View Single Post
Old 04-21-2006, 07:51 PM
picunurse is offline
Join Date: Mar 2003
Location: Seattle
Posts: 11,625
Originally Posted by Qadgop the Mercotan
Most sigmoidoscopies these days are done with a flexible fiberoptic sigmoidoscope. I haven't seen a rigid one done since the early 1980's.
Thank you, I should have guessed that. Luckily for me, I haven't "seen" one since the early '70s.

KGS, Often, a smaller caliber shot will result in more internal damage than a larger on. The reason is the higher velocity projectile will simply pass through everything. Slower, smaller ones tend to bounce around. Say, one is shot in the lower abdomen, the slower bullet, after passing through the large intestine, could bounce off the pelvis or spine, go through a kidney or bladder, or be deflected upward and even hit a lung, liver, or any other vital organ. It can be even worse in the chest, where a bullet will dance around hitting ribs, until it loses momentum.

Let's try to organize this a bit.
1. Gun shot, fall down bleed.

2. Bystander rescurers arrive. First aid. Call 911

3. Pros arrive. Here we have some judgement calls. Stay long enough to put in a line to replace volume and intubate in the field, or use a bag/valve/mask, and scoop and run.
Transport by ground or wait for Airlift. The only time Airlift is preferrable is if the time saved is worth the time wasted. If the incident happens a 15 minute drive from ACLS help, then you drive. If it happens 20 miles from the nearest ER, during rush hour the 45 minutes to an hour waiting for Airlift might be worth it. Remember, Airlift, Lifeflight, what ever your air transport service is called, is only faster once they get to you. When they are notified they have to gather their gear, go from quarters to the ship, which has to warm up before it can takeoff. At your end, it has to have a place to land. Sometimes they have to land a fair distance away, so the first responders load the patient into the bus and drive to the ship, off load from the ambulance, reload into the helicopter. Then Airlift has to make sure the patient is safe to fly and they are safe to fly with him. There isn't a lot of room inside. Often the patient's feet are next to the pilot's head. If the patient is thrashing around from pain, or confusion the nurse or medic will paralyze them and intubate, just for safety. It doesn't do any good to takeoff quickly and have the pilot kicked unconscious and crash.
Also, even though a level one trauma center is preferable, with major, uncontrollable bleeding, closer is better. Any ER is a better environment to control it than the school parking lot. Formost, they have access to banked blood, They can get unmatched
O-neg in a matter of minutes. They can transfer after the patient is stable.

4. In the ER, whether a level one trauma center or Bob's ER, certain things will happen. If the patient isn't intubated, they will be, blood loss causes hypotension, hypotension causes unconsciousness, unconsciousness causes loss of automatic airway protection, loss of airway protection, often causes death. Also, hypoventilation (not breathing enough) along with hypotension, means the cells are being deprived of the oxygen they need.
Even though the endotracheal tube has a cuff ( a circumferential balloon on the tube to prevent liquid from running into the lungs around the tube) a Nasogastric tube will also be placed to prevent vomiting. At least two large bore IVs, or a multilumin central line, will be placed to give blood, supportive medications and fluids rapidly. If they are at their final destination, (ie) a level one trauma center, an arterial line, to monitor blood pressure and to do serial lab work will also go in.
If the bleeding can't be controlled in ER, they would go directly to OR, where all these things would be done, while the surgeon works on stopping the bleeding. There could be upwards of a dozen people working on the patient at the same time.

5. All of the things being done to stop the bleeding and to save the life have their own consequences. Banked blood has an anticoagulant in it, after every 4 units, a reversing agent needs to be given. If it can't be given because the blood is being dumped in so fast, then bleeding from other places may start. Since banked blood has some of the components removed, those components have to be given as well. Platelets, and plasma are the two most important ones. They contain the important clotting factors that have been diluted in the patient.

Blood is cold, a major drop in body temp can cause arrhythmias. fluids, including blood are often given on a Level A rapid infuser. Which delivers large volumes and warms the fluid going in.
If the injury was in the chest, the blood could be collected in a special container and be reinfused, but abdominal wounds run too much risk of contamination.

6. As I mentioned, the blood loss causes hypotension. The hypotension is actually more complicated. It's really hypovolimic shock. If fluids and blood could be replaced fast enough, it would reverse itself once the tank was full again. Unfortunately, that usually doesn't happen. One thing happening, is the tissues aren't getting all the oxygen they require, oxygen deprived cells die. That is brain cells, heart cells, kidney cells, liver cells. if enough die, function stops. Even with the breathing tube, and 100% oxygen, the cells can't get enough if the blood pressure isn't high enough to push the blood to those organs. Eventually hypovolimic shock becomes cardiogenic shock, which is infinitely harder to reverse. So, we introduce pressors. Dopamine, Epinephrine, and last resort, Norepinephrine, brand name, Levophed, nicknamed "Leave-em-dead".
(Here, I find myself wanting to explain the way pressors work. That would take way too much time. Just trust me on this one, unless there's a pharmacist out there willing to explain Alpha and Beta effects of pressors)
The stress of the injury, the blood loss and shock causes the body to use it's catecholamines faster than it can produce them. Dopamine is a precursor to epinephrine. It raises blood pressure with the least negative impact and the end organs. If it dosen't work, or stops working Epinephrine can be added. Epi has more vasoconstrictive properties, and can cause too much stress on an already compromised heart. Norepinephrine is a last resort, because its vasoconstrictive power can compromise even a healthy heart.

Ok, I just looked this over, and I think I may be going off on a tangent. Tell me if any of this is helpful, or if it just sounds like babbling.

gabriela & outlierrn, one of you start it, I'll participate.