Is trauma easier than medical?

[Pavehawk]

Awesome.

Could you tell me the cut and dry solution for managing cerebral perfusion pressures while not causing the patient to bleed to death from an actively hemorrhaging internal wound, mitigate ICP to prevent herniation, but not over ventilate, and prevent the damage to the GI tract while balancing the treatment of systemic BP and kidneys?

It has been a thorn in my side for some time.

Edit: and while we are at it, prevent the ill effects of systemic immune response while still maintaining immunocompetency to prevent sepsis from infiltration of bacteria from the GI to the abd cavity?

Strict glycemic control while balancing the needs of anabolic metabolism?

Osmotic fluid balance without over hydration?

Trauma rattles, trauma rattles, chanting and dancing around the fire... (grass skirt and headress optional except for DIC)

I think he means from a rudimentery on the street back of the ambulance EMS kinda way not in an insulting trauma is "da easy" kinda way

 

[Veneficus]

Trauma rattles, trauma rattles, chanting and dancing around the fire... (grass skirt and headress optional except for DIC)

I think he means from a rudimentery on the street back of the ambulance EMS kinda way not in an insulting trauma is "da easy" kinda way

That is what I figured, but I stand by my earlier statement, what is done in the field influences the outcome no matter what the effort in the hospital.

It is important for field providers to think and make informed and purposeful decisions on what they are doing with these patients, not simply to see how proficently they can perform a set of skills.

 

[abckidsmom]

That is what I figured, but I stand by my earlier statement, what is done in the field influences the outcome no matter what the effort in the hospital.

It is important for field providers to think and make informed and purposeful decisions on what they are doing with these patients, not simply to see how proficently they can perform a set of skills.

So for the people who don't speak in such multisyllabic complex sentences (ie typical medics, technicians not clinicians) pain us a scenario of this complex patient and walk us down both pathways, briefly, and if you have time.

Like you said above, it takes time and experience, and experience without education is useless for learning, or not very useful anyway.

 

[mycrofft]

Mycrofft's Theorem of Medical Cut-ness and Dried-ness

Anything is cut and dried in direct proportion to your degree of willingness to let things take their own course.

(The humbling and seductive part is that so often they do anyway).

 

[Akulahawk]

There are multiple compartments of the leg, you can get compartment syndrome in any of them from an increase in pressure. Not just the anterior compartment.

note that the deep posterior compartment has 2 bones and fascia between those bones that limit where it can expand. While it's possible to get compartment syndrome in any of those compartments, it's the deep posterior and anterior compartments that will experience the compartment syndrome much more readily than the others. Now, here's a twist... encapsulate the whole lower leg in a cast before swelling really sets in and you can cause the whole lower leg to experience compartment syndrome...

 

[Akulahawk]

Awesome.

Could you tell me the cut and dry solution for managing cerebral perfusion pressures while not causing the patient to bleed to death from an actively hemorrhaging internal wound, mitigate ICP to prevent herniation, but not over ventilate, and prevent the damage to the GI tract while balancing the treatment of systemic BP and kidneys?

It has been a thorn in my side for some time.

Edit: and while we are at it, prevent the ill effects of systemic immune response while still maintaining immunocompetency to prevent sepsis from infiltration of bacteria from the GI to the abd cavity?

Strict glycemic control while balancing the needs of anabolic metabolism?

Osmotic fluid balance without over hydration?

Just the fun kind of balancing act that needs a bit of a metabolic tightrope... right under the ICU big-top!

 

[Akulahawk]

That is what I figured, but I stand by my earlier statement, what is done in the field influences the outcome no matter what the effort in the hospital.

It is important for field providers to think and make informed and purposeful decisions on what they are doing with these patients, not simply to see how proficently they can perform a set of skills.

Sounds about exactly like what I was saying in some earlier posts (not sure if I'd said so in this thread) about the things that I do in the minutes after athletic injury that makes a huge difference down the road in recovery. Damage control starts from the moment the injury happens and some of the cascade of events may be too far along by the time EMS gets there to prevent further damage, regardless of what's done in the field OR in the hospital.

Gotta love this stuff!

 

[mycrofft]

Cast causing compartmentalization..why pts get a bivalved splint the first 24 to 48 hrs with a f/u.
So we shouldn't encase the entire leg tightly in Ace wrap (especially with those nifty little finger slashers, I mean clips)? Or do it tightly enough to discourage arterial perfusion into the compartment?
(yeah right)

 

[Veneficus]

So for the people who don't speak in such multisyllabic complex sentences (ie typical medics, technicians not clinicians) pain us a scenario of this complex patient and walk us down both pathways, briefly, and if you have time.

Like you said above, it takes time and experience, and experience without education is useless for learning, or not very useful anyway.

This scenario could be any multisystem trauma patient with TBI. I wasn't joking, this is an old and difficult question with more complexity than I listed.

I once posed it to a trauma surgeon when I was struggling with reconciling treatments that benefit one organ at the expense of another.

He laughed at me, said there was no easy cut and dry answer and if I found one to let him know. (that was nearly 10 years ago)

It is all a balancing act, and it starts with the first person who tries to help. Hyperventilation or not? fluid boluses or not? How much? Of what? Local trauma center or ivory tower?

While surgery and the ICU have a few toys and tehniques to play this balancing act, it really is made diffiuclt by things like 2 large bore IVs running wide open, over oxygenation/ventilation, intubation attempts, poor/no hemorrhage control, etc.

The deeper I get involved with it, the better "don't do anything and just drive to the hospital" looks. It takes a clinician and not a technician. More so when you add a pediatric who requires more than normal saline boluses.

 

[Akulahawk]

Cast causing compartmentalization..why pts get a bivalved splint the first 24 to 48 hrs with a f/u.
So we shouldn't encase the entire leg tightly in Ace wrap (especially with those nifty little finger slashers, I mean clips)? Or do it tightly enough to discourage arterial perfusion into the compartment?
(yeah right)

Oooohhhh, I just love those little finger slashers...:wub:

Done right, an ACE wrap, a little tape, and a little cardboard can do wonders... Done wrong, those same things can cause much damage. When it comes to soft tissue injury, I also like to employ gravity, when appropriate, in my damage control quest.