All right, I guess it's 1031, so we'll get started. And my name is Matt Tavlock, I'm obviously active duty Navy, I'm a trauma critical care surgeon stationed in San Diego, and I also work at UCSD. The four of us are going to give 10 to 12 minute rapid fire talks each, and at the end, we'll have some cases or some questions to bring up, some issues that either were covered in the talks or weren't covered in the talks, but might be interesting to highlight. Before we get started, I'm just curious, how many in the room are medical intensivists primarily? How many are trauma critical care? All right, anybody like anesthesia, surgical critical care, or other? Okay, all right, well, I'm gonna get started here. I'm gonna let each, I guess first I should say thank you to the CHESS Program Committee and then Ryan Maves. We all are just meeting each other for the first time in this group, and so thank you for bringing us all together in Hawaii. And I'm gonna let each presenter sort of introduce themselves. But first, we have John Agapian out of California, and he's gonna get started with his first talk. All right, thank you, Captain Tavlock. My name is John Agapian, I'm an associate professor with the University of California Riverside School of Medicine, and I have no disclosures. I'll be starting off this panel discussion, we're gonna have four of us speaking. The whole topic is gonna be what medical intensivists need to know about trauma, and I'm glad to see that most of the audience is medical intensivists. My talk's gonna be directed towards trauma epidemiology and the organization of trauma care in the U.S. of A. This is a quick outline of what I hope to talk about in the next few minutes. So how did trauma begin as a system in America? Well, it started in the Civil War, when President Lincoln started with the first trauma manual. And this was the first description of how to triage patients in the battlefield, put them in ambulances, and bring them into the hospital. World War II, in the 1940s, hospital emergency departments were becoming a thing. Prior to that, hospitals were just hospitals. But during World War II, the concept of the emergency department was introduced. This set up the foundation for the emergency medical system, and as patients would come to the ER, treatment outcomes and quality improvement metrics were being established. We're gonna talk more about that and how that's one of the cornerstones of trauma, quality improvement metrics. In 1946, the Hill-Burton Act began requiring that hospitals all have emergency departments. This was incentivized with federal funding, to the point where they were giving grants and federal monies for hospitals to open up 24-hour emergency departments. During this time, in the 1913s, the American College of Surgeons was introduced. And in 1922, it started with the Committee on Fractures, which later became the famous Committee on Trauma. This was started in 1950. And here you see the logo, the broken man, for the Committee on Trauma. Prior to the 1950s, interstate transport was only through trains, but the interstate highway system was developed starting in the 1950s. And by 1966, the Highway Safety Act created the National Highway Safety and Administration Bill. And this allowed for federal initiatives for all states to develop ongoing EMS programs. 1966 was a big year because the National Academy of Sciences also put out the accidental death and disability, the neglected disease of modern society. And this is the landmark publication they came out with. It was multidisciplinary with the Committee on Trauma and many other organizations. And it was the first time trauma was identified as a disease process. Emergency Medical Systems Act in 1973 continued ongoing support for the EMS systems. And the idea of air transport was introduced where life, you know, medical life flight programs were being developed. 1969 is an important year, not just for me because that's the year I was born, but that's when the concept of paramedics were started. At that time, Governor Ronald Reagan in 1970 introduced the Wedford-Townsend Paramedic Act. And in 1970, the idea of paramedics began. I'm sure you guys are all familiar with the hit TV show Emergency in the 1970s. That was part of the Los Angeles County Fire Department. And this is another branch of the Los Angeles County Fire Department, the Ocean Lifeguard System. Okay. That was famous because of the TV show Baywatch, if you guys remember that show. Okay. Trauma centers then began developing. And the first two trauma centers started about the same time in 1966. There's controversy which one was the first one. Some people would say Shock Trauma, which is probably more famous now in Baltimore. And where I trained, which is Cook County Hospital, I have this painting in my office. The Emergency Medical Systems Act in 1973, as I mentioned, developed air transport system. And in 1990, the Trauma Care Systems Planning and Development Act continued ongoing development of trauma care systems, and it promoted the concept of having trauma centers across the country. In 2007, this concept continued. This is what your typical trauma triage bay looks like. The model trauma care system was introduced in 1992, and this showed that 15 to 30% decrease in mortality of injured patients were preferentially triaged to verified trauma centers or trauma centers that were in addition to a basic emergency department. This is a paper that was put out in the New England Journal of Medicine that adjusted case fatality rates and relative risks of death after treatment in a trauma center as compared with treatment in non-trauma centers. This is more data demonstrating that trauma centers do portend better outcomes for the injured patient as opposed to regular emergency departments. Well, what is a trauma center? There are different types and levels of trauma centers in America. Particularly, the first distinction is whether it's verified by the American College of Surgeons or it's just state verified. It's a big badge of honor to have the American College of Surgeons come evaluate your trauma facility, go through all your charts and hospital system plan to see if it measures up to the verification standard of the American College of Surgeons. Otherwise, there are trauma centers that are state verified and they're just as good. There are different levels of trauma centers. So for example, level one, everybody knows about that. That's the premium trauma center. It has everything. In addition to having like a full complement of surgeons and physicians for all injured patterns, they do also promote education and research and ongoing quality improvement metrics. We've got level two, level three, and by the time you get to level four, these are emergency departments that are basically trauma centers, but they just stabilize the patient enough so they could repatriate and do a trauma continuation of care to a higher level trauma center. Okay? The big distinction between medical ICU and surgical ICU, well, surgical ICU became a board certified specialty in 1986, and you can see the timeframe of all the other different surgical specialties. The most recent critical care ABS verification process took place in 2021, a couple years ago, where the new neurocritical gear board was introduced. This is the ABS or the American College of Surgeons blurb on the details of what constitutes surgical care, and as promised, we're going to just in the last three minutes talk a little bit about mass shootings. This is a talk our disaster section gave a couple years ago in 2020 during the virtual Congress, and we talked about my experiences during the San Bernardino experience where we had a few of the patients actually come to our hospital here in Riverside. The findings of our action on how we treated these patients were published in an after action report, as you can see here, and quality measures that we got out of that were triage issues, injury patterns, and lessons learned. Now, we all agree that trauma centers provide better care for the injured patient. Well, what happens if HMOs and other network hospitals want to have their patients repatriated back to them? Is there a difference in quality? Well, this is part of an ongoing investigation that we presented at the American College of Surgeons. It's sponsored through EAST. It's a multi-center trial that has different centers, and it talks about what happens to the trauma patient if it has to initially come to a trauma center and then repatriate back to their own HMO. Here's the abstract blurb on that, and basically it says that once they get triaged and settled in a regular verified trauma center, once their active issues have been resolved, then they can move on to their network hospitals without much of a compromise in their ultimate outcome. This is a nice little photo opportunity we took in New Orleans. You can see our own Dr. MJ Reid, who's going to be one of our speakers today, talking about Stop the Bleed, and we're going to get a little bit of that today in one of the other talks. This is my shop here in Riverside, proud to say that a couple of years ago, we too were verified by the American College of Surgeons as a level one trauma center. Thank you. I'll ask one question, just while I'm ... What's the difference between a level one and a level two? I think it's up. We know, but what's the main difference between a level one and a level two trauma center for the audience? We used to be a level two verified trauma center, but we got our level one distinction because of the research. That's something that the American College of Surgeons holds at the highest level, ongoing research and ongoing self-reflection and improvement on your metrics, and providing at least 10 papers a year from your trauma center. All right. I'm going to give a fast-paced overview of the concept of damage control. Again, I'm in San Diego, and I also work at UCSD as well. Nothing to disclose. I'm going to talk about both damage control surgery and damage control resuscitation. Overall, quick history. On the left there, that's on every US Navy ship posted somewhere, the principles of damage control. That's where the term was coined, came from the Navy, but basically the principles are first only do those essential things to keep the ship afloat or your patient alive. It became a formal rating in 1948 during World War II when a lot of ships were being attacked and sunk and whatnot. It combined a bunch of other ratings that were important to keeping the ship afloat. The current rating now focuses on many things, but including firefighting and stability of the ship, and actually biological warfare defense. You can see the pictures on the bottom, people doing damage control training, but stop the inflow of seawater into the ship, fight fires, but basically make the ship so they can absorb damage, right the ship, and survive to fight another day. Now the principles of damage control surgery were developed before the 90s, but it kind of damage control came into both the civilian and military medical lexicon first in 1992 when this abstract was presented at AAST and subsequently published by Rotondo and others talking about the principle of abbreviated abdominal operations in patients who were bleeding to death. In the early 2000s and after this paper, acute care surgeons, trauma surgeons doing emergency general surgery started applying the abbreviated laparotomy principle to emergency general surgery indications. And then during the global war on terror in 2007, John Holcomb coined the term damage control resuscitation. So there are three general phases to damage control before you start thinking about definitive surgery and rehabilitation. The first is temporary bleeding control of either compressible or non-compressible hemorrhage, and I'll get into that in more detail, but that gets into the principles of stop the bleed. Second is hemorrhagic shock resuscitation, and I think this applies to both the trauma setting and the non-trauma setting. And then finally, damage control surgery, where definitive hemorrhage control occurs, but this is applicable not just to the abdomen, but anywhere where traumatic injury may be operated on, and again, to emergency general surgery. So where does it occur? Well, it occurs wherever the patient is. And so the point here is that damage control principles apply at the point of injury in the pre-hospital environment, in the emergency department or trauma bay, in the operating room, in the PACU or in your ICUs. And I think trauma isn't hard, it's very algorithmic, but it becomes hard when somebody's dying in front of you and they're bleeding to death and you're trying to figure it out. And so for trauma, I have my sort of head to toe sort of thought process, depending on the mechanism, where the bleeding may be occurring. And I think for the non-trauma indication, it really depends on why the patient's in the ICU, what their procedure is, but common things may be obstetrical emergencies, ectopic pregnancies or upper and lower GI bleeds, or post-procedure. So for compressible hemorrhage, there's a number of things, and I'm just gonna, this is the standard sort of poster for Stop the Bleed, but I'm just gonna go over these briefly. And never, a well-placed finger can do a lot, and this is just somebody who had a stab wound to the neck, to give you an idea. But if somebody's bleeding from a groin after a calf, or for whatever reason, and it's visible, a glove, well-placed finger will often stop that. One of the things that I see, drives me crazy, is a bunch of gauze over that bleeding wound and people bleeding into that gauze. And so a well-placed finger goes a long way. And sometimes, and we'll talk about tourniquet conversion later, but sometimes in a deep wound, if you have a hemostatic gauze, and you're able to stop the bleed with your finger, sometimes you can pack that wound and it won't bleed, and that'll free up your team or free up yourself. And so that's sort of the point here. There's very few indications for this. This is obviously a stab wound to the neck, but sometimes a Foley balloon placed in that wound, blown up, and then pulled up under pressure. And again, really under the subclavian where it works the best, this can be useful. That's what this is showing. And then, you know, extremity tourniquets. Our experience in the last 20 years of war in Iraq and Afghanistan have shown how useful tourniquets can be, and we'll get into a little bit later, but they can cause problems if they're not used appropriately. And this is just what we teach our medics and corpsmen about the indications for tourniquets. You really want bright red blood, the uniform is soaked with blood, or an obvious amputation. A lot of times in my civilian practice, in the pre-hospital setting, I'll see tourniquets put for minor scratches of the extremity, which is not a big deal if they come off quickly, but if they're not needed, they can cause trouble. And so appropriate use of tourniquets is super important. And then, obviously, a common thing is pelvic hemorrhage. About 70% of bleeding from pelvic hemorrhage is usually venous, and so decreasing the space for the bleeding to occur is very helpful, and this can be done with a pelvic binder or sheet. I'm not going to talk a lot about non-compressible hemorrhage. Is everybody familiar with the concept of Roboa? It's very institution-specific. You know, the institutions I work, we have it, but it's never used. Other places use it routinely. I think it's a team-based capability, and if you're going to use it, it needs to be part of your routine resuscitation strategy, particularly getting that arterial access. But this is one way to buy you some time for non-compressible hemorrhage. Probably most useful for bad arterial pelvic bleeding, or maybe in a postpartum hemorrhage kind of situation. So this is a simplified sort of graph, and we're going to get moving to damage control resuscitation, but when you're bleeding to death, acidosis occurs, hypothermia, you get an endogenous coagulopathy, and this gets into that so-called lethar triad of hypothermia, acidosis, and coagulopathy. But if you resuscitate that patient incorrectly, you're going to make it worse, and a lot of times people talk about the diamond of death when that adds hypocalcemia to that, which I'll talk about a little bit later, but it's important for platelet function, clotting factor function, cardiac contractility, and vasoconstriction. So what are the principles of damage control resuscitation? These are the four principles, and I'm just going to briefly talk about each one of them. First is, and we'll talk about this a little bit later in the panel session, the resuscitation before intubation. But what is hypotensive resuscitation? The concept is you provide enough end-organ perfusion while avoiding, quote-unquote, popping the clot that is there from the injury. The AAST and Committee on Trauma just recently published guidelines that they recommend a systolic blood pressure of greater than 70 or a MAP greater than 50, and they recommend selective use. So that's their recommendation. I'm in the military. The joint trauma system guidelines recommend a systolic blood pressure goal of greater than 100 or a palpable pulse. I mean, over the years, I see the pendulum swing different ways, different environment. So based on your comfort, I currently, I'm military, I resuscitate to about 90 to 100 and not above that, except for traumatic brain injury. And so if your patient is bleeding to death and has a traumatic brain injury, most organizations recommend at least a systolic blood pressure greater than 110. So the other principle of damage control resuscitation is minimize crystalloids. Fluid does not have oxygen-carrying capacity, and as I mentioned before, it can contribute to that dilutional coagulopathy. I mentioned the AAST Committee on Trauma guidelines for massive transfusion, and this is their recommendation, whole blood if available, component therapy, approximating fresh whole blood, and then number three, they recommend balanced crystalloids when blood products are not available. The problem with this in military setting, if I say that crystalloids are okay, then I'm not going to get blood, and so military recommendations have taken crystalloids completely out of it. So they recommend cold stored low titer whole blood, pre-schemed whole blood from a walking blood bank, approximating fresh whole blood, plasma and blood, packed red blood cells in a one-to-one ratio, or whatever you have. And we've taken crystalloid out of the recommendations because somebody is gonna review that and say, well, crystalloid's okay when you're bleeding to death. So that's why the difference there. Next are resuscitation adjuncts. And the big one is recognizing, treating and preventing ongoing hypothermia. Bad things happen when you're cold. You don't clot, things don't work as well. And so it must be an immediate focus when you're evaluating that patient. When the patient first comes in the trauma bay, the first thing we do is strip them naked. And we need to do that to identify injuries. But the next thing that needs to happen is warm blankets, warm fluids. We need to focus on removing that patient and keeping them warm. Other things and other massive transfusion protocols, and every institution is different. They use tranexamic acid in their protocols. In the military, we use that routinely. It's kind of like fluoride. It should be in the water if you're bleeding to death. But some of the data is controversial and it is institution-specific. Some places, pre-hospital will give TXA. Other places don't. A lot of people do a tag-guided correction of coagulopathy and only give TXA if it's indicated based on the tag. And then a lot of protocolized massive transfusion protocols routinely give calcium even before checking ionized calcium. So if you get two or four units of whole blood, you're going to get some calcium. I'm going a little over. I'm going to move over to damage control surgery and briefly talk about this. But the principle of damage control surgery is riding the ship or physiology over anatomy, get that definitive hemorrhage control, restore perfusion, control contamination, and live again to fight a day. And damage control principles apply to neurosurgery, the chest, chest trauma, pelvis, pre-peritoneal packing, and also in extremity trauma. And we use a lot of vascular shunts. And vascular shunts can be used anywhere in the body. If you can shunt it, you can use it. I think an important thing about damage control surgery and temporary abdominal closure, it is not a procedure of last resort. It is something that you're planning. It's a management strategy in your patient, be it trauma or emergency general surgery. Specifically for emergency general surgery, common indications include physiologic derangement. So they're unstable or too acidotic. And if you do, you know, you close that bowel anastomosis or you put them back together, that's going to fail because they're so sick. Or if there's a planned second look, if you're not sure about intestinal viability, unsure of your source control, or if there's significant contamination where you think a second washout's going to be available. Because, you know, if you leave bellies open, bad things happen. You can't close it, long hernia repairs, longer time on the vent in the ICU, et cetera, et cetera. The other indication is if you're going to close that belly and there's a high risk of abdominal compartment syndrome. So these are the three principles I've talked about. Damage control occurs where the patient is. We've talked about compressible, non-compressible hemorrhage, the principles of resuscitation, and then damage control surgery, physiology over anatomy. And these are my references. And we'll go to the next talk here and move right along. And next we have MJ Rhee talking about airway and thoracic trauma. Okay, so I'm not going to belabor the chest because everyone here knows about the chest. But I am MJ Reed. I have no disclosures. We're going to talk briefly about life-threatening injuries to the airway and to the thorax. We'll discuss recognition and initial stabilization. And then we're going to talk a little bit about traumatic injuries in non-traumatic patients. So as all of you know, there's more than just the lungs and the trachea in the chest. There's the great vessels. We have the esophagus. We have the diaphragm. We have the thoracic duct. And then we have the chest wall structures including the ribs and the bony structures. Just to make one comment, remember that the intercostal vessels, arteries, comes directly off the aorta. So they're not small vessels. So the lethal, I will divide them into what I call, what has been called the lethal six. And that is the airway obstruction, cardiac tamponade, tension pneumothorax, open pneumothorax, massive hemothorax, and then flail chest. And then there are the hidden six that you should be aware of that may or may not show up and you have to look for them. And that includes aortic disruption, tracheal bronchial disruption, myocardial injury or blunt cardiac injury, diaphragmatic tears, esophageal injury, and then the pulmonary contusion. So let's talk a little bit about airway trauma. So there was a great review article in Chest a couple years ago. It is rare, but it can be catastrophic. And it's estimated that most significant airway injuries never make it to the hospital, never make it in from the field and die in the field. So we really don't know what the actual incidence is. But 80% of trauma, especially blunt trauma injuries occur to the larynx. Now, it can be iatrogenic during intubation, during things that we do every day, bronchoscopies and all. And we've all been there and seen that. But these can be very significant. This is a nice review article in Trauma a couple years ago on how to approach. And this is where many of you will come in as experts in bronchoscopy to help us manage an airway injury or a suspected airway injury. This here is the upper airway. And then this is the lower airway. The red boxes suggest that once you get past the introitus of the cords, that you place your fiber optic scope and guide it from there. One thing I would say that is not on here is if you have time and you have planned that VV ECMO, we have used at least in three cases of upper airway trauma that has been very helpful. We put in the guide wires for the cannulas and then if we need the cannulas, we do the cannulas. And then we do it most of the time with a trauma bay and or in the operating room. Okay, tension pneumothorax. If you haven't seen a tension pneumothorax, you haven't done ICU enough. So unfortunately, we will oftentimes be the direct responsible for this. But as you know, it can be life-threatening. It's a clinical diagnosis. High index of suspicion if you, and it's a leading cause of preventable death. Conversion to a simple pneumothorax is our goal initially, whether that's with needle decompression or finger decompression. But a thoracoscopy tube is the definitive treatment. Massive pneumothorax is greater than 1500 cc's in a chest or one-third of the patient's blood volume. So that presents usually as a respiratory compromise with hemorrhagic shock. The treatment consists of a tube thoracoscopy and rapid resuscitation with appropriate blood products, followed by definitive operation if necessary. Usually a massive pneumothorax is a sign of a significant underlying vascular injury. Open pneumothoraces or the sucking chest wound, again, is a full thickness injury into the pleural cavity. If the wound is greater than two-thirds of the patient's, the diameter of the patient's trachea, air will preferentially enter the chest during inspiration. That decreases gas exchange and leads to a significant hypoxia, hyper, hypoventilation. Tube thoracoscopy is the definitive treatment. However, in the meantime, a three-sided vented chest occlusive dressing is helpful. However, doing that and forgetting about it, that's something that needs to be checked on a regular basis because if they clot off or they seal off, now you have a tension pneumothorax that can kill the patient. So don't forget about that. The next one is cardiac tamponade. Again, cardiac tamponade in a trauma patient, especially any hypovolemic patient, you are not going to see distended neck veins. It causes obstructive shock, as you know. Beck's triad is a poor, poor indicator, even though we learn about it all the time. So tachycardia and high index of suspicion are one way to think about it, but having the point of care ultrasound has really revolutionized our ability to diagnose this right here. And you can see right ventricular collapse, right atrial collapse. And this is actually fluid in a non-trauma patient. But, and remember that hypovolemia negates distended neck veins. Flail chest is, everyone knows what that is. It's multiple levels of contiguous ribs that then have a paradoxical pathophysiology, as you see here, with mediastinal flutter, hypoventilation, and then the underlying pulmonary contusion that can lead to significant hypoxia and comorbidity and even death. So we all have seen traumatic injuries in non-trauma patients in our non-surgical units. That's the pneumothorax after a procedure. Rib fractures after CPR can lead to sternal fractures, flail chest, hemothoraces, tension pneumothoraces. So these are things that you need to be cognizant of, even though you don't work in a trauma unit, because it can happen outside of there. And then, of course, airway injury after intubation, after bronchoscopy. Just realize that if you have crepitus, you may have a significant airway injury, and you need to intervene sooner than later. Pediatric considerations for those of you who do PEDs, avoid cricothorotomies under the age of 12 if possible. The child's mediastinum is very pliable and moves more, so there's more hemodynamic effect from tension, hemo, and pneumothoraces. And the ribs are more pliant, and significant lung injury can be present without rib fracture. So it takes a lot to break a child's rib. So in summary, chest trauma accounts for a quarter of trauma deaths. Chest trauma contributes significantly to the morbidity and mortality of the polytrauma patient. Awareness of possible iatrogenic life-threatening airway and chest injury in the non-trauma patients in our unit is essential. And the point-of-care ultrasound tool in the toolbox has made chest trauma much more manageable. These are my references. And thank you very much, and don't forget to evaluate the session. And happy sales. Hi, everyone. So I will jump right into ICU management of traumatic brain injury. I'm Stacey Brown. I am a neurointensivist. I work right here in Honolulu. So I'm at the University of Hawaii and the Queens Medical Center, which is the only level one trauma center in Hawaii and has the only neurodedicated ICU. So I'm tasked with discussing traumatic brain injury management and prevention of secondary neurologic injury. So I've struck at this talk by setting. We'll start in the ER and cover the most frequently asked questions there, then move on to surgical frequently asked questions, and then end up at home in the ICU. I don't have much time to talk about this fairly massive topic, so I've got to really hit you over the head with key principles, no pun intended. So I'm going to set some ground rules quickly and try to spend about three to four minutes in each of these settings. So ground rules. We're focusing today on severe TBI, as defined by the Glasgow Coma Scale. It's there for your reference. I'm also assuming that you've already excluded reversible contributors, things like intoxication, seizure, postictal state, or hemodynamic or respiratory instability. So GCS of three to eight, severe TBI, that's what we're focusing on. All right, so let's get started in the ER. Here are my FAQs. What's the blood pressure goal? Should I hyperventilate? And what medications can I give? Hyperosmotics? Steroids? Seizure meds? How about TXA? So starting with blood pressure goal, I wish it were that easy. It's not. Hemodynamic targets do ultimately need to be individualized based on the patient's cerebral perfusion and auto-regulation. This gets pretty complex. But before you know too much about the patient, here is the recommended starting point. It's a level three recommendation and a potentially problematic one if you don't later adjust your blood pressure goal based on the patient's physiology. But the takeaway is this, avoid hypotension. Here's why. Aside from it sounding obvious, what we really care about is cerebral blood flow, which is driven by cerebral perfusion pressure. And CPP is the difference of MAP minus ICP. So you do need an adequate MAP there to support your CPP. Here are the normal ranges of CPP and ICP, as well as the BTF or brain trauma foundation guidelines for your target ranges in severe TBI. So do note here, the very tight target range for CPP. The reason for that is because yes, too low is bad, but so is too high. So long story short, there are advanced neuromonitoring techniques for determining the optimal perfusion pressure, which are out of today's scope, but I'll briefly introduce to you when we get to the ICU setting. In a pinch, aim for a systolic over 100 and you won't be terribly off at the start. Next question. Should I hyperventilate the patient? Hyperventilation leading to cerebral vasoconstriction can quickly reduce blood flow volume and ICP. So aggressive hyperventilation is an effective rescue strategy for the herniating patient who you're trying to temporize as they're whisked away to the OR. This is not, however, a good strategy for a patient you might be admitting for non-operative management, because local metabolic compensation does occur within a couple hours, and the rebound blood flow that you get can lead to the opposite of your intended effect. So for this latter situation, aim for the low end of normal, like a PACO of 35 to 38. All right, how about meds? Can I give hyperosmolar therapy? Yes, you can and you should if there is cerebral edema, herniation, regional or global brain compression. Here are your options. How do you choose? In 2022, I'm sorry, 2020, the Neurocritical Care Society published guidelines that suggested a putative advantage of hypertonic saline over mannitol for TBI patients. Based on the idea that most of your trauma patients are in need of resuscitation for adequate perfusion, and a diuretic agent like mannitol is unlikely to help you there. But this is low evidence, REC aimed at the pre-hospital setting. Know that mannitol is absolutely in your armamentarium for patients with TBI who are unable to receive hypertonic solutions. Use caution in this one scenario though, for a patient with extra axial hemorrhage, so in other words, an epidural or subdural hematoma that's outside the brain. If you're admitting for non-op management, willy nilly osmotic agents will shrink the brain as they're meant to do, and paradoxically create more space for the extra axial hemorrhage to expand. Oh, hey doc, what about steroids? People used to talk about that. It's been studied, steroids carry increased mortality. There's a level one recommendation not to use it, so the answer to this FAQ is no, and I'm not going to spend any more time on it. Seizure medications. Good as prophylaxis against early post-traumatic seizures, no evidence for efficacy to prevent late post-traumatic epilepsy. So we use keprofenatone for seven days as prophylaxis, and then stop. Now, if your patient had a definite witness seizure, they're going to be at higher risk for recurrence, so keep the meds on longer into the outpatient setting where they can be slowly tapered off. Okay, TXA. Fairly recently, the CRASH-3 trial showed a head injury-related mortality benefit in patients with mild to moderate TBI, so GCS 9 to 15 when given within three hours of injury. Confusingly, there was no mortality benefit seen in severe TBI. Some intensivists began adopting TXA into their practice because there was no increase in the incidence of adverse events or clotting vascular complications, and it's dirt cheap, so why not? Well, there were some problems with CRASH-3, and shortly after it was published, this Dutch multicenter cohort study with a sample size of about 1,800 found that there was increased 30-day mortality in patients receiving pre-hospital TXA with isolated severe TBI. So do note that the increased mortality was significant only when considering those patients with isolated TBI, so not in the cohort that included those with polytrauma and other significant injuries. So among most neurointensivists I know, the data is interpreted to say that there is no rationale for using TXA for TBI reasons alone, and it's probably contraindicated for isolated TBI. However, if there's an indication from the point of view of systemic trauma, it's likely okay. Go ahead and use it. All right, so that wraps up the ER. Let's move on to the OR. Who goes for hematoma evacuation? Who gets decompressed? What about other bedside procedures? The first prerequisite for hematoma evacuation is that there's a hematoma to evacuate. That's much more obvious in scenario B, with this epidural hematoma, this subdural, less obvious in this sort of smoldering contusion situation, diffuse subarach, bihemispheric ballistic tract, or diffuse axonal injury. The second prerequisite is that the hematoma you want to evacuate is the driver of the patient's symptoms or deterioration. So keep in mind that many severe traumatic injuries result in multi-compartment hemorrhage. So the neurologic syndrome should match the expected impact of the lesion that you're thinking of evacuating. Localization is out of the scope of today's talk, but what I can do is throw up a slide that came from a resident lecture and give you all the answers. The main takeaway for you is that pupil dilation is not the only sign of herniation. Almost everyone does know to check for the pupils. Almost no one outside of neurology reports other herniation symptoms, so look for and notice things like posturing, persistent down gaze, progressive somnolence, new apnea, riding the vent when they used to. These are a few other red flags. Ultimately, surgical decisions are made using a combination of the radiographic criteria, clinical assessment, anticipated risk of hematoma expansion, and the relative risk of emergent surgery. You can look up trigger sizes in BTF guidelines. For example, a subdural that's at least 10 millimeters thick or has five millimeters of shift, but we all know that one size doesn't fit all. The clinical scenario does matter. Okay, who goes for decompressive craniectomy? First of all, what is that? It's when we do surgery and remove a large bone flap of the skull, and it's purposely left off to accommodate brain swelling and reduce ICPs. Major studies on craniectomy for TBI were the DECRA trial and the RESQ-ICP trial, both published in the last decade or so in the New England Journal. These were relatively higher quality studies, but please know that decompression still remains a controversial topic because TBI research is flawed by the large degree of heterogeneity. However, updated guidelines are here, and generally fell in favor of secondary decompression for late refractory ICP elevation. So as opposed to primary at the onset decompression. So in many places, a decision to go to secondary decompressive craniotomy does very much involve you, the intensivist, because you are the ones declaring when medical therapy has been unsuccessful. All right, other bedside procedures and monitors. So a bunch of places you can place probes. Most commonly used are the intraparenchymal bolt and the EVD. So the EVD goes in the external ventricular drain, goes in the ventricles. It has a functional advantage. So you keep it clamped, you get continuous ICP monitoring. If you end up with hydrocephalus or you need to vent some CSF, all you have to do is open it. However, it is a slightly more involved procedure than just drilling in an intraparenchymal bolt. And the bolts can have more than one lumen, which gives you access to other modalities of monitoring. This is a quote from the BTF guidelines. Basically, it's not placing the monitor or the numbers that you see that matter. It's what you do with those numbers. And that takes us to the ICU. How do I medically manage elevated ICP and what do I tell families about prognosis? This topic I find to be a general source of discomfort among intensivists and for good reason. BTF guidelines used to report on individual TBI treatments, which have been studied in isolation, but little evidence exists to guide combinations of treatments, the ordering of treatments or the relative efficacy of these things. So for that reason, in 2019, international consensus guidelines, oh, sorry, were published, which gives you an algorithm. Lucky for you, I'm not gonna unpack cerebral. I'm gonna talk about hemodynamics today, but there is a recipe and you don't need to be a chef to cook. You can follow this recipe. It's a tiered approach. So more aggressive treatments for more aggressive ICPs. Tier one has some of those ER setting treatments we discussed. Tier two includes things like mild hypokalemia, paralysis and CPP augmentation based on auto-regulation. Tier three is where you get into deep sedation, cooling, hyperventilation, and of course, decompressive preening. I am running out of time, so I'll just fly through and let you know that the field is expanding the evidence base for additional physiologic monitoring, starting with brain tissue oxygenation. There's a boost through trial going on. So you have two parameters to monitor, four scenarios to potentially deal with. Good news, still has a recipe, whether you're dealing with isolated brain tissue hypoxia or the combination of both. So again, I'm not gonna read through all of this, but what you're gonna look up if you're interested is the Seattle International Brain Injury Consensus Conference, where they publish these algorithms. I think the main things to point out are that there are slight differences in the strategy depending on the scenario that you have. And each of these tier twos include something called a map challenge where you, in a controlled manner, elevate the map and watch the other cerebral hemodynamic parameters and try to decide what the auto-regulatory status is. And that may lead to how you prioritize these different treatments. The other thing here on the right side is pointing out that you need to consider what is evolving in your patient's brain that's causing you to have more and more refractory ICPs. A couple of examples of dangerous scenarios, there are two compartments that are smaller and won't accommodate much expansion. So cerebellar hemorrhage can end up effacing the fourth ventricle causing obstructive hydrocephalus and EBD can help with that or suboccipital decompression. The temporal lobe is in the middle cranial fossa, which is also fairly tight and it's right next to the brainstem there. So a small hemorrhage here can cause a lot more herniation than the same size hemorrhage higher up. Just advance through the tiers. If your injury continues to be diffuse injury or cerebral edema, once you get to the third tier, you'll be talking to your neurosurgeons. The point here is that there's more modality monitoring, continuous calculations of cerebral reactivity, cerebral microdialysis, it's out there. The important thing to know is that once you embark on a decision to go through this type of intensive life support or brain support, it is a journey that you embark on with the patient's family and communication of the uncertainty of their prognosis is challenging, it's also very important. In 2019, the NCS launched the Curing Coma Campaign, which tries to re-envision coma after brain injury as a medically approachable entity rather than a knee-jerk poor prognostic indicator. And the main point to drive home here is that your prognosis can drive withdrawal of life support decisions, which ends up making it a self-fulfilling prophecy. And what we know about coma is still very limited, so we all have to have prognostic humility. I'll just demonstrate with this recent JAMA publication. It's a longitudinal cohort study from the TRACT-TBI study, which is ongoing, and extracted those with moderate to severe TBI. Looked at outcomes up to 12 months post-injury, and this is what they found. Approximately half of those with severe TBI, three quarters of those with moderate TBI recovered the ability to function independently for at least eight hours a day. Participants who were in a vegetative state at two weeks, 77% recovered consciousness, 25% regained orientation by 12 months. So the recovery that can take a really long time is a little different from recovery that won't happen at all. And there are also experimental therapies out there for treating disorders of consciousness. The main point here is to be humble about your prognostic abilities. And I will leave you with that. Thank you. While Dr. Reed's coming up, when do you use a bolt in your ICU over an EVD? So a lot of that is a bit of neurosurgeon preference. If there's a clear indication for CSF diversion, like you already have hydrocephalus or you have a large amount of subarachnoid hemorrhage that you anticipate will lead to a non-obstructive hydrocephalus, then an EVD would probably be an advantage. In cases where you have parenchymal hemorrhages that might be creating slit-like ventricles, it makes that target very hard to match and higher risk. An ICP monitor is much easier to place, so that usually is the first go-to. So again, unless you have an indication at the outset, you can always place an EVD later if you develop hydrocephalus. Thank you. I'd like everybody to interact. We have a couple questions I'd like with audience participation. So please go ahead and do that. And while people are scanning that, I'll ask the panel this question. So in my practice, if somebody comes in with a severe TBI, often, depending on their presentation and everything, I'll sometimes give a bolus of hypertonic saline before I have a CT head if I think it's severe. Does anybody else do that? What are your thoughts on that process? I'll have each of you answer, please. Yeah. If you're worried about impending herniation, obviously, you want to give them something to decrease brain edema. And it's nice to know that hypertonic saline is coming back. I know mannitol, as an osmotic diuretic, was on the forefront for a while, but I would certainly give them something like that if I'm worried about impending herniation. Any other thoughts? A lot of us, I avoid mannitol acutely because of potential hypotension, and if they're bleeding, have other injuries. Any other comments? Right. I mean, I think if, as you said, if I'm worried about impending herniation, if I'm worried about something like that, I will give hypertonic saline. I will avoid mannitol if I don't have an imaging. As you said, if it's an extra axial blood, I don't want to make that theoretically worse with mannitol. And again, with the osmotic diuretic as well. All right. Any other comments that you want to add? Yeah. I agree. It's all about the herniation syndrome. Okay. All right. So this isn't a question. This is a whole blood discussion, and I'd like, you know, each of you to form a, give us your opinion. Is whole blood indicated in non-traumatic hemorrhagic shock, specifically upper or lower GI bleeds, massive bleeds that are happening in the unit, perhaps an ectopic pregnancy, advantages, disadvantages? Any comments on that? I don't know if we have the, as we were speaking, if we actually have the literature for non-traumatic hemorrhagic shock. However, many of us in smaller hospitals, the whole blood program may not be, it's oftentimes expensive to start up and it may not be sustainable. For those of you who have massive transfusion protocols, it depends on, for like in my institution, it really depends on if it's outside the trauma bay, I'm less likely to get whole blood for my massive transfusion protocols for my GI bleeders and things like that. A couple of advantages to whole blood, one, it gives you everything you need. It matches whole blood like we've been trying to do. Two, it will go through a rapid transfuser. If you have component blood, remember the components, remember the platelets cannot be rapidly transfused. And also, the downside, also it's less volume and things like that. And it seems, especially in the trauma patient, to have mortality and morbidity. In the non-trauma, I'm not sure we have that literature yet, but I think that most of us bleed, hemorrhagic shock is hemorrhagic shock. You want to avoid that, but that's an opinion that's not borne out. And then the last thing, one thing about whole blood is it has a limited shelf life and looking into low-titer O blood is also a problem. So I think that, I think there's value to it. For me, I get it half the time up on the floors compared to what I get in the trauma bay. Awesome. If no other comments, with the interest of time, I'll go on to the next sort of case. This is a civilian mass casualty situation, some kind of explosion. Your hospital is getting saturated with patients. The surgical teams are operating. You have a 33-year-old woman who's intubated with a GCS of seven with a severe TBI. You can see subarachnoid hemorrhage with hemorrhagic contusions, bad chest injury, all the badness, contusions, chest tubes, hemothorax, flail. And they have a, those things have been managed, the right lower extremity traumatic amputation at the mid-tibia. There's no bleeding. And she arrives from the trauma bay into your ICU, again, this is a mass casualty situation, and there's a tourniquet placed high and tight on the right thigh. And so here's our first question, and I'd like the audience to answer this. I think it's an important discussion, you know, with all the things going on in the world to talk about appropriate management of tourniquets. So hopefully people are, let's see, I think, yeah, all right. All right, so let's talk about that, that's interesting. Let's talk about that. So what is tourniquet replacement, and what is tourniquet conversion? This is what we teach our medics and corpsmen in the military, you know, all tourniquets should not necessarily be placed tight and tight. Once a tourniquet is applied, leave it alone, not true. Tourniquets can only be removed or converted by a surgeon, not true. I think everybody needs to talk about this. So what's replacement, and what's conversion? So replacement is putting on a new tourniquet in a different location to control the bleeding. In the military, if it's applied over the uniform, or if it's applied too proximately, or it's going to be more than two hours before they get an operative intervention. And that's tourniquet replacement, and generally you want to apply that tourniquet two to three inches above the wound. So that's what replacement is. Conversion is once you have evaluated that patient in your trauma bay or whatever location, you don't have any other sources of bleeding, you take down that tourniquet and see if they still need it. This is what we teach the basic medic, because like I said earlier, tourniquets get placed a lot of times for little nicks and for the wrong reasons. So if somebody comes into your ICU with a tourniquet and it's not placed by the orthopedic surgeon turning over to you or the trauma surgeon, you need to decide whether they still need it or not, or if it's in the right place. And so what we teach and what I do in the trauma bay, once everything else is done, you know, I actually take down the tourniquet and see if there's bleeding. But what we teach our medics and corpsmen is to pack that wound, hold pressure for three minutes, place a bandage, and then slowly reduce that tourniquet. That's what you would do in the field. I would take it down and see if there's bleeding personally. Any comments on tourniquet conversion or replacement and your experiences for both of you? You want to add? Go ahead. No, I think that that is, I think it's a key concept to have, especially if you are working, you're doing locums, you're doing, you're in a smaller hospital because tourniquets are more and more, are being used more and more, and you may be the first hospital for a mass shooting, or you may be further out, so you need to be aware of what this is. And so I think that this is, as you said, tourniquets that are placed too high on a leg, so you have that, you have to realize that there's a lot of tissue in that thigh that could be ischemic. If you move it closer, more distally, that it may be more helpful. So the replacement and conversion, I think, is an excellent thing to know because you may be somewhere. Awesome. All right, I'm going to try to, we have one more minute, I don't know what happens if we go over, I'm not sure if there's another session here, so. So this is, I'm going to move on, the order got changed, oh wait a minute, sorry, okay. This is a standard question we ask residents, so mass casualty situation, same sort of situation, PCS of six, hypotensive tachycardic with this patient, when and where should the intubation occur? And so let's see what everybody said. So it should occur in the emergency department, in the emergency department after two units of blood, operating room while surgeon is scrubbing. So D is the right answer, and this is something, whether you're a septic shock or whatever, that I see is the concept, if you can, manage your airway with your airway adjuncts, bag valve mask, NPA, most of the time you can and resuscitate that patient with what they need before intubating, because once you give them all those medications, they're going to crash and they're going to coat on you. That's just a point that I see happen, a lot of times when somebody, something's happening, the team wants to do something and they think they need to intubate right away, and then they make the situation worse. That's the point I wanted to make there, and this is an actual patient that I had that was a woman who was septic that we weren't, the surgery team wasn't involved with until much later. It happened at one of the institutions I work at, and they did intubate her, and then she coated and chest compressions and all those complications from trauma that you had, and so that was the point that I wanted to make there. Any comments in the interest of time about that? I know the concept of AVC is a fundamental concept that's been ingrained in us, but many times we see that people come in shock and under-resuscitated, and as soon as you induce them, they bottom out, crash, and sometimes even die, and to that end I think there's ongoing investigations about bringing C up before A, so instead of doing ABCs, I think people are focusing more on the circulation and then the airway and then the B for breath sounds. I think as long as you have an airway, which means that you could either do a modified jaw thrust or bag ventilate, as long as you've got some type of airway, I don't think the rush to intubation should be there. Intubation should resuscitate the patient first, and then a definitive airway is more of an elective procedure as far as I'm concerned. The other thing is, this is not like the PREPARE trial or the PREPARE 2 trial. If you notice at that patient, retrospectively, it's the hypertension, but also the acidosis and the increased lactate. So we're talking about two different sets of patients, right? So the sicker patient needs to be resuscitated, not just someone who's mildly hypotensive like they had in the PREPARE trial. Last question. I'd like to see what the audience does here. So who takes care of the traumatic brain injury patients in your institution? We'll see. I have to look over here. So not everybody replied. I'd just be curious. Please reply. So trauma critical care surgeon, that's the model that I practice in. It's a closed trauma unit. TBIs come in there, and then we consult neurocritical care for specific issues or when the neurosurgeons want us to. Some places it looks like a medical intensivist does, and their trauma surgeons are doing other stuff I'm assuming, and so they're taking care of those patients. Everybody chose C, and then 13%, so two of you said only physicians board certified in neurocritical care. What happens here in Hawaii for your team? So our model, the neuroICU takes care of a number of things, including things like seborrheic stroke, ICHs. If a trauma patient comes in with moderate to severe TBI and also cervical spinal cord injuries, we actually take over as the ICU team. So we work together with the trauma team as well, but basically run on every ICU level thing. Our rounding team consists of the surgical ICU fellows and general surgery residents who are rotating through the surgical ICU, and we are there attending. That sounds like an ideal model actually, because everybody gets good teaching, I like that. Any other comments for your institutions for the panel here? We have a, I'm neuroboarded as well, so we have a neuroICU, however we also have a trauma ICU. So the TBIs are taken care of in our trauma ICU, unless there's a specific question. However, with the ABS, American Board of Surgery, Pathway to Neurocritical Care, many trauma surgeons are doing that. So that may or may not be the wave of the future. John? I know in our year in review, last year I think it was, we had a whole talk on the evolution and development of the neurocritical care ICU board certification. That's something that started a couple years ago, and it's still available for practicing intensivists. If you guys are interested, there's a grandfather program that will allow you to grandfather in and sit in for the neurocritical care boards. It's verified by the American Board of Medical, ABME, American Medical Board of Examiners. So if that's something up your wheelhouse, and if you're interested, look into that. It's the neurocritical care specialty boards. All right, well, I'm a few minutes over. That was my last sort of question. Thank you to the panelists, and thank you all for being here. I appreciate it. Thank you.

trauma care

trauma epidemiology

damage control surgery

resuscitation

tourniquets

hemorrhagic shock

intubation timing

traumatic brain injury

hypotension

communication with patients