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.
Shotgun - Pregnant female scenario
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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.
Foxbat
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Correct me if I'm wrong, but I thought Quickclot shouldn't be used on abdominal wounds.
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rhan101277
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Real scenario, this came in via ambulance when I was doing clinicals last week.
Smash
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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.
Melclin
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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.
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.
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.
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.
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.
R.O.P.
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Other than O2 and fluids, sounds like they needed a surgeon FAST!
Do you know what their outcome was?
What a nightmare call...
Lifeguards For Life
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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
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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.."
Melclin
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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
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
blindsideflank
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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
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
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.
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...
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.
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.
Lifeguards For Life
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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
Onceamedic
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Nothing kills a fetus as fast as it's mother bleeding out.....
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
Manic_Wombat
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That is what I thought of right off the bat.
redcrossemt
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Why??
You'd be using the powdered form, right? And pouring it on top of the baby's hand through the hole?
redcrossemt
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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?
R.O.P.
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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?