If the patient has a chance of survival then it would be reasonable to
go direct to bypass facilties (this would usually mean a
cardiothoracic unit). By a chance of survival I mean that the patient
has had rapid cooling (such as immersion) and a short period
without resuscitation (depends on age). If the patient has suffered
slow cooling and is hypothermic in cardiac arrest then they are
dead, so should not be transported.

It is worth looking at the differences in timing to definitive
intervention. The penalty for going to the cardiothoracic center is
about 20 to 25 minutes (I guess 7 minutes extra flying, 5 minutes
unloading and 10 minutes transport). This is probably worthwhile if
the cardiothoracic center is set up to get the patient warmed up
more than 20 to 25 minutes quicker than the other hospital.

Levels of interest are also a factor here. Just because a hospital is
larger or has a particular specialist does not mean that the patient
will necessarily get better treatment. If the other hospital is keen,
expert and set up to warm the patient rapidly by non-bypass means
then that may be a better option than a cardiothoracic center where
nobody is that interested.

I find triage decisions between hospitals one of the most difficult
aspects of pre-hospital care. Discussion between those involved
BEFORE the event help to decrease the pressure on pre-hospital
providers and created a seamless continuum of care from pre-
hsopital to hospital stages. These circumstances are entirely
predictable and I would suggest that any pre-hospital system should
have a set of Stabdard Operating Procedures to deal with them.

Tim. Coats

NB: External cardiac massage may be ineffective as a cold chest
wall makes compression difficult. A pre-hospital thoracotomy and
internal cardiac massage may be needed to give an effective cardiac
output (especially if CPR is to be continued in flight).





> Hypothetically, - of course! - You are air-lifting a patient in
> cardiac arrest as a result of hypothermia. Would you overfly an A/E
> hospital with a helipad:- to a hospital  15 miles away without a
> helipad where the landing site is half a mile from the A/E door by
> road but the hospital does have by-pass facilities? Regards Dave
> Fletcher
>   ----- Original Message -----
>   From: David Vickery
>   To: [log in to unmask]
>   Sent: Tuesday, March 13, 2001 8:48 PM
>   Subject: Re: refractory seizures
>
>
>   "andrew.morris7" <[log in to unmask]> wrote:
>
>
>     Whilst on my A+E attachment I saw a patient brought in status. He
>     was given lorazepam which failed to stop the seizures. He had been
>     in before in a similar state and had always previously had sub
>     therapeutic blood levels of phenytoin, so an infusion was started
>     - this also failed. Then the results came back and his phenytoin
>     level was through the roof (taken before the infusion was set up)
>     - is this a case where paraldehyde should have been used? If a
>     patient is taking phenytoin anyway should it be used to treat
>     refractory seizures? Andy morris Medical Student Glasgow
>
>
>   If the patient is already on phenytoin, then it should not be used
>   in the emergency management of status epilepticus. Alternatives
>   include phenobarbitone or chlormethiazole. An urgent phenytoin level
>   should be requested. Paraldehyde remains in the APLS guideline for
>   second-line treatment after lorazepam.
>
>
>
>   In refractory seizures it is interesting to see lorazepam and
>   phenytoin being recommended as simultaneous therapy. At least if
>   they fail, then time has been saved prior to subsequent treatment.
>   The use of propofol with EEG evidence of seizure supression merits
>   further investigation, and may be a promising therapy.
>
>
>
>   The difficulty still remains in defining refractory seizures and
>   predicting associated morbidity. There is quite a large cohort of
>   children on lamotrigine and/or vigabatrin with brittle epilepsy who
>   remarkably come to little harm with prolonged seizures. Conversely
>   there are children who become profoundly acidotic with electrolyte
>   imbalance and resistant seizure activity after a relatively short
>   time span.
>
>
>
>
>   David Vickery
>
>
>
>
>
>
>
>
>
> ----------------------------------------------------------------------
> --------
>   Do You Yahoo!?
>   Yahoo! Auctions - Buy the things you want at great prices!
>



Timothy J Coats MD FRCS FFAEM
Senior Lecturer in Accident and Emergency / Pre-Hospital Care
Royal London Hospital, UK.