Damage Control Resuscitation, Permissive Hypotension, Fluid Restrictive Resuscitation… Regardless of name, with all the enthusiasm surrounding permissive hypotension in the actively bleeding trauma patient, what do we do when they have a TBI? Take a dive into the literature surrounding ideal perfusion pressures of patients suffering from TBIs and traumatic injury to find out if we know what pressure is really the best.Read More
We know that alterations in hemodynamics do not only occur in hemorrhagic shock. Both obstructive (such as from tension pneumothorax) and neurogenic shock (for example, from a spinal cord transection), can result in hemodynamic compromise that would not be corrected by blood product administration. There have been some studies that have shown isolated traumatic brain injury (TBI) can also cause hemodynamic derangements. This article looks at a paper which attempts to examine the incidence of cardiovascular instability in patients with TBI.Read More
Come check-out our Grand Rounds Summary for 12.19.18! We started the morning with some fascinating cases in Morbidity and Mortality Conference with Dr. Baez. Next, we learned the importance and efficacy of mindfulness with Dr. Bernardoni. Dr. Makinen and Dr. Curry went head-to-head on a Clinical Pathologic Conference about a patient with hyperthermia due to sympathomimetic overdose. Lastly, Dr. Frederick taught us the evidence behind PECARN!Read More
The Knights of the (Grand) Rounds Table led us on our educational adventure this week. Dr. Andrew Knight brought us his expertise on teams within the healthcare system. Dr. Ryan Knight MARCHed us through an approach to trauma and lent his perspective and expertise on REBOA. Dr. William Knight rounded out the day with a great lecture on concussion.Read More
Dr. Axelson kicked off Grand Rounds this week with a look at DKA, hypercalcemia, suicide in the ED and more during M&M. Then we learned about Hereditary Angioedema, Thyroid Emergencies, Concussions, NIPPV and got a chalk talk about setting end goals of resuscitation from Dr. Dave Norton.Read More
A couple of weeks back, we kicked off our “Flights” portion of our Air Care Orientation Curriculum. Dr. Latimer outlined a challenging patient case for use to consider and an excellent discussion ensued. As a reminder of the case, here’s how it was posed:
Your patient is a 56 year-old male with unknown medical history who was an un-helmeted motorcyclist found in a ditch roughly 40 feet from his motorcycle which was discovered in the middle of the road by a passing motorist. The accident was un-witnessed, but the bike was found just beyond a sharp downhill curve in the rural farm road. EMS has BLS capabilities only and they have placed the patient on a backboard and loaded him into the unit.Read More
It is mid July and your first shift as the coveted H2 Doc at Air Care 2 is finally upon you. It has been an especially warm and beautiful Saturday and you ponder the possible flights for the evening as you take the scenic drive to Butler County Regional Airport.
You finish checking the aircraft with the flight nurse and sit down to begin the 20:30 brief with the flight crew when the tones drop and you are dispatched for your first flight of the evening, a scene flight to Franklin County, Indiana for an “un-helmeted motorcyclist”. You grab the blood cooler, perform a safety walk-around the aircraft and strap yourself in backRead More
Taming the SRU Case Follow-Up: GSW to the Head with Dr. Grosso
- In one census: 66% of violent deaths are suicide, with 30k suicide deaths annually in the US
- ~50% of suicide attempts include firearms
- GSW to head mortality is 80%, and 71% die on scene
- ~40% of those who survive to hospital have favorable outcomes
- Favorable prognosis: GCS>8, normal pupillary reaction, absence of coagulopathy of trauma/hemodynamic instability
Thanks to everybody who commented and contributed to the discussion on our last "Flight!" If you missed out on the case, check it out here. We had a great discussion which we have recapped here. Take a look below and a listen to the commentary provided by Dr. Bill Hinckley in the embedded podcast. Look for our next flight to lift off in the next couple of weeks!
What medications could be used in the care of this patient? If the patient loses his IV, how does your treatment strategy change?
This first question sparked quite a bit of debate within the community. Everybody agreed that this patient requires sedation, intubation, and more sedation. There was, however, some significant differences in how the providers would go about attaining adequate sedation.Read More
You’re working as the Pod-Doc, having just taken the radio from the off-going UH-doc, you just finish admitting the patient in C40 for NSTEMI when the tones go off.
“Air Care 1 and Pod Doc respond to a scene for motorcycle crash, Northern Kentucky”
You call the B-Pod attending, sign out the pod, grab the blood from the blood cooler and head to the helipad. Flying over the river, landing at a local firehouse’s parking lot you hop out of the back of the helicopter and head to the awaiting squad.
Your patient is a 29 year-old male who was riding his motorcycle (without a helmet) on a local country road. Coming around a blind corner he unexpectedly found a car stopped in the middle of the road. Striking the car from behind at ~35mph, he flew over the handlebars and impacted the back of the car.
On EMS’s arrival he was initially unconscious, but since their arrival has become increasingly combativeRead More
There has long been a concern for increases in ICP with administration of ketamine primarily stemming from reports of increased ICP in the Neurosurgery and Neuroanesthesia literature. These increases were described primarily in patients usually with CSF outflow obstruction undergoing elective neurosurgical procedures. In the time since these articles were published, the use of ketamine in a wide variety of patients with neurologic compromise has been reported. In fact, there have been a couple of recent systematic reviews and meta-analyses on this topic. These systematic reviews and meta-analyses have essentially analyzing all the same existing literature (which is generally poor in quality).Read More
Of the injuries that one will care for in the pre-hospital setting, traumatic brain injury is one of the most challenging. Quite often, more than one organ system has been injured and they require rapid, thoughtful, and precise management of their airway and hemodynamics. In addition, TBI patients require frequent reassessment to detect progression of the primary neurologic injury. This is easier said than done in the dynamic, unpredictable, and resource-limited prehospital environment.
To help simplify their care, the following “Code of Care” forms the core principles that characterize optimal TBI care:
- NO Hypoxia (SpO2 < 90%) – therefore, apneic oxygenation for all TBI patients
- NO Hypotension (sBP < 90 mmHg) – greatest iatrogenic risk is with induction and provision of positive pressure ventilation
- Blown pupil -> Hyperosmotic therapy + Hyperventilate
Permissive Hypotensionis also known as hypotensive resuscitation or low volume resuscitation
What is it?
A resuscitation strategy in the critically ill trauma patient (primarily applicable to penetrating trauma but also adapted to blunt trauma) where we allow the systolic BP to remain as low as necessary to avoid exsanguination while still maintaining critical end organ perfusion. (typically defined as appropriate mental status & or the presence of a radial pulse)
The Thought Process:"Don't pop the clot"...
By allowing lower blood pressures we avoid the potential disruption of an unstable fresh clot and thus worsening bleeding caused by higher BP's.Read More