This lecture on the EMCrit site is incredible.
First off the shock-trauma unit is something else. Does anywhere else in the world have such a place?
This in itself must be quite the intervention, having all the right people in the right place with the same aim. The whole system has a lot to teach us about managing trauma patients where we can barely manage to organise a trauma team! Never mind the fact that our OT, CT scanner and ED are all at different ends of the hospital.
There’s not great RCT evidence for this kind of thing, it’s mostly physiological reasoning supported by some big observational stuff but there’s a lot of work going into it and some trials in progress too.
So when resuscitating a bleeding trauma patient:
- no crystalloids
- stuff the resus get them to a surgeon
- 1:1:1 something they made up but just might be useful
- note that 1:1:1 is not the same as giving whole blood (constituents of 1:1:1 about Hct 30 Pla 80 65% of coag factors)
- remember the calcium (essential for both clotting and inotropy)
- INR is best single predictor of mortality
- they use o+ve regularly and have no problems
- in vietnam there were 600000 matched transfusions and 7 deaths from transfusion reactions (that were actually labelling errors)
- there were 100000 O +ve transfusions and no major reactions
He also does some interesting physiological fiddling during the operation giving patients 100ml fluid boluses (of equal FFP and PRBC as Scott points out in the comments below) and fentanyl to keep them anaesthetised and resuscitated. Though I suspect that this only works well for the young fit men who keep shock-trauma in business.
Speaking of people shot in Baltimore isn’t the Wire the best TV show ever made?
[youtube http://www.youtube.com/watch?v=-Sgj78QG9Bg?rel=0&w=425&h=349]
[youtube http://www.youtube.com/watch?v=KQbsnSVM1zM?rel=0&w=425&h=349]
Andy,
fantastic comments!
Actually, the fentanyl anesthetic method was developed in the cardiac surgery world and is used primarily on elderly folks with bad hearts. Should work on all age groups. In the elderly you are probably shedding less intrinsic sympathetic tone with the fentanyl, so vital sign shifts should be less. No evidence for any of it directly in trauma patients though.
I know you know, but when he says 100 cc boluses of fluid, he talking about 100 cc of equally mixed FFP and PRBC.
cheers,
Scott
cheers scott. thanks for the correction
i’ve corrected it in the text to make it clearer – i’ll confess that i thought he just mean crystalloid! it makes much more sense that it’s blood.
Andy Neill http://EmergencyMedicineIreland.com