibility of fetal viability; Pediatrics; Locations only accessible by air; and 
High profile patients (i.e. - law enforcement, fire). 
• Reason for transport needs to be well documented on the PCR. 
• Hypothermia – see Hypothermia protocol.

edited for formatting


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## usalsfyre (Feb 17, 2012)

Hunter, from what I can see, you understand the point, what I don't understand is why your willing to can a guy who withholds what you agree is a futile treatment because it violates "the standard". 

You speak of changing the standard. It takes people willing to push the limit to change the standard.


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## Veneficus (Feb 17, 2012)

Rocketmedic40 said:


> Possibly a ruptured surgical repair?



More likely an undiscovered wound.

(Do not take this as critisism of the surgeon or surgery, when there is a lot of blood everywhere, it is sometimes very difficult to see if you have actually stopped it all.)

There is also the possibility that a clot from a wound not bleeding during the surgey dislodged during post op resuscitation.


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## FlightMedicHunter (Feb 17, 2012)

NVRob said:


> Your blowing this out of proportion.



Yes, this was me being facetious



NVRob said:


> If you have a shockable rhythm you work it, I have yet to see a protocol that says otherwise.



This is the whole debate here.  I am saying this exact same thing while Veneficus is saying that it is okay for a street medic to make the decision to change this standard.


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## FlightMedicHunter (Feb 17, 2012)

systemet said:


> I seem to remember it being a discussion about the management of traumatic cardiac arrests.  I don't see where the conversation was strictly limited to a US perspective.  Nor do I see why only people who live or are qualified as paramedics in the US have a right to comment on this topic, especially on a website with a lot of international members.



Way back at the beginning I said:


FlightMedicHunter said:


> The standard of care for prehospital cardiac arrest in *America* is to follow ACLS guidelines (unless protocol deviates).  ACLS guidelines are to work the algorithm you are in while searching for and treating possible causes.



So, it seems obvious we were speaking about national standards here in America.





systemet said:


> To me, it didn't seem like Vene was telling anyone to deliberately violate their medical control guidelines, protocols, or established local standards or practice.



Vene clearly stated:  



Veneficus said:


> Personally, if I were to have to make a blanket decision, I would go with rapid transport without defib as there is evidence rapid transport improves outcome in serious trauma.





Veneficus said:


> In the case of defibrillation of traumatic arrest, withholding treatments based on presentation has been a part of EMS for as long as I can remember.



Then I specifically said "Any instructor who teaches that it is okay to withhold defibrillation without having a protocol or orders is doing the student a disservice."  

Vene said "I beg to differ."  

Later on I said ........



FlightMedicHunter said:


> Your argument is that if they were hypovolemic that you would withhold shocking and do rapid transport with fluid resuscitation. You said you would do this because shocking would be futile as a normal heart rhythm would not be perfusing anyway due to the hypovolemia.



The Vene said :



Veneficus said:


> I would also withhold fluid if it was a penetrating mechanism.



It is very clear from all of these statements that we were A. talking about standards here in America and B. that it is okay for a street medic in America to make the decision to withhold deifbrillation on someone who presents in vfib and instead just provide rapid transport.  He also made it very clear that it is okay for me to teach students this method of thinking.

There is a huge difference between arguing about the status quo and arguing about what the standard is.  I am in agreement that there should be progressive thinking in EMS and our paramedics are kept on a tight leash in regards to other countries.  I also agree that Vene's science may hold water and I would love to learn more about the subject.

HOWEVER.......

Vene made it very clear that any ole street medic CURRENTLY has the capability to make that decision.  As I said earlier, any paramedic in America that follows that advice would get fired in a heartbeat.  

Just as the other guy said, 'when we see a shockable rhythm, we shock it.'  This statement deserves no debate about its validity.  This is the standard.  These are our guidelines and we follow them.  Vene says it is okay to ignore the guidelines and make your own decision as long as you can back up the pathophysiology.  As much as I wish we were able to do that in America, we cannot.

Yes, we can use our best judgment as to whether or not to work an arrest in the first place but this was not the argument.  Paramedics can also make their own decisions on whether signs/symptoms point them to this protocol or that protocol.  But once in a protocol i.e. vfib, the paramedic follows that protocol.  Sure, they can deviate from the protocol all they want by calling for orders.  

Again however,,,even if a paramedic called for orders and said "yeah, I would like to withhold defibrillating this patient because he is clearly in arrest due to hypovolemia"  the Doc would then clearly say "just do CPR and follow ACLS guidelines and oh by the way, we need to talk in my office when you get here."

I don't know how else to explain the difference between arguing about changing the standard and arguing about what the standard is or whether or not a paramedic can deviate from defibbing vfib.


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## FlightMedicHunter (Feb 17, 2012)

NVRob said:


> Flightmedichunter, here are my agencies protocols. Since you seem to feel so strongly about the topic, lets hear what you have to say.



Let's take a look...



NVRob said:


> BLUNT TRAUMA
> □ Follow appropriate cardiac dysrhythmia protocol.
> 
> PENETRATING TRAUMA
> □ Follow appropriate cardiac dysrhythmia protocol.



I understand that there are paramedics in Europe and Australia that have a much broader capability to interpret and follow these protocols.  But here in America, once you are in that "cardiac dysrhythmia protocol" you follow the protocol.  Also, no protocol in America will say "Follow appropriate cardiac dysrhythmia protocol.  However, if you see vfib and think that the cause is from hypovolemia, with hold defib and simply transport."

These seem pretty standard.  Yes, you can choose not to resuscitate AT ALL based on presentation but once resuscitation attempts have been started your protocol clearly states to "Follow appropriate cardiac dysrhythmia protocol. "


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## systemet (Feb 17, 2012)

> _Way back at the beginning I said:_
> 
> 
> > _The standard of care for prehospital cardiac arrest in America is to follow ACLS guidelines (unless protocol deviates). ACLS guidelines are to work the algorithm you are in while searching for and treating possible causes. _
> ...



So you entered a discussion about the treatment of traumatic cardiac arrest half way through, and decided to redefine its parameters to restrict discussion to treatment in the US?


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## FlightMedicHunter (Feb 17, 2012)

This thread is turning into 3 arguments in one and it is quickly getting out of control.  

I am an educator and I will remain completely open to discussing new and progressive treatments.  Especially, if they come from more efficient and productive systems such as Europe and Australia.  This is how changes get made and I am all for pushing for change.

But, also as an educator I have to be 100% knowledgeable about what the standard of care is as well as the scope of practice.  There is no excuse for me not to be aware of the standards and what would be considered acceptable practice by a paramedic in America.  I will no longer discuss whether or not it is acceptable for a paramedic in America to withhold shocking vfib on a patient they are working and/or transporting to the hospital because I emphatically know that this is not an accepted practice in this country.

Again, I am all ears about learning new info from anyone including Vene about topics such as this and how we may be able to implement that new info into the system.


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## FlightMedicHunter (Feb 17, 2012)

systemet said:


> So you entered a discussion about the treatment of traumatic cardiac arrest half way through, and decided to redefine its parameters to restrict discussion to treatment in the US?



I mentioned America in that sentence simply to make it clear that I was only talking about the standards in America.  I do not know the standards in any other country and did not want anyone to think I was issuing a blanket statement that would encompass other countries.


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## RocketMedic (Feb 17, 2012)

Veneficus said:


> More likely an undiscovered wound.
> 
> (Do not take this as critisism of the surgeon or surgery, when there is a lot of blood everywhere, it is sometimes very difficult to see if you have actually stopped it all.)
> 
> There is also the possibility that a clot from a wound not bleeding during the surgey dislodged during post op resuscitation.



Figured that- surgery is hard, and there's a lot you can't see.


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## Veneficus (Feb 19, 2012)

*As this thread still is drawing a lot fo attention...*

I would like to restate my position so there is no mistake.

_"Personally, if I were to have to make a blanket decision, I would go with rapid transport without defib as there is evidence rapid transport improves outcome in serious trauma."_ 

Assuming that somebody actually hooked up a defibrillator, which I don't see why they would, if I believed the pt to be viable, I would not hook up a monitor and I would not be inclined to act upon its findings because of the futility of the efforts.

_"I would also withhold fluid if it was a penetrating mechanism." _

I stand by this statement as well, but I should clarify it a bit.

If I believed there was ongoing hemorrhage in a penetrating trauma which arrested, I would withhold fluid resuscitation as I know that class IV shock does not respond to fluid and there is the possibility that clot destruction from this therapy would worsen exanguinating hemorrhage that may be amiable to aggresive surgical therapy and resuscitation.

If the patient had not yet arrested, I would withold fluid in penetrating trauma if I suspected ongoing hemorrhage to probably a systolic of 80-50mmhg in order to possibly increase temporary DO2 in the hopes there was some blood left to circulate. (depending of course on patient presentation and care location) 

My original statement specifically states what my personal decision would be. Based on my knowledge, experience, and level of care.


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## jjesusfreak01 (Feb 19, 2012)

One of these days we are going to get some decent blood substitutes that you can give to allow continued perfusion without killing good clots.


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## Veneficus (Feb 20, 2012)

jjesusfreak01 said:


> One of these days we are going to get some decent blood substitutes that you can give to allow continued perfusion without killing good clots.



I think the British idea of making synthetic blood from stem cell lineage has potential, but still probably a good many years away.


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## RocketMedic (Feb 20, 2012)

What about an artificial clotting agent via infusion?


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## Veneficus (Feb 20, 2012)

Rocketmedic40 said:


> What about an artificial clotting agent via infusion?



I do not think it can be made practical.

In order to work, it would need to recognize what to clot and what not to and when. 

It would also have to not start a generalized clotting cascade and in the event of massive hemorrhage, would need it's own supply of clotting factor as to not use up all of the endogenous and still not have a clot.

There is also the issue of the profoundness of vasoconstrictive effect.

(I am sure somebody in the military is funding a considerable amount of money into this topic, but I am not convinced it is money well spent)

Even after the hemostatic return, it would not increase delivery of oxygen, so it would have to be combined with something that did.

In select patients, there seems to be use for factor VII, but the patients identified as benefitting seem to make up a small cohort.
(given it was devised to treat a small cohort, that shouldn't be surprising really)

I think this sort of thing is just too complex.


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## systemet (Feb 20, 2012)

Check this out (EMCrit transexamic acid):

*http://emcrit.org/podcasts/tranexamic-acid-trauma/*


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## Veneficus (Feb 20, 2012)

systemet said:


> Check this out (EMCrit transexamic acid):
> 
> *http://emcrit.org/podcasts/tranexamic-acid-trauma/*



I have read the link in the study provided for TXA.

I did not listen to the podcast.

I remain skeptical about the potential benefits of TXA.

In my ongoing bid to determine if trauma treatment can be used to help improve outcome in ruptured aneurysm, i reviewed multiple articles of case reports on the use of txa and aprotinin.

In all of the literature, from text books, to clinical trials, to case reports, it is relatively unanimous that these substances only show a benefit it the most complex or severe patient populations in both thoracic and abd aneurysm populations. 

These situations were often defined as significant comorbities or massive transfusion requirement.

Massive transfusion is also considered an independant risk factor and predictor of mortality in almost all of them.

Aprotinin particularly was shown to benefit in these patient populations. With less renal complications than txa.

Most of the supporting evidence for medical therapies to trauma like txa and factor VII come from military trials. 

Civillian centers often report benefit in a much smaller population.

Some of the things to consider:

The military sees a much higher incidence of severe penetrating trauma than the civillian world. Which leads to the conclusion that the population which may actually benefit from these medical interventions prior to surgery may be minimal.

There is also the issue that civillian trauma centers do not maintain the volume and therefore experience in this high level of penetrating trauma, which will degrade the effective identification and desire to use these agents. 

An Military/EMS style protocol is not useful in critical medicine, the patients are simply too variable, with chronic comorbidities, extremes of age, general health status, etc. 

Civilians are not rigorous preselected healthy people.

While the latest I have read shows trauma is on the increase, blunt trauma in the civillian world (particularly motor vehicle accidents) are still more common than penetrating.

These are not conducive to therapies for penetrating trauma. (if they were, survival rates and techniques would be the same)    

There are also limitations to the study in terms of criteria.

Civillian studies on the subject of TXA (and the like) do not find a link or prognostic ability between them and mortality or long term disability. Again they defer to the need of massive transfusion as the independant predictor.

We then must consider the aggression of surgical correction in the civillian world compared to the military. Damage control surgery, while obviously beneficial from all military accounts is not the common standard of care outside of the military.

In fact most surgeons I have spoken with on the matter indicate not only do they not use it, they do not consider it. Citing complications in infection, ICU and surgical resources, and even the inability to maintain patients in the resuscitation/follow-up surgery cycle.

When you compare the trauma system of the military to the civillian world, it is more than a reversal of numbers of levels of care.

In civillian centers there may be 1 trauma/critical care surgeon on duty in a given center. Not a team of them through escalating care. I doubt you will find level III centers who will do temporizing measures like vascular grafts and send these patients on to the level I. According to the ATLS guidlines, as soon as they recognize the patient is of significant severity, minimal intervention prior to transport is the norm and the goal.

Medical resuscitation without surgical intervention in a patient requiring surgery is just delaying the needed care.

A facility not providing temporizing surgery is basically just delaying the patient from somebody who will.

In modern surgery there is also a push to exclude surgical intervention except in cases where it will most likely be successful. That is a far cry from the military idea of "do what you can." or "anything is better than nothing." (there are many factors that create the civillian environment, the 2 biggest I see is the culture of surgeons and money.)

Those are not easily correctable.

So aside from the actual medical benefit/complications of these agents, the system culture and logistics also make these interventions unlikely to succeed.

Regretably, while many places have the trauma center designation, many simply take a conservative approach to trauma.

With the focus on minimally invasive surgery, the opportunity and therefore comfort and proficency with emergent open surgery is decreasing. As this continues, so will the selectivity of the surgeons.    

For these reasons, I do not see the current military advances in trauma transitioning to the civillian world.


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## systemet (Feb 21, 2012)

I figured when I posted it that you were probably already aware of the CRASH-2 study.  The podcast isn't bad, the physician hosting it chats with one of the study authors and they discuss the subgroup analysis a little bit.

Thanks for the interesting and educational post.

As an aside, I think one of the NHS ambulance trusts in the UK is going to be using transexamic acid in the field.  Hopefully they collect and report data.


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## Handsome Robb (Feb 21, 2012)

So this is anecdotal but I was talking with my partner about traumatic arrests today and he was saying that at his old agency a patient with penetrating trauma to the head, neck or chest that presented as pulseless and apneic wasn't even attached to a monitor to check the rhythm. These patients were pronounced on the spot unless there was an extenuating circumstance.


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## Veneficus (Feb 21, 2012)

NVRob said:


> So this is anecdotal but I was talking with my partner about traumatic arrests today and he was saying that at his old agency a patient with penetrating trauma to the head, neck or chest that presented as pulseless and apneic wasn't even attached to a monitor to check the rhythm. These patients were pronounced on the spot unless there was an extenuating circumstance.



In all of my travels, that is generally the accepted practice, with a bit of deviation here and there.


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## wilderness911 (Feb 8, 2016)

zmedic said:


> smooshed by bus and not much left



Heh. In these cases I like to apply a dimensional screening process to my patients. Begin trauma work up on all patients equal to 3D, call coroner for all patients presenting in 2D. Call bariatric ambulance and fire bubbas for all patients presenting in greater than 3 dimensions on arrival


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## wilderness911 (Feb 8, 2016)

Aw shoot guys, still learning the site layout. Got here from a search inquiry and didn't realize I was about to revive a 4 year old thread


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## DesertMedic66 (Feb 8, 2016)

wilderness911 said:


> Aw shoot guys, still learning the site layout. Got here from a search inquiry and didn't realize I was about to revive a 4 year old thread


You can say you shocked this thread back to life..


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## jwk (Feb 8, 2016)

I really like this dimensional screening concept!


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## Summit (Feb 8, 2016)

I wish Veneficus still posted here


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## ExpatMedic0 (Feb 9, 2016)

Summit said:


> I wish Veneficus still posted here


Ya whatever happened to him/her? I am going to Poland next month and could have tried to meet up!


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## Doczilla (Feb 11, 2016)

Ven was always there to drop some knowledge bombs, at the cost of some sarcasm; which is win/win in my book


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## NomadicMedic (Feb 12, 2016)

Doczilla said:


> Ven was always there to drop some knowledge bombs, at the cost of some sarcasm; which is win/win in my book



One of my favorite posters here.


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