July 23, 2020

Background: Trauma remains the leading cause of death in the United States for those aged less than 45 years old. Those who arrest from hemorrhage or other traumatic mechanism often carry a very poor prognosis. Various studies have placed the survival from blunt traumatic arrest at <10%. Much is dependent however on the systems approach to managing these patients – for example those patients who have very rapid access to surgical resuscitative techniques may have better outcomes. Nevertheless, given the typical young age of these victims, a significant effort is often made at resuscitation. This must be balanced with the potential risks to clinical staff, appropriate use of limited resources, and expected quality of life of survivors. To be able to predict better outcomes would be of use both in the prehospital and in-hospital environments.

January 30, 2020

The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) has been a hot topic on the cutting edge of trauma resuscitation for several years now. But who should be doing this procedure, on whom, and when? Tissue ischemia results from REBOA followed by reperfusion injury, organ dysfunction and potential cardiovascular collapse. Although appropriate patient selection is paramount, the system of care that surrounds this procedure is vital to minimizing delays to definitive hemorrhage control as well as the ischemic insult of aortic occlusion. In 2018, the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) published a joint statement on the clinical use of REBOA2. This statement was met with much criticism from the emergency medicine/critical care world. Due to this, a revised statement has been published with different recommendations1. So, what does this statement say and how is it different from the 2018 statement?

December 9, 2019

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?

October 15, 2019

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 [2] 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 [3] 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.

September 11, 2019

Take Home Points:

  • Get definitive airway control when necessary
    • Use modality you’re most comfortable with
  • Hard signs -  pulsatile bleeding, bruit or thrill, expanding hematoma, airway compromise, massive hemoptysis (think airway injury), hematemesis (think esophageal injury), grossly injured trachea, neurologic deficit, subcutaneous emphysema.
  • 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
  • Most hemorrhage will respond to direct pressure
  • Don't miss other injuries!