Do We Make Trauma Patients Worse............

[DFIB]

True that.

I absolutely appreciate all the great response I've received. I just want to be careful because I don't want to come of as being pretentious.

I would not derive an impression of presumption from any of your post. It is very obvious that you share your knowledge because you believe that it may or may not be useful to the rest of us as providers. Your post are received in the spirit that they are given.

Whatever you do, please keep it up. Our flaming friend seems to enjoy posting inflammatory remarks just to see what response he can incite. I don’t know why we give him the time of day except that he makes the forums a little more entertaining.

[croaker260]

I've never hesitated to strip a trauma patient in the cold and snow if I thought that I needed to do so immediately, but have also always covered them with a blanket after. In Colorado I got a bunch of shit because I'd warm my fluid in the pts microwave before transport if I thought that they needed the help. (Did you know that 'everyone' knows that saline when nuked in a soft bag causes toxins to leach out of the bag and makes the fluid toxic too? I didn't, and continue not to know this, but am constantly informed by medics that it's 'obvious' and 'everyone' knows it. Just sayin'...)

Dwayne

Just point out to them that this practice is recommended in this tecxtbook (I have the 4th edition which I am referencing) http://www.amazon.com/Wilderness-Medicine-5th-Paul-Auerbach/dp/0323032281/ref=sr_1_1?ie=UTF8&qid=1324664695&sr=8-1 I believe 2 minutes/liter fluid, shaken (not stirred) prior to administration.

Also, while designed for neonates, I have used this A LOT on potential hypothermic adults ( I place it on their chest). It works awesome, is consistent to 104-110 degrees for about 2 hours. We carry two per rig for deliveries, so they are readily available.

http://www.progressivemed.com/estylez_item.aspx?item=515557

[island emt]

Some assholes just seem to rack up the negative rating points as a challenge.

Chris while you are willing to share knowledge with anyone who might want it, some just need to be antagonistic about everything.

[usalsfyre]

There was a local study done by the trauma council in East Texas, not sure if it was ever put out for publication, but the results were that out of roughly 1000 level 1 trauma activations, all of them came in hypothermic to some degree. Every. Stinking. One. Seems that stripping the patient, pumping in room tempature fluid and setting the ambulance climate control for paramedic rather than patient comfort was enough to overcome a couple of months of 100+ degree days.

People wonder why I insist on having blankets in the summer too. Any critical patient excluding heat stroke gets at least one blanket regardless of ambient temp.

Edited December 27, 2011 by usalsfyre

[Bernhard]

Every patient gets a blanket in any season unless he/she states otherwise. Ambulance is heated inside when in the bay, I usually turn the additional heating up when responding to an outside trauma call (MVA or such). Heating temperature is above normal room temperature and more than the medic will tolerate, so I put off my jacket when entering the ambulance, only having my polo shirt on, even in winter. From time to time a patient complains that it is to warm.

Another thing is to close ambulance doors quick, when getting equipment/stretcher out. And have a heating system that really works fast. Vacuum mattress is stored in the inside, so has about the same temperature as all other equipment. I don't use spineboards (which are stored in the outside compartment) for transport, just to extricate. An issue would be the KED, since it is stored outside, but I npractically never use it anyway.

Plus, our ambulances are equipped with a heating drawer, containing at least 2 Ringer, 2 HES and 2 Glucose5% (500ml each) on a temperature of 25°C (some ambulances have a larger drawer, containing more). The emergency kit is stored in an inside compartment, targeted by a heater, so it and its contents are kept warm a bit.

Before we had all that, I sometimes heated up infusions on the patient's oven in a pot of water, which peels the label off the bottle (we had glass bottle infusions back then, even microwaves were rare). On a regular ice motorbike standby we even carried the infusion bottles on our body to get them warm. That was before park heaters were introduced to our ambulances.

Saying this I must admit I never ever took an initial temperature measurement even on a known hypothermic patient. First: simply never had the time to do it (lame excuse, but at least I had gloves!), second: our thermometers are not really able to measure low temperatures as we would need then. I didn't find a good thermometer for professional and outside use yet. Tips welcome.

So I try to get my patients in a warm environment as soon as possible. If you ever were even just a mock victim in a training scenario, you understand why. One should remember that a blanket OVER the patient doesn't help much when his heat flows into the floor. Had an impressive incident, where a young man involved in an MVA laid on the street on a real warm summer evening. I know him and talked to him later when he recovered from his heavy injuries, the only thing he remembered was that it was real cold as ice laying there and he was really glad when we had him in the warm ambulance.

Two other things to consider in this thread:

• wouldn't be a mild (?) hypothermia a good thing on injured people as well as they (at least ERC, but I think AHA as well) recommend it for CPR?
  
• I recall a study from years ago, that indicates (as far as I remember), that some 500ml don't change body temperature significantly. Can't find the study at the moment, though. But it should be a matter of calculation body weight and fluid flow.
  

Seems I have to do a bit research again (thanks for the impulse).

[island emt]

Just a quick question to ALL !

How many of your services even carry a hypothermic thermometer on your trucks?

We Do!

[Vorenus]

We don`t!

[Bernhard]

How many of your services even carry a hypothermic thermometer on your trucks?

On our career service we even have no thermometers at all on some ambulances, on some just old quicksilver ones...(yes, I know, but meanwhile I'm tired complaining about).

On my volunteer ambulance (where I control the budget) we have electronic thermometers, but only standard fever temperature range. Occasionally I'm scanning the market for a real EMS reliable hypothermic thermometer, but did find only one so far which is beyond our budget.

We Do!

Which one (brand, model)?

[Bieber]

At the start of each shift and after every call that we use an IV on I set up an IV bag and throw it in the warmer. We also keep two bath blankets plus a sheet on our cot and (when I can get my partner to slow down for a second) I try to put a blanket or two over the backboard if we're gonna spinally immobilize someone. At least, I've been doing that since the weather got cold.

[Bernhard]

wouldn't be a mild (?) hypothermia a good thing on injured people as well as they (at least ERC, but I think AHA as well) recommend it for CPR

A quick search revealed:

• mild hypothermia (as propagated in post-reanimation, not below 35°C) saves brain cells (less oxygene need), that's why it is recommended in cardial arrests.
  
• any hypothermia has negative influence on blood coagulation (which may be good in myocardial ischaemy, but not with bleeding trauma)
  
• more than mild hypothermia (below 35°C) has larger negative influences on coagulation, electrolytes, inflammation and general system functions (including heart rhythm)
  
• studies propagating hypothermia in cranial traumata are not trusted much (post-OP anyway)
  
• studies around the topic "therapeutic (mild) hypothermia in trauma" are in progress, I found no result yet.
  

So, at the moment, the current guideline obviously still should be: only a warm(ed) trauma patient is a good patient. One article recommends even warm infusions at 37°C.

If a therapeutic hypothermia in trauma situations is considered someday there sure is the need for adequate measurements, since the border between good and bad seems to be real thin.

I recall a study from years ago, that indicates (as far as I remember), that some 500ml don't change body temperature significantly. Can't find the study at the moment, though. But it should be a matter of calculation body weight and fluid flow.

Found not much yet on this, but the actual studies for post-CPR hypothermia state, that an ice cold (+4°C) infusion decreases body core temperature ("only") by 1,5°C per hour, when given 30ml/kg body weight. Double dose will give almost double temperature decrement. So, there may be a significant hypothermic effect considering higher infusion volume per time on trauma patients, but then those infusions usually are not ice cold. On the other hand, the rather thin infusion line hanging between bottle and needle should be considered as additional cooling factor, especially in chilly circumstances.

Still have to do some calculations for typical infusion volumes and probable fluid temperatures - or find an existing study/calculation covering this. Interesting topic, really!