Trauma ICU Rounds

In this episode we sit down with the Chief of Trauma, Surgical Critical Care, Burns,  & Acute Care Surgery at the University of Arizona, Dr. Bellal Joseph, who share with us his thoughts and research findings on hot topics including frailty, geriatric trauma, leadership, and more.Timestamps:00:12  Introductions01:30  What is frailty? Your physiologic NOT chronologic body.06:58  Injured elderly trauma patients can have good outcomes07:30  Trauma specific frailty index10:48  Failure to rescue13:57  Geriatricians and the trauma surgeons 15:08  4Ms-What Matters, Mobility, Mentation, Medication16:48  Geriatric cohorting/wards22:24  ACS geriatric centers of excellence 29:35  Brain Injury Guidelines (BIG)38:17  The importance of teamwork & servant leadership40:28  Imposter syndrome43:19  Leadership considerations45:25  Final thoughtsReferences:Joseph B, Friese RS, Sadoun M, Aziz H, Kulvatunyou N, Pandit V, Wynne J, Tang A, O'Keeffe T, Rhee P. The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons. J Trauma Acute Care Surg. 2014 Apr;76(4):965-9. doi: 10.1097/TA.0000000000000161. PMID: 24662858.Joseph B, Obaid O, Dultz L, Black G, Campbell M, Berndtson AE, Costantini T, Kerwin A, Skarupa D, Burruss S, Delgado L, Gomez M, Mederos DR, Winfield R, Cullinane D; AAST BIG Multi-institutional Study Group. Validating the Brain Injury Guidelines: Results of an American Association for the Surgery of Trauma prospective multi-institutional trial. J Trauma Acute Care Surg. 2022 Aug 1;93(2):157-165. doi: 10.1097/TA.0000000000003554. Epub 2022 Mar 28. PMID: 35343931.vJoseph B, Pandit V, Haider AA, Kulvatunyou N, Zangbar B, Tang A, Aziz H, Vercruysse G, O'Keeffe T, Freise RS, Rhee P. Improving Hospital Quality and Costs in Nonoperative Traumatic Brain Injury: The Role of Acute Care Surgeons. JAMA Surg. 2015 Sep;150(9):866-72. doi: 10.1001/jamasurg.2015.1134. PMID: 26107247.Joseph B, Pandit V, Sadoun M, Zangbar B, Fain MJ, Friese RS, Rhee P. Frailty in surgery. J Trauma Acute Care Surg. 2014 Apr;76(4):1151-6. doi: 10.1097/TA.0000000000000103. PMID: 24662884.Orouji Jokar T, Ibraheem K, Rhee P, Kulavatunyou N, Haider A, Phelan HA, Fain M, Mohler MJ, Joseph B. Emergency general surgery specific frailty index: A validation study. J Trauma Acute Care Surg. 2016 Aug;81(2):254-60. doi: 10.1097/TA.0000000000001120. PMID: 27257694.Support the show

In this episode, we talk all things critical care the one and only, Dr. Jean-Louis Vincent aka. JLV.  This episode is a MUST listen. We touch upon the evolution of early goal directed therapy, measures of fluid responsiveness, optimizing oxygen delivery, and the importance of integrating data points versus examining  them in isolation when caring for our critically ill and injured patients. This and MUCH MUCH more in arguably one of my favorite episodes to date!!Timestamps00:00 Introduction01:21 What happened to SG catheters and should we use them?04:05 What decreases mortality in critical care patients?05:30 When to transfuse critical care patient? Use your brain! 08:55 Measures of tissue perfusion and fluid responsiveness09:36 JLV breaks down the Rivers trial10:36 Recent EGDT papers 10:54 How to optimize O2 delivery? Late ScVO2, dob challenge, and fluid challenges13:21 Dynamic measures of fluid responsiveness13:46 CVP as a relative value15:14 Passive leg raising (PLR) as a measure of fluid responsiveness21:20 JLV's take on therapeutic nihilism24:45 Don’t isolate; integrate!26:46 Navigating the future of critical care – JLV’s thoughts on AI in the ICU29:55 Rapid fire hot topics in the ICU – Yes or No -Metabolic cocktail-Corticosteroids for septic shock-Albumin and Lasix or Lasix alonePCT/CRP and sepsis/AbxResources:International Symposium on Intensive Care and Emergency Medicine (ISICEM):https://www.isicem.orgISICEM Chats Platform:https://www.isicem.org/e-chat/index.asp          Articles:Passive leg raising:five rules, not a drop of fluid! https://ccforum.biomedcentral.com/articles/10.1186/s13054-014-0708-5The fluid challengehttps://ccforum.biomedcentral.com/articles/10.1186/s13054-020-03443-yBlood lactate levels in sepsis: 8 questionsVincent JL, Bakker J. Blood lactate levels in sepsis: in 8 questions. Curr Opin Crit Care. 2021 Jun 1;27(3):298-302. doi: 10.1097/MCC.0000000000000824. PMID: 33852499.We should avoid the term "fluid overload"https://ccforum.biomedcentral.com/articles/10.1186/s13054-018-2141-7EGDT in the Treatment of Severe Sepsis and Septic Shockhttps://www.nejm.org/doi/full/10.1056/nejmoa010307A Randomized Trial of Protocol-Based Care for Early Septic Shockhttps://www.nejm.org/doi/full/10.1056/nejmoa1401602Support the show

It's been a while! We are coming to you from our new studio in Victoria on Vancouver Island, BC. This Season is PACKED with incredible content, interviews and educational pearls designed to improve the quality of care that you are deliver daily at the bedside to your patients and their loved ones.Support the show

In this episode, we discuss the overarching importance of AVOIDING iatrogenic harm in the ICU with arguably one of the world's leading experts in critical care medicine, the one and only, Dr. Jean-Louis Vincent aka. JLV.Tune in as Dr. Vincent shares with us the importance of having a systematic, problem-based approach to patient care delivery which, of course, involves giving our patients a FAST HUG every day!Time Stamps:2:10 LA Critical Care and Differences between Europe versus USA4:04 COVID, Modern tech and bedside care5:32 ICU Rounds – How I do it6:00 Team Based ICU Care 7:56 Modern advances in critical care9:55 Problem-based approach in the ICU13:18 FAST HUGS14:00 Feeding14:36 Analgesia & Sedation15:46 Thromboembolic prophylaxis16:25Head of the bed elevated17:17Ulcer prophylaxis19:22Glucose control20:48 Tube feeds, yes? Ulcer ppx , no.22:30 OutroSupport the show

Dr. Scott Brakenridge, an expert in acute care surgery and sepsis research at the University of Florida, sheds light on Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS). He discusses its implications for critically ill patients, emphasizing that survival from conditions like sepsis is just the beginning of recovery. Dr. Brakenridge explores risk factors, the role of biomarkers, and the importance of personalized medicine. The conversation reveals groundbreaking advancements in managing sepsis and highlights strategies to prevent muscle loss and promote early mobilization.

In this, our 50th episode, we are in Austin, TX, for the Annual EAST Scientific Meeting where we are joined by Dr. Bryan A. Cotton who shares his expertise and knowledge regarding the use of whole blood (WB) in trauma patients. From the use of whole blood in prior military conflicts to the design and successful implementation of one of the only prospective randomized controlled trials of modified whole blood use in trauma patients, Dr. Cotton provides an incredible overview of the potential benefits of whole blood or as he refers to it - "the dying blood product". Also covered in expert fashion are the role of other hemostatic products and strategies including tranexamic acid, fibrinogen concentrates, and a plasma first resuscitation strategy. Time Stamps:01:16  The rationale for whole blood & a 1:1:1 transfusion strategy04:24  Military experience with WB: What's old is new again!05:44  Modified WB vs. Component Therapy RCT06:02  Leukoreduction of WB07:00  Type-specific WB09:38  Platelet function in WB vs. aphaeresis platelets11:58  Warm fresh WB vs. cold stored12:55  The whole is greater than the sum of its parts15:02  What do we mean by low-titer WB?19:14  O+ vs. O- WB & the potential for alloimmunization24:39  Transfusion reactions & safety of WB in trauma patients25:40  Prehospital WB for the win27:32  LITES Network28:27  Hemorrhage control, 1:1:1, viscoelastic assays, cryoprecipitate & fibrinogen               concentrate32:00  BAC's thoughts on tranexamic acid (TXA)34:47  BAC's thoughts on hypertonic saline (HTS) for COVID-1938:51  Final thoughts & future directionsRecommended Readings:Cotton BA, Podbielski J, Camp E, Welch T, del Junco D, Bai Y, Hobbs R, Scroggins J, Hartwell B, Kozar RA, Wade CE, Holcomb JB; Early Whole Blood Investigators. A randomized controlled pilot trial of modified whole blood versus component therapy in severely injured patients requiring large volume transfusions. Ann Surg. 2013 Oct;258(4):527-32; discussion 532-3.Williams J, Merutka N, Meyer D, Bai Y, Prater S, Cabrera R, Holcomb JB, Wade CE, Love JD, Cotton BA. Safety profile and impact of low-titer group O whole blood for emergency use in trauma. J Trauma Acute Care Surg. 2020 Jan;88(1):87-93. McGinity AC, Zhu CS, Greebon L, Xenakis E, Waltman E, Epley E, Cobb D, Jonas R, Nicholson SE, Eastridge BJ, Stewart RM, Jenkins DH. Prehospital low-titer cold-stored whole blood: Philosophy for ubiquitous utilization of O-positive product for emergency use in hemorrhage due to injury. J Trauma Acute Care Surg. 2018 Jun;84(6S Suppl 1):S115-S119. Sperry JL, Guyette FX, Brown JB, Yazer MH, Triulzi DJ, Early-Young BJ, Adams PW, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Witham WR, Putnam AT, Duane TM, Alarcon LH, Callaway CW, Zuckerbraun BS, Neal MD, Rosengart MR, Forsythe RM, Billiar TR, Yealy DM, Peitzman AB, Zenati MS; PAMPer Study Group. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018 Jul 26;379(4):315-326. doi: 10.1056/NEJMoa1802345. PMID: 30044935.Yazer MH, Jackson B, Sperry JL, Alarcon L, Triulzi DJ, Murdock AD. Initial safety and feasibility of cold-stored uncrossmatched whole blood transfusion in civilian trauma patients. J Trauma Acute Care Surg. 2016 Jul;81(1):21-6. doi: 10.1097/TA.0000000000001100. PMID: 27120323.Websites:LITES Networkhttps://www.litesnetwork.orgSouthwest Texas Regional Advisory Councilhttps://www.strac.org/bloodSupport the show

Dr. Ken Mattox, a renowned trauma surgeon and author of "Top Knife," shares groundbreaking insights into trauma management. He discusses the evolving role of technology, including the use of drones in emergency response, and envisions future advances in acute care. Dr. Mattox critiques current surgical training and emphasizes the importance of experience in decision-making. He also reflects on the significance of connections in surgical practice and calls for continual updates to clinical guidelines, highlighting that there’s always a better way to approach trauma care.

We. Are. Back!! After a (brief?!) hiatus, we are launching 2022 with a 2-part series with the one and only Dr. Ken Mattox. In this episode, Dr. Mattox shares with us his thoughts on what the modern general surgeon should look like and how we as surgeons differ from our medicine counterparts. Additionally, we review the history of modern trauma resuscitation, the paradigm shifts that have occurred as it pertains to permissive hypotension, as well as the technological advances that have occurred over the last century that have improved care of the critically injured patient. This is an episode not to be missed!Time Stamps00:12 Welcome & announcements04:21 What does the modern "surgeon" look like?07:48 The interplay between technology & surgery10:15 Serendipity & Dr. Mattox's early career11:28 Finessing & integrating clinical practice with research opportunities13:45 The 2 most impactful advances in trauma care during the last century: the microchip & organized trauma systems17:00 Dr. Mattox's thoughts on REBOA & intravascular control/treatment techniques22:32 MAST pants: lessons learned25:18 Elevate the BP with MAST and fluids? Increase the mortality!!26:30 Permissive hypotension27:06 Vasopressors in the ER?! Hypotension is teleological!! ReferencesBickell WH, Pepe PE, Wyatt CH, Dedo WR, Applebaum DJ, Black CT, Mattox KL. Effect of antishock trousers on the trauma score: a prospective analysis in the urban setting. Ann Emerg Med. 1985 Mar;14(3):218-22. doi: 10.1016/s0196-0644(85)80443-1. PMID: 3977145.Bickell WH, Wall MJ Jr, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994 Oct 27;331(17):1105-9. doi: 10.1056/NEJM199410273311701. PMID: 7935634.Hirshberg A, Hoyt DB, Mattox KL. From "leaky buckets" to vascular injuries: understanding models of uncontrolled hemorrhage. J Am Coll Surg. 2007 Apr;204(4):665-72. doi: 10.1016/j.jamcollsurg.2007.01.005. Epub 2007 Feb 23. PMID: 17382227.2022 Mattox Vegas TCCACShttps://www.trauma-criticalcare.com/tccacs/program/Support the show

Dr. Wes Ely from Vanderbilt University School of Medicine joins us on Rounds to discuss the evolution of our understanding and the current impact of ICU-acquired brain disease on our patients and their loved ones. In addition to discussing the evidence behind current best practices in the ICU, Dr. Ely shares with us stories from his new book which highlight the importance of listening to, engaging with, and remaining vulnerable to those whom we are so fortunate and blessed to serve-our patients. Support the show

Dive into pelvic binders and their critical role in managing unstable pelvic fractures. Discover when and how to apply them effectively, along with essential post-placement considerations. The discussion also highlights the Young-Burgess classification for pelvic ring fractures and the importance of a collaborative approach in trauma care. Insightful tips on assessing bleeding sources and optimizing trauma resuscitation strategies make this a must-listen for medical professionals in the field.