Difficult to Control - Page 2

swatsurgeon · 03-09-2008, 08:24

I would love to take credit but the human body deserves the credit. A surgeon, medic, nurse or who ever is a facilitator...the body just has to be given all of the support and tools to heal itself. Yes, surgery, a procedure assists or can begin the process but the 'miracle' is the body itself and deserves the credit.

My arm is doing better....about 85% extension, but still lets me know when I reach any limits with movement by invoking the blow torch feeling in the elbow. I have been able to begin operating again and doing okay so far, just no weight bearing (or shooting) for 2.5 more months...that is a true pain in my butt.

ss

sofmed · 03-10-2008, 13:08

Quote:

Originally Posted by swatsurgeon

just no ... (or shooting) for 2.5 more months...that is a true pain in my butt.

ss

I defininitley feel your pain. When I had my second arthroscopic hip surgery to repair the labrum and the psoas ligament, among other torn connective tissues I was unable to run for months, and total time for both surgeries was close to a year without running. For a former jr. triathlete that just plain sucks.

Looking forward to hearing that you're continuing to recouperate well.

Cheers!

Mick

Books · 03-11-2008, 16:22

Getting to this one late. . . too much work makes Books an absent boy.

To the Docs. . . Thanks much for this. We need these cases.

I would add, for the medics in the field who are not able to very quickly get their patient to a FAST or the like, remember that while the arteries will clamp shut on their own, after about 20-30 minutes, they will relax and resume bleeding out. So, as will all treatments, reassess to make sure your hemcon/mosquitos/quickclot/what-have-you is holding the red stuff in. Nothing is a fire and forget. . .

I too would like to know more about preventing the acidosis in the field. Would administering bicarb have been useful in this instance? Thanks in advance.

Books

Heretic · 03-11-2008, 19:38

"I too would like to know more about preventing the acidosis in the field. Would administering bicarb have been useful in this instance? Thanks in advance."

There are several things out there to help fight acidosis. Factor VII is being used limited. This is expensive and has to be temperature controlled. The thought process is that once the body is wounded you have a cascade effect. Shock, you’re not going to stop it just control it. The body does its magic of trying to heal itself by flooding the injured area with clotting factors. The area is going to swell and if a tourniquet was used compartment syndrome comes into play. Throw hypothermia in there and the recipe for acidosis is complete. Your treatments can be spot on and you initially saved the life but days, weeks or even months down the road the PT experiences difficulty due to acidosis. This is all compounded by the coagulation. You dump some fluids in this guy/gal and the body relaxes from the shock and you have a flood of bad stuff traveling out systemically. pH levels are changed by the injury, treatments and the body. Consider acidosis the primer. You control that and the outcome is better for the patient. This is illustrated by the triangle or pyramid of death.

Hypothermia
Coagulation
Acidosis
(I might have this wrong. Its late and the beer is slurring my typing.)

Plus I don’t have access to my med drive right now

swatsurgeon · 03-12-2008, 04:58

The etiology of the acidosis is what needs to be addressed. Remember, acidosis is a result of a generalized/localized shock state = the metabolic demands of the tissues are NOT being met and anaerobic metabolism is occuring to produce energy at the cellular level.
That being said, fix the initial problem and the acidosis will/should resolve. Here is the problem: the more acidotic, the slower the body will turn this around with giving it back fluid, blood, etc. This is where giving adjuncts helps, i.e., bicarb or THAM.
Interesting facts: a pH greater than 7.28 generally won't screw up enough enzyme systems to kill you and should reverse with resuscitation. A pH between 7.2 and 7.27 should be vigorously treated since ~ 50% of all body enzyme systems are now dysfunctional, you begin to see body processes going out of wack: arrhythmias and the like. Below 7.2, > 80% of all enzyme systems quit...now you're screwed. This is why literature in surgery/medicine and Trauma all say the chances of survival with a pH below 6.8 are slim to none. ... not zero but damn close.
Now what can you do in the field......
STOP THE BLEEDING, give small volumes of fluid, make sure the patient is moving air (ventilating and oxygenating). Do not give bicarb...makes the hemoglobin NOT want to give up O2 that it has bound and removes the respiratory compensation your body is doing all by itself.
The body is an amazing thing....it will compensate for a long time if you stop the insult and allow it to begin/continue to compensate.

ss

swatsurgeon · 03-12-2008, 06:41

Quote:

Originally Posted by Heretic

"I too would like to know more about preventing the acidosis in the field. Would administering bicarb have been useful in this instance? Thanks in advance."

There are several things out there to help fight acidosis. Factor VII is being used limited. This is expensive and has to be temperature controlled. The thought process is that once the body is wounded you have a cascade effect. Shock, you’re not going to stop it just control it. The body does its magic of trying to heal itself by flooding the injured area with clotting factors. The area is going to swell and if a tourniquet was used compartment syndrome comes into play. Throw hypothermia in there and the recipe for acidosis is complete. Your treatments can be spot on and you initially saved the life but days, weeks or even months down the road the PT experiences difficulty due to acidosis. This is all compounded by the coagulation. You dump some fluids in this guy/gal and the body relaxes from the shock and you have a flood of bad stuff traveling out systemically. pH levels are changed by the injury, treatments and the body. Consider acidosis the primer. You control that and the outcome is better for the patient. This is illustrated by the triangle or pyramid of death.

Hypothermia
Coagulation
Acidosis
(I might have this wrong. Its late and the beer is slurring my typing.)

Plus I don’t have access to my med drive right now

it is the failure to coagulate which is the problem.. Compound this with hypothermia, your platelets won't work making the coagulopathy worse. Acidosis, based on my previous post: decrease the pH enough and enzyme systems (part of initiating and maintaining coagulation) are shot. Badness at every turn.

ss

swatsurgeon · 03-12-2008, 06:43

Quote:

Originally Posted by Heretic

"I too would like to know more about preventing the acidosis in the field. Would administering bicarb have been useful in this instance? Thanks in advance."

There are several things out there to help fight acidosis. Factor VII is being used limited. This is expensive and has to be temperature controlled. The thought process is that once the body is wounded you have a cascade effect. Shock, you’re not going to stop it just control it. The body does its magic of trying to heal itself by flooding the injured area with clotting factors. The area is going to swell and if a tourniquet was used compartment syndrome comes into play. Throw hypothermia in there and the recipe for acidosis is complete. Your treatments can be spot on and you initially saved the life but days, weeks or even months down the road the PT experiences difficulty due to acidosis. This is all compounded by the coagulation. You dump some fluids in this guy/gal and the body relaxes from the shock and you have a flood of bad stuff traveling out systemically. pH levels are changed by the injury, treatments and the body. Consider acidosis the primer. You control that and the outcome is better for the patient. This is illustrated by the triangle or pyramid of death.

Hypothermia
Coagulation
Acidosis
(I might have this wrong. Its late and the beer is slurring my typing.)

Plus I don’t have access to my med drive right now

it is the failure to coagulate ( coagulopathy) which is the problem.. Compound this with hypothermia, your platelets won't work making the coagulopathy worse. Acidosis, based on my previous post: decrease the pH enough and enzyme systems (part of initiating and maintaining coagulation) are shot. Badness at every turn.

ss

Red Flag 1 · 03-12-2008, 08:15

Are the 18D's taking Bicarb in their aid bags?

RF 1

Heretic · 03-12-2008, 08:26

Quote:

Originally Posted by swatsurgeon

it is the failure to coagulate ( coagulopathy) which is the problem.. Compound this with hypothermia, your platelets won't work making the coagulopathy worse. Acidosis, based on my previous post: decrease the pH enough and enzyme systems (part of initiating and maintaining coagulation) are shot. Badness at every turn.

ss

Yes, I was trying to somewhat get that out last night. Thanks for the insight.

Books · 03-18-2008, 20:55

Quote:

Originally Posted by Red Flag 1

Are the 18D's taking Bicarb in their aid bags?

RF 1

Not in the bag.. At least I'm not. Though it was discussed while in the course by civilian paramedics as a part of their cardiac protocols (though they were in the process of removing it).

Red Flag 1 · 03-19-2008, 09:54

18 Ds,

I would find it interesting to learn how many 18Ds are using Sodium Bacarb in the field? That's the injectable kind gents!

RF 1

Heretic · 03-19-2008, 11:06

I do not carry it. I fail to see the practical application for it. You have no way of measuring the patient's acidotic state. If you are taking labs on the OBJ your priority in treatments needs to be realigned. We carry I-stats in our vehicle bags and that is for the rare case we have to sit on a patient for some time. You want to reduce acidosis? Treat the wounds effectively, treat for hypothermia (even during summer), diligent fluid resuscitation. Let the body maintain the pH. Its way better then you flooding it with fluids and causing fluid shifts hampering the pH more. Not to forget about causing leaky veins etc. On the "X" it does not matter if you are an 18D, 68W or a Trauma doc, all we are is a preventive measure against death. Stay focused on the best medicine for your patient and giving it when it is needed. Example obtaining a ABG is useless if your PT is not breathing.

Red Flag 1 · 03-19-2008, 11:14

heretic,

Thanks

adal · 03-19-2008, 12:44

As an 18D I never carried bicarb. As a civilian ground medic, we carry it but very rarely use it. If we do it's more for an overdose. As a flight medic we carry it and use it a little more often, but even then very sparingly. We had I-stats but put them aside since our usual flight times aren't any longer than 90 min. (Yes it depends on how long the pt was down, type of injury, but we couldn't justify it where we're at.) adal

sofmed · 03-19-2008, 12:51

Quote:

Originally Posted by Heretic

On the "X" it does not matter if you are an 18D, 68W or a Trauma doc, all we are is a preventive measure against death. Stay focused on the best medicine for your patient and giving it when it is needed. Example obtaining a ABG is useless if your PT is not breathing.

I couldn't have said it better myself.

Cheers!

Mick