You are working at a Level 1 Trauma Center; a 35-year-old female arrives via EMS from the scene of a motor vehicle accident. She was an unrestrained passenger, ejected 50 feet. She was hypotensive and hypoxic on scene with concern for head injury with a GCS of 7.She is clearly in shock on arrival with weak pulses, clammy skin, and a BP of 80/50mmHg, HR 140, sats 85%. She is intubated, a chest tube is placed on the left (with improvement in O2 sats to 95%), and a pelvic binder is placed for suspected pelvic fracture. eFast demonstrates free fluid in the pelvis. Massive Transfusion Protocol (MTP) has been activated appropriately, and despite rapid delivery of 4 units Packed Red Blood Cells (PRBCs), 2 units of Fresh Frozen Plasma (FFP) and 1 pack of Platelets, she remains hypotensive, with presumed hemorrhagic shock.The patient is destined for the OR, but you ask yourself, in traumatic hemorrhagic shock, is there a role for vasoactive agents?...Read More
Background: Evidence from the CRASH-2 trial showed an absolute reduction in mortality of 1.5% (NNT = 67) in patients with extracranial bleeding treated with tranexamic acid (TXA) within 3 hours of injury. However, CRASH-2 did not answer the question of effect on mortality in patients with intracranial hemorrhage (ICH), as these patients were excluded from the trial. It makes biologic sense that administration of TXA in patients with traumatic brain injury (TBI) might prevent or reduce ICH expansion and thus avert brain herniation and death. There were two smaller RCTs  that showed a reduction in death with TXA in patients with ICH. However, both of these trials were small and considered to be hypothesis generating only. TICH-2  was an international, randomized, double-blind, placebo-controlled phase 3 trial in adults with ICH from acute stroke with ≈2300 patients and showed no difference between groups in functional status at day 90. TICH-2 did show a small improvement in hematoma expansion at day 2 and death by day 7. Due to the fact that these findings were secondary outcomes they were also hypothesis generating. All of the above positive findings therefore required confirmation in a larger randomized trial, which has finally arrived…CRASH-3....Read More
Soft Signs are hypotension that resolves, stable hematoma, wound in proximity to major vascular structure, minor hemoptysis, dyspnea, dysphagia, chest tube air leak, vascular bruit or thrill (depends on surgeon).
Hard Sign on presentation goes straight to the OR. Soft Sign on presentation gets some imaging done
Resuscitate with blood products -> Activate massive transfusion protocol
Background: Trauma patients can be a rather difficult patient population to treat with multiple ongoing issues. There is always a balance of hemorrhage control vs prophylaxis for venous thromboembolism (VTE), as both can cause increased morbidity and mortality. One method to balance this challenging issue is retrievable inferior vena cava (IVC) filters, which at face value sound like a nice solution (Prevent VTE while avoiding worsening hemorrhage). The main issue with IVC filters is there is limited high quality data to support the use of these devices and IVC filters are not without their own long-term complications as well. Finally, there are also conflicting recommendations depending on which guidelines you choose to read ....Read More
Airway management as the first priority has been the backbone of resuscitation for years. “Address A first, before moving to B and C,” is what we are taught and what we go on to teach successive generations of learners. For appropriately trained clinical teams, either in- or prehospital, the completion of “A” may well mean performing a rapid sequence intubation (RSI)
From its inception in the 1970s, there has been continued evolution in how we approach RSI (and airway management in general) in the physiologically threatened patient – this post will focus on the trauma patient. You can revisit some really well-done blogs and podcasts over the last few years that have highlighted various approaches to prevent peri- and post-intubation problems.
Like cardiac arrest.