okay it’s three o’clock grab a chair and be ready to attend this exciting hopefully it’s an exciting session so basically all patients they have a pre hostile face it’s very rare that they are they are traumatized during hospitalization initially at least and so so it makes sense in the time critical condition to take a smaller version of the hospital and bring it to the patient in the pre-hospital phase so the next three speakers they can tell us their view upon those smaller version of the hospital and the first speaker is Professor Halcomb okay shift gears just a little bit here talking about pre-hospital hemorrhage control oh and resuscitation sorry about that now those closures are the same except this one I do have royalties for Coe inventing a junctional tourniquet I receive enough to buy a case of beer every six months the or one bottle of really good wine right yeah not very much damage control resuscitation we’ve talked about already number one and and I’m gonna hit this pretty hard is stopping bleeding that’s what we’re going to talk a lot about we’ve been saying this for a long time back home resuscitation is much easier and may only be possible when bleeding is controlled so it’s an obvious statement and if you look back at the history resuscitation in trauma surgery in the United States there was a lot of emphasis on surgery and then in the literature less emphasis on surgery and resuscitation and then emphasis on surgery again what we try to do is both and both together put them both together at the same time you can’t forget about one or the other or the patients don’t do well and so we can spend a little bit time here talking about hemorrhage control in pre-hospital hemorrhage control for a long time the United States was run master you know was pressing harder on the gas flying faster and the patience Lord would either live or die really based upon how far away they were from the hospital and you said well maybe we can do something better and we kind of talked about hemorrhage control as being with turn external hemant role external compression with tourniquets where you can get tourniquets on junctional hemorrhage larger than the groin markets don’t work there and then truncal hemostasis chest out and in pelvis it’s still in most places run faster to the hospital but maybe there’s some new alternatives coming down the pike so this slide has is pretty busy has lots of things in the junctional tourniquet up here on the top left are several different varieties of them but they all kind of go on and stop bleeding in the groin that this one is actually an abdominal aortic tourniquet and it goes on above the junction above on the abdomen right that goes right across the umbilicus and you blow it up either manually or with a co2 cartridge and it compresses through the skin the abdominal aorta to the spine now it’s an interesting concept it’s extremely painful for people to put on they can’t breathe a have to get intubated and it’s out there and approved and being very rarely used tourniquets we’ll see some pictures from Iraq and Afghanistan but this is in Houston civilian tourniquet put on a guy with a gunshot wound and a hemostatic dressing this is the BOA catheter we use the resuscitative intra-aortic balloon catheter and you blow the balloon up in the aorta hemostatic dressings combat gauze same thing as this right here there are many varieties John has talked about one of them a little while ago and then of course blood products tranexamic acid pcc’s on and on and on so for the intravascular approach so pretty interesting these new devices that are out there i’ve heard i saw my first tourniquet in 1993 in somalia didn’t had no i was trained in a civilian in army center but we didn’t use tourniquets and then as a young certain took care of this guy actually my hands taking off this tourniquet that this guy put on his leg with a screwdriver and his belt highly effective I can see his left leg is essentially off and was we were pretty impressed by that that’s an N of 1 and of 1 pretty impressive and of one and has helped drive a lot of our efforts since then this is a move forward now a decade of 2003 and unfortunately this medic did not have a commercial tourniquet or the right kind of windlass and died from a popliteal artery injury

although his he was automatic in this unit in Afghanistan the guys knew that he needed a tourniquet tried to make a tourniquet but didn’t have the materials to make an improvised tourniquet and he bled to death with three or four of these tourniquets on his leg he then moved forward only a couple gears this is in Iraq and Baghdad and this guy has two tourniquets put on his legs by non-medical people so non medics they were put on his legs by his fellow infantrymen and although there’s a lot of blood it looks like there’s a lot of blood here’s not actually a lot he’s awake and alert I took care of him as well was awake and alert human a mcclee stable not tachycardic and without a base deficit or elevated lactate when he came in with the two tourniquets put on put on by his non medic folks in he then it obviously completed the amputations and his up walking around actually works at rehabs and we’re taking care of new amputees today so John Craig because tourniquets were at that time you know a decade ago and even less than that were considered somewhat controversial John Craig wrote this paper and published in Journal of trauma went down and saw every every extremity injured patient in Baghdad for six months and so 232 patients with 428 tourniquets as you can imagine several multiple tourniquets on multiple legs and his conclusion after all of this and I’m short circuiting this a little bit because we have 15 minutes is that the tourniquet was highly effective and safe nobody had an amputation from the tourniquet if you look back at this guy the tourniquets did not cause his amp you the amputations done by the wound now the tourniquets might could have been down here right if you were a medic you’d put them down here but if you’re a lay person with no medical training you want to stop the bleeding now there you guys are in a little of firefight as well so it’s a bit different but the tourniquets did not cause the amputation that’s what John showed so now you come to Houston in 2008 and this is a drug deal gone bad the shotgun wound below the knee and the tourniquet gets put on by the medics and the combat gauze again a very effective way to bring the guy in lost control the bleeding and in a fashion that is avoids massive transfusion so we spent a lot of time about talking about transfusing people a lot now we’re trying to keep the blood in the body so we don’t have to give as much blood products so what were you done in Houston so from 2008 we started damage control resuscitation in the hospital then we put tourniquets on our helicopters in 2010 we move that thought plows and I talked about in red cells in the emergency department we then did liquid plows and red cells and ultrasound on our helicopters so now we move we looked at it we studied it with those a good idea in the hospital we move them to our helicopters and then in 2013 now we put three tourniquets on each of the 600 ground ambulances in Houston so there’s multiple different EMS agencies three tourniquets on each one and then they replacing themselves and then a year later we bought two tourniquets and one combat gauze for all five thousand police officers in Houston so we scattered effectively scattered tourniquets and combat GaAs throughout the entire Greater Houston area which serves 7 million people so the tourniquets in combat gauze pre-hospital now are standard across the 150 mile radius that we serve we put junctional tourniquet on the helicopter that’s the thing that I have I get that Rope huge royalty for and then liquid plasma and the end red cells in the edie at our level 3 trauma center so our level 3 trauma centers came to us at about a year and a half ago and said you know what we’re looking at what you guys do or reading the papers we like that we want to have red cells and plasma in the small ers that are surrounding us in that greater area and so now the patients you know some of you all receive these transfer patients in from smaller hospitals and still get crystalloid sometimes some red cells now our patients are coming in transferred with the plasma as well and then this year we’re within a month or two of having plasma and red cells on select ground units in the Greater Houston area so now ground units out there will be able to transfuse patients as well just some pictures without a lot of data this is a tourniquet put on a bad guy by a police officer who had an ulnar artery transected we have published in the Houston area 15 patients who died from isolated extremity entries one from a dorsalis pedis artery treated with duct tape you know didn’t work very well guy bled to death from his dorsalis pedis and you think well why didn’t they hold pressure I don’t know but they didn’t maybe they were getting shot out by that bad guy who knows what was going on you know Houston’s in Texas and a lot of people unfortunately have guns so this is a young guy that I took care of a couple months ago who was sitting in his car driving down the road and a hay baler came in and took out the left side of the car sitting in the backseat seat belted mine his own and minding his own business his wife was driving and took off his left arm his wife held pressure thank goodness the helicopter showed up

and brought blood products and a tourniquet he came in and was talking to us with no other injury and went home in five days so tourniquet blood products and pressure all at the scene I think a beautiful example of significant injury by the civilians this is the junctional tourniquet that we helped that I helped Co develop and it is nothing more than a band that does compression and the screws down the femoral arteries and has been used in Afghanistan and and around several times in the Greater Houston area as well so this foam business who’s heard of this foam that goes into the abdomen foam and they have a pretty interesting idea these are human pictures from humans okay now these patients are patients we did a three Center study and in patients who were dying and had died in the ice on in one case the patient and in other cases the families in assam after they died could we put the foam into the abdomen to see what the pressure was like that dosage was like and so we approached 400 patients were screen 224 didn’t meet the criteria had had no previous abdominal surgery radiation ended up with 21 recently deceased within three hours we put the foam in so the temperature was okay the distribution throughout the outer and the outer noon was okay and the compliance of the Donald wall was okay and missus just recently published in the Journal of trauma this does come out as a large block in about 900 pics this actually does decrease bleeding from liver and iliac artery injuries it does not have to be in contact there’s a pressure phenomena that’s there and I think this is going to be one of the things that we have a proposal in front of the FDA right now for intra abdominal bleeding pre-hospital that holds some promise it’s kind of a crazy idea this is everybody’s response if you stand in the edie and take care of patients over and over and over again who have extended a to pre hospital because there’s no way to stop truncal bleeding on a helicopter other than fly faster they’re already flying at 150 miles an hour and you just can’t get there and when people do this within minutes so the other one is rabo’ah ribeaux –is was help driven by dr. Brogan London he has did the first one pre-hospital actually in the hospital but on the helicopter some combination of that very impressive resuscitate of thoracotomy is one of these big procedures you make an incision this big and somebody doesn’t have a chest injury to put a clamp on the aorta instead what we want to do now is make a incision in the groin or percutaneous but this calf that are up through the femoral artery and do they order and blow the balloon up and you kind of say well which one would you rather have right so there’s no question about that we’ve recently completed a study that’s was presented last year at our trauma meeting and as accepted that Journal of trauma now with about 24 rabo’ah cases we’ve done a subsequent study with 35 and what’s happened at our Center in Baltimore these are combined data becoming Baltimore in Houston is resuscitated thorocotomy is almost going away in our centers to almost going away not quite and during these each of these are three six-month blocks so 18 months such data thoracotomy Goes Down and Robo agos up in the trend has only continued so the clinicians both in the ER and that surgeons are voting with their feet on this after they see it done and opting for a balloon occlusion they order rather than thoracotomy I’ve showed this slide once before so once you’ve worked a stop leading the tourniquets junctional rubella foam right pre-hospital then how that we were sustained we’ve talked about that a bunch so I’m not going to go into that the pre-hospital blood products we as I said have put our products on a helicopter about four years ago and it published the results associated because it’s non randomized in this study associate with improved early outcomes with no long-term difference and you know the talking about our helicopters and we were talking about this earlier the honor helicopters we do number one is not slowed down from scene of injury into the hospital once on the helicopter we have a 68th minute median transport time on the helicopter because we go out pretty far distance and so we do have tourniquets and hemostatic dressings junctional image control devices pre-hospital plasmon red cells in that or the medics start plasma first and then red cells if they need them ultrasound so they can do the ABC score and look for pneumothorax and blood in the in the abdomen or around the heart portable blood warmers the medics are nurses are really good we can do LVAD and ECMO on the helicopter and transported when they do transfers between centers and we were like doing the new technology obviously we put new technology that has to be effective we try it out in the hospital first and the emergency department usually it’s effective and doable after training put it on the helicopter the way that the guys do blood product is you might imagine there’s blood warmers and packaging to keep the blood products appropriately cold for their blood we

spent a lot of time with our blood bankers because they were very concerned about this it stressed our blood bank to take the blood products from the blood bank to the IDI and it really stressed them when we put it on the helicopter but they recovered and what we do is we treat the blood products that have the same temperature controls and the same monitoring all the same paperwork that they do from the blood products from the blood bank and the it’s exactly the same so that made them much more comfortable along the lines of the earlier discussion people are putting platelets in the IDI and there’s people putting platelets on helicopters now putting whole blood out there on these devices kind of the same idea as as we talked about earlier with if it works in the hospital why not fit it pre-hospital there was a question asked earlier about whole blood we did a whole blood study so we’re working right now having starting we’ve done multiple meetings about creating a blood bank for whole blood for bleeding patients and then you have a blood bank with components for everybody else and that were basing that experience off this prospective and randomized whole blood study that’s green 1600 enrolled 107 is a pilot trial that was published a couple years ago so pre-hospital resuscitation it does seem like there’s a consensus to start in the hospital one to one to one it almost I hesitated typing those that little line I did it after listening to all you guys talk over the last day and a half I’ve never typed that line before but at this meeting it seems to be a consensus so why not start this pre hospital so if we do it in the hospital and we think it’s a good idea why not do it and you come into the logistics and it’s kind of just the ability to do this and one thing you have storage issues there’s different storage for platelets and there are red cells and plasma different expirations for these two things it’s really it would be problems to take care of listen you just have to hang three backs anybody been on a helicopter yeah you want to hang three bags on one patient went after the other than right sequence and keep track of it absolutely not right no way what about whole blood you hang one bag so you talk to the medics and nurses are on helicopter and say which would you rather hang one bag or three pretty simple answer you know when you’re pre-hospital it’s just less people less stuff less time less equipment and I think everything you do to make it easier it makes sense plus all that seems like a really good idea we have an ongoing study we follow that single Center study with a prospective observational study pros which is pre-hospital resuscitation on helicopter red cells and FFP versus crystalloid we’ve enrolled 699 patients since January 21 percent of the patients pre-hospital they’re on helicopters that carry blood products or have a receiving transfusion and do anything set 9 sinners the the enrollment is gonna be hard for you to see here but these are the sinners rolling pretty quickly we’ve looked at about 8,000 or so patients admitted during this time 1300 got on the helicopter and 699 or the highest risk get all you know the ones that get everything done to him intubation is chest tubes and transfusions and that sort of thing we expect to be done with a study in January and as I said a 21% pre-hospital transfusion rate at the sinners who transfuse blood products I think this will provide a solid framework when we have the retrospective study single Center prospective observational study within which to do a randomized pre-hospital study and an ethical and pragmatic approach there’s multiple different products out there all of them dried there’s multiple companies working this area we’ve talked about all of them today this slide doesn’t capture all of them but I think there’s great opportunities to take these products and move them pre-hospital to those patients that are in and really the greatest need and the greatest logistical risk with a smallest number of people taking care of them the way forward is stop bleeding with devices and products and interventions optimal resuscitation that would be consistent between the pre-hospital and Hospital area I think we have an opportunity to further improve survival and decrease complications and you know as most things this all this started in the combat zone with a group of folks who work pretty hard together taking care of a lot of patients injured from a lot of different places thank you very much thank you very much and questions in the end so next up is Professor Brody okay so Matlin’s thoracotomy and rubella are they worth it which is a rather

provocative title and so I thought I would really discuss whether it is worth it to do these interventions but really to talk about whether it’s worth doing it on a specific patient who is in front of you again I think like John more and more we’re saying that there is no specific boundary between the hospital and the pre-hospital phase so if on average 25 percent of patients who have severe hemorrhage are going to die one in four of those patients will die within the first three hours of being injured and depending on where you are that leaves you somewhere between two hours and no hours in hospital – to treat that that patient so the question really is in your context in your hospital in your trauma system in your environment are you going to be seeing enough patients who would benefit from such interventions and can you justify therefore the resource in terms of the investment in people skills training expertise in which to deliver at that and that actually doesn’t matter whether you’re talking about in the hospital in the emergency department or pre-hospital in the pre-hospital phase but actually people get very confused and exercised and upset about both resuscitative thoracotomy and Ribera in terms of thinking about who should get it and who should not get it and the data that are out there are actually not that helpful for all all sorts of reasons but I thought I would start just by getting you to think about different patients and whether you would actually consider it reasonable to do a thoracotomy on those patients will come on to Ribera briefly later but just to think about thoracotomy first and we won’t use the fancy voting things because we’ll be here all day so show of hands essentially 17 year old boy stabbed in the left chest he’s wheeled into the emergency department and he loses his central pulse all things being equal you see a candidate for a thoracotomy raise your hand if you think no okay he loses the central pulse five minutes before he hits the emergency department so he’s been with the paramedics he’s had a central pulse but five minutes they haven’t been able to feel anything for five minutes before he walks in she’s still a candidate for thoracotomy it’s the only one think no he loses the central pulse 15 minutes before it hits the emergency department so he’s at a new central output for 15 minutes yes or no hands up for yes hands up for now okay so now it’s sort of 7525 in the other direction 60 year-old man stabbed in the left chest lost the central pulse 15 minutes before the emergency department yes three people four people thirteen-year-old girl stabbed in the left chest 15 minutes before who wouldn’t open the chest on thirteen-year-old girls who can’t make a decision thirteen year old girl hit by a car blunt trauma this time lost her pals fifteen minutes before hands up four yes potentially hands up I know oh sorry you need more help jack oh I’m sorry oh I’m sorry do you need to take say everything that you’re taught is Blanco penetrating yes have they been down for five minutes whatever have they been down for meetin’s and ago so it’s actually very difficult for people to make a reasonable informed decision when the the criteria that are given to you are so difficult plus all the data is retrospective cohort studies essentially

they’re all done in an era of crystalloid resuscitation as well essentially so everything that is related to modern damage control resuscitation is actually very few large cohort studies investigating these aspects so it’s actually difficult to generate a framework within your head of what you should actually do so I’m going to just take what you through the ethics if you like of it so why would you do a thoracotomy on any of those patients and obviously the main reason is because they might survive so why wouldn’t you do it well they might die and therefore essentially to the certain extent your intervention has been futile they might also have a poor outcome they might have a poor neurological outcome so you might save them but they end up in a persistent vegetative state and be dependent on the families in the state there is this concept that as aberration in the emergency department it risks the team of exposure and whatever and there’s also a feeling that in some circumstances it’s done for personal self gratification or because you know it’s something that you feel that the unit or the service should do it’s very important that as a pre-hospital service we do thoracotomies because that a lot of do thoracotomies and how can we call ourselves a service if we don’t do thoracotomy and so there’s a the idea that you do it actually because for the good of yourself or the service or rather than the patient so let’s put some numbers on these then so on average I’m going to give you number of people out of hand rather than percentages and try and stick to like real humans here if you do a hundred of these in modern series you have about an 8% all comer survival right now obviously patient choice and patient selection is the biggest issue here with all these studies but they on average overall you have an eight eight people will survive if you do hundreds of these and ninety-two people will die there are a couple of studies looking at long term outcomes of these these patients and actually probably 80% of patients who live will have a good outcome that is they will not they will have a good neurological outcome and they will turn to some independent and status so overall then you’re now looking at two of the hundred people who will have a poor neurological outcome and end up dependent and so the group that out of that hundred essentially six people have had a good outcome and again this is all comers so this is the average depending on where you where you come from and what your patient base is so would you do it are based on those numbers so for a lot of people six 100 is not enough to justify the the intervention and for a lot of people it is I think the issues around it risking the team well you know we do operations all the time that expose the team to exactly the same risk if not more so I’m not I think if you believe that you put your team at risk and doing a procedure then you need to look at how you do your procedures and obviously as a unit you need to be sure that you are doing things and as a person you need to be sure that you’re doing things for the patient and otherwise I’ll sort of take those out of the equation for them in a minute but the other thing that you have to consider in the modern area is organ donation and while the organ donation done doesn’t benefit the person in front of you it does benefit people and it does benefit and society so the people who are eligible for them they’d actually be essentially the people that you get at after a brain after an injury but who have a poor brain outcome who go on to to brain death and those numbers are going to vary depending on the organ donation program is and how many people you get back but take the conservative estimate and say that 20 of those 92 patients about one in five patients will will go on to donate so if you consider a good outcome then as being around a quarter of the patients and a bad outcome as being three-quarters then it moves the argument on from just a you know one just a six people out of a hundred again benefit to a much wider group but it doesn’t mean that you actually sit and have to be set up for a really aggressive program to keep people’s people and organs supported and to actually go on to that donation and it also means that you can’t do it in isolation as a service you have to do it in the context of a wider system that is both your trauma system and your

critical care system and your organ and donation system so you need to consider the context of these people in the context of those numbers and in the context of your your system now for many of you this patient is you never see it you never see stabbings you never see gunshot wounds and things so your experience of this person with a tamponade who would have a much better likelihood of outcome is is much less than somebody who’s been pretending potentially the blank form and group the six year old man is almost never going to do well in in these situations but nevertheless for a specific injury complex in a specific situation may have an output and young girl again blunt trauma so again you have to contextualize her potential outcome so a much lower overall outcome rate for blunt trauma but much better neurological survival rate because she’s a young a young girl so you know the numbers change but the principles stay and the same so what do I do so I don’t do any of that I think there are three things that you need to think about when you see the patient in front of you as to whether you’re going to go for an aggressive early hemorrhage control intervention first of all can we fix this is the rating issue comes in but it’s much more subtle and nuanced than are they just blunt or penetrating injuries the second question is is the heart alive and I think this is the crux of the matter and is far more important than how long they have been down or how long they’ve not had a central output for you can have no central palpable pulse that have maintained coronary perfusion and cerebral perfusion it may not be perfect but it may be adequate so in my mind coronary perfusion is the absolute predictor of whether this patient has a chance or not and the indicator of coronary perfusion is pulseless electrical activity or that they continue to have normal formed complexes on their on their on their trace so 60 year-old man who as penetrating trauma who has been down down for 15 minutes but has a rhythm I might world out for a 17 year old boy who’s been down five minutes and has been a systolic for five minutes I may not go for 13 year-old girl I probably go for every time to be honest so coronary perfusion so that the name of the game the absolute name of the game in these interventions is to restore coronary perfusion the second aim of the game is to restore cerebral perfusion and that’s a key understanding in this most people go for the head first but it’s coronary perfusion coronary artery perfusion that is the key a key step so is the half-life do they have reasonably complex electrical activity and then the other thing to do is remember that there are multiple opportunities to withdraw so you may start this process and the heart not respond to feeling not respond to – to your resuscitative attempts and you can stop you can give blood and blood products and you can say you know this person’s now had ten units 20 units we’re not getting anywhere we can stop the patient may get back and they may get up to ICU and they may have that poor neurological outcome evidenced on mr or their or no most functional blown pupils later and there are multiple operations options there to have a discussion that actually involves family members and to then stop and also to engage with organ donation prospects so you know if you had a cancer patient in front of you you wouldn’t make a decision on whether they should live or die without having a conversation with them if you had an aortic aneurysm patient in front you wouldn’t make a decision on whether they should live or die a snap decision based on knowing how old they were and how long they’ve had it for and again in this procedure you can start get more information either immediately about how they respond or secondarily about how so I think those are the three things that will tell you whether you it is worth doing the procedure or not what about rabo’ah so I’m not going to talk much about rubber because I think the questions are on rubber are actually the same as around thoracotomy except exsanguination with thoracotomy has a universally poor outcome in the area of crystalloid resuscitation it’s probably better in the area of damage control balanced but resuscitation but it’s not

great certainly and so there is a need for more advanced methods to both achieve hemostasis and to restore coronary perfusion I would say we don’t yet know whether Ribera is that device or not because it’s you’ve been used in multiple different contexts in multiple different ways where it is a possibility so is it worth it it depends thank you and next speakers professor Dutton but as a veteran of a number of these conferences it’s interesting see how they have changed over the years and and how each one of the meetings focuses this one has been very pharmacologic I have to say a lot of discussion about what to give and and the very exciting idea of endothelial resuscitation now emerging this one this talk will be going backwards a little bit so I have nothing to disclose most of this talk is based on practical experience in the big white box of chaos in downtown Baltimore where I spent many years and if we talk about hemodynamic monitoring whether in the field or in the trauma center this is kind of what we want to get is this person dying and if so how fast because if they’re not dying we can take our time figuring it out right and we have labs and really expensive x-ray machines and so on that will help us with that but what we really want to know is you know are they dying right now do we need to do something about it and then assuming we do do something about it we want to be able to monitor the effect so our trend over time how are how are things proceeding are we gaining or losing airway and breathing issues obviously most of us in the room are anesthesiologist we would start there you just heard mention of tamponade when Kareem didn’t say is that seven out of the eight survivors of edy thoracotomies are the ones who turn out to have had a tamponade not because that’s probably the the most fixable thing we could find and then most of this conference has been focused on the slightly slower process of bleeding and resuscitation so this is the figure I use to talk about volume with my residents and unlike most of the conference which has been focused on what do we give this is the question I asked yesterday of the surgeons unfortunately which is how much and this is what we have to figure out so what you’re looking at here is a where you have vascular capacity how much blood could we fill this person up with right and this is actually a much much larger number than most of us realize if every vessel in your body dilated maximally right now that would create a space of something like 30 or 35 liters so obviously we don’t do that because we’re all upright most of your blood vessels are constricted most of the time this is an important lesson is that we live in a very vaso constricted state an actual blood flow at the cellular level sort of migrates around your body in response to where it needs oxygen on the bottom you have vascular filling so how much fluid do we have in that space and really all of anesthesia physiology can be explained by this right we take a person here right here at the star in the middle so you are five liters of blood in a five liter volume and I know that so because you’re you’re upright you have a positive blood pressure and we believe them and this reduces the amount of blood they have in the same space so they go over here into the blue side which is the hypotensive side of the picture but very rapidly you compensate right you vasoconstrict and you get back to this center line you notice the center line isn’t the isobar here of normal blood pressure and most of the trauma patients we see as they roll in the door into the back of the ambulance have bled a bunch compensated a bunch and are back here with a normal pressure so your classic femur fracture 1500 MLS of bleeding but then the person very rapidly equilibrate sit is often normal when they hit the trauma center in the o.r every day we do the experiment the opposite way right we anesthetize people this increases their vascular capacity right and they get hypotensive as a result and then we fill

them up we fill that space what I will suggest you about trauma and what we’re trying to do is keep the person back here at the middle so if they bleed and compensate what we need to done do is anesthetize and fill so they get back in here at the happy spot of good perfusion and that’s that’s it everything you need to know so how do we figure out where we are on that graphic and I begin with the one-second test we’re actually all extremely good at this right well perfused people what we’re trying to measure our pink their vertical all right they’re communicating so it’s actually relatively easy to figure this out and when you see somebody who isn’t the belle typically rings in your head very quickly they don’t look right John used to wander through our tremor resuscitation unit in the dark of the night from time to time and often find me sitting there with my feet up on the desk watching stretchers roll by with my residents grappling with them and usually I’d be sitting there doing a Sudoku or something but every so often I’ve watched one roll by and then stand up and go follow after it and it’s because of these cues it’s the one-second test and you should pay attention to that little voice in your head that says there’s something wrong with this person because you’re probably right the rest of this stuff can be relatively easily measured that does not make it entirely useful but this is where most pre-hospital monitoring runs and having given a lot of fancy monitoring devices for human dynamics to pre-hospital providers most of them end up gathering dust as you’ve already heard they’re very busy they don’t like carry stuff they don’t like anything that involves paperwork and they don’t like anything that’s going to take their time away from the basic job of getting the person to the trauma center so what we need is are things that can be very simple and the same applies early in resuscitation in the emergency department or the operating room blood pressure we’ve entered this a long time ago it’s not completely useless but pretty close because it’s not actually measuring what we want to know and if we go back a couple slides to the picture the problem is you can have the same blood pressure all along this line at very different states of filling and perfusion so it doesn’t really tell us where we need to be pulse pressure is a clue and as you get sensitized to this if the blood pressure is 130 over 110 as the patient rolls on the door I suggest you should worry about that patient because the next one’s not gonna be so good pulse oximetry actually much better monitor and it measures oxygen delivery to the tissue so in many ways it’s very very reassuring if you’re looking at a hypotensive patient with a hundred percent saturation at their fingertip it’s a pretty safe bet that their brain and their coronaries are fine as well regardless of what their blood pressure is we have unfortunately gone the wrong way with this monitor though if we had developed a pulse oximeter before the blood pressure cuff all of resuscitation would be very different because this is what we use and this is what would be mentally calibrated – and we would use it much more as a perfusion monitor and less as a specific indicator of oxygenation which is how we think of it now and unfortunately Massimo and your other companies that have put a lot of work into oximeters have mostly designed them now to disregard the perfusion settings in order to give you a good saturation number and they’re actually throwing away some of the most important data that you could get from it which is how much blood is flowing through the fingertip I’m going to hit some cool new stuff quickly we’ve had the opportunity we had the opportunity to Shock Trauma to play with lots of new toys most of this doesn’t work but it’s you know shiny you can get very fancy devices for your operating room now that will precisely calculate the urine output that’s a fancy your Rimet or in case you we’re wondering it’s just a bag but it counts and you get a big number on it I haven’t found urine output very useful for resuscitating trauma patients the problem is that your kidneys sensitivity to perfusion your kidneys can be perfectly happy and not make you’re in any way and the signal from urine flow in the acute phase at least is almost completely overwhelmed by diuretics like alcohol for example and circadian rhythms so at 2:00 in the morning nobody makes urine just they just don’t and trying to make them make your and it can be very frustrating pulse pressure variation this is better I won’t go into specific science but you’ve all seen this and probably played with these monitors in the O R now some comments about this I find this a very useful technology a very useful monitor for my set piece one dimensional in aesthetics where I get to anesthetize

the patient paralyze them set them up on the ventilator have them in a stable position with a stable surgical stimulus so once the Bookwalter goes in and the abdomen is is open that’s it all right and then it becomes a very useful monitor for telling me if the patient needs more volume and the trend in that situation is great in the emergency department where I have no idea what’s bleeding and situation is very dynamic it doesn’t work very well so then the absolute number is not nearly as helpful and I haven’t found it correlates very well it doesn’t tell me anything I don’t know about the patient already peripheral tissue oximetry this was a popular in Texas John before you got there still using this yeah that’s sort of my idea too again oxygen directly in the tissue this might make sense I found it didnt calibrate very well we got a lot of random numbers from it and we used it for a while cute resuscitations and then sort of stopped and it’s gathering dust somewhere at the moment it is bothered by things that affect peripheral perfusion but may not have central relevance we played with this this is a sublingual Kappa Namit er let’s look at acidosis in the tissue under the tongue it’s a nice central vascular bed it’s easy to get at you can do this again not very correlation I will mention the scientific catch-22 you take devices like this to assess two places like the Shock Trauma Center but unfortunately it’s not going to tell me as much as it might tell a medic with a much lower level of experience or sophistication so it’s hard to get but assessments of the devices in the area you actually want them so this was a DARPA project a few years back about 20 years ago this was the original bring acoustic monitor this thing that looks like an arterial pulse trace is actually an acoustic signal from the carotid and is actually a measure of perfusion of the brain after a few years and a couple million dollars of airforce money it got to looking like this where we got it down to a Palm Pilot and it turns out you can measure acoustically you can measure blood flow in the brain pretty well and also blood flow and peripheral arteries and if you put those two traces up next to each other you can tell a patient’s in shock because they have brain blood flow but not radial artery blood flow and we fiddled with this for I don’t know something like a decade write that Shock Trauma the inventor has since died unfortunately and this has never gone anywhere so I don’t know that anybody else has ever used this there’s one that’s out there here’s one I haven’t actually pride myself but it’s out in the literature and it’s sort of cool thermographic imaging will just point the fancy camera at the person take a picture it will tell us what’s perfused and what’s not as I say I haven’t used this one myself I suspect it’s highly sensitive to environmental conditions and also has the problem what we really want to know is brain perfusion not palm perfusion and the skulls in the way so I suspect probably not so useful in the acute phase and now let’s talk about what does work if it is 2:00 in the morning and I’m standing the operating room and dealing with some multi trauma case and dr. Holcomb is taking out the guy’s spleen and I’m trying to figure out is he full or empty where are we on that square you know do I need to fluid or not and how much this is where I go and I am nothing like an ultrasound expert that would be dr. Sikorsky but this is this is the quick and dirty answer and even a knucklehead like me can do trauma ultrasound so put the probe somewhere near the heart and look at it is it full is it empty and you pretty quickly get sensitivity for that especially if you do we thoracotomies and periodically you look at a heart that’s full or empty and then is it beating Razavi and how hard so full empty beating not beating with a little extra sophistication you can figure out if there’s a tamponade so one thing I would say before opening a chest in any of doctor bro he’s cases what did the ultrasound show because if there was a tamponade yeah he might go for it and if the heart is completely empty as he said probably not going to help much all right normal for chamber view tamponade and believe me if the tamponade is big enough to be human dynamically significant it’s not subtle normal trans gastric short access so this is for contraction if you on the other hand put the probe in and it looks like this it

and diastole you have a problem you need to add some volume to this case and I was asking Bob earlier about current use of ultrasound at Shock Trauma still the go-to tool for this probably changes our therapy I don’t know any acute phase something like a quarter to half the time the ultrasound of the patient you learn something you didn’t know and it helps to guide your therapy so this is where I think we’re gonna go this is pre-hospital compatible John are they using it yeah so I think this is where to sink your money but if all of this doesn’t work I have a one other alternative to offer the closest trauma center in my house as in much of Midwest America is operated by the Catholic Church and it is a full-service trauma center so with that I will leave you very much