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Off Label

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Everything posted by Off Label

  1. Off Label

    CRASH 3; TBI and TXA

    The issues of hyperfibrinolysis and fibrinolysis shutdown are issues that bring to the fore the importance of timing of TXA, TBI aside. Multisystem trauma is pretty likely in patients with TBI, and I think one of the CRASH trials does suggest that if you don't get the timing right, you may do harm.
  2. The guy is probably there because of some well intentioned charitable gesture someone is making. Is there really a concern he'll make it to something more than routine IFT's if even that? I'd just consider graciously tolerating him part of my training. Take the high road and just complete the course work and go.
  3. Radiographic interpretation is an advanced practice/physician level skill that requires credentialing and a formal privileging process. Out of scope for pre-hospital use.
  4. Aux États-Unis, le niveau de sophistication médicale de l'ambulance ne peut pas prendre en charge de telles entités de diagnostic avancées. De nombreuses fois, nous ne pouvion s pas traiter ce que nous avons trouvé avec ces appareils de toute façon.
  5. Without the order, I guess you don't treat the pain. I wouldn't give an order for pain with what you've given here...what was the report to the doc?
  6. What are we supposed to get from an abstract? I couldn't read the whole study so all I can say is that the authors are saying that mask ventilation isn't inferior to intubation. Unless someone has passed the pay wall for this journal, no one else can make any coherent statement either. "Not inferior" is being used as a a statistical term here and does not have the same significance as a conversational "just as good". Abstracts are useless, really.
  7. What additional resources would have helped here?
  8. I'd say he died from complications of obesity.
  9. That medics know just enough to look stupid? That's as rude as calling someone you don't know a moron. That he died of a debilitating and painful disease is a real tragedy, but if he was the upstanding guy he apparently was, he'd own that.
  10. As quiet as this site is, it's better than nuthin'
  11. I wondered why that took so long to be challenged too.
  12. Glad you're OK and doing well.
  13. Don't forget a little salt and pepper and some butter.....oh, and some napkins
  14. Facebook? Over at Nurseanesthesia.org, it was the same thing. Now it's an echo chamber for people wanting to see how competitive they are for anesthesia training.
  15. You might be drifting into the tall weeds here. To break it down, "crush injury" for the purposes here is distinct from blunt trauma, although blunt trauma is obviously a major component in the crush syndrome. Crush syndrome or injury or whatever you want to call it is a constellation of problems that are superimposed on the blunt trauma problem, and, as your question suggests, does not require blunt trauma to set in motion. So....the problems we've identified so far... 1. Massive liberation of muscle protein, myoglobin, into the vascular space leading to renal damage/failure (rhabdomyolysis) 2. Sudden release of severe, blood flow restricting limb/pelvis compression after an extended period of entrapment. Accumulation of anaerobic metabolites and cellular release of potassium from cell death, (to say nothing of vascular injury and thrombus formation) is capable of causing sudden and catastrophic cardiovascular collapse via sudden and profound metabolic acidosis and hyperkalemia. How can these present through a medical mechanism? 1. Rhabdomyolysis can occur when a poorly conditioned athlete attempts an activity that is far out of his depth, ie a marathon. Hyperthermic emergencies, diabetic emergencies, drug reactions, certain infectious diseases can all have the same effect. 2. As far as this goes, a scenario will be instructive...Say a poorly conditioned alcoholic is on a binge one weekend and spends the weekend on the couch drinking and goes into a fib (maybe has a history of p-afib). He ignores it and continues to drink until Monday when he sobers up. As the week progresses he notices pallor pain in both legs which he ignores for a couple of days until the pain is unbearable. He's admitted to the hospital for pulseless lower extremities 2/2 embolization of thrombus most likely caused by is immobility and a fib. Several days of no flow to both legs from a clot does the same thing as a two ton concrete block on the pelvis. When the surgeon fishes out those clots and reperfuses the lower half of the body, that "acid wash" will occur and the consequences are the same as if he were extricated from a building collapse...get it? Obviously, the severity of the syndrome with vary with the situation. While these things can occur, most times the degree to which they present are not clinically significant and resolve on their own with no treatment except rest and fluids.
  16. Good article, Ruff... there are "medical" v. "traumatic" causes of the syndrome, which is actually a misnomer, IMO, because while the syndrome can be caused by crush or blast injuries, the actual cause of end organ damage isn't exclusive to trauma. It'd be like calling the effects of acute, significant blood loss a "syndrome" like "penetrating hepatic trauma syndrome". You can have the same "syndrome" from an acute GI bleed. Might be kind of splitting hairs, but there is a lot in medicine that is confusing that doesn't have to be...so to the OP, the cause of the end organ damage that is caused by blast or crush injury is identified in the posted link.
  17. Kenny, I just ask because I don't understand what cytochrome oxidase at cytochrome A3 is let alone cytochrome A3. I was asking because I was curious as to the back round you were bringing to your training. Good news for me is that I don't need to know that stuff to treat cyanide poisoning!
  18. Reversing carfentanil and reversing fentanyl is the difference between pushing a car and pushing a shopping cart.
  19. Curious as to choosing NE instead of an inotrope like epi or even dopamine. Is there a specific element here that you like NE for?
  20. Counter intuitive, giving volume in that situation. Then take it off with Lasix. Perhaps just a stop gap measure to get the coronary perfusion pressure up.
  21. O2 for SaO2 > 92, epi for MAP > 70 mmHg (start with .03/kg/min) while en route. Determining DNR is a good idea, verbal is OK just to tell the receiving hospital what the patient said in the event he becomes unresponsive. A pretty hard buy to not resuscitate then and there based on what the guy says in his living room or back of the ambulance unless someone produces a document or corroborator. Based on hx/ PE, I'd say his LV was pooping out (as opposed to his RV 2/2 PHTN). If he pulls through, someone could suggest palliative care?
  22. Sound like the Afib here was 2/2 the type of surgery and problem the patient was having. I'm going to guess he didn't have a CHADS score that would suggest risk of a LA thrombus. I'd say you were pretty safe in DCCV'ing this guy (not that it sounded like you had much of a choice.) Good call on the pads. I can't say I'd have thought to do that.
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