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!

June 10, 2019

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.

May 1, 2019

Take Home Points on Blunt Cardiac Injury

  • No single test can be used to exclude BCI. However a thorough physical exam combined with a 12-lead EKG, troponin measurement, and echocardiography can be used to characterize BCI and direct care
  • Obtain a 12-lead EKG in all thoracic trauma patients 
  • A chest x-ray may help to identify associated injuries. However, isolated musculoskeletal injuries such as sternal fractures do not correlate with a risk of BCI
  • Bedside TTE can quickly evaluate for life-threats such as cardiac tamponade; A TEE is both sensitive and specific across the spectrum of BCI pathology and is part of a comprehensive evaluation
  • BCI can be excluded in a patient without EKG abnormalities and a negative troponin I

March 25, 2019

Background: TXA is a synthetic lysine derivative that binds with the lysine site on plasminogen and inhibits fibrinolysis.  TXA is not a new drug. Studies from the late 1960s and early 1970s have shown reduced bleeding and need for transfusions in many surgical and medical settings.  Fast forward to today and we are finding all kinds of uses for TXA other than trauma including post-partum hemorrhage, epistaxis, hemoptysis, gastrointestinal hemorrhage, and many more.

March 23, 2019

The management of the critically hemorrhaging trauma patient has seen a large amount of change over last decade, from bringing care far forward to the field to early use of blood products to civilian translation and application tourniquets to name a few. The reality unfortunately is that there is still a subgroup of patients who continue to suffer early mortality from hemorrhage, primarily because they are bleeding in the torso.  This is particularly challenging for both prehospital and in-hospital clinicians to manage as these areas do not allow control through direct compression. Enter resuscitative endovascular balloon occlusion of the aorta (REBOA) – a technique that builds on principles from vascular surgery and sees the placement of a balloon catheter into the aorta via the femoral artery.  Acting as an internal tourniquet, it temporarily occludes flow to the bleeding vessel thus providing circulatory support and precious time to get the patient to definitive care. With the alternative being death from hemorrhage, REBOA came as a breath of fresh air – a minimally invasive means of achieving hemorrhage control in these extremely sick patients. There were innovators and early adopters and reports of fantastic saves – patients were surviving who would never have survived before. 
0