Discussion the use of Prehospital Antibiotics.

[tniuqs]

I am having a major conflict with my Topside Medical Director, frankly I wish to choke him slowly.

Senario:

Remote postings with transport times in excess of 3 hours with workers in VERY remote areas and access by helo only, with crappy comunications a wait time for me to reach them could be in excess of an additional hour, and if weather craps out or nightfall times could be even more excessive, like overnight.........!

BTW my MD is a GP......argh!

So any penetrating injuries to abdomen, compound fractures, or animal bites (ie Grizzly Bears and Cougars) should these patients NOT recieve broad spectrum bug juice? My pick would be ROCEPHIN (CEFTRIAXONE) 1gm IV.

Comments SVP ?

cheers

[chbare]

The good old shotgun approach, something to consider in special situations. What is your medical directors stance? I would be cautious about shotgunning all types of injuries that have delayed evac with a 3rd gen cephalosporin. For example, some types of animal bites are best treated with Augmentin. However, still something to consider in some situations.

Take care,

chbare

[AZCEP]

That is quite the unique situation.

Most are going to be ill prepared to have a reasonable discussion on this one. I'd be curious as to why your medical director is hesitant to allow them. For most, the initial dosing can wait, but if the delay of transport is extended it might be a consideration.

Good luck on this one.

[tniuqs]

That is quite the unique situation.

[chbare]

I think you took my comment out of context. Hitting somebody with a 3rd gen cephalosporin is shotgunning. Broad spectrum activity. I did not disagree with ABO coverage in the presence of delayed evac. In fact, I had to cover patients with ABO therapy because of a similar situation when I was deployed following Katrina. Does your service have aggressive wound management guidelines for such situations?

Take care,

chbare.

[tniuqs]

"chbare"I think you took my comment out of context. Hitting somebody with a 3rd gen cephalosporin is shotgunning. Broad spectrum activity. I did not disagree with ABO coverage in the presence of delayed evac. In fact, I had to cover patients with ABO therapy because of a similar situation when I was deployed following Katrina.

Sorry but "good old shotgun approach" sounded demeaning, no offence taken or intended.

Yes: I do see your point but this IS common practice in the OR or ER, I don't have C+S capabilities or gram staining where I am and no incubator, besides the fact I have no background in bugs to even know what I was even looking at!

I know it could be hit and miss but something should be done or at least attemped to promote remote Paramedical Practice.

If you have an opinion on what would be the best broad spectrum you should know that my major demographic group of "possible patients" is aboriginal north americans, with many penicillin and sulfa "allergies" I am totally open to suggestions.

The receiving surgeon was the one that ripped me a new orifice..... nothing like getting between a GP and a Surgeon... I felt like monkey in the middle!

Does your service have aggressive wound management guidelines for such situations?

Sorry no and not certain what you mean, a surgical scrub with betadine on board a chopper?

Not trying to be a smart ass... I am all ears though, your input is really appreciated.

cheers

[Ridryder 911]

Many prefer not to use the "shotgun" approach and rather use more specific antibiotic therapy. Using a broadspread antibiotic has its good and bad points. Many do not feel prophylatic therapy is a needed idea until they know what bacteria they are really dealing with since so many patients are now becoming resistant to antibiotic therapy. Giving the wrong antibiotic can make some situations worse.

Although Rocephin is a great antibiotic therapy, many use cefazolin as was mentioned like Ancef prior to skeletal and orthopedic injuries. Wound care is time involving and requires much more care that I believe that can and should be given in field settings. I agree preventative measures should be more addressed.

R/r 911

[chbare]

Ridryder911, I tend to agree with your points. I agree that ABO therapy has a place; however, we must be careful when considering how and when to employ broad spectrum agents. I think it could be considered in the unique situation of delayed evac. I am talking greater than 8 hours.

In addition, if you have evac times that exceed 24 hours, I think that more involved wound care could add to improved outcomes. Tnigus, this is what I was contemplating. Why we are waiting for evac, we can use those several hours to perform aggressive irrigation and possible debridement of soft tissue injuries that can be managed in such a way. You can use the time to identify devitalized tissue areas and possibly obtain a wound culture if infection is suspected.

However, I could be reading this wrong. Are you on scene with a patient for several hours waiting for evac, or are you picking up patients that received their injuries several hours ago and transporting them to definitive care. If the later is the case, then I apologize, as I would agree with Ridryder911 that the limited amount of time during transport would really limit your ability to provide effective wound care. Then, perhaps a wide spread campaign of education and preventative medicine organized by your service could help with teaching people about these kinds of injuries and also assist with developing rapport with your clients.

In any event, the decision to use antimicrobials in the field should be a well thought out plan. There are many potential problems to consider when administering ABO's. Not only are we talking about MRSA & VRE, but approx 10% of people (do not quote me) with an allergy to PCN will have a cross reaction to cephalosporins. This among many other problems must be considered.

Take care,

chbare.

PS, sorry for the typos. I have not developed the skill of "Treo Typing."

[Spock]

The cross over reaction between ancef and PCN exists but is not very common. I think the rate is around 1-2%. Unless the allergy to PCN is anaphylaxis or uticaria we give them ancef. Also, the orthopedic surgeons call ancef orthocillin. Just a joke. Not all patients in the OR get ABO prophylaxis. Some surgeons do not give it for lap chole's as an example. Single doses of ABO's have been know to cause megacolon which can be fatal.

The issue of ABO's for remote areas is complex and I think the time involved is critical. The longer it takes to reach definitive care the greater the need for ABO coverage. The surgeon was a jerk not to recognize it wasn't your fault the patient didn't receive ABO's.

Live long and prosper.

Spock

[tniuqs]

"chbare"] Are you on scene with a patient for several hours waiting for evac, or are you picking up patients that received their injuries several hours ago and transporting them to definitive care. If the later is the case, then I apologize, as

Take care,

chbare.

No need to apologise at all, the later was the senario in these 2 cases I am enjoying all the input and learning lots thank you all. If I had been forced by weather or nightfall to go the ground route (at least an addittional 3 hours minimum) I would now modify my care to more thourough wound care. I had 24 minute window from recieving both patients, medivaced to me in an intermediate helo, assessment and transported to a medium Bell 212 that was being refueled for the flight to definitive care center, the helos are NOT dedicated Medivac configuration and not exactly a clean enviroment. One thing I did learn is that LED light sources are NOT the best for finding veins, the bluish hue of a headlamp is not optimal in this situation.

Spock: The surgeon was a jerk not to recognize it wasn't your fault the patient didn't receive ABO's.

* EDIT* my first comment was a bit of literary licence, I guess, The surgeon was quite fair really and polite to me he understood the remote enviroment and was supportive, just a head shaking in disbelief in front of my patients was really put down 'unintentionally" because they just don't know the ins and outs of medical politics.

Frankly my issue is with the GP medical director..... its the old adage used in climbing....if you don't have a hat, you can't put it on! The GP has flatly refused to even consider this ABO option, I have another concern too....ABOs for dental problems, oral meds would save an estimated "lost man days x 2" so I will try to justify the $$$ route.

cheers