# Shotgun - Pregnant female scenario



## rhan101277

You arrive on scene after police confirm scene is safe to find a 25 Y/O female with an obvious gunshot wound to the abdominal area.  You find out from family on scene that she is 37 weeks pregnant with a due date of 12/25/09.  Initial assessment reveals a responsive patient who is extremely concerned about here baby.  Her blood pressure is 115/90, HR 120, RR 30, skin cool, clammy.  Pt is responsive but is somewhat confused you get a GCS score of 14, (E4, V4, M6).  She is bleeding profusely from the gunshot wound.  You notice a baby hand moving from the hole created by the shotgun blast.

What do you do?


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## Two-Speed

rhan101277 said:


> You arrive on scene after police confirm scene is safe to find a 25 Y/O female with an obvious gunshot wound to the abdominal area.  You find out from family on scene that she is 37 weeks pregnant with a due date of 12/25/09.  Initial assessment reveals a responsive patient who is extremely concerned about here baby.  Her blood pressure is 115/90, HR 120, RR 30, skin cool, clammy.  Pt is responsive but is somewhat confused you get a GCS score of 14, (E4, V4, M6).  She is bleeding profusely from the gunshot wound.  You notice a baby hand moving from the hole created by the shotgun blast.
> 
> What do you do?



Abdo pad on the shotgun wound, 02, 12-Lead, quickclot (R), Load & Go, I wouldn't want to keep her on scene any longer than necessary.  Transport Code 4 CTAS 1 to the nearest hospital, MediVac if possible.

(Primary Care Paramedics, cannot intubate or do IV's)


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## DrParasite

panic???

load and go, make sure the trauma team knows what is going on, have an OB team waiting with the trauma team, drive really really fast to the hospital (medivac might be a good idea) make sure the trauma attending and the OB attending know what is going on, control all bleeding with trauma dressings, drive really really really fast to a trauma center.


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## Onceamedic

Make sure you get a couple of large bore IVs.  Your big problem is going to be hypovolemic shock. Might be a good idea to review your drip rates for dopamine.


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## Akulahawk

This is a situation where the EMT-B instinct of "Load & Go" should kick in. Attempt to control whatever bleeding you can, load in the ambulance, try to get a couple large bore IV's in place before the peripheral veins collapse due to lack of volume, apply much diesel to a Trauma Center, advise them to have an OB team ready, and why. If you can delegate some of these tasks to another provider, do it. 

You want the bare minimum scene time you can. This patient and her fetus need a surgeon. *Now*. This patient is already well into shock, probably starting to decompensate. Another round of vitals or two would likely confirm that. BP will be one of the last things to go. Kaisu makes a good point... hypovolemic shock is going to be the problem we see in the field. Dopamine? Well, that might work if the vasculature still has volume in it... don't pop clots. That would be bad...

Beyond that... hope the patient and her fetus survive.


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## Seaglass

As a basic with no medic... yeah, panic sounds pretty good... 

More seriously, this would be a flyout, in my area. Our local hospitals aren't bad, but this would be going to the trauma center two counties away. I'd call ALS as well in case anyone's close enough to show up before the helicopter arrives. In the meantime, try to control bleeding (if at all possible), pad over the abdominal area, administer O2, keep patient warm and calm, and elevate legs. 

If the weather sucks too bad for a helicopter, then load and go, call for ALS intercept, confirm which hospital can and should take her, and drive really fast.


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## Smash

*Scary job*

Nasty job.  Is it a real one or hypothetical?  Not that it matters for the discussion, so don't worry about answering that if yo don't want to .

I agree, load and go to appropriate facility.  O2 cos I can, dressing, large bore IV x however many you can.  Permissive hypotension is good, but we need to consider the foetus as well.  Of course the foetus will suffer first, so we may not be able to do much for it anyway.  Fly them out if distance/time/weather dictates.   Notify early.  As akulahawk has mentioned, this patient is shocked, which means the foetus is more shocked already, and they need surgery soon.

A couple of questions:

Kaisu: do you regularly use inotropes in hypovolemic shock?  As far as I am aware (which may indeed not be very far at all, it must be said) inotropes are not indicated for hypovolemic/hemorrhagic shock and may in fact cause worse outcomes from increased HR, decreased filling time, increased MvO2.

Two-speed:  I'm curious as to the usefulness of a 12 lead in this patient.  I suspect that having a 12 lead will not provide any useful information in this setting and may take time away from more important tasks (like changing underwear)


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## Onceamedic

Smash said:


> Kaisu: do you regularly use inotropes in hypovolemic shock?  As far as I am aware (which may indeed not be very far at all, it must be said) inotropes are not indicated for hypovolemic/hemorrhagic shock and may in fact cause worse outcomes from increased HR, decreased filling time, increased MvO2.



I wouldn't say regularly but it is done.  Usually, fluid and rapid diesel bolus preclude the need for dopamine - the only drug I carry that could possibly be of use.  I mention for this case primarily to stress the extreme bleeding a compromised uterus causes.  

Not that replacing a patient's blood volume with Kool-aid is all that good either.  In this situation, I would be happy if the systolic stays above 80.  Below that, and I would have to do something.


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## DV_EMT

I'd start by controlling bleeding... probably throw her in shock position (just in case). Then High flow O2 and transport code 3 (l&s).

As a medic... bolus fluids and a 12 lead if available...


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## reaper

I ask the same question that Smash asked. What is with the 12 leads?


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## DV_EMT

reaper said:


> I ask the same question that Smash asked. What is with the 12 leads?



Its just good to get V4-6.... helps with more interpretation. Its little bit limited with only a 3 and 5 lead. some medics im sure can extrapalate a little bit on the benefits.


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## boingo

DV_EMT said:


> I'd start by controlling bleeding... probably throw her in shock position (just in case). Then High flow O2 and transport code 3 (l&s).
> 
> As a medic... bolus fluids and a 12 lead if available...



Shock position?  Not sure what that is exactly.  What do you think about the L side, seeing she's 37wks?  Hand sticking through the hole means pretty damn big hole, can you elaborate??


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## Smash

DV_EMT said:


> Its just good to get V4-6.... helps with more interpretation. Its little bit limited with only a 3 and 5 lead. some medics im sure can extrapalate a little bit on the benefits.



I understand what a 12 lead is for, I'm just not clear how useful it is to obtain one in this kind if scenario. It is _possible_ that this patient is having some myocardial ischaemia. It is definite however that she and the fetus are bleeding to death. Even in the unlikely event that a 25 year old female is somehow having a STEMI (whilst at the same time having been shot with a shotgun in the stomach; how unlucky can you get?!) what are you going to do about it? Aspirin? Nitrates? 

In the event that there were changes, one would have to be suspicious that they would be related to global hypoperfusion secondary to loss of circulating volume as opposed to the rupture of a plaque. 

I just don't think that a 12 lead has any real use in such a scenario, and at worst may detract or take time away from more important tasks.


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## Lifeguards For Life

Smash said:


> I understand what a 12 lead is for, I'm just not clear how useful it is to obtain one in this kind if scenario. It is _possible_ that this patient is having some myocardial ischaemia. It is definite however that she and the fetus are bleeding to death. Even in the unlikely event that a 25 year old female is somehow having a STEMI (whilst at the same time having been shot with a shotgun in the stomach; how unlucky can you get?!) what are you going to do about it? Aspirin? Nitrates?
> 
> In the event that there were changes, one would have to be suspicious that they would be related to global hypoperfusion secondary to loss of circulating volume as opposed to the rupture of a plaque.
> 
> I just don't think that a 12 lead has any real use in such a scenario, and at worst may detract or take time away from more important tasks.


i agree and think that your time would be much better spent doing a host of other services to this patient than getting a EKG


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## Seaglass

boingo said:


> Shock position?  Not sure what that is exactly.



It's also known as Trendelenburg. Supine on back with legs elevated. 

Left side is usually recommended for pregnant women, but come to think of it, I don't know what to do with someone who's both heavily pregnant and in shock. Left side with legs elevated?


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## Lifeguards For Life

Seaglass said:


> It's also known as Trendelenburg. Supine on back with legs elevated.
> 
> Left side is usually recommended for pregnant women, but come to think of it, I don't know what to do with someone who's both heavily pregnant and in shock. Left side with legs elevated?



The Trendelenburg position is taught in schools and on the wards as an initial treatment for hypotension. Its use has been linked to adverse effects on pulmonary function and intracranial pressure. Recognizing that the quality of the research is poor, that failure to prove benefit does not prove absence of benefit, and that the definitive study examining the role of the Trendelenburg position has yet to be done, evidence to date does not support the use of this time-honoured technique in cases of clinical shock, and limited data suggest it may be harmful. Despite this, the ritual use of the Trendelenburg position by prehospital and hospital staff is difficult to reverse, qualifying this as one of the many literature resistant myths in medicin


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## Melclin

Lifeguards For Life said:


> The Trendelenburg position is taught in schools and on the wards as an initial treatment for hypotension. Its use has been linked to adverse effects on pulmonary function and intracranial pressure. Recognizing that the quality of the research is poor, that failure to prove benefit does not prove absence of benefit, and that the definitive study examining the role of the Trendelenburg position has yet to be done, evidence to date does not support the use of this time-honoured technique in cases of clinical shock, and limited data suggest it may be harmful. Despite this, the ritual use of the Trendelenburg position by prehospital and hospital staff is difficult to reverse, qualifying this as one of the many literature resistant myths in medicin



The amount of times I've been in a prac tute at uni or doing a scenario with St Johns with a haemorrhaging/hypovolaemic pt, and at the end had them say something like, "Yep, I'm happy, except you should have raised their legs".  50% of their blood volume is on the ground, and you want me to raise their legs like its a life or death intervention? Eugh.


Rhan, I might be wrong, but I feel like you're trying to suggest that their is some sort of dilemma between mother and baby (the hand sticking out through the hole...37 weeks...you're not hoping for one of us to say emergency caesar right?).

Other than the obvious and substantial emotional component to a case like this, I don't really see how the prehospital management is going to be any different than a normal abdominal GSW with the same vitals, with the obvious exception of the post handover consumption of a case a beer. 

+3 on the "whats with the 12 leads". What can you possibly hope to gain from using 2/4 hands for a few minutes to do a 12 lead. Whats ganna happen? "Hey Joe, our lady has 2mil of ST^ in V3-5, better activate the cath lab, her GSW/dying baby is just ganna have to wait". While we're at it ordering up wacky and useless tests, we should call Derick Sheppard for a neuro consult


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## Smash

Also agree with the stuff about trendlenburg position. It was used originally in abdominal surgery to allow better access to the pelvic region by having everything shifted up. For some reason this then became a standard for shocked patients. One can understand the idea behind doing it, however all it does for us is impair respirations and raise ICP whilst having no effect on hemodynamics at all. It's one of those deeply ingrained habits that is really hard to get rid of but has no data to support it's use. 
I'll post a study or two when I get a chance.

I trust we weren't heading for an emergency in-field c-section. These two are sick enough without ambos with scalpels fossicking around in there.


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## DV_EMT

for the trandeleberg.... I was taught that by elevating the legs... your using gravity to help move the blood that is stored in your thighs towards the organs in the abdominal cavity. since theres about 2-4 Liters of blood in the legs, and Basics can't start IV's to restore the bodily fluid, its meant to be used in the field while transporting on a BLS rig.

As for the 12 lead... I know that most rigs (if not all) use the 5 lead... so I'd go a 5 lead.


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## Lifeguards For Life

DV_EMT said:


> for the trandeleberg.... I was taught that by elevating the legs... your using gravity to help move the blood that is stored in your thighs towards the organs in the abdominal cavity. since theres about 2-4 Liters of blood in the legs, and Basics can't start IV's to restore the bodily fluid, its meant to be used in the field while transporting on a BLS rig.
> 
> As for the 12 lead... I know that most rigs (if not all) use the 5 lead... so I'd go a 5 lead.



here is a decent link
http://ajcc.aacnjournals.org/cgi/content/full/14/5/364


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## Seaglass

Lifeguards For Life said:


> here is a decent link
> http://ajcc.aacnjournals.org/cgi/content/full/14/5/364



Thanks! It continues to surprise me how little study there is about some commonly used interventions, and how they're taught as gospel truth anyways.


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## Foxbat

Two-Speed said:


> Abdo pad on the shotgun wound, 02, 12-Lead, quickclot (R), Load & Go, I wouldn't want to keep her on scene any longer than necessary.  Transport Code 4 CTAS 1 to the nearest hospital, MediVac if possible.



Correct me if I'm wrong, but I thought Quickclot shouldn't be used on abdominal wounds.


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## rhan101277

Real scenario, this came in via ambulance when I was doing clinicals last week.


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## Smash

DV_EMT said:


> for the trandeleberg.... I was taught that by elevating the legs... your using gravity to help move the blood that is stored in your thighs towards the organs in the abdominal cavity. since theres about 2-4 Liters of blood in the legs, and Basics can't start IV's to restore the bodily fluid, its meant to be used in the field while transporting on a BLS rig.
> 
> As for the 12 lead... I know that most rigs (if not all) use the 5 lead... so I'd go a 5 lead.



That is certainly the theory behind using such a position, however as with a lot of things that seem like a good idea at the time, it doesn't actually work, and may in fact be harmful in most circumstances.  The same is true for inotropes, crystalloids, colloids, MAST pants.... the list goes on.

Restoring bodily fluid in the setting of penetrating truncal trauma is also not a very good idea.  Intravenous crystalloids cause a number of problems that actually exacerbate this patients problems.

1)  It doesn't carry oxygen to cells, or waste away, so even though you may replace some volume, you don't replace the ability to provide for cellular function, and you dilute clotting factors.
2)  It increases hydrostatic pressure "popping the clot".  Clotting occurs more readily in a low pressure environment, allowing clots to form to slow or halt bleeding.  Increasing hydrostatic pressure can wash away clots that are forming, increasing bleeding coupled with diluted clotting factors.
3)  It makes people cold (unless you use a fluid warmer) and hypothermia is an independant predictor of mortality in trauma patients.
4)  It causes an inflammatory response, and the inflammatory response is the mother of all evil.

Patients with uncontrolled hemorrhage who recieve aggressive fluid resuscitation typically get coagulopathies (from both dilution of clotting factors and cold induced), abdominal compartment syndrome, renal failure, respiratory failure (ARDS or Da Nang lung) and generally do worse.

Of course allowing a ptient to exsanguinate is not a good show either, so there needs to be a point at which we start fluid resus and at whcih we end fluid resus.  This is hotly debated, and there is no clear answer, although some figures crop up repeatedly:  A BP of 80 systolic (although systolic BP is probably one of the least reliable indicators of shock), a palpable radial pulse or normal mentation, after which very cautious fluid aliquots should be given (Mattox recommends 25 ml boluses).

There is lots of research into permissive hypotension and it is considered the standard of care now.  Read Pepe, Revell, Porter, Greaves, Mattox and probably others for a whole lot better explanation than mine.

The point with the 12 lead, or the 5 lead or even the 3 lead is that it is not providing you with any useful information in this setting that can't be obtained by other means (like taking a pulse), whilst taking time to do; time that could be better spent on other things.  This patient doesn't have cardiac problems, and the only arrythmia that will occur will be bradycardia followed by asystole as she bleeds out while a 12 lead is done 

I would probably put a 3 lead monitor on if I had spare hands, as this allows a quick look at heart rate, which I can then correlate with other observations to get an idea of her hemodynamic status, and it doesn't take long to slap 3 leads on, especially as placement is not critical.


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## Melclin

As smash said, some form of permissive hypotension is the go these days, but its not actually backed up by a great deal of evidence. It makes good intuitive sense, and I think there are some animal models kicking around, but I'm told by someone who knows better than I (Professor & Head of Trauma at the Alfred Hospital), that that's about the extent of it, and he's not keen on it. He's one of the doctors on the state service's medical advisory committee, and consequently, we are not allowed to give any fluids to a person with penetrating truncal trauma.

Some interesting work coming out of the various battlefields of Iraq and Afghanistan in the past few years though. Not exactly high levels of evidence involved, but the experience of military trauma docs makes for interesting reading on the matter anyhow. Here's a couple of papers from my reference list that I found very interesting when I was writing about it for uni:

48.	Jansen JO, Thomas R, Loudon MA, et al. Damage control resuscitation for major trauma. BMJ. 2009;338:1778

49.	Holcomb JB, Jenkins D, Rhee P, Johannigman J,Mahoney P, Mehta S, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma 2007;62:307-10.

50.	Hodgetts TJ, Mahoney PF, Kirkman E. Damage control resuscitation. JR Army Med Corps 2007; 153: 299-300.


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## spinnakr

rhan101277 said:


> You notice a baby hand moving from the hole created by the shotgun blast.


Didn't this remind anyone else of the movie ALIEN?!  I've got a mental image that is absolutely comical (in a Monty Python sort of way).  I don't mean to make light of the scenario - this would be an unbelievably stressful one - but a little humor never hurts.

A thought:  Where was scene safety in all of this?  I don't want to devalue the patient, but with an obvious shotgun wound to a full-term pregnant woman is a pretty good indication that SOMETHING is going seriously wrong.



DV_EMT said:


> As for the 12 lead... I know that most rigs (if not all) use the 5 lead... so I'd go a 5 lead.


Like Smash said, I think you're missing the forest for the trees.  Knowing her rhythm isn't going to do you a whole lot of good when she is very clearly a top-priority patient for far more obvious reasons.  Don't even bother.



Smash said:


> I would probably put a 3 lead monitor on if I had spare hands, as this allows a quick look at heart rate, which I can then correlate with other observations to get an idea of her hemodynamic status, and it doesn't take long to slap 3 leads on, especially as placement is not critical.


Personally, with this patient, even running with an ALS crew I'd just do a pulseox.  If somebody found time for the leads in-transit then great, but it'll take less time to slap the doohickey on her finger, toe, or earlobe and run with it.  It'll also give you at least _some_ indication of her oxygenation.  Given the patient though, I would expect weak distal pulses - so I'd probably go for the earlobe with the pulseox.


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## R.O.P.

rhan101277 said:


> Real scenario, this came in via ambulance when I was doing clinicals last week.



Other than O2 and fluids, sounds like they needed a surgeon FAST!
Do you know what their outcome was?
What a nightmare call...


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## Lifeguards For Life

R.O.P. said:


> Other than O2 and fluids, sounds like they needed a surgeon FAST!
> Do you know what their outcome was?
> What a nightmare call...



she does not need fluids yet. Smash, gave some very good input on fluid res in trauma patients. This patient has an increased blood volume from simply being pregnant. Pregnant  patients also have a lower blood pressure than they normally would. 


i think this patient was 39 weeks pregnant? At full term many mothers have 40-50% more blood volume than their non pregnant counter parts. Cardiac output typically increases by as much as 12 percent during pregnancy! Fibrinolytic activity is depressed during pregnancy and labor, although the precise mechanism is unkown. The placenta may be partially responsible for this alteration in fibrinolytic status.Plasminogen levels increase concomitantly with fibrinogens levels, causing an equilibration of clotting and lysing activity.

Resuscitation of the more serious trauma patient must focus on the mother because the most common cause of fetal death is maternal shock or death. It is important to remember that the mother will maintain her vital signs at the expense of the fetus. Because plasma volume is increased 50% and the mother is able to shunt blood away from the uterus, maternal shock may not manifest itself until maternal blood loss exceeds 30%. During the initial ABC assessment, the fetus is addressed only during evaluation of circulation.
Fluid would raise her bp, causing her to bleed  more, at the same time dilluting her blood with a substance that has NO ABILITY TO TRANSPIRT OXYGEN.


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## Smash

Melclin said:


> As smash said, some form of permissive hypotension is the go these days, *but its not actually backed up by a great deal of evidence.* It makes good intuitive sense, and I think there are some animal models kicking around, but I'm told by someone who knows better than I (Professor & Head of Trauma at the Alfred Hospital), that that's about the extent of it, and he's not keen on it. He's one of the doctors on the state service's medical advisory committee, and consequently, we are not allowed to give any fluids to a person with penetrating truncal trauma.
> 
> Some interesting work coming out of the various battlefields of Iraq and Afghanistan in the past few years though. Not exactly high levels of evidence involved, but the experience of military trauma docs makes for interesting reading on the matter anyhow. Here's a couple of papers from my reference list that I found very interesting when I was writing about it for uni:
> 
> 48.	Jansen JO, Thomas R, Loudon MA, et al. Damage control resuscitation for major trauma. BMJ. 2009;338:1778
> 
> 49.	Holcomb JB, Jenkins D, Rhee P, Johannigman J,Mahoney P, Mehta S, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma 2007;62:307-10.
> 
> 50.	Hodgetts TJ, Mahoney PF, Kirkman E. Damage control resuscitation. JR Army Med Corps 2007; 153: 299-300.



I agree that many of the studies are not necessarily of high power, and many are (by necessity) in animal models however I think that "poor evidence" is a relative term in prehospital medicine when one considers the lack of evidence we have for much that we take as gospel truth.

Hyoptensive resuscitation is a concept that has been around since the first world war following the work of Cannon and later Wiggers.  It is obviously impossible to carry out a blinded RCT, however there is a significant weight of evidence behind it and it certainly is the standard of care now.  For a lecture I wrote back in 2004 I have over 90 individual references that deal with permissive hypotension.  There are quite clearly a significant number of new papers that deal with this and damage control surgery since then.  Now compare this with the number of papers that support the use of supplemental O2 in ACS patients who present without hypoxemia (or even better, CVA)

Kwan does a good review published in the Cochrane archives, however it is a few years out of date now.  If I wasn't so lazy I would see if it has been updated in the last 7 years.  But I am.

By the way, that is a nice non-sequiter there:  "our MD doesn't like it, consequently we do it.."


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## Melclin

I should have been more clear.

When I said permissive hypotension, I was referring to the idea of titrating fluids in small amounts to a target blood pressure, as opposed to what we do now, which is give none at all. 

I know that its an old idea (1) and the there is plenty of evidence for not giving any at all in the prehospital setting and it is plenty possible to do an RCT, its been done (2). 

What I was getting at is that there's no evidence to suggest that titrating small amounts of fluids is safer than a lot of fluids, nor if it provides better outcomes than no fluids at all.  A wealth of literature agrees than none is better than lots, but no one knows if some is better than none - however, the latter is fairly common practice.

1.	Cannon WB, Fraser J, Cowell EM. The preventive treatment of wound shock. JAMA. 1918;70:618-621

2.	Bickell WH, Wall MJ, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL. Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries. N Engl J Med. 1994;331(17):1105-1109


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## blindsideflank

so somebaody said theyd be happy with a bp at around 80.this will starve the fetus yes? as for positioning of the patient? dunno but i dont think its the deciding factor here. spinal?
anyone here worried about uterine contraction and does anyone have anything in their kit for this?
for bp/fluid admin, id assume your on the phone with the doc the whole way to the hospital and your under his licence doing things out of your scope, like drug admin for whatever reasons. when its prenatal/neonatal rules get skewed


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## spinnakr

blindsideflank said:


> as for positioning of the patient? dunno but i dont think its the deciding factor here.


Maybe not THE deciding factor, but it is definitely of great importance.  You could - especially if there's a long transport time - kill this patient (or her baby) with bad positioning.



blindsideflank said:


> spinal?


What's more imminently life threatening:  the fact that she is hemorrhaging from her uterus, or the possibility of low-level spinal damage?  One might give her some minor paralysis.  The other will kill her within a few hours.  I'm not saying it's an excuse not to backboard, but given the risk of her going into labor...  



blindsideflank said:


> anyone here worried about uterine contraction and does anyone have anything in their kit for this?


Anything to stop contractions?  Haha, in a squad?  Doubt it.  Positioning is about all you're going to get, and that won't stop contractions - it'll just keep the baby from coming.  This baby needs delivery in an OR.  Asap.



blindsideflank said:


> for bp/fluid admin, id assume your on the phone with the doc the whole way to the hospital and your under his licence doing things out of your scope, like drug admin for whatever reasons. when its prenatal/neonatal rules get skewed


When rules get skewed, responders get screwed.  Doesn't matter who's on the phone.  My former BLS instructor loved to tell us a story about two medics who were sued, found guilty, lost their certs, and were facing criminal charges because they did an emergency C-section on a deceased, full-term pregnant woman, via telephone with a surgeon.  It's outside their practice to pronounce someone dead, and you can't operate outside the scope of practice just because a doctor is telling you what to do on the phone - even if there's a baby involved.  This patient needs diesel.


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## Lifeguards For Life

spinnakr said:


> Anything to stop contractions?  Haha, in a squad?  Doubt it.  Positioning is about all you're going to get, and that won't stop contractions - it'll just keep the baby from coming.  This baby needs delivery in an OR.  Asap.



Fluid res itself will be tocolytic in this patient. administration of roughly 1L of fluid, intravenously, increases the intravascular fluid volume,which inhibits ADH secretion from the neurohypophysis. since oxytocin and ADh are secreted from the same area of the pituatary gland, inhibition of ADH secretion also inhibits oxytocin release, causing uterine contractions to stop.
(a poor choice for this particular patient)
Sedation of the patient, with narcs or barbituates allows the patient to rest. Often, after a period of "rest", contractions will stop on their own.

Generally, tocolysis in the field is limited to sedation, and hydration. though a last ditch effort, magnesium sulfate, or a beta agonist such as terbutaline or ritdrine may be administered to stop labor by inhibiting uterine smooth muscle contraction


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## Onceamedic

blindsideflank said:


> so somebaody said theyd be happy with a bp at around 80.this will starve the fetus yes?



Nothing kills a fetus as fast as it's mother bleeding out.....


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## emtzach03

80 would still give you palpaple radius pulses, yes, and if the fetus is at the core of the mother the fetus would be getting as much blood volume as the mothers vital organs. however it still comes down to blood volume not fluid volume, you can keep pressure up for some time but not actual blood amounts i dont believe civilian medics have anything that works like hextend


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## Manic_Wombat

spinnakr said:


> Where was scene safety in all of this?



That is what I thought of right off the bat.


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## redcrossemt

Two-Speed said:


> 12-Lead



Why??



Two-Speed said:


> quickclot (R)



You'd be using the powdered form, right? And pouring it on top of the baby's hand through the hole?


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## redcrossemt

spinnakr said:


> A thought:  Where was scene safety in all of this?



 First sentence:



rhan101277 said:


> You arrive on scene after police confirm scene is safe


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## Seaglass

spinnakr said:


> When rules get skewed, responders get screwed.  Doesn't matter who's on the phone.  My former BLS instructor loved to tell us a story about two medics who were sued, found guilty, lost their certs, and were facing criminal charges because they did an emergency C-section on a deceased, full-term pregnant woman, via telephone with a surgeon.  It's outside their practice to pronounce someone dead, and you can't operate outside the scope of practice just because a doctor is telling you what to do on the phone - even if there's a baby involved.  This patient needs diesel.



Seems like you'd be screwed either way--for not listening to medical control if you don't, and for operating outside your scope if you do. 

Anything happen to the surgeon?


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## R.O.P.

Lifeguards For Life said:


> Sedation of the patient, with narcs or barbituates allows the patient to rest.



Are you sure you'd want to administer opioids to this pt?  Couldn't that result in a decreased respiratory drive and some vasodilation, yielding possible lower o2 sat and bp?


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## Lifeguards For Life

R.O.P. said:


> Are you sure you'd want to administer opioids to this pt?  Couldn't that result in a decreased respiratory drive and some vasodilation, yielding possible lower o2 sat and bp?



I would not do any of those to this patient, but someone had asked about ways to stop contractions


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## Smash

emtzach03 said:


> 80 would still give you palpaple radius pulses, yes, and if the fetus is at the core of the mother the fetus would be getting as much blood volume as the mothers vital organs. however it still comes down to blood volume not fluid volume, you can keep pressure up for some time but not actual blood amounts i dont believe civilian medics have anything that works like hextend



Actually the fetus would be compromised at this level.  One of the first things that happens in the injured pregnant woman is that blood is shunted away from the fetus to keep the mother alive.  So pregnant women will actually maintain a better BP from having greater blood volume, but still be in a dangerously compromised state.

However if we bleed the mother out from using lots of fluids, it is a moot point as to whether the fetus will survive anyway.

Hetastarch is not used on any civilian rigs that I am aware of, and the problem is still that there is a lack of oxygen carrying ability.


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## spinnakr

redcrossemt said:


> First sentence:


Whoops.  There I go again, not reading carefully.



Seaglass said:


> Seems like you'd be screwed either way--for not listening to medical control if you don't, and for operating outside your scope if you do.
> 
> Anything happen to the surgeon?


In court, you'll be much better off it you refuse to do something outside your scope of practice.  At least that's what I've been told.

Don't know what (if anything) happened to the surgeon.

What it comes down to though is this:  if someone wants to sue, he/she will find something to sue over.  You have to make sure you're operating under your legal scope in order to be able to defend yourself.


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## blindsideflank

Smash said:


> Actually the fetus would be compromised at this level.  One of the first things that happens in the injured pregnant woman is that blood is shunted away from the fetus to keep the mother alive.  So pregnant women will actually maintain a better BP from having greater blood volume, but still be in a dangerously compromised state.
> .



this is what i figured. Man, i feel outclassed here on these boards, its refreshing. so if this fetus wanted to come out (birth canal not through the wound) would you encourage this or want to avoid it. anyone consider knee to chest positioning? i dont really see any indication for it unless you want to delay a birth but there is too much going on i suppose to justify this.

i think i common mistake with people is worrying about the fetus
ultimately the mother (in my opinion) is priority, not that you can do much for either.
after reading  smoeones reply, do you have protocol to bolus for a delivery if you had a limb presentation etc.?


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## Lifeguards For Life

emtzach03 said:


> 80 would still give you palpaple radius pulses, yes, and if the fetus is at the core of the mother the fetus would be getting as much blood volume as the mothers vital organs. however it still comes down to blood volume not fluid volume, you can keep pressure up for some time but not actual blood amounts i dont believe civilian medics have anything that works like hextend



Blood flow to the uterine arteries is normally maxillary vasodilated, so blood delivery to the uterus is maximal in the normal physiologic state. Maternal hypovolemia may result in vasoconstriction of the uterine vasculature. The third trimester fetus(as in this scenario) can adapt to a decrease in uterine blood flow and oxygen delivery by diverting blood distribution to the heart, brain, and adrenal glands. Because fetal hemoglobin has a greater affinity for oxygen than does adult hemoglobin, fetal oxygen consumption does not decrease until the delivery of oxygen is reduced by 50%. Thus, maternal shock may have a significant impact on the developing embryo/fetus.


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## truetiger

I'm not so sure about a 12 lead either, but I would hook her up to a 3 lead with the combo pads just incase she de-compensates.


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## Akulahawk

Smash said:


> Actually the fetus would be compromised at this level.  One of the first things that happens in the injured pregnant woman is that blood is shunted away from the fetus to keep the mother alive.  So pregnant women will actually maintain a better BP from having greater blood volume, but still be in a dangerously compromised state.
> 
> However if we bleed the mother out from using lots of fluids, it is a moot point as to whether the fetus will survive anyway.
> 
> *Hetastarch is not used on any civilian rigs that I am aware of, and the problem is still that there is a lack of oxygen carrying ability.*


The other problem is that admin of hetastarch will increase blood volume, primarily by drawing fluid from other compartments, thus increasing the BP, and the volume expansion is harder to control in the field than it is with a crystalloid. 

Either way, if you "pop the clot", the patient begins hemorrhaging uncontrollably again... and all the stuff used in making the first clots haven't been replaced yet, so... you could potentially have a patient who is bleeding uncontrollably who also has a limited ability to create the clots needed. 

If anything can be considered "good news", it's that thanks to our overseas military operations, we're learning LOTS about trauma resuscitation and damage control surgery. While the "Golden Hour" itself is a myth, the idea behind it is good. That is... get thee to a trauma Doc fast, for time wasted is time taken from getting definitive damage control. Once the trauma victim has taken the damage, their golden hour might be 20 min or 4 hours long... 

Now as to the scope of practice thing... you really would be far better off sticking to refusing to perform a procedure that's outside your scope of practice than doing (in the other case mentioned here) an emergency C-section. I do not believe the surgeon in that case received much in the way of disciplinary actions... Now if I were to exceed the normal scope of practice, and do something that is accepted elsewhere AND I've been trained to do that... I'd have a better chance of retaining my license. However, once you go outside your authorized scope of practice, you start crawling out further and further on that limb where your cert/license becomes more and more in jeopardy and there will be fewer and fewer people able to defend/back your decision to do so. Eventually... it'll be just YOU hanging in the breeze...


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## Smash

Akulahawk said:


> The other problem is that admin of hetastarch will increase blood volume, primarily by drawing fluid from other compartments, thus increasing the BP, and the volume expansion is harder to control in the field than it is with a crystalloid.
> 
> Either way, if you "pop the clot", the patient begins hemorrhaging uncontrollably again... and all the stuff used in making the first clots haven't been replaced yet, so... you could potentially have a patient who is bleeding uncontrollably who also has a limited ability to create the clots needed.
> 
> If anything can be considered "good news", it's that thanks to our overseas military operations, we're learning LOTS about trauma resuscitation and damage control surgery. While the "Golden Hour" itself is a myth, the idea behind it is good. That is... get thee to a trauma Doc fast, for time wasted is time taken from getting definitive damage control. Once the trauma victim has taken the damage, their golden hour might be 20 min or 4 hours long...



We don't even teach the "Golden Hour" anymore except as part of the discussion on the history of trauma care and trauma systems. 

We do teach our students to be conscious of time to definitive care and to consider all their options. In some settings, such as isolated TBI for example you will do the patient no favours by loading and going instead of taking the time to manage them appropriately. In other cases (such as this one) PUHA is absolutely appropriate. 

You are right of course about hetastarchs other problems. Until a genuine blood replacement comes along it appears we will be continuing to fight a losing battle.


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## gamma6

rhan101277 said:


> You arrive on scene after police confirm scene is safe to find a 25 Y/O female with an obvious gunshot wound to the abdominal area.  You find out from family on scene that she is 37 weeks pregnant with a due date of 12/25/09.  Initial assessment reveals a responsive patient who is extremely concerned about here baby.  Her blood pressure is 115/90, HR 120, RR 30, skin cool, clammy.  Pt is responsive but is somewhat confused you get a GCS score of 14, (E4, V4, M6).  She is bleeding profusely from the gunshot wound.  You notice a baby hand moving from the hole created by the shotgun blast.
> 
> What do you do?



damn!!!! now that would be a notch up on my weird shatometer.


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## Akulahawk

Smash said:


> We don't even teach the "Golden Hour" anymore except as part of the discussion on the history of trauma care and trauma systems.
> 
> We do teach our students to be conscious of time to definitive care and to consider all their options. In some settings, such as isolated TBI for example you will do the patient no favours by loading and going instead of taking the time to manage them appropriately. In other cases (such as this one) PUHA is absolutely appropriate.
> 
> You are right of course about hetastarchs other problems. Until a genuine blood replacement comes along it appears we will be continuing to fight a losing battle.


When I started on my path towards being a Paramedic, the Golden Hour was still being taught. We were taught to regard it as each patient has their own Golden Hour and it's unique to them and their situation. We learned to consider time to definitive care... by ground OR by air. That lesson also applies to BLS vs ALS transports as well. If your patient needs ALS care and all you have is a BLS transport unit and that BLS unit can get to the hospital faster than an ALS unit can get to the patient... it's appropriate for the BLS crew to transport. Ideally, this scenario shouldn't happen, but in places that have either tiered response systems or the system becomes so overloaded that all ALS units locally are unavailable...


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## kittaypie

i saw a scenario like this on "she survived that- pregnant?" on discovery health last night. the wound was leaking amniotic fluid and she started having contractions. ended up in surgery and both she and the baby were fine.


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## Jeffrey_169

I agree with a lot of the others; I would give lots of O's, control bleeding, and call for immediate air transport and ALS. I would be finding the long skinny pedal to the right on the floor here as well. Surgery will be the definitive care, IV fluids for the patient would be a must, and again...*HIGH FLOW DEISEL!!!* Reassess vitals, treat for shock, and maintaining of the airway is really all that can be done here. Unfortunately there is not much a basic can do, and outside of a few drugs and dual large bore IVs there isn't must ALS can do either (Intubation can be considered based on your protocol). As stated, surgery and the Lord above is the definitive care for the patients, and the faster the better.

Remember, by treating Mom you are treating Baby.


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## jrm818

Lifeguards For Life said:


> Fluid res itself will be tocolytic in this patient. administration of roughly 1L of fluid, intravenously, increases the intravascular fluid volume,which inhibits ADH secretion from the neurohypophysis. since oxytocin and ADh are secreted from the same area of the pituatary gland, inhibition of ADH secretion also inhibits oxytocin release, causing uterine contractions to stop.
> (a poor choice for this particular patient)
> Sedation of the patient, with narcs or barbituates allows the patient to rest. Often, after a period of "rest", contractions will stop on their own.
> 
> Generally, tocolysis in the field is limited to sedation, and hydration. though a last ditch effort, magnesium sulfate, or a beta agonist such as terbutaline or ritdrine may be administered to stop labor by inhibiting uterine smooth muscle contraction



I just stumbled over this post, so I know this is both late and in general not a major consideration for the treatment of this patient, but I though anyone who though deeply enough about that effect of hydration on OT might find this interesting:

I'm very curious if what you say about the inhibition of oxytocin is correct.  I'd caution you about generalizing about the combined control of Vasopressin (VP) and Oxytocin (OT).  Though they are both released from the posterior pituitary, the control of the two is not _necissarily_ intertwined.  I don't think anyone knows specifically how control works in the humans.

Most of the research relating to the control of VP/OT release under conditions of hypovolemia was done in a rat model in the context of studies focusing on plasma osmolality as well.  A few of these were also done in dogs.  

In the setting of osmolality, it was found that in a rat an increase in plasma osmolality (pOsm) increased secretion of VP into the bloodstream accompanied by OT.  However, in dogs, it was found that ONLY VP was secreted....OT was unaffected by an increase in pOsm.  Thus VP and OT are are not necessarily controlled by the same mechanisms in all circumstances, and there are differences across species, even among mammals.

Unfortunately, in the realm of hypoVOLEMIA, I am not aware of any dog research that addresses the issue of differential control of VP and OT.  It is true that in a rat hypovolemia leads to VP and OT secretion (just as they are in response to increased pOsm), and that removal of hypovolemia will remove the stimulus for VP and OT secretion.  However, I would not be surprised to find that in a dog only VP is secreted, just as in increased pOsm.  A quick search turned up no information, and I believe I have asked this question before and that there was no data on the issue.  If there is no dog data, I would be shocked to find there is any human data, and I have been unable to find any.

Similarly, I am not aware of any data indicating that an increase in vascular volume would acutally _inhibit_ VP or OT secretion.  Repair of hypovolemia will indeed remove the stimulus for their secretion, but in the context of a pregnancy, I am willing to bet money that it is simply not known how an increase in vascular volume would effect baseline OT secretion, when the baseline OT level is already influenced by pregnancy.  My guess is that by repairing the loss in volume from the GSW (and I doubt 1L of fluid is enough to even reach normal volume, and only transiently if at all), you would simply return to the normal baseline OT level, rather than actually inhibiting OT.



Overall, unless there is new data that I haven't seen, it's unlikely that we know for sure how the loss of blood, or subsequent infusion of NS would affect the OT levels in this patient.  I'd be surprised to learn that there is any new information, as the studies relating to volume and OT are all pretty old.  If there is new information, I'd love to see it (serious, not sarcastic).  

Your suggestion does strike me as incredibly interesting for another reason: it raises the question of the effect of hypovolemia on OT levels in a pregnant patient, and the possibility that hypovolemia may encourage parturition.  I have no idea what blood level of OT we are talking about here, or even if hypovolemia does effect OT, as discussed, but my curiosity is certianly up.  Very quick search turned up nothing of interest, unfortunately.  Again, I'd love to see any relevant data.

EDIT: 
I did a bad quick search....just found a few relevant articles...only had time to scan, but it appears as if hydration has little effect on preventing pre-term labor....which goes along with most of what I've said.  None look like they directly address the OT mechanism.


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## Smash

Melclin said:


> I should have been more clear.
> 
> When I said permissive hypotension, I was referring to the idea of titrating fluids in small amounts to a target blood pressure, as opposed to what we do now, which is give none at all.
> 
> I know that its an old idea (1) and the there is plenty of evidence for not giving any at all in the prehospital setting and it is plenty possible to do an RCT, its been done (2).
> 
> What I was getting at is that there's no evidence to suggest that titrating small amounts of fluids is safer than a lot of fluids, nor if it provides better outcomes than no fluids at all.  A wealth of literature agrees than none is better than lots, but no one knows if some is better than none - however, the latter is fairly common practice.
> 
> 1.	Cannon WB, Fraser J, Cowell EM. The preventive treatment of wound shock. JAMA. 1918;70:618-621
> 
> 2.	Bickell WH, Wall MJ, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL. Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries. N Engl J Med. 1994;331(17):1105-1109



None at all?  Surely at some point one has to attempt to maintain some perfusion, even if it is with substandard fluids. Is not the alternative allowing arrest to occur?

RCTs have been done, (by others as well as Mattox and his mates too  ) but I was referring to the "gold standard" of trials, the double blinded trial, which would obviously be impossible to carry out when the two arms are -giving something- and -not giving something-


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## Smash

Jeffrey_169 said:


> Surgery will be the definitive care, IV fluids for the patient would be a must,



Fluids a must?  Really? 



> (Intubation can be considered based on your protocol).



It certainly could be considered.  Personally I would consider it to be a very bad idea.  The patient has a GCS of 14: any attempt at intubation would therefore have to be made using sedation and probably paralysis, or by allowing the patient to become obtunded to the point of loss of airway reflexes through hypovolemia alone.  This is not going to be conducive to the survival of this patient who is in a haemodynamically tenuous position in the first place.



> As stated, surgery and the Lord above is the definitive care for the patients, and the faster the better.



Surgery: certainly.  The rest... not so sure.  It does however, beg the question of why a benevolent, omnipotent god would subject an unborn child and young mother the terror and suffering associated with such an event and injury, not to mention the high risk of painful death from the injury, subsequent bleeding and inevitable infection; nor the pain and humiliation of debridements, colostomy, loss of function, life long scarring both physical and mental; not to mention the psychological trauma to the family members, EMTs, medical staff and LEOs who attend the scene and patient; not to mention the enormous cost to society both in the treatment and subsequent rehabilitation of these patients and in the investigation, prosecution and imprisonment of the perpertrator; not to mention arguably the loss of a second life as someone is incarcerated for such a heinous crime instead of having had the opportunity to become a loving husband and father through the grace of said loving, all-powerful diety.  

That is assuming of course, that the Lord to whom you refer is indeed the normally imagined beneficent, omipotent, omniscient (ignoring the inherent impossibility of holding those two characteristics at once) Lord that all current monotheistic religions believe in, and not, say Ba‘al Zebûb.

But that is probably a topic for a different thread.


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## Melclin

Smash said:


> None at all?  Surely at some point one has to attempt to maintain some perfusion, even if it is with substandard fluids. Is not the alternative allowing arrest to occur?
> 
> *No, with a but. Penetrating trauma = arrest haemorrhage + transport at .5 past light speed. Unless a carotid pulse is lost, in which case a PEA algorithm begins and they get their fluids. Which is what I argued against in an essay I wrote for uni - it didn't seem to make sense that u'd sit their and watch a person circle the drain, giving no fluids knowing in a few minutes you'd be hooking a fire hose up to their IV. But I have since been told about a few qualifying factors by one of the MDs involved in the sevice's guidelines, which I think I've mentioned before. *
> 
> RCTs have been done, (by others as well as Mattox and his mates too  ) but I was referring to the "gold standard" of trials, the double blinded trial, which would obviously be impossible to carry out when the two arms are -giving something- and -not giving something-
> *
> Hehe yes it would be difficult to double blind a study like that. Although in that sort of acute setting where the clinicians don't necessarily have a lot of contact with the patient and in any case its not for very long (unlike say, an oncologist and a new cancer drug), you don't get so much of that confounding experimenter variable, so I'm not sure that matters too much.*




10 characters


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## Melclin

Jeffrey_169 said:


> I agree with a lot of the others; I would give lots of O's, control bleeding, and call for immediate air transport and ALS. I would be finding the long skinny pedal to the right on the floor here as well. Surgery will be the definitive care, IV fluids for the patient would be a must, and again...*HIGH FLOW DEISEL!!!* Reassess vitals, treat for shock, and maintaining of the airway is really all that can be done here. Unfortunately there is not much a basic can do, and outside of a few drugs and dual large bore IVs there isn't must ALS can do either (Intubation can be considered based on your protocol). As stated, surgery and the Lord above is the definitive care for the patients, and the faster the better.
> 
> Remember, by treating Mom you are treating Baby.



D**king around with RSI is quite possibly the worst intervention I could imagine in this situation.

You know, its not a new topic, and certainly not something we should be discussing here I suppose, but it continues to confuse me as to why people say things like the lord is her definitive care after having let it happen in the first place, and then after the hard work of the trauma team, place the save in the "god" column. I wonder if people would feel similarly fond of a trauma surgeon who went out and shot a pregnant lady only to save her a little while later on the operating table...probably not going have everyone coo and say things like oh Dr. John works in mysterious ways. Pfft.


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## Jeffrey_169

I couldn't agree more about the RSI. I am not a big fan of it; it a patient is that bad off there other considerations and other ways to secure the airway without the time consumptoin involved, but there are places where protocol does not agree with me. 

As too the reference concerning my religion, I did not intend to offend you however; i have seen more then one instance where I am certain there was a divine hand, and in my opinion, there can be no other explanation.


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## Veneficus

I was doing my best to stay away from public posting but I just couldn’t help myself after reading this, so please indulge my opinion. 

Having been part in the care of many shotgun wounds, this was done at a range close enough to make a hole you can see a fetal hand moving in. That indicated either a single projectile, a few very large ones, or for the firearm folks, something larger than #7 shot at less than 10 feet.

Without an exist this demonstrates there was considerable force transfer, and the cavitation injuries will likely affect the fetus if there wasn’t a direct penetration to it from the start.

A heavy bleed would make me strongly suspicious of disruption of the placenta at the chorion. Which means the mother basically has multiple arterial bleeds that I conclude would require considerable electrocautery to stop. That may not be a viable intervention do to volume/time constraints. Furthermore, there is likely bleeding from arteries supplying the abdomen and bladder, adding more difficulty to bleeding control.

I would bet the farm the first intervention in the trauma bay will be a crash c section. This baby is well into term. I cannot see a reasonable way to assess it for injury while trying to control uterine hemorrhage. If the baby does have an open or closed bleed, it will act like an extra body cavity the mother is bleeding into. If by some possibility you could stop the bleeding with intervention short of radical hysterectomy your skill as a surgeon would be legendary.

The logic of save the mother/save the baby, I would not apply to this case. 
***At no point am I suggesting any “heroic” measures outside of your scope of practice or protocol.*** 

But the knowledge of what the likely course of this mysterious “surgery” that keeps being mentioned is very important.  The purpose of damage control surgery is just that. To stop things from getting worse, not to make people the way they were.

  If this baby starts to come out, the faster the better. Then you could treat it as a second patient. Especially since the open wound may have stimulated breathing in it and while in a bleeding uterus its airway is definitely not controlled, much less protected. It would also make controlling the mother’s bleeding easier.

If she is GCS 14, maybe some o2 and get ready to bag or tube as required. At this point there is an airway and breathing, try to slow the bleeding.  I would give no fluids!!!  IV starts if possible without delay. The placental circulation works on pressure, increasing the arterial pressure proximal to the placenta will make it bleed faster. Unless you are autotransfusing in the field or delivering massive blood infusion, not a good idea.

I would suggest calling the hospital and asking for permission to pack the crap out of the abd. With everything I could stuff in there and try to locate and protect the potential fetal airway if possible. If this permission was denied, I’d do my best to control bleeding putting pads over the abd. 
O2, is not going to make a difference here, enzyme kinetics dictates the available heme is already saturated and giving oxygen to tissues it is reaching. Simply blood is not returning to the pulmonary circuit for gas exchange. 

Try to keep calm, driving fast or careless puts more people at risk and could kill somebody else. Not everyone is savable, as though it sucks, babies die. There is no reason to kill anyone else trying to be heroic. Pregnant women are the most abused cohort worldwide. It seems unlikely it will be the only time in your career you encounter stuff like this. Staying calm, acting safely, thinking logically, not emotionally, is the best thing you can do. 

PS. Don’t forget to check for signs of a pneumo because of possible shearing of the diaphragm from the bottom and/or the pressure wave of the blast shearing the pleura. 

In summary: maintain the airway that you have now, assist with BVM if need be, start IVs w/o fluid if you have time, attempt to control bleeding, deliver fetus if labor occurs, in this specific case, I would consider the baby a second patient. By remaining calm, the “save” you make might be yourself.
Sorry for the length. Quit even considering things like "driving fast" "diesel bolus" and anything else that increases the risk to providers.


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## Sasha

Welcome back Vene! A+ post.


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## JeffDHMC

truetiger said:


> I'm not so sure about a 12 lead either, but I would hook her up to a 3 lead with the combo pads just incase she de-compensates.



Not going to help lad. Needs a surgeon.


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## jrbigelow

Kaisu said:


> Make sure you get a couple of large bore IVs.  Your big problem is going to be hypovolemic shock. Might be a good idea to review your drip rates for dopamine.



Please tell me you are joking about the dopamine for hemoragic shock? Correct me if I'm wrong, and well, I know I'm not, but you don't give dopamine for hemoragic shock. You might want to recheck your medication contraindications, not to mention common sense.


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## kittaypie

JeffDHMC said:


> Not going to help lad. Needs a surgeon.



yes she needs a surgeon but what are you going to do if she codes on the gurney with no leads or pads on? scramble to get everything ready instead of preparing for it?


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## Jeffrey_169

I am more experienced as a Basic then a Medic (as I have only been a medic a few months), but why would you defib. a trauma pt? The H's and T's are your issue, and until they are properly addressed defibrillating will only damage the heart further, right?


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## kittaypie

Jeffrey_169 said:


> I am more experienced as a Basic then a Medic (as I have only been a medic a few months), but why would you defib. a trauma pt? The H's and T's are your issue, and until they are properly addressed defibrillating will only damage the heart further, right?



if a trauma patient is bad enough to be in cardiac arrest, the last thing I'm going to worry about is a little electrical damage to the heart. basically the only thing we can do for this patient is aggressive fluid resuscitation and proper oxygenation. if, despite all this, she arrests and goes into vfib/vtach,
I wouldn't skip a beat (no pun intended) in defib-ing. at that point, it's their only chance of survival.


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## Jeffrey_169

I see your point. We're taught a little bit differently. In the trauma situation we were taught to treat the cause because defib. won't help until you treat the underlying cause(s). I think its a matter of protocol and state requirments. They taught we could apply it if we had time, but not to make it a prioty. Another reason could be becasue we have paddles here, and we were taught the "quick look method" where the patches are not necessary; we can use the paddles to get a picture of the rhythm. 
Regardless, I do see your point. "Treat the pt. not the text book"


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## kittaypie

I'm confused about your treatment. if you saw a shockable rhythm on the monitor would you just continue with fluids? I see your point in treating the underlying cause, but if the patient is not perfusing wouldn't you rather shock and possibly get a rhythm back (thus aiding perfusion) or just leave them in the rhythm and continue other treatments?


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## Lifeguards For Life

jrbigelow said:


> Please tell me you are joking about the dopamine for hemoragic shock? Correct me if I'm wrong, and well, I know I'm not, but you don't give dopamine for hemoragic shock. You might want to recheck your medication contraindications, not to mention common sense.



Dopamine is indicated in situations where we need to increase end-organ perfusion in patients in cardiogenic shock, or in hemodynamicaly significant hypotension. A _relative contraindication_ is hypovolemia in cases where complete fluid resuscitation has not been attempted.

Dopamine is a dose dependant drug, meaning there is a different mechanism of action at different dosages. At low dosages  (1 to 5mcg/kg/minute), dopamine directly stimulates dopaminergic receptors on arteries in the kidneys, abdomen, heart, and brain and causes vasodilatation. At these doses, urine output may increase, but blood pressure and heart rate are usually not affected.

Correct me if I'm wrong, and well, I know I'm not, but Dopamine in low dosages would be a_"very bad thing"_



> The leading cause of death with regard to civilian and military traumas is hemorrhagic shock.1 Since hemorrhagic shock has a high mortality rate, research is crucial in finding the most effective treatment. The article provides a review of the 4 types of shock, the 4 classes of hemorrhagic shock, and the latest research on resuscitative fluid. The 4 types of shock are categorized into distributive, obstructive, cardiogenic, and hemorrhagic shock. Hemorrhagic shock has been categorized into 4 classes, and based on these classes, appropriate treatment can be planned. Crystalloids, colloids, *dopamine*, and blood products are all considered resuscitative fluid treatment options. Each individual case requires various resuscitative actions with different fluids. Healthcare professionals who are knowledgeable of the information in this review would be better prepared for patients who are admitted with hemorrhagic shock, thus providing optimal care.




Correct me if I'm wrong, and well, I know I'm not, but at higher dosages (greater than 10 mcg/kg/min), Dopamine exerts effects primarily alpha-receptors, and extensive vasoconstriction causes blood pressure to increase.

http://www.ncbi.nlm.nih.gov/pubmed/8124958
http://www.abbott.com.pk/pdf/DOPAMINEPI.PDF
http://www.nursingcenter.com/prodev/ce_article.asp?tid=774877
http://www.koreamed.org/SearchBasic.php?DT=1&RID=174302

While I would not be pushing Dobutamine at the point in time described by the original poster, you may wish to reconsider your statements regarding the use of Dobutamine and hemorrhagic shock

"You might want to recheck your medication contraindications, not to mention common sense."


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## Jeffrey_169

In this case I would treat for shock, high flow O2, and bleeding control. I would most likely apply the three lead so I could maintain a visual on what the heart is doing, but the shock would be my main concern. I do not want her gong into shock. My job here is to prevent the patient from going into V-Tac/ V-fib. In this scenario the patient is slightly hypotensive and presents with a severe bleed, so these are my first concerns. 

IN this scenerio she is conscious, has a pulse, is slightly hypotensive, RR are rapid, adn obviously has a pulse. My priority is to prevent her from getting worse, going into shock, and disrhythmias. 

Again I am saying you are wrong, and I am not saying I completely disagree with you. I just think there are drugs which can do more, and taking time to set up a 12 lead would not be high on my list in this case. I could be wrong, as stated above, and the truth is you probably have more experience then I as a Paramedic, but this is simply my opinion.


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## Lifeguards For Life

Jeffrey_169 said:


> In this case I would treat for shock, high flow O2, and bleeding control. I would most likely apply the three lead so I could maintain a visual on what the heart is doing, but the shock would be my main concern. I do not want her gong into shock. My job here is to prevent the patient from going into V-Tac/ V-fib. In this scenario the patient is slightly hypotensive and presents with a severe bleed, so these are my first concerns.
> 
> IN this scenerio she is conscious, has a pulse, is slightly hypotensive, RR are rapid, adn obviously has a pulse. My priority is to prevent her from getting worse, going into shock, and disrhythmias.
> 
> Again I am saying you are wrong, and I am not saying I completely disagree with you. I just think there are drugs which can do more, and taking time to set up a 12 lead would not be high on my list in this case. I could be wrong, as stated above, and the truth is you probably have more experience then I as a Paramedic, but this is simply my opinion.



I am not in disagreeing with you. As stated, regarding this patinets vitals and mechanism of injury, my treatment plan would mainly be supportive, while anticipating how this patient will be presenting in the next few seconds. At the point in time described by the OP I would not be pushing Dopamine, I only disagree with the jbigelows incorrect blanket statement and insulting demeanor.

It has just now came to my attention that this post was probably not directed toward me, but Kittaypie......

oh well


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## redcrossemt

Jeffrey_169 said:


> I see your point. We're taught a little bit differently. In the trauma situation we were taught to treat the cause because defib. won't help until you treat the underlying cause(s). I think its a matter of protocol and state requirments. They taught we could apply it if we had time, but not to make it a prioty. Another reason could be becasue we have paddles here, and we were taught the "quick look method" where the patches are not necessary; we can use the paddles to get a picture of the rhythm.
> Regardless, I do see your point. "Treat the pt. not the text book"



Applying defib patches isn't a bad idea, but I'd probably be so busy with other stuff that I probably and unfortunately  wouldn't get to them until the patient coded.

Defibrillation in traumatic arrests... interesting stuff. I guess I would attempt defibrillation while continuing aggressive fluid management. Probably won't do much good unless you can fix the H's and T's, but at the same time, fluid resuscitation is not going to magically convert v-fib to a perfusing rhythm.

Research shows patches have significantly faster times to shock delivery, and they free up your hands... Many services and hospitals no longer have external paddles, which is a good thing.

12-lead is useless here. No one's advocating that.


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## Smash

*I'm confused.*

Can I get a quick straw poll here:  How many people actually advocate cyclic crystalloid resuscitation (aggressive fluid administration) for an uncontrolled, penetrating truncal trauma?  Hands up high so I can count them!

Ok, now who advocates the use of either "renal dose" dopamine or pressors in said uncontrolled penetrating truncal trauma?  Hands up!  Higher, don't be scared!



Let me tally the votes and I'll get back to you with your marks.


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## Veneficus

Smash said:


> Ok, now who advocates the use of either "renal dose" dopamine or pressors in said uncontrolled penetrating truncal trauma?  Hands up!  Higher, don't be scared!.




I advocate unequivically *not* to put crystalloid in *any* uncontrolled bleeding.

please see my earlier comments.

it is the *truncal trauma* that I would say rules out the dopamine as it will actually dilate central artioles through D1 and D2 receptors. That would likely increase the rate of bleed as well as "tank" expansion.

My adding caveats probably doesnt help the pole.


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## Smash

On the contrary, it shows a good appreciation of the physiology, pathophysiology and aims of treatment that we are after.

Ok, I'll just come out and say it.  In the setting of uncontrolled hemorrhage in the prehospital setting there is absolutely no role for dopamine, or any other inotropes.  There is a role for such agents after the damage control surgery has been carried out to maintain perfusion.  You need to plug the hole first though.

There are some major issues with using either "renal dose" dopamine or higher doses:

"Renal dose" dopamine (as venficus pointed out) dilates your afferent renal arterioles.  This is then thought to improve renal blood flow, which we want to maintain - if your kidneys die, you die.  However, for this to be effective, you need something to flow through them in the first place.  Which the hemorrhaging shocked patient doesn't have.  All that is going to happen is that you are going to increase the intravascular volume that needs to be filled with the precious little red stuff that remains.  Furthermore, whilst studies have shown that low does dopamine improves O2 tensions in the kidneys and liver, it decreases flow to the gut.  This causes all sorts of ongoing problems assuming that the patient survives:  the gut is very, very important, far more so than we usually give it credit for being. 

Ultimately, despite many studies into renal dosing of dopamine in many critically ill patients of varying etiologies, there is extremely scant evidence that there is any increase in survival despite the improvement in physiological parameters.


There is also no role for higher doses of dopamine or any other vasoactive drugs in the setting of uncontrolled hemrrhage.  These patients are already maximally vasoconstricted: no further benefit can be gained in attempting to vasoconstrict further, and all of these drugs (dopamine, dobutamine, epi, nor-epi) cause profound myocardial hypoxia and dysfunction and are extremely arrythmogenic in this setting.

Aggressive fluid resuscitation is also an absolute no-no in uncontrolled hemorrhage.  Whilst the finer points of how/when/where/why and how much are still being worked on, I know of no reputable trauma surgeon who would advocate the old formula of 3:1 fluid resuscitation for uncontrolled hemorrhage in the prehospital setting.  Heck, in my service that would get me fired!

Karim Brohl (owner of Trauma.org, surgeon and contemporary of Ken Mattox) states:  _*ALS/ACLS algorithms DO NOT APPLY to traumatic arrest.*

The primary causes of traumatic arrest are hypoxia, hypovolaemia due to haemorrhage, tension pneumothorax, and cardiac tamponade. Hypoxic arrests respond rapidly to intubation and ventilation. Hypovolaemia, tension pneumothorax and cardiac tamponade are all characterised by loss of venous return to the heart. External chest compressions can provide a maximum of 30% of cardiac output in the medical arrest situations and are dependent on venous return to the heart. Chest compressions in the trauma patient are wholly ineffective, may increase cardiac trauma by causing blunt myocardial injury and obstruct access for performing definitive manoeuvers.


The treatment of massive thoracic haemorrhage is control of haemorrhage, not intravenous fluid therapy. Fluid therapy prior to haemorrhage control worsens outcome in penetrating thoracic trauma (and perhaps all penetrating trauma patients). If there is no response to a small (500ml) fluid challenge, fluid administration should be halted until haemorrhage control is achieved._

This is obviously problematic if the patient arrests in the field with no means of controlling the bleed.  Actually, maybe it isn't problematic: if this happens, the patient is dead.

VF/VT are unlikely to be your presenting rhythms in arrest following exsanguination, and it is highly unlikely that defib is going to be of any benefit in this scenario anyway.


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## pvfd62med22

Lifeguards For Life said:


> i agree and think that your time would be much better spent doing a host of other services to this patient than getting a EKG


In MA at my service that's what us basics are for  We hook up the 12 leads and stuff while the medic does his interventions.. And since we r in the sticks up here.. we would draft a cop or FF to drive and we would both be in back:wacko:..


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## Veneficus

Smash said:


> On the contrary, it shows a good appreciation of the physiology, pathophysiology and aims of treatment that we are after.
> 
> Ok, I'll just come out and say it.  In the setting of uncontrolled hemorrhage in the prehospital setting there is absolutely no role for dopamine, or any other inotropes.  There is a role for such agents after the damage control surgery has been carried out to maintain perfusion.  You need to plug the hole first though.
> 
> There are some major issues with using either "renal dose" dopamine or higher doses:
> 
> "Renal dose" dopamine (as venficus pointed out) dilates your afferent renal arterioles.  This is then thought to improve renal blood flow, which we want to maintain - if your kidneys die, you die.  However, for this to be effective, you need something to flow through them in the first place.  Which the hemorrhaging shocked patient doesn't have.  All that is going to happen is that you are going to increase the intravascular volume that needs to be filled with the precious little red stuff that remains.  Furthermore, whilst studies have shown that low does dopamine improves O2 tensions in the kidneys and liver, it decreases flow to the gut.  This causes all sorts of ongoing problems assuming that the patient survives:  the gut is very, very important, far more so than we usually give it credit for being.
> 
> Ultimately, despite many studies into renal dosing of dopamine in many critically ill patients of varying etiologies, there is extremely scant evidence that there is any increase in survival despite the improvement in physiological parameters.
> 
> 
> There is also no role for higher doses of dopamine or any other vasoactive drugs in the setting of uncontrolled hemrrhage.  These patients are already maximally vasoconstricted: no further benefit can be gained in attempting to vasoconstrict further, and all of these drugs (dopamine, dobutamine, epi, nor-epi) cause profound myocardial hypoxia and dysfunction and are extremely arrythmogenic in this setting.
> 
> Aggressive fluid resuscitation is also an absolute no-no in uncontrolled hemorrhage.  Whilst the finer points of how/when/where/why and how much are still being worked on, I know of no reputable trauma surgeon who would advocate the old formula of 3:1 fluid resuscitation for uncontrolled hemorrhage in the prehospital setting.  Heck, in my service that would get me fired!
> 
> Karim Brohl (owner of Trauma.org, surgeon and contemporary of Ken Mattox) states:  _*ALS/ACLS algorithms DO NOT APPLY to traumatic arrest.*
> 
> The primary causes of traumatic arrest are hypoxia, hypovolaemia due to haemorrhage, tension pneumothorax, and cardiac tamponade. Hypoxic arrests respond rapidly to intubation and ventilation. Hypovolaemia, tension pneumothorax and cardiac tamponade are all characterised by loss of venous return to the heart. External chest compressions can provide a maximum of 30% of cardiac output in the medical arrest situations and are dependent on venous return to the heart. Chest compressions in the trauma patient are wholly ineffective, may increase cardiac trauma by causing blunt myocardial injury and obstruct access for performing definitive manoeuvers.
> 
> 
> The treatment of massive thoracic haemorrhage is control of haemorrhage, not intravenous fluid therapy. Fluid therapy prior to haemorrhage control worsens outcome in penetrating thoracic trauma (and perhaps all penetrating trauma patients). If there is no response to a small (500ml) fluid challenge, fluid administration should be halted until haemorrhage control is achieved._
> 
> This is obviously problematic if the patient arrests in the field with no means of controlling the bleed.  Actually, maybe it isn't problematic: if this happens, the patient is dead.
> 
> VF/VT are unlikely to be your presenting rhythms in arrest following exsanguination, and it is highly unlikely that defib is going to be of any benefit in this scenario anyway.



I have had the honor of Meeting Dr. Brohi in person as well as spending several days with his service. 

Like most contemporary trauma surgeons, 1:1:1 blood products as demonstrated abundantly in recent wars is the goal of fluid replacement. Some of the contemporaries also advocate 3:3:1 or other massive transfusions.

I wasn't advocating dopamine as a method to help maintain renal perfusion with a bleed, I was suggesting it could be used to help control peripheral bleeding, by its mechanism. Also epi can be used topically to help localize and control bleeding. While often used in surgery, it can be used in the ED (A&E) as well. I can't think of any reason it could not be applied prehospital for the same. 

Like any other tool in the box, vasoconstrictors have a time and place, I agree with an uncontrolled bleed it is not the time or place. As well, if you are using ACLS arrest procedures, the outcome will be an extremely stable patient. Delta G will = 0, doesn't get any more stable than that


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## PrincessAnika

just out of curiousity (coming from a basic/exmedic student - long story) - exactly how big is this hole?  we are not qualified nor cleared to do emerg. c/s in the field but what would be the ruling, if the hole is big enough to pull baby out of?


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## Smooth

i've heard of a shotgun wedding but a shotgun pregnancy!


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## terrible one

Wow interesting read ... and I didn't get through them all,
12 Leads? RSI? Dopamine? 

What else do we carry in the bus that will be time consuming and ineffective? 
Thisn pt needs a surgeon asap, O2, control bleeding, grab some lines while en-route. I dont know why we are doing much of anything else, maybe i just missed something...?


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