Why not shock a trauma code?

FlightMedicHunter

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Your blowing this out of proportion.

Yes, this was me being facetious

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

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

FlightMedicHunter

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

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

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



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

Vene clearly stated:

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

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

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

Vene said "I beg to differ."

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

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

The Vene said :

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

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

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

HOWEVER.......

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

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

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

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

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

FlightMedicHunter

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

Let's take a look...

BLUNT TRAUMA
□ Follow appropriate cardiac dysrhythmia protocol.

PENETRATING TRAUMA
□ Follow appropriate cardiac dysrhythmia protocol.

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

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

systemet

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

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

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

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

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

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

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

FlightMedicHunter

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

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

RocketMedic

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More likely an undiscovered wound.

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

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

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

Veneficus

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

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

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

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

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

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

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

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

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

jjesusfreak01

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

Veneficus

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

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

RocketMedic

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What about an artificial clotting agent via infusion?
 

Veneficus

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What about an artificial clotting agent via infusion?

I do not think it can be made practical.

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

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

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

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

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

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

I think this sort of thing is just too complex.
 
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Veneficus

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

I did not listen to the podcast.

I remain skeptical about the potential benefits of TXA.

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

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

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

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

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

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

Civillian centers often report benefit in a much smaller population.

Some of the things to consider:

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

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

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

Civilians are not rigorous preselected healthy people.

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

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

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

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

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

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

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

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

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

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

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

Those are not easily correctable.

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

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

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

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

systemet

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

Thanks for the interesting and educational post.

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

Handsome Robb

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

Veneficus

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

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

wilderness911

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smooshed by bus and not much left

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

wilderness911

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

DesertMedic66

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Aw shoot guys, still learning the site layout. Got here from a search inquiry and didn't realize I was about to revive a 4 year old thread :oops:
You can say you shocked this thread back to life..
 
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