The Surge: Trauma. Surgery. Critical Care.

How good are you at rounding?

How could you making it better?

Whats in your ICU rounding checklist?

My own checklist.

Selected References:

The JAMA paper.

The Attitudes at Rounds paper.

The exploirative discriptive paper.

The two Cochrane Reviews:

https://www.ncbi.nlm.nih.gov/pubmed/10796485

https://www.ncbi.nlm.nih.gov/pubmed/19588316

The Diffusion of Evidence Based Practice statewide paper. 

The checklist paper. 

The computer bsed decision making algorithim paper. 

What is Massive Transfusion?

What's in an MTP?

When to Trigger? 

What's in the box?

New trends and controversies. 

When to halt your MTP. 

 

Selected References:

Early high ratio platelet transfusion in trauma resuscitation and its outcomes.

Trauma resuscitation requiring massive transfusion: a descriptive analysis of the role of ratio and time.

Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom: increased plasma and platelet use correlates with improved survival.

Massive transfusion protocols: the role of aggressive resuscitation versus product ratio in mortality reduction.

Improvement of Treatment Outcomes after Implementation of a Massive Transfusion Protocol: A Level I Trauma Center Experience.

Massive transfusion policies at trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program.

Use of prothrombin complex concentrate as an adjunct to fresh frozen plasma shortens time to craniotomy in traumatic brain injury patients.

Plus the PROMTT and PROPPR Trials ofcourse. 

THERE IS NO SUCH THING AS AN ED STERNOTOMY! 

BUT There are emergent sternotomies. 

and they are exteremly fulfilling. 

Just a short commentary on a cool video ! 

Chapter Mentioned. 

Pictures Referenced. 

Dr Tongmeesee

How many lumens do you actually need in the real world? 

Is a single lumen enough?

How much more flow can I get from a pressure bag?

What's the optimal way to set up line access?

 

Copy of the powerpoint.

Selected readings:

An In Vitro Assessment of the Efficacy of Various

IV Cannulas for the Rapid IV Fluid Administration

Mineto Kamata, MD1; Hina Walia, MBBS2; Mumin Hakim, MBBS2; Dmitry Tumin, PhD2;

Joseph D. Tobias, MD

Double-barrelled resuscitation: A feasibility and simulation study of dual-intraosseous needles into a single humerus Matthew J. Douma a,1,*, Gurpaul S. Bara b,1, Domhnall O’Dochartaigh c,1, Peter G. Brindley d,1 a Trauma and Emergency Services, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, Edmonton, AB, Canada T5H3V9 b Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada c Shock Trauma Air Rescue Society, Edmonton, Canada d Neurosciences Intensive Care, Alberta, Canada

 

 

What are vasoelastic assays?

How do I read them?

What do I do?

Is it ready for primetime?

TEG VS ROTEM - the format wars. 

Whats the future like? 

Selected references: 

Effect of thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review

An assessment of clinical interchangeability of TEG and RoTEM thromboelastographic variables in cardiac surgical patients.

TEG and ROTEM: technology and clinical applications.

The use of viscoelastic haemostatic assays in goal-directing treatment with allogeneic blood products – A systematic review and meta-analysis

Point-of-Care Coagulation Tests Monitoring of Direct Oral Anticoagulants and Their Reversal Therapy: State of the Art.

What factor within the Japanese Association for Acute Medicine (JAAM) disseminated intravascular coagulation (DIC) criteria is most strongly correlated with trauma induced DIC? A retrospective study using thromboelastometry in a single center in Japan.

Hypercoagulability after distal pancreatectomy: Just meaningless alterations?

Traumatic Abdominal Solid Organ Injury Patients Might Benefit From Thromboelastography-Guided Blood Component Therapy

All the bang without the bucks: Defining essential point-of-care testing for traumatic coagulopathy.

Last but not least REBEL reviews.

 

Copy of the slides can be found here.

A play by play video of a scalpel finger bougie cric. 

 

As much as I'd like to take credit, original video was filmed by Reuben Strayer with patients consent. 

 

Simply mind blowing how much cognitive work goes into a surgical airway and the video is just an amazing example. Another good example can be found here by Dr Rhee which shows a more traditional surgical approach although a prefer the scalpel finger bougie similar to Scott Wiengart, although I've had favourable experiences with the lifestat recently (seperate episode) .

Other References: 

The formulation and introduction of a 'can't intubate, can't ventilate' algorithm into clinical practice.

Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple ‘scalpel–finger–tube’ method

 

....or an argument against throwing the baby out with bathwater. Invariably we've all heard it on the podcasts, blogs and at the conferences. The reasons why we shouldn't do panscans are all over the internet. From conspiracy theories that radiologists and hospital admins are doing it for the money to the argument that it dulls clinical accumen. 

IMHO panscans are a product of technology moving too fast for the literature. We keep asking questions like we did in 1999 when we're seeing the technology of 2017.

The question shouldn't be do panscans influence outcome or "flow" in the ED. The question should be: "In which patients has focused history, examination and selective CT scanning failed us?" 

By and large the studies on which we've based our arguements against panscans are based on older CT scanners, retrospective data and radiation "risk" that is miniscule compared to the risk of missed injuries. You cannot use retrospective studies in which hemodynamically unstable patients are taken for a CT in 2000 (17 years ago) to make a point that panscans are evil. You can however say "just because the microwave is there doesn't mean we have to use it every day" . Like your microwave your panscan should have indications for use (never try and make pancakes in a microwave BTW), the trouble is we haven't figured them out yet. 

Some alternative points of view that are probably more valid than mine : 

ALIEM Top ten trasons not to Panscan. 

Life in the Fast Lane Brief review .

Trauma.co.nz , The Debate:Panscan.

well .... most times ....

This podcast can't be about resuscitation if I didn't include an airway talk in the first 5 episodes. 

It happens to all of us from time to time, you get called at 2 am for a can't intubate, can't ventilate disaster that's been going on for far too long .... this episode is about how to avoid it. FRom pre planning to setting up a comfortable bailout plan. 

References Mentioned: 

Laryngoscope as a murder weapon.

 

RSI from Life in the Fast Lane.

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults

C. Frerk, V. S. Mitchell, A. F. McNarry, C. Mendonca, R. Bhagrath, A. Patel, E. P. O’Sullivan, N. M. Woodall and I. Ahmad, Difficult Airway Society

intubation guidelines working group

British Journal of Anaesthesia, 115 (6): 827–848 (2015) doi:10.1093/bja/aev371

 

Preoperative airway assessment - experience gained from a multicentre cluster randomised trial and the Danish Anaesthesia Database.

Diagnostic accuracy of anaesthesiologists' prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database.

 

Apologies if I didn't recap at the end .... completely forgot. 

 

Saud

In my mind this is probably the first real episode of the podcast. 

Time and time again and see people pontificate over the amount of blood to give and whether it's being used for resuscitation or oxygen exchange or both and what cut off to use so I figured why not start with some basic numbers and fun facts on the ultimate colloid. 

Some useful links mentioned in the podcast: 

The JPAC transfusion handbook. PDF.

Hema-Quebec 

That animal model crit/concentration paper .

That paper where they bled healthy volunteers and gave them back their blood.

 

Figured I'd start with a little about my self and why I'm doing this. 

The reality is that I'm not sure. 

More (better) sources of #foamed and another introduction to it: 

 

Life in the Fast Lane. 

 

Scott on Emcrit.