Podcasts about j trauma

While it is proven to be lifesaving in carbon monoxide poisoning, is there any evidence that hyperbaric oxygen therapy helps with cerebral palsy, autism, long covid, migraines and many other conditions? Can HBOT be both a valid medical therapy and a pseudoscience? Guest co-host Pedro Mendes joins Dr. Chris Labos to parse out fact from fiction. Bonus points if you know the one condition where hyperbaric oxygen therapy is strictly contra-indicated.   Become a supporter of our show today either on Patreon or through PayPal! Thank you! http://www.patreon.com/thebodyofevidence/ https://www.paypal.com/donate?hosted_button_id=9QZET78JZWCZE   Email us your questions at thebodyofevidence@gmail.com.   Editor:    Robyn Flynn Theme music: “Fall of the Ocean Queen“ by Joseph Hackl Rod of Asclepius designed by Kamil J. Przybos Chris' book, Does Coffee Cause Cancer?: https://ecwpress.com/products/does-coffee-cause-cancer   Obviously, Chris not your doctor (probably). This podcast is not medical advice for you; it is what we call information. References:   Hyperbaric oxygen therapy – Health Canada https://www.canada.ca/en/health-canada/services/healthy-living/your-health/medical-information/hyperbaric-oxygen-therapy.html   Chris' article on hyperbaric oxygen therapy: https://www.montrealgazette.com/opinion/columnists/article560792.html   Recent child's death https://www.medscape.com/viewarticle/clinic-death-raises-questions-about-oxygen-therapy-2025a10003wa?ecd=wnl_tp10_daily_250216_MSCPEDIT_etid7230220&uac=207389HY&impID=7230220   Trauma Bouachour G, Cronier P, Gouello JP, Toulemonde JL, Talha A, Alquier P. Hyperbaric oxygen therapy in the management of crush injuries: a randomized double-blind placebo-controlled clinical trial. J Trauma. 1996 Aug;41(2):333-9. doi: 10.1097/00005373-199608000-00023. PMID: 8760546.   Burns Brannen AL, Still J, Haynes M, Orlet H, Rosenblum F, Law E, Thompson WO. A randomized prospective trial of hyperbaric oxygen in a referral burn center population. Am Surg. 1997 Mar;63(3):205-8. PMID: 9036884.   Radiation injury Lin ZC, Bennett MH, Hawkins GC, Azzopardi CP, Feldmeier J, Smee R, Milross C. Hyperbaric oxygen therapy for late radiation tissue injury. Cochrane Database Syst Rev. 2023 Aug 15;8(8):CD005005. doi: 10.1002/14651858.CD005005.pub5. PMID: 37585677; PMCID: PMC10426260.   Chronic wounds: Kranke P, Bennett MH, Martyn-St James M, Schnabel A, Debus SE, Weibel S. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev. 2015 Jun 24;2015(6):CD004123. doi: 10.1002/14651858.CD004123.pub4. PMID: 26106870; PMCID: PMC7055586.   Cerebral palsy Collet JP, Vanasse M, Marois P, Amar M, Goldberg J, Lambert J, Lassonde M, Hardy P, Fortin J, Tremblay SD, Montgomery D, Lacroix J, Robinson A, Majnemer A. Hyperbaric oxygen for children with cerebral palsy: a randomised multicentre trial. HBO-CP Research Group. Lancet. 2001 Feb 24;357(9256):582-6. doi: 10.1016/s0140-6736(00)04054-x. PMID: 11558483.  

A patient with a large TBSA burn injury is transferred to a regional burn center. You are faced with some difficult clinical decisions as the resuscitation proves to be challenging. Join Drs. Tam Pham, Rob Cartotto, Julie Rizzo, Alex Morzycki and Jamie Oh as they discuss the clinical challenges in titrating and troubleshooting during acute burn resuscitation.  Hosts: ·  Dr. Tam Pham: UW Medicine Regional Burn Center ·  Dr. Robert Cartotto: University of Toronto, Ross Tilley Burn Centre  ·  Dr. Julie Rizzo: Brooke Army Medical Center  ·  Dr. Alex Morzycki: UW Medicine Regional Burn Center ·  Dr. Jamie Oh: UW Medicine Regional Burn Center Learning Objectives: ·  Understand the role of colloids as complement/rescue to standard crystalloid fluid titration.  ·  Identify the fluid threshold associated with development of abdominal compartment syndrome ·  Understand the role of continuous renal replacement therapy for patients with acute kidney injury during the resuscitation phase. ·  List specific patient populations who may experience a more difficult resuscitation. References: 1.     Ivy ME, Atweh NA, Palmer J, et al. Intra-abdominal hypertension and abdominal compartment syndrome in burn patients. J Trauma 2000 https://pubmed.ncbi.nlm.nih.gov/11003313/ 2.     Cartotto R, Johnson LS, Savetamal A, et al. American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation. J Burn Care Res 2023 https://pubmed.ncbi.nlm.nih.gov/38051821/ 3.     Greenhalgh DG, Cartotto R, Taylor SL, et al. Burn Resuscitation practices in North America: results of the Acute Burn ResUscitation Prospective Trial (ABRUPT). Ann Surg 2023 https://pubmed.ncbi.nlm.nih.gov/34417368/ 4.     Cartotto R, Callum J. A review of the use of human albumin in burn patients. J Burn Care Res 2012 https://pubmed.ncbi.nlm.nih.gov/23143614/ 5.     Cruz MV, Carney BC, Luker JN, et al. Plasma ameliorates endothelial dysfunction in burn injury. J Surg Res 2019 https://pubmed.ncbi.nlm.nih.gov/30502286/ 6.     Falhstrom K, Boyle C, Makic MBF. Implementation of a nurse-driven burn resuscitation protocol: a quality improvement project. Critical Care Nurses 2013 https://pubmed.ncbi.nlm.nih.gov/23377155/ 7.     Salinas J, Chung KK, Mann EA, et al. Computerized decision support system improves fluid resuscitation following severe burns: an original study. Crit Care Med 2011 https://pubmed.ncbi.nlm.nih.gov/21532472/ 8.     Kenney CL, Singh P, Rizzo J, et al. Impact of alcohol and methamphetamine use on burn resuscitation. J Burn Care Res 2023 https://pubmed.ncbi.nlm.nih.gov/37227949/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

Did you know that 13% of trauma patients who go home with an opioid prescription will develop opioid dependence?  Multimodal pain regimens not only reduce opioid consumption, but also improve pain control.  On this episode of the BIG T TRAUMA series, we explore a multimodal approach to pain management...and tackle some surgical dogma along the way.   Hosts: Patrick Georgoff, MD, Trauma Surgeon, Duke University, @georgoff Teddy Puzio, MD, Trauma Surgeon, University of Texas Houston Gabby Hatton, MD, Trauma Surgery fellow, University of Texas Houston  References: 1.     Rate and Risk Factors Associated With Prolonged Opioid Use After Surgery: A Systematic Review and Meta-analysis. JAMA Netw Open 2020: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2767637 2.     Traumatic injuries and persistent opioid use in the USA: findings from a nationally representative survey. Injury Prevention 2017: https://pubmed.ncbi.nlm.nih.gov/27597400/ 3.     Ketamine For Acute Pain After Trauma (KAPT): A Pragmatic, Randomized Clinical Trial. J Trauma 2024: https://pubmed.ncbi.nlm.nih.gov/38689402/ 4.     EAST PMG: Efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute pain after orthopedic trauma (2023): https://www.east.org/education-resources/practice-management-guidelines/details/efficacy-and-safety-of-nonsteroidal-antiinflammatory-drugs-nsaids-for-the-treatment-of-acute-pain-af 5.     Systematic Review and Meta-Analysis of the Association Between Non-Steroidal Anti-Inflammatory Drugs and Operative Bleeding in the Perioperative Period. JACS 2021: https://pubmed.ncbi.nlm.nih.gov/33515678/ 6.     Is the use of nonsteroidal anti-inflammatories after bowel anastomosis in trauma safe? J Trauma 2023: https://pubmed.ncbi.nlm.nih.gov/36728125/ 7.     University of Texas at Houston Multimodal Pain Guideline: https://med.uth.edu/surgery/acute-trauma-pain-multimodal-therapy/ 8.     ACS TRAUMA QUALITY PROGRAMS BEST PRACTICES GUIDELINES FOR ACUTE PAIN MANAGEMENT IN TRAUMA PATIENTS: https://www.facs.org/media/exob3dwk/acute_pain_guidelines.pdf Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

A patient with a large TBSA burn injury presents to a local emergency department and you are the only surgeon on duty that evening. With snow covered roads and poor visibility, the patient requires initial stabilization prior to transfer to the regional burn center. You are faced with some difficult clinical decisions as you begin their resuscitation. Join Drs. Tam Pham, Rob Cartotto, Julie Rizzo, Alex Morzycki and Jamie Oh as they discuss the clinical challenges in initiating burn resuscitation, pitfalls in long-distance transport, and more.  Hosts: ·       Dr. Tam Pham: UW Medicine Regional Burn Center ·       Dr. Robert Cartotto: University of Toronto, Ross Tilley Burn Centre  ·       Dr. Julie Rizzo: Brooke Army Medical Center  ·       Dr. Alex Morzycki: UW Medicine Regional Burn Center ·       Dr. Jamie Oh: UW Medicine Regional Burn Center Learning Objectives: ·       Describe initial fluid strategies, including the recommendations of the Advanced Burn Life Support (ABLS) course, traditional resuscitation formulas, and the Rule of 10.   ·       Describe logistical and medical challenges of long-distance transport to a regional burn center. ·       Understand recent advances learned from recent conflicts in military burn casualty care.  ·       List options for intravenous access.  ·       Understand endpoints of resuscitation, including adjuncts which may help guide fluid titration.  1.     Cartotto R, Johnson LS, Savetamal A, et al. American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation. J Burn Care Res 2023 https://pubmed.ncbi.nlm.nih.gov/38051821/ 2.     Renz EM, Cancio LC, Barillo DJ, et al. Long-Range Transport of War-Related Burn Casualties. J Trauma 2008 https://pubmed.ncbi.nlm.nih.gov/18376156/ 3.     Adibfar A, Camacho F, Rogers AD, Cartotto R. The Use of Vasopressors During Acute Burn Resuscitation. Burns 2021 https://pubmed.ncbi.nlm.nih.gov/33293152/ 4.     Chung KK, Wolf SE, Cancio LC, et al. Resuscitaiton of Severely Burned Military Casualties: Fluid Begets More Fluid. J Trauma 2009 https://pubmed.ncbi.nlm.nih.gov/19667873/ 5.     Chung KK, Salinas J, Renz EM, et al. Simple Derivation of the Initial Fluid Rate for the Resuscitation of Severely Burned Adult Combat Casualties: in Silico Validation of the Rule of 10, J Trauma 2009 https://pubmed.ncbi.nlm.nih.gov/20622619/ Joint Trauma System Clinical Practice Guideline (CPG)-Burn Care, updated 2022 Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

This is Part 2. Derek, an experienced clinician in burn care, joins us to delve into the intricacies and challenges of treating burn patients. This discussion provides valuable insights into the unique aspects of burn injuries, the importance of a comprehensive assessment, and the latest trends in burn treatment. Blog post- The Critically Burned Patient Key Topics Covered Complexity of Burn Injuries: Derek begins by explaining why burn patients require a unique approach compared to other trauma patients. He highlights the potential for burns to mask other critical injuries, underscoring the necessity of a thorough and trauma-informed initial assessment. The 'Big Three' Considerations: The conversation shifts to what Derek refers to as the "big three" — polytrauma, airway loss, and inhalation injuries — which are crucial early considerations in burn care. He stresses the importance of recognizing these potentially life-threatening conditions alongside the burn injury itself. Fluid Resuscitation: A significant portion of the discussion is dedicated to fluid resuscitation, a critical aspect of burn care. Derek talks about the Parkland formula for calculating fluid needs based on the total body surface area affected by burns but a better simpler method is- 500 ml/hr for an adult (

Contributor: Ricky Dhaliwal MD Educational Pearls: Three zones of the neck with different structures and risks for injuries: Zone 1 is the most caudal region from the clavicle to the cricoid cartilage Zone 2 is from the cricoid cartilage to the angle of the mandible Zone 3 is superior to the angle of the mandible Zone 1 contains the thoracic outlet vasculature (subclavian arteries and veins, internal jugular veins), carotid arteries, vertebral artery, apices of the lungs, trachea, esophagus, spinal cord, thoracic duct, thyroid gland, jugular veins, and the vagus nerve.  Zone 2 contains the common carotid arteries, internal and external branches of carotid arteries, vertebral arteries, jugular veins, trachea, esophagus, larynx, pharynx, spinal cord, and vagus and recurrent laryngeal nerves Lower risk than Zone 1 or Zone 3 Zone 3 contains the distal carotid arteries, vertebral arteries, jugular veins, pharynx, spinal cord, cranial nerves IX, X, XI, XII, the sympathetic chain, and the salivary and parotid glands Hard signs that indicate direct transfer to OR: Airway compromise  Active, brisk bleeding Pulsatile hematomas Hematemesis Massive subcutaneous emphysema  Soft signs that may obtain imaging to determine further interventions: Hemoptysis Oropharyngeal bleeding Dysphagia Dysphonia Expanding hematomas Soft sign management includes ABCs, type & screen, and airway interventions followed by imaging of the head & neck area Patients with dysphonia or dysphagia with subsequent negative CTAs may get further work-up via swallow studies References Asensio JA, Chahwan S, Forno W, et al. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. J Trauma. 2001;50(2):289-296. doi:10.1097/00005373-200102000-00015 Azuaje RE, Jacobson LE, Glover J, et al. Reliability of physical examination as a predictor of vascular injury after penetrating neck trauma. Am Surg. 2003;69(9):804-807. Ibraheem K, Wong S, Smith A, et al. Computed tomography angiography in the "no-zone" approach era for penetrating neck trauma: A systematic review. J Trauma Acute Care Surg. 2020;89(6):1233-1238. doi:10.1097/TA.0000000000002919 Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: A guide to evaluation and managementx. Ann R Coll Surg Engl. 2018;100(1):6-11. doi:10.1308/rcsann.2017.0191 Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII  

This chapter we talk with Dr. Henry Schiller, trauma surgeon and professor of surgery at Mayo Clinic, about a variety of hematomas including Morel Lavellee lesions, retroperitoneal hematomas, rectus sheath and more! Alex even gets to ask a question about REBOA that he has been hoping to do for a long time.  CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Nickerson TP, Zielinski MD, Jenkins DH, Schiller HJ. The Mayo Clinic Experience with Morel-Lavallee lesions: Establishment of a practice management guideline. J Trauma Acute Care Surg. 2012. Vol 76, Number 2 493-497 Demetriades D, Chan LS, Velmahos G, Berne TV, Cornwell III EE, Belzberg H, Asensio JA, Murray J, Berne J, Shoemaker W. TRISS methodology in trauma: the need for alternatives. British Journal of Surgery 1998, 85,379-384 Meyer DM, Jessen ME, Grayburn PA. Use of echocardiography to detect occult cardiac injury after penetrating thoracic trauma: A prospective study. J Trauma. 1995 Nov;39(5):902-7      

Has the pendulum swung too far?  Is it time to put the drill down??  Or, drill, baby, drill!  While the number of rib plating cases has exploded the data supporting the practice is less-than-stellar.  On this episode of the BIG T Trauma series Drs. Patrick Georgoff, Teddy Puzio, and Jason Brill bring you up to speed on rib plating. If you haven't already, we recommend you listen to Behind the Knife episode 298, published in May 2020. (https://behindtheknife.org/podcast/big-t-trauma-series-ep-10-rib-fractures/)  This episode covers comprehensive management of rib fractures, including multimodal pain control, regional blocks, pulmonary toilet, BiPAP, etc.   REFERENCES: GUIDELINES EAST PMG Rib Plating (2017): https://www.east.org/education-resources/practice-management-guidelines/details/rib-fractures-open-reduction-and-internal-fixation-of-update-in-process EAST PMG Rib Fracture Non-Surgical Management (2022): https://www.east.org/education-resources/practice-management-guidelines/details/nonsurgical-management-and-analgesia-strategies-for-older-adults-with-multiple-rib-fractures-a-systematic-review-metaanalysis Chest Wall Injury Society Guidelines (2020): https://cwisociety.org/wp-content/uploads/2020/05/CWIS-SSRF-Guideline-01102020.pdf FLAIL/UNSTABLE CHEST Operative vs Nonoperative Treatment of Acute Unstable Chest Wall Injuries: A Randomized Clinical Trial, JAMA 2022: https://jamanetwork.com/journals/jamasurgery/fullarticle/2796556 Prospective randomized controlled trial of operative rib fixation in traumatic flail chest, JACS 2013: https://pubmed.ncbi.nlm.nih.gov/23415550/ Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status, Interact Cardiovasc Thoracic Surg 2005: https://pubmed.ncbi.nlm.nih.gov/17670487/ Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients, J Trauma 2002: https://pubmed.ncbi.nlm.nih.gov/11956391/ Surgical Rib Fixation of Multiple Rib Fractures and Flail Chest: A Systematic Review and Meta-analysis, J Surg Research 2022: https://pubmed.ncbi.nlm.nih.gov/35390577/ Surgical versus nonsurgical interventions for flail chest, Cochrane Review 2015: https://pubmed.ncbi.nlm.nih.gov/26222250/ NON-FLAIL CHEST Randomized Controlled Trial of Surgical Rib Fixation to Nonoperative Management in Severe Chest Wall Injury, Ann Surgery 2023: https://pubmed.ncbi.nlm.nih.gov/37317861/ Rib fixation in non-ventilator-dependent chest wall injuries: A prospective randomized trial, J Trauma 2022: https://pubmed.ncbi.nlm.nih.gov/35081599/ A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (NONFLAIL), J Trauma 2020: https://pubmed.ncbi.nlm.nih.gov/31804414/ Operative versus nonoperative treatment of multiple simple rib fractures: A systematic review and meta-analysis, Injury 2020: https://pubmed.ncbi.nlm.nih.gov/32650981/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out the rest of the BIG T Trauma episodes here: https://behindtheknife.org/podcast-series/big-t-trauma/

The anterior abdominal stab wound! Who gets explored? When do you get imaging? Who gets serial abdominal exams? How does this change depending on the location of injury? Join Drs. Cobler-Lichter, Kwon, Meizoso, and Urréchaga in their first episode as the new Miami Trauma team  - as they discuss how to navigate the nuances of stab wounds to the torso! Hosts: - Michael Cobler-Lichter, MD, PGY2: University of Miami/Jackson Memorial Hospital/Ryder Trauma Center @mdcobler (twitter) - Eva Urrechaga, MD, PGY6/R4: University of Miami/Jackson Memorial Hospital/Ryder Trauma Center @urrechisme (twitter) - Eugenia Kwon, MD, Trauma/Surgical Critical Care Fellow: University of Miami/Jackson Memorial Hospital/Ryder Trauma Center - Jonathan Meizoso, MD, MSPH Assistant Professor of Surgery University of Miami/Jackson Memorial Hospital/Ryder Trauma Center @jpmeizoso (twitter) Learning Objectives: - Identify the differences in management of abdominal/thoracoabdominal stab wounds depending on location of injury - Identify who needs immediate operative intervention and who can undergo further evaluation - Define the management pathways for patients with abdominal stab wounds without an immediate indication for the OR - Define thoracoabdominal stab wound and when to evaluate for thoracic injuries - Discuss the role of diagnostic imaging when evaluating a patient with a stab to the torso Quick Hits: 1. Don't forget about the blunt trauma that may be associated with an assault! 2.  Don't miss injuries- always start with the ABCs and do a thorough head to toe exam  3. For stab wounds to the torso- hemodynamic instability, evisceration, peritonitis, impalement, or gross blood should go to the OR. 4. The three general clinical pathways for patients without a clear indication for the OR, include serial abdominal exams, local wound exploration, or diagnostic imaging. 5. Serial abdominal exams require frequent monitoring ideally by the same team member every time to detect changes early. 6. Local wound exploration requires adequate lighting and retraction to visualize the anterior rectus fascia. A negative LWE rules out an intra-abdominal injury, but a positive LWE does not necessarily rule it in. 7. Left thoracoabdominal stab wounds require evaluation of the diaphragm to rule out a traumatic diaphragm injury. 8. If there are no clear indications for the OR, diaphragm evaluation should be performed via laparoscopy after a period of 8 - 12 hours from injury. 9. A negative pericardial ultrasound does not rule out a cardiac injury in patients with a left-sided hemothorax. 10. Patients with flank and back stab wounds should be evaluated with CT scan to rule-out retroperitoneal injuries References 1. Martin MJ, Brown CVR, Shatz DV, Alam HB, Brasel KJ, Hauser CJ, de Moya M, Moore EE, Rowell SE, Vercruysse GA, Baron BJ, Inaba K. Evaluation and management of abdominal stab wounds: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg. 2018 Nov;85(5):1007-1015. doi: 10.1097/TA.0000000000001930. PMID: 29659472. 2. Como JJ, Bokhari F, Chiu WC, Duane TM, Holevar MR, Tandoh MA, Ivatury RR, Scalea TM. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma. 2010 Mar;68(3):721-33. doi: 10.1097/TA.0b013e3181cf7d07. PMID: 20220426. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this trauma episode, check out our BIG T Trauma Series here: https://behindtheknife.org/podcast-series/big-t-trauma/

On this episode of the BIG T Trauma series Drs. Patrick Georgoff, Teddy Puzio, and Jason Brill discuss hemodynamically unstable pelvic fractures.  These patients are sick!!  Really sick.  Join as for a practical discussion about best to manage gnarly pelvic fractures.  From binders to angioembolization to pelvic packing to REBOA, we cover it all.   Papers:  Burlew et al, Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. J Trauma 2017: https://pubmed.ncbi.nlm.nih.gov/27893645/ McDonogh et al, Preperitoneal packing versus angioembolization for the initial management of hemodynamically unstable pelvic fracture: A systematic review and meta-analysis. J Trauma 2022: https://pubmed.ncbi.nlm.nih.gov/34991126/ Li et al, Role of pelvic packing in the first attention given to hemodynamically unstable pelvic fracture patients: a meta-analysis, J ournal of Orthopaedics and Traumatology 2022: https://pubmed.ncbi.nlm.nih.gov/35799073/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out the rest of the BIG T trauma series here: https://behindtheknife.org/podcast-series/big-t-trauma/

Christina J - Trauma Hypnotherapist * on the Pink Cloud 9 Vodcast™ video-podcast youtube/spotify * watch episode till the end for Marketing Tip of the Day I am a trauma hypnotherapist who helps women overcome PTSD, depression, and anxiety with a combination of RTT®, energy healing, and herbology https://Facebook.com/christinajnl https://Instagram.com/christinaj_hypnotherapy How to connect w Pink Cloud 9: Join Entrepreneurs FB Group & further promote your business here: https://www.facebook.com/groups/pinkcloud9 You can watch & subscribe: https://www.youtube.com/c/PinkCloud9/videos If you would like to be on this vodcast™ show to promote your business/works/projects/books/etc contact here: https://linktr.ee/PinkCloud9 Read & Fill Out Form completely to be on this show: https://docs.google.com/forms/d/e/1FAIpQLSfedtxI4thfhp-LKWwaR63Lu4JoP-6r2FuQyYkLLYcA0xxfRg/viewform Buy Me Coffee or Donate here: https://cash.app/$pinkcloud9ks or https://paypal.me/pinkcloud9ks or https://account.venmo.com/u/pinkcloud9ks You will receive a Thank You Gift directly from me #Entrepreneur & #Creatives #Promotional #Interviews #Marketing #Entrepreneurs #Creatives #CEO #vodcast #podcast #videopodcast #spotify #youtube #pinkcloud9 #pinkcloud9ks #garyvee #oprahwinfrey #tonyrobbins #brenebrown --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app --- Send in a voice message: https://anchor.fm/pinkcloud9/message Support this podcast: https://anchor.fm/pinkcloud9/support

In this episode I bid farewell to my passing out residents and discuss some trauma myths like Manual in line stabilization and the use of steroids in acute spinal cord injuries. You all can go through the following articles to learn more - 1. Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann Emerg Med. 2007 Dec;50(6):653-65. doi: 10.1016/j.annemergmed.2007.05.006. Epub 2007 Aug 3. PMID: 17681642. 2.Manoach S, Paladino L. Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions. Ann Emerg Med. 2007 Sep;50(3):236-45. doi: 10.1016/j.annemergmed.2007.01.009. Epub 2007 Mar 6. PMID: 17337093. 3. Thiboutot F, Nicole PC, Trépanier CA, Turgeon AF, Lessard MR. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth. 2009 Jun;56(6):412-8. doi: 10.1007/s12630-009-9089-7. Epub 2009 Apr 24. PMID: 19396507. 4. Kapp JP. Endotracheal intubation in patients with fractures of the cervical spine [technical note]. J Neurosurg. 1975;42:731-732. 5. Hachen HJ. Idealized care of the acutely injured spinal cord in Switzerland. J Trauma. 1977;17:931-936 6. Bohlman HH. Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature. J Bone Joint Surg Am. 1979;61:1119-1142. 7. Podolsky S, Baraff LJ, Simon RR, et al. Efficacy of cervical spine immobilization methods. J Trauma. 1983;23:461-465. 8. Hugenholtz H, Cass DE, Dvorak MF, Fewer DH, Fox RJ, Izukawa DM, Lexchin J, Tuli S, Bharatwal N, Short C. High-dose methylprednisolone for acute closed spinal cord injury--only a treatment option. Can J Neurol Sci. 2002 Aug;29(3):227-35. doi: 10.1017/s0317167100001992. PMID: 12195611. 9. Suberviola B, González-Castro A, Llorca J, Ortiz-Melón F, Miñambres E. Early complications of high-dose methylprednisolone in acute spinal cord injury patients. Injury. 2008 Jul;39(7):748-52. doi: 10.1016/j.injury.2007.12.005. Epub 2008 Jun 9. PMID: 18541241. 10. Bracken MB, Shepard MJ, Collins WF, Holford TR, Young W, Baskin DS, Eisenberg HM, Flamm E, Leo-Summers L, Maroon J, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med. 1990 May 17;322(20):1405-11. doi: 10.1056/NEJM199005173222001. PMID: 2278545. 11. Bracken MB, Collins WF, Freeman DF, Shepard MJ, Wagner FW, Silten RM, Hellenbrand KG, Ransohoff J, Hunt WE, Perot PL Jr, et al. Efficacy of methylprednisolone in acute spinal cord injury. JAMA. 1984 Jan 6;251(1):45-52. PMID: 6361287. 12. Evaniew N, Noonan VK, Fallah N, Kwon BK, Rivers CS, Ahn H, Bailey CS, Christie SD, Fourney DR, Hurlbert RJ, Linassi AG, Fehlings MG, Dvorak MF; RHSCIR Network. Methylprednisolone for the Treatment of Patients with Acute Spinal Cord Injuries: A Propensity Score-Matched Cohort Study from a Canadian Multi-Center Spinal Cord Injury Registry. J Neurotrauma. 2015 Nov 1;32(21):1674-83. doi: 10.1089/neu.2015.3963. Epub 2015 Jul 17. PMID: 26065706; PMCID: PMC4638202.

In this episode, I have discussed a little bit about some advances in trauma resuscitation, some goals and how ATLS should be the basic trauma skill an emergency physician should have. I did not mean to break any hearts, but yes trauma resus goes beyond ATLS. Do not believe what I say blindly, do your research. You can go through the following mind blowing papers and up your trauma game and prepare your own trauma protocols for your emergency departments. The papers you can go through (not in any order of preference). And these are not exhaustive - 1. Harris T, Davenport R, Mak M, Brohi K. The Evolving Science of Trauma Resuscitation. Emerg Med Clin North Am. 2018 Feb;36(1):85-106. doi: 10.1016/j.emc.2017.08.009. PMID: 29132583. 2. Leibner E, Andreae M, Galvagno SM, Scalea T. Damage control resuscitation. Clin Exp Emerg Med. 2020;7(1):5-13. doi:10.15441/ceem.19.089 3. Carrick MM, Leonard J, Slone DS, Mains CW, Bar-Or D. Hypotensive Resuscitation among Trauma Patients. Biomed Res Int. 2016;2016:8901938. doi: 10.1155/2016/8901938. Epub 2016 Aug 9. PMID: 27595109; PMCID: PMC4993927. 4. https://www.jsomonline.org/References/PDF/Damage_Control_Resuscitation_03_Feb_2017_ID18.pdf 5. Petrosoniak A, Hicks C. Resuscitation Resequenced: A Rational Approach to Patients with Trauma in Shock. Emerg Med Clin North Am. 2018 Feb;36(1):41-60. doi: 10.1016/j.emc.2017.08.005. PMID: 29132581. 6. Mutschler, M., Nienaber, U., Münzberg, M., Wölfl, C., Schoechl, H., Paffrath, T., Bouillon, B., Maegele, M., & TraumaRegister DGU (2013). The Shock Index revisited - a fast guide to transfusion requirement? A retrospective analysis on 21,853 patients derived from the TraumaRegister DGU. Critical care (London, England), 17(4), R172. https://doi.org/10.1186/cc12851 7. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma. 2003 Jun;54(6):1127-30. doi: 10.1097/01.TA.0000069184.82147.06. PMID: 12813333. 8. Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, del Junco DJ, Brasel KJ, Bulger EM, Callcut RA, Cohen MJ, Cotton BA, Fabian TC, Inaba K, Kerby JD, Muskat P, O'Keeffe T, Rizoli S, Robinson BR, Scalea TM, Schreiber MA, Stein DM, Weinberg JA, Callum JL, Hess JR, Matijevic N, Miller CN, Pittet JF, Hoyt DB, Pearson GD, Leroux B, van Belle G; PROPPR Study Group. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015 Feb 3;313(5):471-82. doi: 10.1001/jama.2015.12. PMID: 25647203; PMCID: PMC4374744. 9. Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019 Mar 27;23(1):98. doi: 10.1186/s13054-019-2347-3. PMID: 30917843; PMCID: PMC6436241. 10. Spinella PC, Holcomb JB. Resuscitation and transfusion principles for traumatic hemorrhagic shock. Blood Rev. 2009 Nov;23(6):231-40. doi: 10.1016/j.blre.2009.07.003. Epub 2009 Aug 19. PMID: 19695750; PMCID: PMC3159517. 11. Wiles MD. ATLS: Archaic Trauma Life Support? Anaesthesia. 2015 Aug;70(8):893-7. doi: 10.1111/anae.13166. PMID: 26152249. 12. Mutschler M, Nienaber U, Brockamp T, Wafaisade A, Wyen H, Peiniger S, Paffrath T, Bouillon B, Maegele M; TraumaRegister DGU. A critical reappraisal of the ATLS classification of hypovolaemic shock: does it really reflect clinical reality? Resuscitation. 2013 Mar;84(3):309-13. doi: 10.1016/j.resuscitation.2012.07.012. Epub 2012 Jul 24. PMID: 22835498.

En este nuevo episodio hablo del Diamante letal en trauma. Pasamos de la triada letal con la acidosis, coagulopatía e hipotermia y añadimos hipocalcemia en el manejo al paciente con trauma grave. Espero que os guste. Bibliografía consultada: - Ditzel, Ricky, Anderson, Justin, Eisenhart, William, Rankin, Cody, DeFeo, Devin, Oak, Sangki, et al. (2020). A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond?. Journal of Trauma and Acute Care Surgery, 88, 434-439. https://doi.org/10.1097/TA.0000000000002570 - Bjerkvig CK, Strandenes G, Eliassen HS, Spinella PC, Fosse TK, Cap AP, Ward KR. "Blood failure" time to view blood as an organ: how oxygen debt contributes to blood failure and its implications for remote damage control resuscitation. Transfusion. 2016;56(Suppl 2):S182-S189. - Dyer M, Neal MD. Defining the lethal triad. In: Pape HC, Peitzman A, Rotondo M, Giannoudis P, eds. Damage Control Management in the Polytrauma Patient. Cham, Switzerland: Springer; 2017:41-53. - Dobson GP, Letson HL, Sharma R, Sheppart FR, Cap AP. Mechanisms of early trauma-induced coagulopathy: the clot thickens or not? J Trauma. 2015;79(2):301-309. - Eddy VA, Morris JA Jr., Cullinane DC. Hypothermia, coagulopathy, and acidosis. Surg Clin North Am. 2000;80(3):845-854. - Niles SE, McLaughlin DF, Perkins JG, Wade CE, Li Y, Spinella PC, Holcomb JB. Increased mortality associated with the early coagulopathy of trauma in combat casualties. J Trauma. 2008;64(6):1459-1465. - Martini WZ, Holcomb JB. Acidosis and coagulopathy: the differential effects on fibrinogen synthesis and breakdown in pigs. Ann Surg. 2007;246(5):831-835. - Armand R, Hess JR. Treating coagulopathy in trauma patients. Transfus Med Rev. 2003;17(3):223-231. - Hastbacka J, Pettila V. Prevalence and predictive value of ionized hypocalcemia among critically ill patients. Acta Anaesthesiol Scand. 2003;47:1264-1269. - Cherry RA, Bradburn E, Carney DE, Shaffer ML, Gabbay RA, Cooney RN. Do early ionized calcium levels really matter in trauma patients? J Trauma. 2006;64(4):774-779. - Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007;62(2):307-310. - Lier H, Krep H, Schroeder S, Stuber F. Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma. J Trauma. 2008;65(4):951-960. - Hoffman M, Monroe DM. Coagulation 2006: a modern view of hemostasis. Hematol Oncol Clin North Am. 2007;21:1-11. - Hoffman M. A cell-based model of coagulation and the role of factor VIIa. Blood Rev. 2003;17(suppl 1):S1-S5. - Ho KM, Leonard AD. Concentration-dependent effect of hypocalcaemia on mortality of patients with critical bleeding requiring massive transfusion: a cohort study. Anaesth Intensive Care. 2011;39(1):46-54. - Magnotti LJ, Bradburn EH, Webb DL, Berry SD, Fischer PE, Zarzaur BL, Schroeppel TJ, Fabian TC, Croce MA. Admission ionized calcium levels predict the need for multiple transfusions: a prospective study of 591 critically ill trauma patients. J Trauma. 2011;70(2):391-397. - Kornblith LZ, Howard BM, Cheung CK, et al. The whole is greater than the sum of its parts: hemostatic profiles of whole blood variants. J Trauma Acute Care Surg. 2014;77(6):818-827. - Li K, Xu Y. Citrate metabolism in blood transfusions and its relationship due to metabolic alkalosis and respiratory acidosis. Int J Clin Exp Med. 2015;8(4):6578-6584. - Giancarelli A, Liu-Deryke X, Birrer K, Hobbs B, Alban R. Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. 2016;202:182-187. - Webster S, Todd S, Redhead J, Wright C. Ionised calcium levels in major trauma patients who received blood in the emergency department. Emerg Med J. 2016;33(8):569-572. - Kyle T, Greaves I, Beynon A, Whittaker V, Brewer M, Smith J. Ionised calcium levels in major trauma patients who received blood en route to a military medical treatment facility. Emerg Med J. 2017;35(3):176-179. - MacKay EJ, Stubna MD, Holena DN, Reilly PM, Seamon MJ, Smith BP, Kaplan LJ, Cannon JW. Abnormal calcium levels during trauma resuscitation are associated with increased mortality, increased blood product use, and greater hospital resource consumption: a pilot investigation. Anesth Analg. 2017;125(3):895-901. - Shackelford SA, Del Junco DJ, Powell-Dunford N, Mazuchowski EL, Howard JT, Kotwal RS, Gurney J, Butler FK Jr., Gross K, Stockinger ZT. Association of prehospital blood product transfusion during medical evacuation of combat casualties in Afghanistan with acute and 30-day survival. JAMA. 2017;318(16):1581-1591. - DailyMed - Teruflex blood bag system anticoagulant citrate phosphate dextrose adenine (CPDA-1) - anticoagulant citrate phosphate dextrose adenine (cpda-1) solution. US National Library of Medicine. 2012. - Cap AP, Gurney J, Spinella PC, et al. Damage Control Resuscitation (CPG ID:18). Joint Trauma Service Clinical Practice Guideline. Joint Trauma System, the Department of Defense Center of Excellence for Trauma. 2019. - Pedersen KO. Binding of calcium to serum albumin. II. Effect of pH via competitive hydrogen and calcium ion binding to the imidazole groups of albumin. Scand J Clin Lab Invest. 1972;29(1):75-83. - Maxwell MJ, Wilson MJ. Complications of blood transfusion. BJA Educ. 2006;6(6):225-229. - Lang RM, Fellner SK, Neumann A, Bushinsky DA, Borow KM. Left ventricular contractility varies directly with blood ionized calcium. Ann Intern Med. 1988;108(4):524-529.

Date: December 28th, 2021 Reference: Kulvatunyou et al. The small (14 Fr) percutaneous catheter (P-CAT) versus large (28–32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial. J Trauma and Acute Care Surgery. November 2021. Guest Skeptic: Dr. Chris Root is a second-year resident physician in the Department of Emergency Medicine at the University […]

Welcome to the first Surgical Palliative Care Journal Club, the second of a six-part series focused on the integration of palliative care into the practice of surgery.  Join us as we discuss the first study of how to best integrate palliative medicine principles into the care of trauma ICU patients.  We then tackle the question:  Why are surgeons often unwilling to discontinue life-sustaining treatments in the post-operative period?   We discuss a 2013 study about “surgical buy-in” and review alternatives to making “informal contracts” with patients before surgery.   References: Mosenthal AC, Murphy PA, Barker LK, et al. Changing the culture around end-of-life care in the trauma intensive care unit. J Trauma. 2008;64(6):1587-1593. doi:10.1097/TA.0b013e318174f112. Schwarze ML, Redmann AJ, Alexander GC, Brasel KJ. Surgeons expect patients to buy-in to post-operative life support preoperatively: results of a national survey. Crit Care Med. 2013;41(1):1-8. doi: 10.1097/CCM.0b013e31826a4650. Dr. Red Hoffman (@redmdnd) is an acute care surgeon and associate hospice medical director in Asheville, North Carolina, host of the Surgical Palliative Care Podcast (@surgpallcare) and co-founder of the recently launched Surgical Palliative Care Society (www.spcsociety.org).  Dr. Zara Cooper (@zaracMD) is an acute care surgeon at Brigham and Women's Hospital where she serves as Kessler Director for the Center of Surgery and Public Health (@csph_bwh).  She is Associate Professor of Surgery at Harvard Medical School, associate faculty at Adriane Labs, and adjunct faculty at the Marcus Institute for Aging Research.  Dr. Amanda Stastny (@manda_plez) is a PGY-2 in the General Surgery program at Mountain Area Health Education Center (MAHEC) in Asheville, NC. Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

Contributor: Chris Holmes, MD Educational Pearls: Parkland Formula: 4 mL x [Total Body Surface Area Burned (%)] x [body weight (kg)] given in 24 hours 50% given over 8 hours and 50% given over the next 16 hours Brooke Formula: 2 mL x [Total Body Surface Area Burned (%)] x [body weight (kg)] given in 24 hours 50% given over 8 hours and 50% given over the next 16 hours 2009 military study evaluated Parkland vs. Brooke formulas for severe burn patients and found the outcomes were the same Guidelines are in flux on which formula to use, but reducing the overall volume using the Brooke formula can be done without significant change in morbidity or mortality Using fluid responsiveness by measuring urine output and signs of fluid overload can help guide overall resuscitative approach in burn patients References Chung KK, Wolf SE, Cancio LC, et al. Resuscitation of severely burned military casualties: fluid begets more fluid. J Trauma. 2009;67(2):231-237. doi:10.1097/TA.0b013e3181ac68cf Schaefer TJ, Nunez Lopez O. Burn Resuscitation And Management. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430795/ Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD ********************* The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today! Diversity and Inclusion Award

For paramedics, click here for CE credits.  Brought to you by Urgent Admin which is an intuitive one-touch solution that connects in-field clinicians and medical directors in real-time, this episode covers the complex nature of traumatic arrests. ,  Do we treat it the same as a medical arrest?  Do we have different treatment and decision priorities for these traumatic patients?  What makes caring for these patients in the prehospital environment so unique and how does that affect our care of these patients?  We discuss these questions and more with our special guest: Dr.  Rawan Safa @rawansafa93 Emergency Medicine Resident at Washington University Click here to check it out today! Thank you for listening! Hawnwan Philip Moy MD  Gina Pellerito EMT-P John Reagan EMT-P Noah Bernhardson MD References Millin MG, Galvagno SM, Khandker SR, Malki A, Bulger EM, Standards and Clinical Practice Committee of the National Association of EMS Physicians (NAEMSP)., Subcommittee on Emergency Services–Prehospital of the American College of Surgeons' Committee on Trauma (ACSCOT). J Trauma Acute Care Surg. 2013 Sep; 75(3):459-67. Lockey, D, Crewdson, K, Davies, G. Traumatic cardiac arrest: who are the survivors? Ann Emerg Med 2006; 48:240-244. Russell, RJ, Hodgetts, TJ, McLeod, J, Starkey, K, Mahoney, P, Harrison, K. The role of trauma scoring in developing trauma clinical governance in the Defense Medical Services. Phil Trans R Soc B 2011; 366:171-191. Morrison, JJ, Poon, H, Rasmussen, TE, Khan, MA, Midwinter, MJ, Blackbourne, LH. Resuscitative thoracotomy following wartime injury. J Trauma 2013; 74: 825- 829. Kouwenhoven, WB, Jude, JR, Knickerbocker, GG. Closed-chest cardiac massage. JAMA 1960; 173: 1065-1067. Luna, GK, Pavlin, EG, Kirkman, T, Copass, MK, Rice, CL. Hemodynamic effects of external cardiac massage in trauma shock. J Trauma 1989; 29:1430-1433. Leis C. Traumatic cardiac arrest: should advanced life support be initiated?. Journal of Acute Care Surgery. 2013;74:634-638. Keith J Roberts. The role for surgery in pre-hospital care. 2015; 18(2): 92-100. Escott ME, Gleisberg GR, Kimmel K, Karrer A, Cosper J, Monroe BJ. Simple thoracostomy. Moving beyond needle decompression in traumatic cardiac arrest. 2014 Apr; 39(4): 26-32. Martin M, Satterly S, Inaba K, Blair K. Does needle thoracostomy provide adequate and effective decompression of tension pneumothorax? Journal of Trauma and Acute Care Surgery. 2012; 73(6): 1412-1417. Stevens RL, Rochester AA, Busko J, et al. Needle Thoracostomy for Tension Pneumothorax: Failure Predicted by Chest Computed Tomography. Prehospital Emergency Care. 2009; 13(1): 14-17. Inaba K, Ives C, McClure K, et al. Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. Arch Surg. 2012 Sep; 147(9): 813-8. Ball CG, Wyrzykowski AD, Kirkpatrick AW, et al. Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length. Can J Surg. 2010 Jun; 53(3): 184-8. Brian Wernick, Heidi H Hon, Ronnie N Mubang, et al. Complications of needle thoracostomy: A comprehensive clinical review. Int J Crit Illn Inj Sci. 2015 Jul-Sep; 5(3): 160–169. Smith JE, Rickard A, Wise D. Traumatic cardiac arrest. J R Soc Med. 2015;108(1):11-16. Leis CC, Hernández CC, Blanco MJ, et al. Traumatic cardiac arrest: Should advanced life support be initiated? J Trauma Acute Care Surg. 2013;74(2):634-638. Jørgensen H, Jensen CH, Dirks J. Does prehospital ultrasound improve treatment of the trauma patient? A systematic review. Eur J Emerg Med. 2010;17(5):249-253.  

Contributor: Donald Stader, MD Educational Pearls: Hip Dislocation Prolonged dislocations can impair blood supply to femoral head Hip dislocation for >6 hours puts patient at high risk for needing a hip replacement in the next two year Knee Dislocation High mechanism Often looks anatomically normal on knee x-ray Vascular injuries of the popliteal artery can cause significant morbidity with some studies suggesting an 80% amputation rate if not treated within 6 hours Ankle Dislocation Common dislocation and often co-occurs with ankle fractures (bimalleolar/trimalleolar) Pressure on the skin from the displaced joint can cause skin tenting, which can lead to skin necrosis Hematoma blocks work well for ankle reductions as an adjunct to or substitute for procedural sedation References Arnold C, Fayos Z, Bruner D, Arnold D. Managing dislocations of the hip, knee, and ankle in the emergency department. Emerg Med Pract. 2017;19(12):1-28. Dawson-Amoah K, Raszewski J, Duplantier N, Waddell BS. Dislocation of the Hip: A Review of Types, Causes, and Treatment. Ochsner J. 2018;18(3):242-252. doi:10.31486/toj.17.0079 Patterson BM, Agel J, Swiontkowski MF, Mackenzie EJ, Bosse MJ; LEAP Study Group. Knee dislocations with vascular injury: outcomes in the Lower Extremity Assessment Project (LEAP) Study. J Trauma. 2007;63(4):855-858. doi:10.1097/TA.0b013e31806915a7 Ross A, Catanzariti AR, Mendicino RW. The hematoma block: a simple, effective technique for closed reduction of ankle fracture dislocations. J Foot Ankle Surg. 2011;50(4):507-509. doi:10.1053/j.jfas.2011.04.037 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

James clarifies what the process of permissive hypotension is and how and why to use it as a temporary management strategy.    Top 3 tips:   1.    Try not to think about a specific number in these patients but look at the bigger picture. Assess for multiple signs of shock when deciding how to treat these patients.  2.    Think about the patient's journey - how far do they need to go, how you are going to get there and how long will it take? Patient's requiring a longer journey may require more resuscitation that those undergoing a shorter journey. 3.    Think carefully before giving large amounts of crystalloid to these patients, it may be the only option in some patients but there are negative effects to its use.   Biography:     James is an anaesthetic registrar based in Edinburgh. He has worked for a number of pre-hospital organisations around the UK and is currently a fellow with the Emergency Medical Retrieval Service in Glasgow. He has completed sub-speciality training in Pre-hospital Emergency Medicine (PHEM) and holds the Fellowship in Immediate Medical Care (FIMC). His main interests inside medicine include trauma, from scene to theatre, and retrieval medicine. Outside of work he spends most of his time baking bread, enjoying mountains and looking after his 3 children.   Links and resources:      RCT comparing immediate vs delayed fluid resuscitation for patients with penetrating torso trauma.  Bickell WH, Wall MJ, Pepe PE, Martin RR, Ginger VF, Allen MK, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. New England Journal of Medicine 1994;331(17):1105-9.     Cochrane Review relating to timing and volume of fluid resuscitation in patients with bleeding.  Kwan I, Bunn F, Chinnock P, Roberts I. Timing and volume of fluid administration for patients with bleeding. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD002245. DOI: 10.1002/14651858.CD002245.pub2.     Systematic Review of animal trials regarding fluid strategies in trauma.  Mapstone J, Roberts I, Evans P. Fluid resuscitation strategies: a system- atic review of animal trials. J Trauma. 2003;55:571–589.      Correlation of SBP and pulse location in hypovolaemic shock.  Charles D Deakin, J Lorraine Low. Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: observational study. BMJ 2000;321:673–4.      Rat model of TBI and Haemorrhage comparing no fluid vs fluid.  Talmor D, Merkind V, Artru AA, et al. Treatment to support blood pressure increases bleeding and/or decreases survival in a rat model of closed head trauma combined with uncontrolled hemorrhage. Anesth Analg. 1999;89:950–956.      Secondary analysis of PAMPER trial showing benefit of FFP over crystalloid in TBI.  Danielle S. Gruen, Francis X. Guyette, Joshua B. Brown et al. Association of Prehospital Plasma With Survival in Patients With Traumatic Brain InjuryA Secondary Analysis of the PAMPer Cluster Randomized Clinical Trial. JAMA Netw Open. 2020;3(10):e2016869. doi:10.1001/jamanetworkopen.2020.16869.  

References: Hsu, S. D., Chen, C. J., Chou, Y. C., Wang, S. H., & Chan, D. C. (2017). Effect of Early Pelvic Binder Use in the Emergency Management of Suspected Pelvic Trauma: A Retrospective Cohort Study. International journal of environmental research and public health, 14(10), 1217. https://doi.org/10.3390/ijerph14101217 Nickson. (2019). Weingart on Pelvic Trauma. Retrieved from https://litfl.com/weingart-on-pelvic-trauma/ Shlamovitz GZ, Mower WR, Bergman J, Chuang KR, Crisp J, Hardy D, Sargent M, Shroff SD, Snyder E, Morgan MT. How (un)useful is the pelvic ring stability examination in diagnosing mechanically unstable pelvic fractures in blunt trauma patients? J Trauma. 2009 Mar;66(3):815-20. doi: 10.1097/TA.0b013e31817c96e1. PMID: 19276759. This podcast is hosted by ZenCast.fm

Episode 21, Season 2.   Chuck and Chris talk lumps and bumps, specifically ganglion cysts.  While the topic may seem mundane, the banter is decidedly not.  Join us and learn about Chris' PTSD and Chuck thermal approach.  A few citations are relavent.Gross and Gelberman Metacarpal Rotational Osteotomy,  J Hand Surg 1985 10: 105-8Balazs, Donohue, Drake, et al.  Outcomes of Open DWG excision in active- duty military personnel.  J Hand Surg 2015  40: 1739- 47Gelberman and Blasingame The Timed Allen Test.  J Trauma 1981 21:477-9As always, thanks to @iampetermartin for the amazing introduction and conclusion music.theupperhandpodcast.wustl.edu.  And thanks to Eric Zhu, aspiring physician and podcast intern.Survey Link:Help Chuck and Chris understand better what you like and what we can improve.  And be entered for drawing to win a mug!  https://bit.ly/349aUvz

Dr. Clay Cothren Burlew is a trauma surgeon in Denver, Colorado. She is world-renowned for her work on pelvic packing as well blunt cerebrovascular injuries, among many other things. We caught up with her to find out how she manages stay so productive, and specifically to talk to us about pelvic packing and blunt cerebrovascular injury. Twitter: https://twitter.com/ClayBurlew?s=20 Links: 1. Treatment for blunt cerebrovascular injuries: equivalence of anticoagulation and antiplatelet agents. Cothren CC, Biffl WL, Moore EE, Kashuk JL, Johnson JL. Arch Surg. 2009 Jul;144(7):685-90. 2. Preperitoneal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. J Trauma. 2007 Apr;62(4):834-9; 3. Occam's razor is a double-edged sword: concomitant pulmonary embolus and fat embolism syndrome. Cothren CC, Moore EE, Vanderheiden T, Haenel JB, Smith WR. J Trauma. 2008 Dec;65(6):1558-60. Bio (from https://www.eventscribe.com/2020/AAST2020/fsPopup.asp?Mode=presenterInfo&PresenterID=931211): Dr. Clay Cothren Burlew is a Professor of Surgery at Denver Health Medical Center/University of Colorado. Dr. Burlew grew up in San Antonio, Texas. She is a graduate of Amherst College, earning her degree in Biology magna cum laude. She attended medical school at UT Southwestern Medical School, where she was ranked 1st in her class and was elected to the Alpha Omega Alpha medical honor society. She completed her general surgery residency and Surgical Critical Care fellowship at the University of Colorado. At DHMC she is the Associate Chief of the Department of Surgery and the Director of the Surgical Intensive Care Unit. She is also the Program Director of the Surgical Critical Care Fellowship and the AAST-approved Trauma & Acute Care Surgery Fellowship. Dr. Burlew is an active surgical investigator, educator, and clinician; she has received multiple awards in each of these areas including the J. Cuthbert Owens Award, the DHMC Award for Academic Excellence, the Bartle Faculty Teaching Award, the Eiseman Medical Student Teaching Award, the Academy of Medical Educator's award for Excellence in Mentoring, and the 2017 American College of Surgeons Travelling Fellowship to Australia/New Zealand. She serves on the Committee on Trauma for the American College of Surgeons, the Board of Managers for the American Association for the Surgery of Trauma, and is a Past-President of the Southwestern Surgical Congress. She is on the Editorial Board of The Journal of Trauma and Acute Care Surgery, The World Journal of Emergency Surgery, and Trauma Surgery and Acute Care Open, and reviews for an additional 15 journals in an ad hoc capacity. She has authored over 200 peer-reviewed articles and 70 book chapters. She has given over 100 national lectures and scientific presentations.

Neck trauma Hosts: Patrick Georgoff, MD and Jayne McCauley, MD The inaugural episode of the BIG T TRAUMA series!  This series will offer clinically oriented material that focuses on how best to care for traumatically injured and critically ill patients.  The information presented in this podcast is designed for surgical trainees but is appropriate for anyone with an interest in trauma surgery, including medical students, advanced practice providers, and nurses.    This episode will cover neck trauma, and includes important learning points related to blunt and penetrating injury.  Demystify neck trauma today!!!   References: Burlew et al, J Trauma 2012, Blunt cerebrovascular injuries: Redefining screening criteria in the era of noninvasive diagnosis (https://www.ncbi.nlm.nih.gov/pubmed/22327974) Biffl et al, J Trauma 1999, Blunt carotid arterial injuries: implications of a new grading scale (https://www.ncbi.nlm.nih.gov/pubmed/10568710) EAST guideline: Clinical Practice Guideline: Penetrating Zone II Neck Trauma (https://www.ncbi.nlm.nih.gov/pubmed/18469667) East guideline: Blunt Cerebrovascular Injury Practice Management (https://www.ncbi.nlm.nih.gov/pubmed/20154559)

Author: Aaron Lessen, MD Educational Pearls: Traditional technique of needle thoracostomy for tension penumothorax is along the 2nd intercostal space at the midclavicular line Inserting a large angiocatheter along the 4th or 5th intercostal space at the mid-axillary line may provide a thinner area that is more easily identified, overcoming many of the obstacles of the traditional approach The 10th Edition of ATLS now recommends this location as well A finger thoracostomy, where a scalpel and then the finger are used to penetrate the pleural cavity at the same location, is another method to provide quick decompression of a traumatic tension pneumothorax, allowing a tube thoracostomy to be performed later References Laan DV, Vu TD, Thiels CA, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2016;47(4):797–804. doi:10.1016/j.injury.2015.11.045 Inaba K, Branco BC, Eckstein M, Shatz DV, Martin MJ, Green DJ, Noguchi TT, Demetriades D.   Optimal positioning for emergent needle thoracostomy: a cadaver-based study. J Trauma. 2011 Nov;71(5):1099-103; discussion 1103. doi: 10.1097/TA.0b013e31822d9618. Summarized and edited by Erik Verzemnieks, MD

Contributor:  Erik Verzemnieks, MD Educational Pearls: Knee dislocations are most common in high energy trauma, such as a motor vehicle accident The knee may appear grossly normal on initial inspection since dislocations can spontaneously reduce - Look for such findings as hemarthrosis, instability, or ecchymosis, as clues to an occult dislocation.  Knee dislocations are often associated with damage to the popliteal artery that runs behind the knee.  Assess for pulse deficit on exam. If you are concerned - use the ankle-brachial index (normal >0.9). If the ABI is abnormal, evaluate with CT angiogram and a vascular surgery consult.    References Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma. 2004 Jun;56(6):1261-5. Steele HL, Singh A. Vascular injury after occult knee dislocation presenting as compartment syndrome. J Emerg Med 2012; 42:271. Sillanpää PJ, Kannus P, Niemi ST, et al. Incidence of knee dislocation and concomitant vascular injury requiring surgery: a nationwide study. J Trauma Acute Care Surg 2014; 76:715. Summarized and written by myself

Author: Rachel Brady, MD Educational Pearls: Elderly patients (>65 years old) have a higher trauma mortality compared to younger patients, even though they have lower mechanisms of injury  Elder trauma is often under-triaged due to low-energy mechanisms and lack of physiologic response due to age and medications such as beta-blockers. Do not be reassured by normal vital signs.  Image elderly patients with head injury aggressively since they are at high risk of intracranial bleeds Be sure to ask about anticoagulation use. Up to 15% of asymptomatic head injury patients  on warfarin will have intracranial bleeds on CT.  Be on the lookout for unstable C-spine injuries such as type II odontoid fractures Central cord syndrome is a possibility with any neck extension injury Rib fractures are common, with mortality increasing greatly with more than 2 ribs involved The elderly are more prone to musculoskeletal injuries due to loss of bone density Always discuss goals of care with these patients  References Rathlev NK, Medzon R, Lowery D, Pollack C, Bracken M, Barest G, Wolfson AB, Hoffman JR, Mower WR. Intracranial pathology in elders with blunt head trauma. Acad Emerg Med. 2006 Mar;13(3):302-7. doi: 10.1197/j.aem.2005.10.015. PubMed PMID: 16514123. Keller JM, Sciadini MF, Sinclair E, O'Toole RV. Geriatric trauma: demographics, injuries, and mortality. J Orthop Trauma. 2012 Sep;26(9):e161-5. doi: 10.1097/BOT.0b013e3182324460. PubMed PMID: 22377505. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma.2000 Jun;48(6):1040-6; discussion 1046-7. doi: 10.1097/00005373-200006000-00007. PubMed PMID: 10866248. Hashmi A, Ibrahim-Zada I, Rhee P, Aziz H, Fain MJ, Friese RS, Joseph B. Predictors of mortality in geriatric trauma patients: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2014 Mar;76(3):894-901. doi: 10.1097/TA.0b013e3182ab0763. Review. PubMed PMID: 24553567. Brooks SE, Peetz AB. Evidence-Based Care of Geriatric Trauma Patients. Surg Clin North Am. 2017 Oct;97(5):1157-1174. doi: 10.1016/j.suc.2017.06.006. Review. PubMed PMID: 28958363.

'Patients with GCS scores of 8 or less require prompt intubation', that's what ATLS tells us. The mantra of GCS 8, intubate has pervaded teaching for those involved in the management of patients with a reduced GCS (Glasgow Coma Scale). But on reflection it would seem slightly odd that the gain or loss of a single point on the Glasgow Coma Scale could simply account for a change in the decision as to whether a patient would benefit from intubation and ventilation. So should the patient with a GCS of 9 be best managed without a definitive airway, but when that slips to 8 we should reach for the portex®? In this podcast we take a deeper look at the GCS, we have a think about the role that it was designed to perform and consider how it should best be applied to acutely ill patients when considering protecting their airway. The podcast is based upon the blog from the TEAM Course blog(Training in Emergency Airway Management), make sure to go and have a look at the post and other resources available on that site. Enjoy! Simon, Rob & James References GCS 8 intubate; TEAMcourse Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg.2013;74(5):1363-6.Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-4. Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G.The Glasgow Coma Scale at 40 years: standing the test of time.Lancet Neurol. 2014;13(8):844-54. Duncan R, Thakore S. Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department. J Emerg Med. 2009;37(4):451-5. Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale.Ann Emerg Med. 2011;58(5):427-30. Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow Coma Scale score: motor score alone is a better predictor.J Trauma. 2003;54(4):671-8. Isbister GK, Downes F, Sibbritt D, Dawson AH, Whyte IM. Aspiration pneumonitis in an overdose population: frequency, predictors, and outcomes.Crit Care Med. 2004;32(1):88-93. Adnet F, Baud F. Relation between Glasgow Coma Scale and aspiration pneumonia.Lancet. 1996;348(9020):123-4. Kulig K, Rumack BH, Rosen P. Gag reflex in assessing level of consciousness.Lancet. 1982;1(8271):565. Rotheray KR, Cheung PS, Cheung CS, et al. What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population?.Resuscitation. 2012;83(1):86-9. Moulton C, Pennycook A, Makower R. Relation between Glasgow coma scale and the gag reflex.BMJ. 1991;303(6812):1240-1.

The following is a short list of salient points related to the podcast and the corresponding source literature. As always, read the source literature and critically appraise it for yourself. Take none of the following as a substitution for local protocol or procedure. 2018 NAEMSP Spinal Immobilization paper https://naemsp.org/resources/position-statements/spinal-immobilization/ Securing a patient to the stretcher mattress significantly reduces lateral motion: Am J Emerg Med. 2016 Apr;34(4):717-21. doi: 10.1016/j.ajem.2015.12.078. Epub 2015 Dec 30. C-Collar limits visible external motion in the intact spine, but not internal motion in the unstable injured spine: Horodyski M, DiPaola CP, Conrad BP, Rechtine GR 2nd. Cervical collars are insufficient for immobilizing an unstable cervical spine injury. J Emerg Med. 2011 Nov;41(5):513-9. doi: 10.1016/j.jemermed.2011.02.001. Epub 2011 Mar 12. PubMed PMID: 21397431. C-Collar increases ICP: Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial pressure. Injury. 1996 Nov;27(9):647-9. PubMed PMID: 9039362. C-Collar causes distraction of unstable C-spine: Ben-Galim P, Dreiangel N, Mattox KL, Reitman CA, Kalantar SB, Hipp JA. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. J Trauma. 2010 Aug;69(2):447-50. doi:10.1097/TA.0b013e3181be785a. PubMed PMID: 20093981. Lador R, Ben-Galim P, Hipp JA. Motion within the unstable cervical spine during patient maneuvering: the neck pivot-shift phenomenon. J Trauma. 2011 Jan;70(1):247-50; discussion 250-1. doi: 10.1097/TA.0b013e3181fd0ebf. PubMed PMID: 21217496. Spinal immobilization negatively impacts the physical exam: March J et al. Changes In Physical Examination Caused by Use of Spinal Immobilization. Prehosp Emerg Care 2002; 6(4): 421 – 4. PMID: 12385610 Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med. 1994 Jan;23(1):48-51. PubMed PMID: 8273958. Chan D, Goldberg RM, Mason J, Chan L. Backboard versus mattress splint immobilization: a comparison of symptoms generated. J Emerg Med. 1996 May-Jun;14(3):293-8. PubMed PMID: 8782022. Even Manual In Line Stabilization alone increased difficulty during intubation and increases forces applied to the neck: Thiboutot F, Nicole PC, Trépanier CA, Turgeon AF, Lessard MR. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth. 2009 Jun;56(6):412-8. doi: 10.1007/s12630-009-9089-7. Epub 2009 Apr 24. PubMed PMID: 19396507. Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, Todd MM. Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Anesthesiology. 2009 Jan;110(1):24-31. doi: 10.1097/ALN.0b013e318190b556. PubMed PMID: 19104166. Spinal immobilization makes it harder to breath and decreases forced expiratory volume: “...produce a significantly restrictive effect on pulmonary function in the healthy, nonsmoking man.” Chan, D., Goldberg, R., Tascone, A., Harmon, S., & Chan, L. (1994). The effect of spinal immobilization on healthy volunteers. Annals of Emergency Medicine, 23(1), 48–51. https://doi.org/10.1016/S0196-0644(94)70007-9 Schafermeyer RW, Ribbeck BM, Gaskins J, Thomason S, Harlan M, Attkisson A. Respiratory effects of spinal immobilization in children. Ann Emerg Med. 1991 Sep;20(9):1017-9. PubMed PMID: 1877767. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. 1999 Oct-Dec;3(4):347-52. PubMed PMID: 10534038. Prehospital providers can effectively apply selective immobilization criteria without causing harm: Domeier, R. M., Frederiksen, S. M., & Welch, K. (2005). Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Annals of Emergency Medicine, 46(2), 123–131. https://doi.org/10.1016/j.annemergmed.2005.02.004 Out of 32,000 trauma encounters, a prehospital clearance protocol resulted in ONE patient with an unstable injury that was not immobilized. This patient injured her back one week prior, required fixation, but had no neurological injury: Burton, J.H., Dunn, M.G., Harmon, N.R., Hermanson, T.A., and Bradshaw, J.R. A statewide, prehospital emergency medical service selective patient spine immobilization protocol. J Trauma. 2006; 61: 161–167 Ambulatory patients self extricating with a cervical collar results in less cervical spine motion than with the use of a backboard: Shafer, J. S., & Naunheim, R. S. (2009). Cervical Spine Motion During Extrication: A Pilot Study. Western Journal of Emergency Medicine, 10(2), 74–78. https://doi.org/10.1016/j.jemermed.2012.02.082 Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS. Cervical spine motion during extrication. J Emerg Med. 2013 Jan;44(1):122-7. doi:10.1016/j.jemermed.2012.02.082. Epub 2012 Oct 15. PubMed PMID: 23079144 Lift and slide technique is superior to log roll: Boissy, P., Shrier, I., Brière, S. et al. Effectiveness of cervical spine stabilization techniques. Clin J Sport Med. 2011; 21: 80–88 Despite there not being any randomized control trials evaluating spinal immobilization, patients transferred to hospitals immobilized have more disability than those transported without immobilization: Hauswald, M., Ong, G., Tandberg, D., and Omar, Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998; 5: 214–219 “Mechanism of injury does not affect the ability of clinical criteria to predict spinal injury” Domeier, R.M., Evans, R.W., Swor, R.A. et al. The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury.Prehosp Emerg Care. 1999; 3: 332–337 Spinal immobilization in penetrating trauma is associated with an increased risk of death: Vanderlan, W.B., Tew, B.E., and McSwain, N.E. Jr. Increased risk of death with cervical spine immobilisation in penetrating cervical trauma. Injury. 2009; 40: 880–88 Stuke, L.E., Pons, P.T., Guy, J.S., Chapleau, W.P., Butler, F.K., and McSwain, N.E.Prehospital spine immobilization for penetrating trauma-review and recommendations from the Prehospital Trauma Life Support Executive Committee. J Trauma. 2011; 71: 763–769 “The number needed to treat with spine immobilization to potentially benefit one patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66.” Haut, E.R., Kalish, B.T., Efron, D.T. et al. Spine immobilization in penetrating trauma: more harm than good?. J Trauma. 2010; 68: 115–121 Vanderlan WB, Tew BE, Seguin CY, Mata MM, Yang JJ, Horst HM, Obeid FN, McSwain NE. Neurologic sequelae of penetrating cervical trauma. Spine (Phila Pa 1976). 2009 Nov 15;34(24):2646-53. doi: 10.1097/BRS.0b013e3181bd9df1. PubMed PMID: 19881402. Velopulos CG, Shihab HM, Lottenberg L, Feinman M, Raja A, Salomone J, Haut ER. Prehospital spine immobilization/spinal motion restriction in penetrating trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma (EAST). J Trauma Acute Care Surg. 2018 May;84(5):736-744. doi:10.1097/TA.0000000000001764. PubMed PMID: 29283970. Use of LSB can cause sufficient pressure to create pressure ulcers in a short period of time: Cordell W:H, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995 Jul;26(1):31-6. PubMed PMID: 7793717. The natural progression of some C-spine injuries is to get worse, sometimes because we force them into immobilization devices, sometimes because of hypotension, vascular injury, or hypoxia, but surprisingly not because of EMS providers… Harrop JS, Sharan AD, Vaccaro AR, Przybylski GJ. The cause of neurologic deterioration after acute cervical spinal cord injury. Spine (Phila Pa 1976). 2001 Feb 15;26(4):340-6. PubMed PMID: 11224879. Reports of asymptomatic but clinically important spine injuries are, at best, dubious: McKee TR, Tinkoff G, Rhodes M. Asymptomatic occult cervical spine fracture: case report and review of the literature. J Trauma. 1990 May;30(5):623-6. Review. PubMed PMID: 2188001. Bresler MJ, Rich GH. Occult cervical spine fracture in an ambulatory patients. Ann Emerg Med. 1982 Aug;11(8):440-2. PubMed PMID: 7103163.

Head injury worldwide is a significant cause of morbidity and mortality. Besides prevention there isn't anything that can be done to improve the results from the primary brain injury, there is however a phenomenal amount that can be done to reduce the secondary brain injury that patients suffer, both from a prehospital and in hospital point of view. In the podcast we run through head injuries, all the way from initial classification and investigation, to specifics of treatment including neuro protective anaesthesia and hyperosmolar therapy, to give a sound overview of the management of these patients. As always we welcome feedback via the website or on Twitter and we look forward to hearing from you. Enjoy! Simon, Rob & James References & Further Reading Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. Chauny JM. J Emerg Med. Jul 26 2016 Mannitol or hypertonic saline in the setting of traumatic brain injury: What have we learned? Boone MD. Surg Neurol Int. 2015 Life in the fast lane; hypertonic saline Life in the fast lane; Traumatic brain injury Traumatic brain injury in England and Wales: prospective audit of epidemiology, complications and standardised mortality. T Lawrence. BMJ Open. 2016 Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysis. M.Majdan. The Lancet. 2016 The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. Gale SC. J Trauma. 2005 What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population? Rotheray KR. Resuscitation. 2012 NICE Head Injury Guidelines 2014 MDCALC Canadian Head Injury TheResusRoom; The AHEAD Study TheResusRoom; Anticoagulation, head injury & delayed bleeds Management of Perceived Devastating Brain Injury After Hospital Admission; A consensus statement  A case for stopping the early withdrawal of life sustaining therapies in patients with devastating brain injuries. Manara AR. J Intensive Care Soc. 2016

Traumatized children need your full attention. Protocols work well for adults, but trauma in children requires that we exercise our clinical muscles just a bit more.   Two main reasons:  Children have specific injury patterns  Their physiologic response to trauma is unique.   Crash course in pediatric anatomy and physiology in trauma When you think of trauma in children, think of Charlie Brown. Large head, no neck, his chest and abdomen form an underdeveloped, amorphous shape. Alternatively, think of children as apples – they are rounder than they are tall, with a large increased surface area. Apples don’t have a hard shell or thick rind to protect them. If you drop them, you may not see any evidence of damage to the outside, but there can be considerable bruising just under the surface. A child has thin skin, less subcutaneous deposits than an adult, and a non-calcified, pliable thorax that deforms more than it protects or shields. The child’s abdominal muscles are not yet developed. There is less peritoneal fat to cushion a blow, and so traumatic forces transmit readily into internal organs, often without external bruising. The child’s large surface area also causes him to dissipate heat more quickly. He may be wet from urine or blood, and in a major trauma, this faster cool-down predisposes him to coagulopathy. Case A 5-year-old boy who was playing with his older brother in front of their home when the ball rolled into the street. He ran after it, and was struck by a sedan going approximately 30 mph. This is the so-called Wadell’s triad that occurs in a collision of auto versus pedestrian or auto versus bicycle. The initial impact is the greatest, and will vary depending on the child’s height and what part of his body reaches up to the bumper of the car. Depending on the height of the child and the height of the car, the initial impact will cause a femur fracture, a pelvic fracture, or direct abdominal trauma. The second impact happens as the child is flung onto the grill or the hood of the car, causing usually thoracic trauma. The third impact can be the coup de grace – to add insult to major injury, the child is then propelled forward, worsening the two previous impacts’ injuries and adding a third – severe blunt head trauma. Intubation Pearl #1: If your patient has any subtle change in mental status, intubate early. In pediatric trauma, we need to be proactive. Hypoxia is our enemy. Intubation Pearl #2: Thankfully cervical spine injuries in children are uncommon, and when they do occur, they typically occur at the child’s fulcrum, which is at C2. Compare this with an adult’s injury pattern with our fulcrum at C7. Be careful and minimize manipulation of the cervical spine, but do what you must to visualize the chords and place the tube. Keep the neck midline, and realize that the child’s usual decrease respiratory reserve is even more affected by trauma. Preoxygenate and pass that tube quickly. Chest Tube Pearl #1: Chest tube sizing in pediatrics is straightforward if we remember that the traditional chest tube size is 4 x the ETT size. Chest Tube Pearl #2: Try using a pigtail catheter. Safety Triangle Lateral edge of the pectoral muscle Lateral edge of the latisimus dorsi Line along the fifth intercostal space at the level of the nipple. It’s roughly where you would put on a generous dose of deodorant. Insertion here minimizes the risk of damage to nerves, vessels and organs. Resuscitative Thoracotomy in Children In a 40-year review of ED thoracotomy, Moore et al. analyzed 1,691 patients who received ED thoracotomy. Overall all-cause adult survival was 6.1%. In children ? 15 years of age, overall all-cause survival was considerably less, at 3.4%. In a large case series and review of the literature for pediatric ED thoracotomy, Allen et al. found a survival rate in penetrating trauma of 10.2%, with a much lower survival rate in blunt pediatric arrest, at 1.6%. Adolescents had more penetrating injuries, and younger children had more blunt trauma. To synthesize, the rarity of ED thoracotomy in children is due to the fact that: Traumatic full arrest in children is uncommon. It is most often blunt trauma. Blunt traumatic arrest in children is mostly non-survivable. REBOA If you have access to resuscitative endovascular balloon occlusion of the aorta or REBOA, this may be an option to temporize the child to get him to the relative control of the operating room. REBOA involves accessing the common femoral artery, passing a vascular sheath, floating a balloon catheter to the appropriate section of the aorta, and inflating the balloon to occlude blood flow. Brenner et al. described a case series of 6 patients from two Level I trauma centers. They used REBOA for refractory hemorrhagic shock due to either blunt or penetrating injury. After balloon occlusion, blood pressure improved sufficiently to take the patient either to interventional radiology or to the OR. Four patients lived, two died. The AORTA trial is underway to investigate its use in trauma. Summary: Children are like Charlie Brown – large head, no neck, amorphous, underdeveloped and unprotected thorax and abdomen. Or, if you like, they’re like, apples – they have a large surface area and are easily internally bruised, often without overt signs of external bruising. Chest tubes for children are very similar to the adult procedure – the traditional chest tube size is 4 x the child’s ETT size. Try to use smaller pigtail catheters, available in commercial kits, whenever possible. They’re easy, safe, and effective. Resuscitative thoracotomy is for penetrating trauma with signs of life wthin 10-15 minutes of arrival. Find the correctable surgical cause of the arrest. Resuscitative thoracotomy for blunt trauma has a dismal prognosis in children. Selected References Allen CJ, Valle EJ, Thorson CM, Hogan AR, Perez EA, Namias N, Zakrison TL, Neville HL, Sola JE. Pediatric emergency department thoracotomy: a large case series and systematic review. J Pediatr Surg. 2015 Jan;50(1):177-81. American College of Surgeons Committee on Trauma; American College of Emergency Physicians Pediatric Emergency Medicine Committee; National Association of Ems Physicians; American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Pediatrics. 2014 Apr;133(4):e1104-16. Holscher CM, Faulk LW, Moore EE, Cothren Burlew C, Moore HB, Stewart CL, Pieracci FM, Barnett CC, Bensard DD. Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk. J Surg Res. 2013 Sep;184(1):352-7. Moore HB, Moore EE, Bensard DD. Pediatric emergency department thoracotomy: A 40-year review. J Pediatr Surg. 2015 Oct 19. Scaife ER, Rollins MD, Barnhart DC, Downey EC, Black RE, Meyers RL, Stevens MH, Gordon S, Prince JS, Battaglia D, Fenton SJ, Plumb J, Metzger RR. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. J Pediatr Surg. 2013 Jun;48(6):1377-83. Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011 Dec;71(6):1869-72. Pediatric Trauma on WikEM   This post and podcast are dedicated to Dr Al Sacchetti, MD, FACEP. Thank you for promoting the emergency care of children and for spreading the message that you don’t need subspecialty training to take good care of acutely ill and injured children. Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP

A review of the suprascapular, intercostal and paravertebral nerve blocks.  A preview of Dr. Rosenblum's course on the ultrasoung guided suprascapular, intercostal and paravertebral nerve blocks at the 2015 AIUM conference in Orlando.   Reference “Combination of physical treatment with Suprascapular nerve block is a safe and efficacious treatment for the treatment of shoulder pain in frozen and arthritis.”     Abdelshafi ME, Yosry M, Elmulla AF, Al-Shahawy EA, Adou Aly M, Eliewa EA. Relief of chronic shoulder pain: a comparative study of three approaches. Middle East J Anesthesiol. 2011 Feb;21(1):83-92   —“Suprascapular nerve block can be considered the preferred treatment for non-specific shoulder pain because of being as effective as steroid injection with rare side effects.     Taskaynatan MA, Yilmaz B, Ozgul A, Yazicioglu K, Kalyon TA. Suprascapular nerve block versus steroid injection for non-specific shoulder pain. Tohoku J Exp Med. 2005 Jan; 205(1):19-25. —“Suprascapular nerve block is a safe and efficacious treatment for the treatment of shoulder pain in degenerative disease and/or arthritis. It improves pain, disability, and range of movement at the shoulder compared with placebo. It is a useful adjunct treatment for the practicing clinician to assist in the management of a difficult and common clinical problem.”     Shanahan EM, Ahern M, Smith M, Wetherall M, Bresnihan B, FitzGerald O. Suprascapular nerve block (using bupivacaine and methylprednisolone acetate) in chronic shoulder pain. Ann Rheum Dis. 2003 May;62(5):400   —“Ultrasound assisted approach is a simple, reproducible technique in most patients with an easy to understand ultrasound anatomy. Adequate analgesia could be provided through a single puncture and may be an alternative to neuroaxial blocks.”    Dieguez Garcia P, et al. Ultrasound-assisted approach to blocking the intercostal nerves in the mid-axillary line for non-reconstructive breast and axilla surgery. [Article in spanish]. Rev Esp Anestesiol Reanim 2013 Aug-Sep;60(7):365-70.     —In Percutaneous nephrolithotomy (PCNL) with nephrostomy tube placement US-guided intercostal nerve block (ICNB) performed at the 11th and 12th intercostal spaces provided effective analgesia.   Ozkan D, et al. Effect of ultrasound-guided intercostal nerve block on postoperative pain after percutaneous nephrolithotomy : Prospective randomized controlled study. Anaesthetist 2013 Nov 1 [Epub anead of print]   —“Utilization of continous intercostal nerve block (CINB) significantly improves pulmonary function, pain control, and shortens length of stay (LOS) in patients with rib fractures.”   Truitt MS, et al. Continuous intercostal nerve blockade for rib fractures: ready for primetime? J Trauma 2011 Dec;71(6):1548-52.   —“Concurrent combination therapy with proper medications and appropriate intercostal nerve blocks could offer satisfactory pain relief in the majority of elderly patients with Post Herpetic Neuragia (PHN).”   Chau SW, et al. Clinical experience of pain treatment for postherpetic neuralgia in elderly patients. Acta Anesthesiol Taiwan. 2007 Jun;45(2):95-101     —“Ultrasound guided multilevel paravertebral block (PVB) with total intravenous anesthesia provides reliable anesthesia, improves postoperative analgesia.”     Abdallah FW, et al. Ultrasound-guided Multilevel Paravertebral blocks and Total Intravenous Anesthesia Improve the Quality of Recovery after Ambulatory Breast Tumor Resection. Anesthesiology. 2013 Sep 26.   — —“A transverse in-line ultrasound-guided technique improves the feasibility of placing paravertebral nerve block (PVNB) catheters using in a wide range of pediatric patients.”     Boretsky K, et al. Ultrasound-guided approach to the paravertebral space for catheter insertion in infants and chuildren. Paediatr Anaesth. 2013 Jul 27   DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.  You should regularly consult a physician in matters relating to yours or another's health.  You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.  Copyright © 2015 David Rosenblum All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.  

Hi folks, Sorry about the voice--got a cold off those damn ED keyboards Thanks to my friend Reuben, this week we'll talk about the asthmatic patient that codes while on the vent The DOPE mnemonic gives you a path to figure out why a patient is desaturating (If anyone knows who created the DOPE mnemonic, please add a comment or send me an email. An EMCrit listener solved the mystery) If the pt is asthmatic, add an "S" to make DOPES The "S" stands for Stacked Breaths--and it's the first thing to address. Address it by disconnecting the vent circuit. Don't think about it, don't dither, just disconnect the vent. "E" is for equipment. Attach a BVM hooked up to O2 and you'll eliminate ventilator equipment failures. "D" is for tube displacement. Verify the tube with ETCO2, either qualitative or quantitative. "O" reminds you to check for obstruction of the tube. See if you can put a suction cath all the way down. If all of these don't fix the problem, then consider "P" for pneumothorax. Lung sounds are not always definitive. Throw on the UTS if you have the time. Otherwise perform bilateral finger thoracostomies. What the hell is that, you say? Listen to the podcast. Then you can read more about it in this article C.D. Deakin, G. Davies and A. Wilson, Simple thoracostomy avoids chest drain insertion in prehospital trauma, J Trauma 39 (2) (1995), pp. 373–374. Update: Is the tube mainstem, is there a ball-valve obstruction? Consider reintubation Consider Bronchoscopy Finger Thoracostomy BET Emerg Med J 2017;34:417-418.