What Happens When??

[Atlgtr29]

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My partner and I(EMS in Atl.) delivered a burn pt. to the trauma center last week and I got to wondering(after seeing a gunshot victim being readied for the OR), what the anesthetic plan is like for the trauma pt. who spends only 10-15 minutes in the ED before being transported to surgery for intervention after being shot in the belly by one of his ghetto cohorts. I just couldn"t help but think that this situation has to be kind of touch and go when you guys get the seriously volume depleted GSW. This might be an asinine question, but is there a "generic" anesthetic plan for the pt. that you have only minutes to plan for? Not long ago I was coming out of the ED and my co-worker and his partner were taking their pt.(GSW to the upper chest and abdomen) strt to the OR from the ambulance bay. I found myself thinking about how easy our job is given our short amount of time with this pt. compared to having this dropped on you @ 3 in the AM with no time to have a game plan established. Thanks in advance for any replies. Just curious.

 

[jetproppilot]

This is about as cookbook as it gets, bro.

GSW dude is gonna do better if he comes directly to the OR, instead of intervention pre-hospital/in the ER that is only eating up precious minutes.

The only thing that saves these dudes is a scalpel to the belly/chest.

And the faster that happens, the better chance he has of waking up tomorrow.

No problem on this end.

Drop'em off in the OR.

Hell, wheel your stretcher in for all I care. You don't need scrubs or a cap/mask either.

Just wheel 'em in.

They all get rapid sequence induction and volume lines.

We protect their airway, control their hemodynamics, push blood/products/crystalloid, keep 'em warm and peeing.

Surgeon studette does her magic to save the gangsta so he can go shoot some more crackheads upon discharge.

Piece of cake.

Thanks for your post. 👍

 

[Atlgtr29]

So, on yall's end, these are straightforward cases. Appreciate the insight. As far as the volume lines go, we're definitely going 16 or 14 prehospital with alot of fluid runnin wide open. I knew the only chance for recovery is definitive care but I also wondered if it was, as you said, "cookbook". Obviously, time is not on their side. Getting a good set of lung sounds on scene is about the only thing we do before we get off scene. Everything else is done bouncin down the road. I appreciate your response Jet. I have been reading on this site for a while now and all I can say is keep up the good work.

 

[jetproppilot]

So, on yall's end, these are straightforward cases. Appreciate the insight. As far as the volume lines go, we're definitely going 16 or 14 prehospital with alot of fluid runnin wide open. I knew the only chance for recovery is definitive care but I also wondered if it was, as you said, "cookbook". Obviously, time is not on their side. Getting a good set of lung sounds on scene is about the only thing we do before we get off scene. Everything else is done bouncin down the road. I appreciate your response Jet. I have been reading on this site for a while now and all I can say is keep up the good work.

Thanks, Atl.

And keep puttin' in those big angiocaths, since God knows the ER is infamous for putting the pink ones in the AC....oh....and with the little pigtail thinghy on it.

Hope you post more often.

You're welcome here.

 

[dhb]

So, on yall's end, these are straightforward cases. Appreciate the insight. As far as the volume lines go, we're definitely going 16 or 14 prehospital with alot of fluid runnin wide open. I knew the only chance for recovery is definitive care but I also wondered if it was, as you said, "cookbook".

What are the end points of your standard pre-hospital resuscitation?

 

[swpm]

And keep puttin' in those big angiocaths, since God knows the ER is infamous for putting the pink ones in the AC....oh....and with the little pigtail thinghy on it.

At least the 20s are big enough for the wire in a RIC set.

It's the antecubital 22s that make me want to run through the ER with a handful of succ darts stabbing people.

 

[psychbender]

What are the end points of your standard pre-hospital resuscitation?

Standard prehospital resuscitation endpoints will often vary between different squads, and depend on when the protocols were last revised. When I started, I remember being told to start two large bore IVs and let them run wide open (sounds like what Atlgtr29's protocols say). My current protocol says for multiple traumas to start two large bore IVs, then run them at a rate "sufficient to maintain peripheral pulses. Contact medical control after two liters of fluid have been infused." I know of some medics and squads that still perform the former, but more are catching on that more fluid is not necessarily better.

 

[jetproppilot]

Standard prehospital resuscitation endpoints will often vary between different squads, and depend on when the protocols were last revised. When I started, I remember being told to start two large bore IVs and let them run wide open (sounds like what Atlgtr29's protocols say). My current protocol says for multiple traumas to start two large bore IVs, then run them at a rate "sufficient to maintain peripheral pulses. Contact medical control after two liters of fluid have been infused." I know of some medics and squads that still perform the former, but more are catching on that more fluid is not necessarily better.

I get emotional when a rescuscitative-type case shows up from the ER with 2 large bore IVs.

Makes our job so much easier....and benefits the patient.

Almost never happens.

 

[Atlgtr29]

As far as fluid resuscitation, we will not give more than 3 liters pre-hospital. That number is based on what I learned in school. In atlanta though, our txports are generally of the shorter times so we generally don't give as much as a rural service prolly would. I actually read an article, cant remember where, that talked about pre-hospital going away from masive fluid bolus in traumatic injuries. Im pretty sure it was in regards to increasing ICP in the head injured pt. with these huge a@# amounts of fluid that have been the standard until recently. As far as our ED goes, the only 2-3 times Ive seen the ED staff place lines, they were placing large peripheral IV's. They do a pretty jam up job with it. My main goal is to try and get at least a systolic of 90 and then keep it there. Thanks for yalls input.

 

[Atlgtr29]

I get emotional when a rescuscitative-type case shows up from the ER with 2 large bore IVs.

Makes our job so much easier....and benefits the patient.

Almost never happens.

That is unreal! Our ER staff is awesome with trauma patients.

 

[drccw]

Our medics here in Seattle are very aggressive.. 14-16 G IVs in the trauma victims... in wierd places sometime though (seriously, the calf? who puts an IV therE).. but they flow like butter....

resucitation wise here they have trialed (or are trialing ) 3%... i dont know what the results were.. they have also trialed pre-hospital cooling for arrests....

when I say our medics are very aggressive- I mean it's almost impossible to not buy yourself a tube.... complain too much they tube you for being too aggressive... not talk too much they tube you for altered mental status... oh standard unduction here for the medics? Morphine 10, valium 4, sux, tube oh and then 10 of panc... everyone shows up with sufficient BP let's just say....

 

[svaefinga]

Never got a big trauma without at least one large IV - on the other hand, over here it is anesthetists who take care of them initially as we take part in pre-hospital emergency medicine.

 

[Noyac]

Morphine 10, valium 4, sux, tube oh and then 10 of panc... everyone shows up with sufficient BP let's just say....

Keeping them awake throughout the intubation and afterwards probably does a real good job of preventing the hypotension from 10mg MS bolus.😱

 

[coprolalia]

Channeling MilMD for a moment, these are what we call "no lose" cases. Everyone expects the patient to die. If you do any better than that, you're in clover.

Big PIV's are a major plus. We tube 'em and take 'em to the OR. But, I always poke 'em again once we're in the OR. EJ's seem to work nice with a big ole 14 in them. No big whoop. They live, or they die. Them's the breaks when you get a large, sharp or a small, fast moving piece of metal piercing various organs.

-copro

 

[Jeff05]

4 of valium and 10 of morphine can cause profound hypotension in a volume depleted trauma patient, perhaps the reason why it does NOT is the sympathetic clampdown from being awake and paralyzed (those drug doses are insufficient to produce general anesthesia in most adult patients).

 

[psychbender]

when I say our medics are very aggressive- I mean it's almost impossible to not buy yourself a tube.... complain too much they tube you for being too aggressive... not talk too much they tube you for altered mental status... oh standard unduction here for the medics? Morphine 10, valium 4, sux, tube oh and then 10 of panc... everyone shows up with sufficient BP let's just say....

That is beyond F-ed up. Any chance of getting ahold of their medical director and letting him know what his people are up to? I've known a few medics that tell stories about how their combative patient protocol simply involved RSI...and how they forgot to administer any sedation on more than a few occassions. Cowboy antics like that give the rest of us a bad name.