Certainly agree that a cardiothoracic surgeon is not needed.
From the pre-hospital perspective, ringing to determine the
resources and expertise available is not an option at the time - This
really needs pre-planning by all those involved (ambulance service,
A&E consultants and ITU / Cardiothoracic).
Unless pre-planned it is unlikely that the appropriate resources and
expertise will be mobilised efficiently. Hence my emphasis on
having a Standard Operating Procedure. Too often still the pre-
hospital and hospital services are not really working together in this
sort of planning of clinical management.
Tim
> Tim
>
> Why not ring up your nearest ITU for these patients. Many DGHs
> without renal physicians on site have ICUs with the capability to
> perform venovenous filtration. You need to check that the machine has
> a warming circuit (most have), and the patient could be rapidly warmed
> this way. Unlike dialysis, no special water supply is needed and
> theoretically it could be done in A&E with ICU support. Only venous
> access is required for the line. An example of this was recently
> published in the journal of A&E medicine.
>
> Francis Andrews FFAEM
> Lecturer in Intensive Care Medicine
> Department of Medicine
> University of Liverpool
> Daulby St
> L693GA
>
> ---------------- reply ----------------
> > 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. >
Timothy J Coats MD FRCS FFAEM
Senior Lecturer in Accident and Emergency / Pre-Hospital Care
Royal London Hospital, UK.
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