Trauma ICU Rounds: Recent Episodes
Dr. Dennis Kim
Medical education podcast dedicated to providing high-quality, concise, and clinically relevant multimedia content spanning the spectrum of surgical critical care, emergency general & trauma surgery
Join us after hours at Dr. Bryan A. Cotton's pop-up bourbon bar at the AAST 2022 Meeting in Chicago. In this FANTASTIC & FUN episode, we talk amongst friends about cutting edge research at this year's meeting. To no one's surprise, coagulopathy, damage control resuscitation, whole blood, and factor replacement therapy just happen to be but a few of the topics discussed on Rounds.
Time Stamps:
00:12 AAST 2022 - Intro
00:42 Sex diamoprhisms in coagulation
01:52 Hemostatic profiles of female donors
02:48 Pediatric whole blood (WB) is safe
03:10 WB for TBI
03:31 Leukoreduction is unnecessary
05:30 TXA, TEG and trauma
06:44 STAAMP trial
07:21 TXA: go early, big or go home
07:52 Calcium...early!
09:33 Canadian perspective on TXA and TEG – Neil Perry from London, ON
11:25 Nori Bradley from Edmonton, AB
13:53 Jordan Weinberg, not Canadian – Phoenix, AZ
16:12 Issues with WB – COMBAT vs PAMPer
17:31 Cold stored platelets
18:22 Rapid transfusers and whole blood: Only the strong survive!!
19:42 How are we doing with our resuscitation? 1:1:1 is just the beginning, not the end!
21:44 Timing is everything!
23:38 Plasma first resuscitation: “…God damn good!” -BAC
24:37 Dr. Joshua B. Brown - Pittsburgh, PA
25:31 More Canadian perspectives with Perry and Bradley
29:48 Less is best!
31:27 Prothrombin complex concentrate: Yay or nay?
32:18 More on the endotheliopathy of trauma
33:38 Just messing around and having a blast
34:22 What was the best bourbon tonight?
References:
CRASH-2 trial collaborators, Shakur H, Roberts I, Bautista R, Caballero J, Coats T, Dewan Y, El-Sayed H, Gogichaishvili T, Gupta S, Herrera J, Hunt B, Iribhogbe P, Izurieta M, Khamis H, Komolafe E, Marrero MA, Mejía-Mantilla J, Miranda J, Morales C, Olaomi O, Olldashi F, Perel P, Peto R, Ramana PV, Ravi RR, Yutthakasemsunt S. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010 Jul 3;376(9734):23-32. doi: 10.1016/S0140-6736(10)60835-5. Epub 2010 Jun 14. PMID: 20554319.
Gruen DS, Guyette FX, Brown JB, Okonkwo DO, Puccio AM, Campwala IK, Tessmer MT, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Neal MD, Zuckerbraun BS, Yazer MH, Billiar TR, Sperry JL. Association of Prehospital Plasma With Survival in Patients With Traumatic Brain Injury: A Secondary Analysis of the PAMPer Cluster Randomized Clinical Trial. JAMA Netw Open. 2020 Oct 1;3(10):e2016869. doi: 10.1001/jamanetworkopen.2020.16869. PMID: 33057642; PMCID: PMC7563075.
Guyette FX, Brown JB, Zenati MS, Early-Young BJ, Adams PW, Eastridge BJ, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Alarcon LH, Callaway CW, Zuckerbraun BS, Neal MD, Forsythe RM, Rosengart MR, Billiar TR, Yealy DM, Peitzman AB, Sperry JL; STAAMP Study Group. Tranexamic Acid During Prehospital Transport in Patients at Risk for Hemorrhage After Injury: A Double-blind, Placebo-Controlled, Randomized Clinical Trial. JAMA Surg. 2020 Oct 5;156(1):11–20. doi: 10.1001/jamasurg.2020.4350. Epub ahead of print. Erratum in: JAMA Surg. 2021 Jan 1;156(1):105. PMID: 33016996; PMCID: PMC7536625.
Moore HB, Moore EE, Chapman MP, McVaney K, Bryskiewicz G, Blechar R, Chin T, Burlew CC, Pieracci F, West FB, Fleming CD, Ghasabyan A, Chandler J, Silliman CC, Banerjee A, Sauaia A. Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: a randomised trial. Lancet. 2018 Jul 28;392(10144):283-291. doi: 10.1016/S0140-6736(18)31553-8. Epub 2018 Jul 20. PMID: 30032977; PMCID: PMC6284829.
Pusateri AE, Moore EE, Moore HB, Le TD, Guyette FX, Chapman MP, Sauaia A, Ghasabyan A, Chandler J, McVaney K, Brown JB, Daley BJ, M
Support the show
In this episode we sit down with the Chief of Trauma, Surgical Critical Care, Burns, & Acute Care Surgery at the University of Arizona, Dr. Bellal Joseph, who share with us his thoughts and research findings on hot topics including frailty, geriatric trauma, leadership, and more.
Timestamps:
00:12 Introductions
01:30 What is frailty? Your physiologic NOT chronologic body.
06:58 Injured elderly trauma patients can have good outcomes
07:30 Trauma specific frailty index
10:48 Failure to rescue
13:57 Geriatricians and the trauma surgeons
15:08 4Ms-What Matters, Mobility, Mentation, Medication
16:48 Geriatric cohorting/wards
22:24 ACS geriatric centers of excellence
29:35 Brain Injury Guidelines (BIG)
38:17 The importance of teamwork & servant leadership
40:28 Imposter syndrome
43:19 Leadership considerations
45:25 Final thoughts
References:
Joseph B, Friese RS, Sadoun M, Aziz H, Kulvatunyou N, Pandit V, Wynne J, Tang A, O'Keeffe T, Rhee P. The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons. J Trauma Acute Care Surg. 2014 Apr;76(4):965-9. doi: 10.1097/TA.0000000000000161. PMID: 24662858.
Joseph B, Obaid O, Dultz L, Black G, Campbell M, Berndtson AE, Costantini T, Kerwin A, Skarupa D, Burruss S, Delgado L, Gomez M, Mederos DR, Winfield R, Cullinane D; AAST BIG Multi-institutional Study Group. Validating the Brain Injury Guidelines: Results of an American Association for the Surgery of Trauma prospective multi-institutional trial. J Trauma Acute Care Surg. 2022 Aug 1;93(2):157-165. doi: 10.1097/TA.0000000000003554. Epub 2022 Mar 28. PMID: 35343931.v
Joseph B, Pandit V, Haider AA, Kulvatunyou N, Zangbar B, Tang A, Aziz H, Vercruysse G, O'Keeffe T, Freise RS, Rhee P. Improving Hospital Quality and Costs in Nonoperative Traumatic Brain Injury: The Role of Acute Care Surgeons. JAMA Surg. 2015 Sep;150(9):866-72. doi: 10.1001/jamasurg.2015.1134. PMID: 26107247.
Joseph B, Pandit V, Sadoun M, Zangbar B, Fain MJ, Friese RS, Rhee P. Frailty in surgery. J Trauma Acute Care Surg. 2014 Apr;76(4):1151-6. doi: 10.1097/TA.0000000000000103. PMID: 24662884.
Orouji Jokar T, Ibraheem K, Rhee P, Kulavatunyou N, Haider A, Phelan HA, Fain M, Mohler MJ, Joseph B. Emergency general surgery specific frailty index: A validation study. J Trauma Acute Care Surg. 2016 Aug;81(2):254-60. doi: 10.1097/TA.0000000000001120. PMID: 27257694.
Support the show
In this episode, we talk all things critical care the one and only, Dr. Jean-Louis Vincent aka. JLV. This episode is a MUST listen. We touch upon the evolution of early goal directed therapy, measures of fluid responsiveness, optimizing oxygen delivery, and the importance of integrating data points versus examining them in isolation when caring for our critically ill and injured patients. This and MUCH MUCH more in arguably one of my favorite episodes to date!!
Timestamps
00:00 Introduction
01:21 What happened to SG catheters and should we use them?
04:05 What decreases mortality in critical care patients?
05:30 When to transfuse critical care patient? Use your brain!
08:55 Measures of tissue perfusion and fluid responsiveness
09:36 JLV breaks down the Rivers trial
10:36 Recent EGDT papers
10:54 How to optimize O2 delivery? Late ScVO2, dob challenge, and fluid challenges
13:21 Dynamic measures of fluid responsiveness
13:46 CVP as a relative value
15:14 Passive leg raising (PLR) as a measure of fluid responsiveness
21:20 JLV's take on therapeutic nihilism
24:45 Don’t isolate; integrate!
26:46 Navigating the future of critical care – JLV’s thoughts on AI in the ICU
29:55 Rapid fire hot topics in the ICU – Yes or No
-Metabolic cocktail
-Corticosteroids for septic shock
-Albumin and Lasix or Lasix alone
PCT/CRP and sepsis/Abx
Resources:
International Symposium on Intensive Care and Emergency Medicine (ISICEM):
https://www.isicem.org
ISICEM Chats Platform:
https://www.isicem.org/e-chat/index.asp
Articles:Passive leg raising:five rules, not a drop of fluid! https://ccforum.biomedcentral.com/articles/10.1186/s13054-014-0708-5
The fluid challenge
https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-03443-y
Blood lactate levels in sepsis: 8 questions
Vincent JL, Bakker J. Blood lactate levels in sepsis: in 8 questions. Curr Opin Crit Care. 2021 Jun 1;27(3):298-302. doi: 10.1097/MCC.0000000000000824. PMID: 33852499.
We should avoid the term "fluid overload"
https://ccforum.biomedcentral.com/articles/10.1186/s13054-018-2141-7
EGDT in the Treatment of Severe Sepsis and Septic Shock
https://www.nejm.org/doi/full/10.1056/nejmoa010307
A Randomized Trial of Protocol-Based Care for Early Septic Shock
https://www.nejm.org/doi/full/10.1056/nejmoa1401602
Support the show
It's been a while! We are coming to you from our new studio in Victoria on Vancouver Island, BC. This Season is PACKED with incredible content, interviews and educational pearls designed to improve the quality of care that you are deliver daily at the bedside to your patients and their loved ones.
Support the show
In this episode, we discuss the overarching importance of AVOIDING iatrogenic harm in the ICU with arguably one of the world's leading experts in critical care medicine, the one and only, Dr. Jean-Louis Vincent aka. JLV.
Tune in as Dr. Vincent shares with us the importance of having a systematic, problem-based approach to patient care delivery which, of course, involves giving our patients a FAST HUG every day!
Time Stamps:
2:10 LA Critical Care and Differences between Europe versus USA
4:04 COVID, Modern tech and bedside care
5:32 ICU Rounds – How I do it
6:00 Team Based ICU Care
7:56 Modern advances in critical care
9:55 Problem-based approach in the ICU
13:18 FAST HUGS
14:00 Feeding
14:36 Analgesia & Sedation
15:46 Thromboembolic prophylaxis
16:25Head of the bed elevated
17:17Ulcer prophylaxis
19:22Glucose control
20:48 Tube feeds, yes? Ulcer ppx , no.
22:30 Outro
Support the show
"Getting patients resuscitated through sepsis, septic shock, and hemorrhagic shock is not the end...it's the beginning."
In this episode, Dr. Brakenridge from Harborview Medical Center joins us to discuss PICS and the impact of this syndrome on our critically ill and injured patients and their families. Also referred to as the Post-Intensive Care Syndrome, Dr. Brakenridge shares with us the evolution and results of translational research into this now well-recognized morbid condition which often occurs in the setting of chronic critical illness. From the importance of breaking the cycle of "sepsis recidivism" to the. application of the SCCM A to F bundle, this episode is a MUST listen for those of us taking care of patients in the ICU.
TIME STAMPS00:12 Introduction
01:46 What is PICS? The role of chronic critical illness (CCI)
05:13 Phenotypes vs. endotypes
06:47 The role of biomarkers in PICS
08:50 When does acute critical illness turn into CCI?
10:14 Risk factors for PICS
15: 07 Prognostication and determining patient trajectory
18:32 The Glue Grant Experience: Genomics of Injury
22:48 Hemorrhagic shock resuscitation: Then and now
25:33 Sepsis recidivism & avoiding secondary insults
29:08 ICU delirium
31:55 The role of early mobilization
32:41 The impact of catabolism in sepsis
34:50 Is there a role for anabolic steroids to counteract PICS?
37:52 What's ahead in terms of PICS translational research?
39:44 Cytokine and immunomodulator therapies
41:49 Final thoughts
RECOMMENDED READINGS
Brakenridge SC, Wang Z, Cox M, Raymond S, Hawkins R, Darden D, Ghita G, Brumback B, Cuschieri J, Maier RV, Moore FA, Mohr AM, Efron PA, Moldawer LL. Distinct immunologic endotypes are associated with clinical trajectory after severe blunt trauma and hemorrhagic shock. J Trauma Acute Care Surg. 2021 Feb 1;90(2):257-267.
Efron PA, Mohr AM, Bihorac A, Horiguchi H, Hollen MK, Segal MS, Baker HV, Leeuwenburgh C, Moldawer LL, Moore FA, Brakenridge SC. Persistent inflammation, immunosuppression, and catabolism and the development of chronic critical illness after surgery. Surgery. 2018 Aug;164(2):178-184. doi: 10.1016/j.surg.2018.04.011. Epub 2018 May 26.
Sauaia A, Moore FA, Moore EE. Postinjury Inflammation and Organ Dysfunction. Crit Care Clin. 2017 Jan;33(1):167-191.
Stortz JA, Murphy TJ, Raymond SL, Mira JC, Ungaro R, Dirain ML, Nacionales DC, Loftus TJ, Wang Z, Ozrazgat-Baslanti T, Ghita GL, Brumback BA, Mohr AM, Bihorac A, Efron PA, Moldawer LL, Moore FA, Brakenridge SC. Evidence for Persistent Immune Suppression in Patients Who Develop Chronic Critical Illness After Sepsis. Shock. 2018 Mar;49(3):249-258.
Support the show (https://www.patreon.com/traumaicurounds)
In this, our 50th episode, we are in Austin, TX, for the Annual EAST Scientific Meeting where we are joined by Dr. Bryan A. Cotton who shares his expertise and knowledge regarding the use of whole blood (WB) in trauma patients. From the use of whole blood in prior military conflicts to the design and successful implementation of one of the only prospective randomized controlled trials of modified whole blood use in trauma patients, Dr. Cotton provides an incredible overview of the potential benefits of whole blood or as he refers to it - "the dying blood product". Also covered in expert fashion are the role of other hemostatic products and strategies including tranexamic acid, fibrinogen concentrates, and a plasma first resuscitation strategy.
Time Stamps:
01:16 The rationale for whole blood & a 1:1:1 transfusion strategy
04:24 Military experience with WB: What's old is new again!
05:44 Modified WB vs. Component Therapy RCT
06:02 Leukoreduction of WB
07:00 Type-specific WB
09:38 Platelet function in WB vs. aphaeresis platelets
11:58 Warm fresh WB vs. cold stored
12:55 The whole is greater than the sum of its parts
15:02 What do we mean by low-titer WB?
19:14 O+ vs. O- WB & the potential for alloimmunization
24:39 Transfusion reactions & safety of WB in trauma patients
25:40 Prehospital WB for the win
27:32 LITES Network
28:27 Hemorrhage control, 1:1:1, viscoelastic assays, cryoprecipitate & fibrinogen
concentrate
32:00 BAC's thoughts on tranexamic acid (TXA)
34:47 BAC's thoughts on hypertonic saline (HTS) for COVID-19
38:51 Final thoughts & future directions
Recommended Readings:
Cotton BA, Podbielski J, Camp E, Welch T, del Junco D, Bai Y, Hobbs R, Scroggins J, Hartwell B, Kozar RA, Wade CE, Holcomb JB; Early Whole Blood Investigators. A randomized controlled pilot trial of modified whole blood versus component therapy in severely injured patients requiring large volume transfusions. Ann Surg. 2013 Oct;258(4):527-32; discussion 532-3.
Williams J, Merutka N, Meyer D, Bai Y, Prater S, Cabrera R, Holcomb JB, Wade CE, Love JD, Cotton BA. Safety profile and impact of low-titer group O whole blood for emergency use in trauma. J Trauma Acute Care Surg. 2020 Jan;88(1):87-93.
McGinity AC, Zhu CS, Greebon L, Xenakis E, Waltman E, Epley E, Cobb D, Jonas R, Nicholson SE, Eastridge BJ, Stewart RM, Jenkins DH. Prehospital low-titer cold-stored whole blood: Philosophy for ubiquitous utilization of O-positive product for emergency use in hemorrhage due to injury. J Trauma Acute Care Surg. 2018 Jun;84(6S Suppl 1):S115-S119.
Sperry JL, Guyette FX, Brown JB, Yazer MH, Triulzi DJ, Early-Young BJ, Adams PW, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Witham WR, Putnam AT, Duane TM, Alarcon LH, Callaway CW, Zuckerbraun BS, Neal MD, Rosengart MR, Forsythe RM, Billiar TR, Yealy DM, Peitzman AB, Zenati MS; PAMPer Study Group. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018 Jul 26;379(4):315-326. doi: 10.1056/NEJMoa1802345. PMID: 30044935.
Yazer MH, Jackson B, Sperry JL, Alarcon L, Triulzi DJ, Murdock AD. Initial safety and feasibility of cold-stored uncrossmatched whole blood transfusion in civilian trauma patients. J Trauma Acute Care Surg. 2016 Jul;81(1):21-6. doi: 10.1097/TA.0000000000001100. PMID: 27120323.
Websites:
LITES Network
https://www.litesnetwork.org
Southwest Texas Regional Advisory Council
https://www.strac.org/blood
Support the show (https://www.patreon.com/traumaicurounds)
In the second episode of a two-part series, Dr. Mattox shares his insights and thoughts on hot research topics in trauma in need of investigation. Additionally, he helps us to envision what acute trauma management may look like in the future, while also sharing with us how his book (and one of my ALL-TIME fave surgery books!), Top Knife, came into being. From lessons learned to lessons in need of learning, Dr. Mattox has all of the bases (and basics) covered.
Time Stamps
0:00 Introduction
00:12 "The resuscitation is the incision."
00:44 Welcome & Announcements/Call to Action
02:24 Whole blood is good but.....what should our endpoint of resuscitation be?
03:05 Drones in the prehospital setting
08:03 Reimagining the ER
08:57 General Surgery training: Then & now
10:00 Top Knife, Trauma, Rich’s Vascular Trauma
11:33 How Top Knife came into being – Saturday mornings, coffee, Mary Allen & a tape recorder
16:57 To operate or not operate?
22:11 Mattox Vegas TCCACS
26:11 Final thoughts: ”There’s always a better way."
Support the show (https://www.patreon.com/traumaicurounds)
We. Are. Back!!
After a (brief?!) hiatus, we are launching 2022 with a 2-part series with the one and only Dr. Ken Mattox. In this episode, Dr. Mattox shares with us his thoughts on what the modern general surgeon should look like and how we as surgeons differ from our medicine counterparts. Additionally, we review the history of modern trauma resuscitation, the paradigm shifts that have occurred as it pertains to permissive hypotension, as well as the technological advances that have occurred over the last century that have improved care of the critically injured patient. This is an episode not to be missed!
Time Stamps00:12 Welcome & announcements
04:21 What does the modern "surgeon" look like?
07:48 The interplay between technology & surgery
10:15 Serendipity & Dr. Mattox's early career
11:28 Finessing & integrating clinical practice with research opportunities
13:45 The 2 most impactful advances in trauma care during the last century: the microchip & organized trauma systems
17:00 Dr. Mattox's thoughts on REBOA & intravascular control/treatment techniques
22:32 MAST pants: lessons learned
25:18 Elevate the BP with MAST and fluids? Increase the mortality!!
26:30 Permissive hypotension
27:06 Vasopressors in the ER?! Hypotension is teleological!!
ReferencesBickell WH, Pepe PE, Wyatt CH, Dedo WR, Applebaum DJ, Black CT, Mattox KL. Effect of antishock trousers on the trauma score: a prospective analysis in the urban setting. Ann Emerg Med. 1985 Mar;14(3):218-22. doi: 10.1016/s0196-0644(85)80443-1. PMID: 3977145.
Bickell WH, Wall MJ Jr, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994 Oct 27;331(17):1105-9. doi: 10.1056/NEJM199410273311701. PMID: 7935634.
Hirshberg A, Hoyt DB, Mattox KL. From "leaky buckets" to vascular injuries: understanding models of uncontrolled hemorrhage. J Am Coll Surg. 2007 Apr;204(4):665-72. doi: 10.1016/j.jamcollsurg.2007.01.005. Epub 2007 Feb 23. PMID: 17382227.
2022 Mattox Vegas TCCACS
https://www.trauma-criticalcare.com/tccacs/program/
Support the show (https://www.patreon.com/traumaicurounds)
Dr. Wes Ely from Vanderbilt University School of Medicine joins us on Rounds to discuss the evolution of our understanding and the current impact of ICU-acquired brain disease on our patients and their loved ones. In addition to discussing the evidence behind current best practices in the ICU, Dr. Ely shares with us stories from his new book which highlight the importance of listening to, engaging with, and remaining vulnerable to those whom we are so fortunate and blessed to serve-our patients.
Support the show (https://www.patreon.com/traumaicurounds)
In follow-up to a recent pro-con debate on the use of pre-hospital pelvic binders, we explore the why, when, and how of pelvic binder placement. From the indications to post-placement considerations and importance of a multidisciplinary approach to the management of these life-threatening injuries, this episode of Rounds is a great addition to Season 1 Episode 24 Hemodynamically Unstable Pelvic Fractures with Dr. Clay Burlew.
Time Stamps
00:12 Welcome
02:52 Learning Objectives
03:43 Introduction
05:58 Initial Assessment & Management of Patients with Suspected Hemodynamically Unstable Pelvic Fractures
09:54 Young-Burgess Classification of Pelvic Ring Fractures
12:00 Indications, Technique, and Considerations for Properly Placing a Pelvic Binder
17:30 Hemostatic Adjuncts in the Management of Patients with Hemodynamically Unstable Pelvic Fractures
22:13 Take Home Points
23:11 Outro & Call to Action
Support the show (https://www.patreon.com/traumaicurounds)
In this episode, we sit down with Dr. Carlos VR Brown from the Dell Seton Medical Center at the University of Texas to discuss issues relevant to both junior and mid-career trauma & acute care surgeons.
Topics covered include: military-civilian trauma, finding one's niche in academic surgery, work-life balance, and learning from our mistakes. As I prepare to enter a new phase in my academic surgical career, the timing of this interview could not have been more perfect. This episode is packed with career pearls and words of wisdom that are not to be missed!
Time Stamps00:12 Introduction
02:37 Welcome Dr. CVR Brown
05:39 When did your interest in trauma surgery begin?
08:26 Military versus civilian trauma surgery
11:16 Carlos Brown is a Hero (No Matter What He Says)
13:18 Military & advances in clinical knowledge
14:29 Research & the importance of mentorship
15:04 The path to academic surgery: LAC-USC 2002-2007
17:45 Mentorship and research
20:31 Coming home & the opportunity to build
23:33 What is really important in a job? People, place, and family
26:32 “If you build it, they will come” BUT you need to surround yourself with REALLY GOOD people. Oh, and time management is also essential!
28:08 If you don’t have to be at work, leave! And go do the things that bring pleasure to you outside of work.
30:25 “We all make mistakes….”
31:36 Ask yourself, “What’s the best fit for both your career and family?”
32:51 Outro and call to action
Links:
Carlos Brown is a Hero (No Matter What He Says)
https://www.texasmonthly.com/articles/carlos-brown-is-a-hero-no-matter-what-he-says/
Support the show (https://www.patreon.com/traumaicurounds)
Massive upper GI bleeds can be intimidating and lethal. An expeditious, multidisciplinary approach is required to improve survival and optimize patient outcomes.
Time Stamps:
00:12 Welcome & Introduction
01:55 Goals & Objectives
02:29 Common Etiologies & Differential Diagnosis for UGIBs
05:15 Initial Evaluation
10:52 Initial Management
15:38 Indications & Timing of Endoscopic and Non-Endoscopic Interventions
18:19 Forrest Classification of Peptic Ulcers
20:43 Indications & Timing of Surgical Interventions
21:30 Surgical management of Bleeding Peptic Ulcers
23:40 Take Home Points
25:10 CTA
Consider becoming a Patron of the Show!
Support the show (https://www.patreon.com/traumaicurounds)
Our first in-person interview since the start of the COVID pandemic! Join us for National Stop the Bleed Day as Dr. Kenji Inaba from LAC+USC joins us to discuss management of penetrating cardiac injuries, the Los Angeles County Hospital Emergency Response Team (HERT), and recent updates to the Stop the Bleed campaign. From the utility of FAST to the diagnostic (and potentially therapeutic?!) role of subxyphoid windows, this episode has it all and is not to be missed!
Also, remember to check out Season 1 , Episode 11 - National Stop the Bleed Day & Tourniquet Use in 2020.
Support the show (https://www.patreon.com/traumaicurounds)
Join us as we discuss surgical management options for the difficult gallbladder. Is it better to open or proceed with a laparoscopic subtotal cholecystectomy? If the latter, fenestrated or reconstituted? What's the difference?! This week on Rounds, we have several guest professors join us to discuss their perspectives and experience on managing patients with a difficult gallbladder. Joining us from Texas (and favoring subtotal cholecystectomy) are Drs. Sharmila Dissanaike and Michael Truitt. Drs. Angela Neville and Jessica Keeley from California discuss the merits of converting to an open cholecystectomy for patients with a difficult gallbladder. Also, joining us is Dr. Christian de Virgilio, who co-moderates this lively and educational podcast episode alongside me.
Support the show (https://www.patreon.com/traumaicurounds)
Bowel obstructions may be due to mechanical or functional causes. Although acute colonic pseudo-obstruction (ACPO) falls into the latter category, we must ALWAYS rule out mechanical causes for massive distension of the colon.
In this episode, we make our way down the GI tract and discuss the pathophysiology, risk factors, diagnostic and therapeutic considerations for what Dr. Ogilvie coined "Large-intestine Colic" in 1948.
Support the show (https://www.patreon.com/traumaicurounds)
Whether due to occlusive or nonocclusive obstruction of the arterial inflow or obstruction of venous outflow, acute mesenteric ischemia (AMI) continues to be associated with high mortality rate. Early recognition based on a high index of suspicion is critical to early diagnosis and intervention, particularly among patients presenting with pain out of proportion to physical exam findings. In this episode, we discuss the pathophysiology of AMI, together with common causes, the initial clinical presentation, and management strategies for patients with this life-threatening and elusive surgical disease process.
Support the show (https://www.patreon.com/traumaicurounds)
Rare. Morbid. Lethal. NSTIs area group of infections which result in aggressive tissue destruction, systemic toxicity, and can involve any layer of the soft tissue. The key to successful management (like so many disease processes) is having a high index of suspicion together with administration of early, broad-spectrum antibiotics and surgery.
Support the show (https://www.patreon.com/traumaicurounds)
Dr. Scott Weingart joins us on Rounds to discuss a topic that's of great interest to the both of us - surgical cricothyroidotomy. Tune in to hear how Scott's approach to performing a cric has evolved over time and why "trauma surgeons are the worst people to learn crics from?!" From 3 strikes and your out to the use of bougies, this episode covers all things cric.
Also check out Episode 23 of Rounds "Surgical Cricothyroidotomy: How I Do It". Even better go to: https://emcrit.org/emcrit/surgical-airway/ and review the FANTASTIC content that has been put together by Scott and his team at EMCrit.
Support the show (https://www.patreon.com/traumaicurounds)
What are the determinants of mean airway pressure? Is too much PEEP ever a bad thing? In this episode, we review determinants of oxygenation in mechanically ventilated patients and discuss the benefits and risks of high versus low PEEP strategies, as well as the utility of lung volume recruitment maneuvers.
Check out our previous related episodes 1, 3, 6, 10, and 36.
Support the show (https://www.patreon.com/traumaicurounds)
Back to the basics! In this episode we review the evolving criteria, etiologies, and pathophysiology of ARDS. A brief review of ventilator induced lung lung injury and initial vent setup provide the groundwork for future episodes exploring how to troubleshoot the vent and therapies for ARDS that have been shown to improve oxygenation and mortality. Please check out Episodes
Support the show (https://www.patreon.com/traumaicurounds)
Dr. Jamie Coleman from Denver Health joins us on Rounds to share her insights and knowledge surrounding wellness, sleep, and stress among surgeons and frontline workers. From healthy pre-call preparation and tips on healthy sleep hygiene to harnessing resilience and measuring the burden of unacknowledged mental health disorders on health care professionals, this episode is a MUST listen for all of us who need to be reminded that sometimes, "It's okay not to be okay".
Support the show (https://www.patreon.com/traumaicurounds)
Dr. Martin Zielinski from the Mayo Clinic, Rochester, MN, joins us on Rounds to discuss best practices in the management of bowel obstruction. In this episode, we review common etiologies for bowel obstruction, discuss the role of imaging, as well as the significance of clinical and radiographic findings on the likelihood of operative intervention. Dr. Zielinski also shares with us the Gastrografin swallow protocol that has been successfully developed and implemented at the Mayo Clinic in the management of patients with small bowel obstruction.
Support the show (https://www.patreon.com/traumaicurounds)
In this follow-up episode to our discussion with Dr. Scott Weingart of EMCrit, we review the indications for performing a resuscitative thoracotomy, together with the potential application of a circulation first resuscitation strategy, and some intricacies regarding performing a surgical cricothyroidotomy.
Support the show (https://www.patreon.com/traumaicurounds)
Dr. Walt Biffl from Scripps Memorial Hospital La Jolla joins us on Rounds to discuss the evolution of BCVI management from the early 1990s to present day. Topics discussed include screening criteria, the diagnostic approach and imaging modalities for accurately identifying these injuries in our blunt polytrauma pateints. Grading criteria, antithrombotic therapies, and the use of endovascular stents round out this informative discussion with one of the world's leading experts on the topic.
Check out the Show Notes at www.traumaicurounds.com
Also, you can find the updated 2020 EAST BCVI PMG here:
https://www.east.org/education/practice-management-guidelines/blunt-cerebrovascular-injury-evaluation-and-management-of
Support the show (https://www.patreon.com/traumaicurounds)
Who should be primarily responsible for managing vascular injuries? Trauma surgery? Vascular surgery? BOTH?! In this episode, we join the teams from the highly successful Behind the Knife and Audible Bleeding Podcasts to discuss the importance of a collaborative approach to the management of vascular trauma in an era marked by a decrease in general surgery resident experience with operative vascular trauma cases, together with an increase in the number of programs offering an integrated vascular surgery residency. Drs. Tanya Zakrison and Matt Martin (Team Trauma) debate Drs. Benjamin Starnes and Wesley Ohman (Team Vascular) on a topic that has brought about some "heated" exchanges on social media platforms such as Twitter.
Support the show (https://www.patreon.com/traumaicurounds)
Dr. Joel Topf joins us on Rounds to discuss and review key concepts in the recognition and management of acute kidney injury (AKI) in the SICU. AKI is a common and morbid complication among hospitalized patients. Further, trauma and surgical patients, in particular, are at an increased risk for AKI due to the myriad of pre-, intra-, and postrenal insults that commonly occur at the time of injury, during resuscitation, surgery,, as well as from iatrogenic insults including IV contrast, NSAIDs, antibiotics (aminoglycosides and the infamous Pip/Tazo/Vanco ice cream sandwich).
From the use of a DDAVP clamp in patients with severe hyponatremia to the use of balanced solutions in critically ill patients, kidney_boy breaks it down for us as only a true salt whisperer can!
Support the show (https://www.patreon.com/traumaicurounds)
In recognition of Sepsis Awareness Month, Dr. Matt Martin joins us once again on Rounds to discuss state-of-the-art sepsis management in 2020. Also joining us on Rounds is Dr. Vanessa Ho from MetroHealth Medical Center in Cleveland, Ohio, who authored a recently published review paper in Surgical Infections earlier this year, "Sepsis 2019: What Surgeons Need to Know".
Support the show (https://www.patreon.com/traumaicurounds)
What are the 5 or 6 Ps? If you answered Pain, Pain, Pain, Pain, Pain, and Pain, you can go right ahead and skip this episode. Extremity compartment syndrome is an acute surgical emergency and requires a HIGH index of suspicion in order to make the diagnosis. Therapy consists of fasciotomy. If left untreated, numerous complications and sequelae may develop including AKI and even death.
Support the show (https://www.patreon.com/traumaicurounds)
Over the course of 30+ episodes, we'll be discussing fundamental surgical disease processes & conditions that may prove challenging to even the most seasoned acute care surgeon. Along the way, we'll be joined on Rounds by an incredible group of guest professors who will share their experiences, expertise, and results of recent research investigations with us.
Support the show (https://www.patreon.com/traumaicurounds)
So apparently not all of the listeners of the show are on Twitter?! In this brief recap of Season 1 (yes, Season 1 is done!) we pay thanks to all of our guest professors, provide you with an update of where we are in terms of the Season 2 launch, and, as usual, invite you to engage with me, the show, and our social media account.
Support the show (https://www.patreon.com/traumaicurounds)
Dr. Megan Brenner joins us on Rounds to discuss the evolving role of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the management of trauma & acute care surgery patients with non-compressible torso hemorrhage. Advances in technology, evolving indications, and controversies regarding the appropriate and safe deployment of REBOA are but a few of the topics covered in this episode.
Support the show (https://www.patreon.com/traumaicurounds)
Dr. Clay Burlew from Denver Health joins us Rounds to discuss the management of trauma patients with hemodynamically unstable pelvic ring fractures. Topics covered during this episode include utility and technique of preperitoneal packing (PPP), evolution of the institutional multidisciplinary pathway for the management of unstable pelvic fractures at Denver Health, and use of REBOA as an adjunct to hemorrhage control in patients with these potentially devastating injuries.
Support the show (https://www.patreon.com/traumaicurounds)
Knife. Finger. Tube. Sounds simple enough. And you read correctly....a bougie is both unnecessary and superfluous! In this episode I share you some tricks of the trade for performing a cric successfully, together with post-surgical airway considerations including hemorrhage control and the decision to convert to a formal tracheostomy.
Support the show (https://www.patreon.com/traumaicurounds)
In this episode we discuss endpoints of resuscitation with a focus on the pros and cons of both passive and dynamic hemodynamic measurements including arterial pressure waveform analysis, ultrasonography, and passive leg raising. Please visit www.traumaicurounds.com and check out the Vidcast for this episode.
Support the show (https://www.patreon.com/traumaicurounds)
Dr. Eric Simms joins us on Rounds to share with us his foolproof and fun way of remembering the dreaded coagulation cascade. Supplementing this podcast is a vidcast (https://www.traumaicurounds.ca/vidcasts) that provides us with a helpful visual explanation for understanding the key factors, steps, and intricacies of the coagulation cascade.
Support the show (https://www.patreon.com/traumaicurounds)
Dr. Eric Ley from Cedars-Sinai Medical Center joins us on Rounds to discuss the recently published Western Trauma Association's Critical Decisions Algorithm for reducing VTE in trauma patients. Early risk stratification, timing and initial dose of LMWH, weight-based dosing, and surveillance screening are just a few of the key topics we discuss on this episode.
Support the show (https://www.patreon.com/traumaicurounds)
Dr. Martin Schreiber, Division Head of Trauma, Critical Care, and Acute Care Surgery at Oregon Health and Science University (OHSU) joins us on Rounds to discuss the results of his recently accepted prospective RCT of prehospital TXA use in adult patients with traumatic brain injury. In addition, we discuss the rise of hemostatic adjuncts, balanced resuscitation, and the potential challenges associated with publishing research in one of the top medical journals - JAMA.
Support the show (https://www.patreon.com/traumaicurounds)
In this Rapid Rounds, we provide a quick and closer look at the Yang & Tobin index as originally described in the 1991 NEJM paper.
Support the show (https://www.patreon.com/traumaicurounds)
Determining whether or not your intubated and ventilated patient requires ongoing ventilatory support should not be overly complicated. In this episode we review the approach to determining if our mechanically ventilated patients can be safely extubated. In addition to discussing readiness for spontaneous breathing trial (SBT) criteria, we also discuss the potential utility of "weaning" criteria, choice of method of SBT, and considerations when removing the endotracheal tube.
Support the show (https://www.patreon.com/traumaicurounds)
Which of your patients are at risk for developing intraabdominal hypertension (IAH) and the abdominal compartment syndrome (ACS)? In this episode, we review the classification, pathophysiology, and widespread systemic effects of this potentially fatal and, often times preventable, surgical disease process. We also discuss key diagnostic and therapeutic strategies as outlined by the WSACS - The Abdominal Compartment Society.
Support the show (https://www.patreon.com/traumaicurounds)
Dr. Sam Tisherman from the Shock Trauma Center joins us on Rounds to discuss his ongoing, cutting-edge research in EPR-CAT. Colloquially known as "suspended animation", EPR-CAT may provide trauma & acute care practitioners with the desperately needed time that's required to repair lethal exsanguinating injuries through the induction of profound hypothermia after traumatic arrest. During Rounds, we discuss everything from indications for EPR-CAT to the role of selective aortic arch perfusion, integration of resuscitative endovascular techniques, and common ethical considerations that arise when performing resuscitation research.
Support the show (https://www.patreon.com/traumaicurounds)
Dr. Paula Ferrada joins us on Rounds this week to discuss several topics ranging from a circulation first approach in hemodynamically unstable trauma patients to the importance of inclusion, diversity, and equity in surgery & medicine. Clinical pearls, invaluable insight, and career advice for learners at different stages of their careers round out a fantastic episode that you'll want to share with your friends and colleagues.
Support the show (https://www.patreon.com/traumaicurounds)
Time is tissue. Early recognition of shock with immediate institution of lifesaving therapies are critical to successful patient outcomes. Establishment of functional IV access together with augmentation of cardiac output through increased preload and appropriate use of vasoactive agents are key aspects in the initial management of sick patients.
Support the show (https://www.patreon.com/traumaicurounds)
To trach or not to trach? That is the question we're addressing in our first Rapid Rounds. One topic. Two to three questions. All in under 10 minutes. This week's rounds is informed by 2 recent articles in the trauma critical care literature published in Trauma Surgery Acute Care Open (TSACO) and the Journal of Trauma and Acute Care Surgery (JTACS).
Support the show (https://www.patreon.com/traumaicurounds)
Pressure. Packing. Tourniquet. In this episode, we provide a glimpse into the American College of Surgeons Stop the Bleed Program, from inception to present day. We also discuss the increasing use of tourniquets as an adjunct to hemorrhage control in patients with severe extremity injuries.
Support the show (https://www.patreon.com/traumaicurounds)
In this follow-up episode to Episode 3, we discuss and review the key factors (3 Ts) that define a mode of mechanical ventilation. In addition to the Targeted control variable (volume or pressure), the other key factors determining a mode include the Type of breath and Timing of breath delivery. In addition to discussing what defines a mode, we also review when and why one particular mode might be selected over another.
Support the show (https://www.patreon.com/traumaicurounds)
What are the indications for ECMO beyond ARDS and refractory cardiogenic shock? In which patients should we consider eCPR and is this the new standard of care for patients sustaining out-of-hospital cardiac arrest? Finally, how do I work towards safely and efficiently weaning my patient from VV or VA ECMO?
These are just a few of the questions that we address on Rounds with our guest faculty member and Director of the UCLA Adult ECMO Program, Dr. Peyman Benharash. In this comprehensive review of ECMO we also explore the regionalization of ECMO care here in Los Angeles County, as well as the day-to-day considerations that you want to bear in mind when assessing and caring for your patients requiring extracorporeal life support.
Learning ObjectivesBy the end of rounds you should be able to:
-
Understand the indications & contraindications to VV and VA ECMO support
-
Describe the basic components of an ECMO circuit
-
Describe the role of eCPR in the management of adult patients with out-of-hospital cardiac arrest
-
Discuss key management strategies to safely wean patients from ECMO
-
Describe common complications of ECMO and strategies to mitigate them
Take Home Points
- ECMO is time-sensitive, therefore, early and safe cannulation is an important determinant of outcome
- ECMO is a bridge to therapy
- Use of scoring systems like the Murray Score may be useful to stratify the severity of ARDS among patients being considered for VV ECMO support
- The indications for ECMO are expanding to include technically challenging operative cases
- eCPR is a promising therapy for patients presenting to an ECMO center of excellence with refractory VF/VT cardiac arrest
- ECMO therapy, particularly VA ECMO, may affect virtually organ system
- The potential role of ECMO therapy during the current COVID-19 pandemic remains to be defined
Time Stamps
- 00:12 Introduction
- 01:16 Overview of Rounds
- 02:13 The rise of ECMO
- 02:46 CESAR & EOLIA trials summarized
- 05:40 Venovenous (VV) vs. Venoarterial (VA) ECMO
- 08:24 How to decide whether or not to place a patient on VA ECMO?
- 10:33 Timing & indications for ECMO support
- 11:38 Murray Score explained
- 12:24 Contraindications & patient selection for VV & VA ECMO
- 13:56 Expanding indications for ECMO
- 15:23 ECMO in the Setting of Trauma: Pneumonectomy & Retrohepatic IVC injuries
- 17:45 Regionalization of ECMO in Los Angeles County
- 21:52 Who should be cannulating?
- 23:22 Approach to cannulation
- 24:50 Distal perfusion catheters for VA ECMO
- 26:10 Differences between VV & VA ECMO
- 28:24 The W5H of eCPR
- 34:26 Considerations for access for VV ECMO
- 35:53 Avalon catheter
- 37:51 VV versus VA ECMO circuits/set-up explained
- 43:30 Getting your patient off of ECMO& other key considerations
- 48:56 Vasopressor & inotropic therapy during VA ECMO
- 50:31 Virchow’s triad, antithrombotic therapy & bleeding on ECMO
- 54:30 AKI, end-organ dysfunction & the daily assessment of patients on ECMO
- 57:22 ECMO 2.0 & the role of evolving technologies
- 61:20 Role of ECMO during the COVID-19 pandemic
- 66:45 Take-home points
- 68:38 Outro
Support the show (https://www.patreon.com/traumaicurounds)
Is there an ideal time to place a tracheostomy? What factors might influence my decision to proceed with an open versus percutaneous tracheostomy? In this episode, we discuss common perioperative considerations influencing our decision to proceed with tracheostomy in critically ill patients requiring prolonged mechanical ventilation. Over the course of rounds, I'll share with you some "tricks of the trade" and review key management principles for safely dealing with potentially life-threatening tracheostomy complications in the postoperative period including unplanned early decannulation and bleeding.
Support the show (https://www.patreon.com/traumaicurounds)
What is shock? A clear grasp of this concept is a MUST for any practitioner taking care of patients. Shock is many things. It is dynamic. It is elusive. It is lethal. A high index of suspicion is required to identify patients in shock. While lifesaving therapies are initiated, we must have an organized approach to to shock in order to identify the best diagnostic and therapeutic pathways for our patients. As such, we will review a simple classification system for shock. In a follow-up episode, we'll further examine the clinical presentation and management of patients presenting with hypovolemic, cardiogenic, distributive, or obstructive shock.
Support the show (https://www.patreon.com/traumaicurounds)
This episode follows-up on Episode 1 and focuses on the assessment and initial treatment of patients with acute respiratory failure. Through a focused clinical exam, we can identify signs of increased work of breathing which should alert us to the need for support in the form of oxygen and ventilatory therapies. The 3 major types of oxygen delivery systems are also discussed including low- and high-flow, as well as reservoir systems.
Support the show (https://www.patreon.com/traumaicurounds)
In this episode we review the "lethal 6" and "hidden 6" chest injuries that comprise the deadly dozen of thoracic trauma. Mechanism of injury together with vital signs and findings from the physical exam should provide us with the data needed to identify life-threatening thoracic injuries on our primary survey. For hidden injuries, the diagnostic adjuncts required to identify these injuries are also discussed.
Support the show (https://www.patreon.com/traumaicurounds)
Dr. Matt Martin from Scripps Mercy Hospital in San Diego, CA joins us on Rounds to discuss topics related to the resuscitation of critically injured patients with a focus on endpoints of resuscitation. The basic approach to the assessment of "sick" versus "not sick" patients and utility of early transfusion of whole blood are explored, along with the usefulness of physical exam findings and other adjuncts in guiding our resuscitation efforts.
Support the show (https://www.patreon.com/traumaicurounds)
In this episode we review and discuss the core physiologic concepts required to understand basic mechanical ventilation. By examining the respiratory equation of motion or force balance equation, we'll gain insight into the pressures that need to be generated to deliver a positive pressure breath and those pressures that can be monitored during the care of vented patients. This will form the groundwork for Basic Mechanical Ventilation II: Modes of Ventilation.
Support the show (https://www.patreon.com/traumaicurounds)
In this episode we explain what rapid sequence intubation or RSI is and the indications for its use in securing a definitive airway. More importantly, we share lessons learned regarding COVID-specific considerations for intubating patients with acute hypoxemic respiratory failure.
Support the show (https://www.patreon.com/traumaicurounds)
In this, our inaugural episode, we explore common mechanisms underlying acute hypoxemic and hypercapneic respiratory failure. Concepts discussed include the oxygen delivery equation, differentiating hypoxia from hypoxemia, and a discussion of V/Q mismatch and shunts. In the follow-up episode - Acute Respiratory Failure II: Clinical Management & Oxygen Therapies - we'll apply these concepts to the management of acute respiratory failure and discuss the benefits and harms of oxygen therapy.
Support the show (https://www.patreon.com/traumaicurounds)
Look. Listen. Feel. In this trailer for the Trauma ICU Rounds podcast, I outline the objectives of this medical education series. Key topics that will be addressed span the spectrum of surgical critical care, acute care and emergency general surgery, as well as trauma. We'll also explore issues related to professional development and highlight the results of influential and novel research studies. In addition to auditory learning, visit the website http://www.traumaicurounds.ca. for additional learning materials in the form of blogs, vlogs, vidcasts, and surgical procedural videos.
Support the show (https://www.patreon.com/traumaicurounds)