 |
 |
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.