runswithneedles Posted February 27, 2012 Share Posted February 27, 2012 So sorry mobey. How far out are we from the appropriate facility? Whats his 2nd set of vitals while enroute. Is he developing SOB? Is bleeding still controlled? Link to comment Share on other sites More sharing options...
Kiwiology Posted February 27, 2012 Share Posted February 27, 2012 (edited) Not to be too big of an ass, but OP if we could get back to the scenario instead of centering yet another thread around kiwi and australian speech antics I would be very appreciative. You're just jealous Canadaspeakz is not the subject of threads An uncontrolled haemorrhage happens when bleeding occurs from a hole in a large blood vessel or a high pressure bed of big vessels such as the placenta. This includes: • penetrating trunk and neck trauma • leaking abdominal aortic aneurysm • all penetrating wounds • pregnancy related haemorrhage If the nature of injury or the disease process suggests that there is hole in a pipe then it’s likely to be uncontrolled haemorrhage. Why don’t we want to give fluids to these patients? There are two primary reasons. Firstly, these patients have a hole in a pressurised pipe. When the pressure is high the flow out of the hole will be higher than when the pressure is low. By allowing the patient to have a low BP we reduce the pressure in the pipe and hence flow out the hole. The second thing that fluid replacement does is dilute clotting factors making it more difficult for clotting to occur. By restricting fluid there is less dilution. We also know that wild swings in blood pressure interfere with the clotting process and disrupt the formation of a clot. By restricting fluid therapy and tolerating the lower pressure, we prevent this see-sawing of the blood pressure. The evidence is clear that patients with uncontrolled haemorrhage do better with little or no fluid. We aim to give just enough fluid to perfuse the patients’ brain. We do not give fluids to these patients unless they have no radial pulse, an un-recordable blood pressure or a falling conscious state. Uncontrolled haemorrhage is treated by operation. Where possible the patient should be transported to a centre which has a 24/7 surgical capacity. Only give IV fluid if profoundly shocked e.g. no radial pulse or un-recordable blood pressure. Give adults one litre of 0.9% NaCl as a bolus and children 20 ml/kg of 0.9% NaCl as a bolus. It is clear that giving fluids to patients with uncontrolled haemorrhage can worsen the outcome for that patient. As with most things in medicine it is not always black and white. If you are uncertain about what type of shock you are dealing with it is best to follow the controlled haemorrhage procedure, keeping volumes as low as practical. Edited February 27, 2012 by kiwimedic Link to comment Share on other sites More sharing options...
DwayneEMTP Posted February 27, 2012 Share Posted February 27, 2012 Why don’t we want to give fluids to these patients? There are two primary reasons. Firstly, these patients have a hole in a pressurised pipe. When the pressure is high the flow out of the hole will be higher than when the pressure is low. By allowing the patient to have a low BP we reduce the pressure in the pipe and hence flow out the hole. Ahhh...another one of those statements! We don't know that we don't want to give fluids to 'these' patients, but only that we don't initially want to give fluid to 'this' patient. If the blood pressure is the issue in your leaking pipe, then the initial hypovolemia in a volume challenged person is going to cause a compensation that will raise their pressure, right? Sometimes a lot! And a realistic way to lower it is to add the fluids that will help mitigate the compensation. Of course the trick follows to do that without tipping the scales over to the other side, or as the underworlder says, diluting the clotting factors to a point where we've begun to go sideways. Just wanted to add that note... Cause I can... It's what I do...I'm a giver... Link to comment Share on other sites More sharing options...
runswithneedles Posted February 27, 2012 Share Posted February 27, 2012 But I didnt say give patient fluids in my original post. I stated start two large bore ivs and keep at to keep open rate. and from what I understand TKO is usually 5-10ml per hour. And even running two for a ten minute transfer to the hospital it would give only a fraction of that. However I would like to state if given the option to use a saline lock over TKO i would. Less tubing and stuff to carry in with me. But I want that second IV because even though it is controlled I do not know if it went through an artery or major vein and the only reason that it stopped bleeding is because that pole has plugged the hole. Id be worried that while enroute the pole shifts and it unplugs the vein or artery it punctured. Link to comment Share on other sites More sharing options...
Kiwiology Posted February 27, 2012 Share Posted February 27, 2012 We don't know that we don't want to give fluids to 'these' patients, but only that we don't initially want to give fluid to 'this' patient. We do not want to be giving fluid to these patients before hospital unless profoundly shocked; what the Anaesthetist does in hospital is of great interest to me but not my concern right up in the now at the road side If the blood pressure is the issue in your leaking pipe, then the initial hypovolemia in a volume challenged person is going to cause a compensation that will raise their pressure, right? Sometimes a lot! And a realistic way to lower it is to add the fluids that will help mitigate the compensation. Yes there will be some compensation, why is why initially a patient with uncontrolled haemmorhage will appear grossly normal upon physical examination i,e, compensated shock The compensation mechanism will be quickly overwhelmed by massive exsanguination and the patient will decompensate; it is these decompensated patients we want to give only a little fluid to so cerebral perfusion is maintained. Remember that arms, legs, gut, bowel and other bits and pieces (and Kiwi's too) can go many hours without adequate blood supply before they get truly irreversibly ischaemic; the brain cannot. Of course the trick follows to do that without tipping the scales over to the other side, or as the underworlder says, diluting the clotting factors to a point where we've begun to go sideways. Underworlder, shit make me sound bad mate, you've been talking to my ex wife again haven't you It's what I do...I'm a giver... Good to know, I will remember that at our BBQ But I want that second IV because even though it is controlled I do not know if it went through an artery or major vein and the only reason that it stopped bleeding is because that pole has plugged the hole. Id be worried that while enroute the pole shifts and it unplugs the vein or artery it punctured. The days of two big drips are long gone my friend, if the pole shifts and he starts to haemmorhage the best treatment is to tightly pack wound with very very firm, direct pressure, put up one bag of fluid and let it run, oh and step on the gas Venous bleeding is not much of a problem veins are under very low pressure ~10mmHg, arteries are the problem (unless of course you nunnger your vena cava or something then you're a bit rooted bro) Link to comment Share on other sites More sharing options...
runswithneedles Posted February 27, 2012 Share Posted February 27, 2012 ........Youre right. How do you say my greenhorn is showing in Kiwi? Link to comment Share on other sites More sharing options...
Kiwiology Posted February 27, 2012 Share Posted February 27, 2012 ........Youre right. How do you say my greenhorn is showing in Kiwi? That's like asking what is a white man's dialogue in a Spike Lee movie Something like your got your head up your arse ow! Link to comment Share on other sites More sharing options...
runswithneedles Posted February 27, 2012 Share Posted February 27, 2012 UGH!!! Im gonna have to crack open my trauma management book again. For the amount of information a medic must learn and maintain. This profession is WAY underpaid. Link to comment Share on other sites More sharing options...
Kiwiology Posted February 27, 2012 Share Posted February 27, 2012 (edited) Somebody should have gone to the 12 week Paramedic school for Houston Firefighters Far less demanding that program right there ... Edited February 27, 2012 by kiwimedic Link to comment Share on other sites More sharing options...
runswithneedles Posted February 27, 2012 Share Posted February 27, 2012 HA!!!! Whats their pass ratio for nationals. Zelch? Link to comment Share on other sites More sharing options...
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