Prehospital and Retrieval Medicine – THE PHARM dedicated to the memory of Dr John Hinds

There’s been a lot of stimulating discussion after parts 1 and 2 of this series from Dr Alan Garner (you can check those here and here). Here’s part 3. 

Thanks for sticking with the discussion so far. In part 2 we had a look at AP compression injuries and lateral compression injuries. Short summary is binders make sense and there is some observational evidence of benefit in AP compression injuries. However in lateral compression, binders make no biomechanical sense and there is definite evidence they increase fracture displacement both in cadavers and real live trauma patients.

The final group that we have not yet considered in the Young and Burgess classification is the vertical shear group. These patients are complex because the injuries are both horizontally and vertically unstable. You will see what I mean if you have a look at this Xray:

Is putting a binder around the…

The fluids of choice in prehospital field are, in most cases, cristalloids (Norma Saline or Lactate Ringer).

But what is the physiological impact of saline solutions when administered in large amounts (as the latest ATLS guidelines indicates) to hypotensive trauma patients?

Is aggressive Fluid resuscitation the right strategy to be pursued?

The triad of post-trauma lethal evolution is:

• Hypotermia
• Acidosis
• Coagulopathy

Aggressive fluid resuscitation with cristalloids, and saline solutions in particular, can be detrimental in many ways:

1. Cristalloids tend to displace the already formed clots and improves bleeding
2. Normal Saline produce hypercloremic acidosis worsening coagulation and precipitating renal and immune dysfunction
3. Cristalloids diluts the coagulation factors and precipitate the coagulation system (dilution coagulopathy)
4. Cristalloids rapidilly shift in intercellular space worsening SIRS process and interstitial edema (brain edema, bowel wall edema) with consequent compartment hypertension
   

So wich is the perfect fluid to infuse in trauma?

The perfect fluid doesn’t exists.

Balanced saline…

Dr Andrew Weatherall does prehospital doctor stuff but spends lots of time serving the somnolent god of anaesthesia  in a tertiary paediatric hospital. He has particular interests in cardiac, thoracic, trauma and liver transplant anaesthesia and is trying to be a PhD student in his spare time.  You can also find him as @doc_andy_w 

Little creatures have the potential to cause significant stress. It’s true of spiders. It’s true of parasites. And for many medicos, it’s true of paediatric patients. All too often, the experienced clinician confronted with the alien life-form of a kid goes through a rapid medical devolution, retreating to the almost foetal uselessness of a medical student confronted for the first time by having to do a procedure they’ve only read about.

Dance all you like tiny peacock spider, still wary. [via Jurgen Otto on Flickr under “Some Rights Reserved CC licence 2.0] It’s entirely reasonable to feel…

If you have a patient with a King LT in place and want to intubate him use the Bougie and the videolaryngoscope. It works perfectly.

Here is the video tutorial.