Podcasts about resuscitative

On Critical Care Time we are - of course - HUGE fans of POCUS. On this episode, Nick and Cyrus take this love for POCUS to the next level with our discussion on Resuscitative Transesophageal Echocardiography (Resus-TEE) with Canadian intensivist, Dr. Ross Prager (@ross_prager), creator of simplesage.io and Resus-TEE expert aficionado! On this show, we discuss the basics of Resus-TEE including indications, pitfalls and pearls, the practicality of implementing this modality at your hospital and some of the medico-legal considerations. We had a ton of fun recording his with Ross and hope you enjoy listening to it! Hosted on Acast. See acast.com/privacy for more information.

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In this episode, we review Resuscitative endovascular balloon occlusion of the aorta (REBOA), notably dissecting the recent Jansen et al trial in JAMA. Shownotes / References:  FOAMcast.org Thanks for listening! Jeremy Faust & Lauren Westafer

In the high-stakes world of emergency medicine, innovations continually push the boundaries of what's possible. One such groundbreaking procedure is Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Dr. Ernest E Moore, who has literally written the book on trauma surgery, teaches us what REBOA is and how it is being used to save lives in critical situations. Another episode from the Rocky Mountain Trauma and Emergency Medicine Conference.  See more on this topic from the blog post on our website: https://emspodcast.com/resuscitative-endovascular-balloon-occlusion-of-the-aorta-reboa/  

This is the first of a special podcast series on obstetric critical care.  I am joined on this series by Dr. Elizabeth Garchar, MD, FACOG.  She is an OB/GYN and Maternal Fetal Medicine (MFM) specialist who has a special interest in obstetric critical care.  She is also unique in that she flies regularly with our critical care transport teams and acts as one of our Assistant Medical Directors for the flight program.  So, Dr. Garchar has unique insight into managing this population in transport. This podcast focuses on severe postpartum hemorrhage.  We discuss the epidemiology and risk factors as well as the nuances of diagnosis, specifically how blood loss is actually quantified in this setting.  We also go through the importance of point-of-care ultrasound to help identify and manage the causes of postpartum hemorrhage.  Then, we transition to the discussion of management, focusing on the medical management of uterine atony, and also go over advanced interventions such as uterine packing, balloon tamponade devices, and REBOA.  Finally, Dr. Garchar discusses the indication and procedure for emergent hysterectomy as well as the post-procedure management critical care transport crews may have to perform.   References   Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. Oct 2017;130(4):e168-e186. doi:10.1097/aog.0000000000002351 Abdel-Aleem H, Singata M, Abdel-Aleem M, Mshweshwe N, Williams X, Hofmeyr GJ. Uterine massage to reduce postpartum hemorrhage after vaginal delivery. Int J Gynaecol Obstet. Oct 2010;111(1):32-6. doi:10.1016/j.ijgo.2010.04.036 Abul A, Al-Naseem A, Althuwaini A, Al-Muhanna A, Clement NS. Safety and efficacy of intrauterine balloon tamponade vs uterine gauze packing in managing postpartum hemorrhage: A systematic review and meta-analysis. AJOG Glob Rep. Feb 2023;3(1):100135. doi:10.1016/j.xagr.2022.100135 Aibar L, Aguilar MT, Puertas A, Valverde M. Bakri balloon for the management of postpartum hemorrhage. Acta Obstet Gynecol Scand. Apr 2013;92(4):465-7. doi:10.1111/j.1600-0412.2012.01497.x Bagga R, Jain V, Kalra J, Chopra S, Gopalan S. Uterovaginal packing with rolled gauze in postpartum hemorrhage. MedGenMed. Feb 13 2004;6(1):50. Borger van der Burg BLS, van Dongen T, Morrison JJ, et al. A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination. Eur J Trauma Emerg Surg. Aug 2018;44(4):535-550. doi:10.1007/s00068-018-0959-y Castellini G, Gianola S, Biffi A, et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major trauma and uncontrolled haemorrhagic shock: a systematic review with meta-analysis. World J Emerg Surg. Aug 12 2021;16(1):41. doi:10.1186/s13017-021-00386-9 Collaborators WT. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. May 27 2017;389(10084):2105-2116. doi:10.1016/S0140-6736(17)30638-4 Cunningham FG, Nelson DB. Disseminated Intravascular Coagulation Syndromes in Obstetrics. Obstet Gynecol. Nov 2015;126(5):999-1011. doi:10.1097/AOG.0000000000001110 D'Alton M, Rood K, Simhan H, Goffman D. Profile of the Jada(R) System: the vacuum-induced hemorrhage control device for treating abnormal postpartum uterine bleeding and postpartum hemorrhage. Expert Rev Med Devices. Sep 2021;18(9):849-853. doi:10.1080/17434440.2021.1962288 Dildy GA, 3rd. Postpartum hemorrhage: new management options. Clin Obstet Gynecol. Jun 2002;45(2):330-44. doi:10.1097/00003081-200206000-00005 Dueckelmann AM, Hinkson L, Nonnenmacher A, et al. Uterine packing with chitosan-covered gauze compared to balloon tamponade for managing postpartum hemorrhage. Eur J Obstet Gynecol Reprod Biol. Sep 2019;240:151-155. doi:10.1016/j.ejogrb.2019.06.003 Erez O. Disseminated intravascular coagulation in pregnancy: New insights. Thrombosis Update. 2022;6doi:10.1016/j.tru.2021.100083 Erez O, Mastrolia SA, Thachil J. Disseminated intravascular coagulation in pregnancy: insights in pathophysiology, diagnosis and management. Am J Obstet Gynecol. Oct 2015;213(4):452-63. doi:10.1016/j.ajog.2015.03.054 Erez O, Othman M, Rabinovich A, Leron E, Gotsch F, Thachil J. DIC in Pregnancy - Pathophysiology, Clinical Characteristics, Diagnostic Scores, and Treatments. J Blood Med. 2022;13:21-44. doi:10.2147/JBM.S273047 Feng S, Liao Z, Huang H. Effect of prophylactic placement of internal iliac artery balloon catheters on outcomes of women with placenta accreta: an impact study. Anaesthesia. Jul 2017;72(7):853-858. doi:10.1111/anae.13895 Higgins N, Patel SK, Toledo P. Postpartum hemorrhage revisited: new challenges and solutions. Curr Opin Anaesthesiol. Jun 2019;32(3):278-284. doi:10.1097/ACO.0000000000000717 Ji SM, Cho C, Choi G, et al. Successful management of uncontrolled postpartum hemorrhage due to morbidly adherent placenta with Resuscitative endovascular balloon occlusion of the aorta during emergency cesarean section - A case report. Anesth Pain Med (Seoul). Jul 31 2020;15(3):314-318. doi:10.17085/apm.19051 Kellie FJ, Wandabwa JN, Mousa HA, Weeks AD. Mechanical and surgical interventions for treating primary postpartum haemorrhage. Cochrane Database Syst Rev. Jul 1 2020;7(7):CD013663. doi:10.1002/14651858.CD013663 Kogutt BK, Vaught AJ. Postpartum hemorrhage: Blood product management and massive transfusion. Semin Perinatol. Feb 2019;43(1):44-50. doi:10.1053/j.semperi.2018.11.008 Levi M, Toh CH, Thachil J, Watson HG. Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology. Br J Haematol. Apr 2009;145(1):24-33. doi:10.1111/j.1365-2141.2009.07600.x Liu C, Gao J, Liu J, et al. Predictors of Failed Intrauterine Balloon Tamponade in the Management of Severe Postpartum Hemorrhage. Front Med (Lausanne). 2021;8:656422. doi:10.3389/fmed.2021.656422 Lohano R, Haq G, Kazi S, Sheikh S. Intrauterine balloon tamponade for the control of postpartum haemorrhage. J Pak Med Assoc. Jan 2016;66(1):22-6. Maier RC. Control of postpartum hemorrhage with uterine packing. Am J Obstet Gynecol. Aug 1993;169(2 Pt 1):317-21; discussion 321-3. doi:10.1016/0002-9378(93)90082-t Makin J, Suarez-Rebling DI, Varma Shivkumar P, Tarimo V, Burke TF. Innovative Uses of Condom Uterine Balloon Tamponade for Postpartum Hemorrhage in India and Tanzania. Case Rep Obstet Gynecol. 2018;2018:4952048. doi:10.1155/2018/4952048 Natarajan A, Alaska Pendleton A, Nelson BD, et al. Provider experiences with improvised uterine balloon tamponade for the management of uncontrolled postpartum hemorrhage in Kenya. Int J Gynaecol Obstet. Nov 2016;135(2):210-213. doi:10.1016/j.ijgo.2016.05.006 Natarajan A, Kamara J, Ahn R, et al. Provider experience of uterine balloon tamponade for the management of postpartum hemorrhage in Sierra Leone. Int J Gynaecol Obstet. Jul 2016;134(1):83-6. doi:10.1016/j.ijgo.2015.10.026 Okoye HC, Nwagha TU, Ugwu AO, et al. Diagnosis and treatment of bbstetrics disseminated intravascular coagulation in resource limited settings. Afr Health Sci. Mar 2022;22(1):183-190. doi:10.4314/ahs.v22i1.24 Ordonez CA, Manzano-Nunez R, Parra MW, et al. Prophylactic use of resuscitative endovascular balloon occlusion of the aorta in women with abnormal placentation: A systematic review, meta-analysis, and case series. J Trauma Acute Care Surg. May 2018;84(5):809-818. doi:10.1097/TA.0000000000001821 Papageorgiou C, Jourdi G, Adjambri E, et al. Disseminated Intravascular Coagulation: An Update on Pathogenesis, Diagnosis, and Therapeutic Strategies. Clin Appl Thromb Hemost. Dec 2018;24(9_suppl):8S-28S. doi:10.1177/1076029618806424 Pingray V, Widmer M, Ciapponi A, et al. Effectiveness of uterine tamponade devices for refractory postpartum haemorrhage after vaginal birth: a systematic review. BJOG. Oct 2021;128(11):1732-1743. doi:10.1111/1471-0528.16819 Quandalle A, Ghesquiere L, Kyheng M, et al. Impact of intrauterine balloon tamponade on emergency peripartum hysterectomy following vaginal delivery. Eur J Obstet Gynecol Reprod Biol. Jan 2021;256:125-129. doi:10.1016/j.ejogrb.2020.10.064 Rattray DD, O'Connell CM, Baskett TF. Acute disseminated intravascular coagulation in obstetrics: a tertiary centre population review (1980 to 2009). J Obstet Gynaecol Can. Apr 2012;34(4):341-347. doi:10.1016/S1701-2163(16)35214-8 Revert M, Rozenberg P, Cottenet J, Quantin C. Intrauterine Balloon Tamponade for Severe Postpartum Hemorrhage. Obstet Gynecol. Jan 2018;131(1):143-149. doi:10.1097/AOG.0000000000002405 Sadek S, Lockey DJ, Lendrum RA, Perkins Z, Price J, Davies GE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in the pre-hospital setting: An additional resuscitation option for uncontrolled catastrophic haemorrhage. Resuscitation. Oct 2016;107:135-8. doi:10.1016/j.resuscitation.2016.06.029 Schmid BC, Rezniczek GA, Rolf N, Saade G, Gebauer G, Maul H. Uterine packing with chitosan-covered gauze for control of postpartum hemorrhage. Am J Obstet Gynecol. Sep 2013;209(3):225 e1-5. doi:10.1016/j.ajog.2013.05.055 Shimada K, Taniguchi H, Enomoto K, Umeda S, Abe T, Takeuchi I. Hospital transfer for patients with postpartum hemorrhage in Yokohama, Japan: a single-center descriptive study. Acute Med Surg. Jan-Dec 2021;8(1):e716. doi:10.1002/ams2.716 Simpson KR. Update on Evaluation, Prevention, and Management of Postpartum Hemorrhage. MCN Am J Matern Child Nurs. Mar/Apr 2018;43(2):120. doi:10.1097/NMC.0000000000000406 Singer KE, Morris MC, Blakeman C, et al. Can Resuscitative Endovascular Balloon Occlusion of the Aorta Fly? Assessing Aortic Balloon Performance for Aeromedical Evacuation. J Surg Res. Oct 2020;254:390-397. doi:10.1016/j.jss.2020.05.021 Snyder JA, Schuerer DJE, Bochicchio GV, Hoofnagle MH. When REBOA grows wings: Resuscitative endovascular balloon occlusion of the aorta to facilitate aeromedical transport. Trauma Case Rep. Apr 2022;38:100622. doi:10.1016/j.tcr.2022.100622 Soued M, Vivanti AJ, Smiljkovski D, et al. Efficacy of Intra-Uterine Tamponade Balloon in Post-Partum Hemorrhage after Cesarean Delivery: An Impact Study. J Clin Med. Dec 28 2020;10(1)doi:10.3390/jcm10010081 Stensaeth KH, Sovik E, Haig IN, Skomedal E, Jorgensen A. Fluoroscopy-free Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for controlling life threatening postpartum hemorrhage. PLoS One. 2017;12(3):e0174520. doi:10.1371/journal.pone.0174520 Suarez S, Conde-Agudelo A, Borovac-Pinheiro A, et al. Uterine balloon tamponade for the treatment of postpartum hemorrhage: a systematic review and meta-analysis. Am J Obstet Gynecol. Apr 2020;222(4):293 e1-293 e52. doi:10.1016/j.ajog.2019.11.1287 Theron GB, Mpumlwana V. A case series of post-partum haemorrhage managed using Ellavi uterine balloon tamponade in a rural regional hospital. S Afr Fam Pract (2004). May 11 2021;63(1):e1-e4. doi:10.4102/safp.v63i1.5266 Tran QK, Hollis G, Beher R, et al. Transport of Peripartum Patients for Medical Management: Predictors of Any Intervention During Transport. Cureus. Nov 2022;14(11):e31102. doi:10.7759/cureus.31102 Weir R, Lee J, Almroth S, Taylor J. Flying with a Safety Net: Use of REBOA to Enable Safe Transfer to a Level 1 Trauma Center. Journal of Endovascular Resuscitation and Trauma Management. 2022;5(3)doi:10.26676/jevtm.v5i3.214 Wu Q, Liu Z, Zhao X, et al. Outcome of Pregnancies After Balloon Occlusion of the Infrarenal Abdominal Aorta During Caesarean in 230 Patients With Placenta Praevia Accreta. Cardiovasc Intervent Radiol. Nov 2016;39(11):1573-1579. doi:10.1007/s00270-016-1418-y Zeng KW, Ovenell KJ, Alholm Z, Foley MR. Postpartum Hemorrhage Management and Blood Component Therapy. Obstet Gynecol Clin North Am. Sep 2022;49(3):397-421. doi:10.1016/j.ogc.2022.02.001  See omnystudio.com/listener for privacy information.

Resuscitative Hysterotomy is an amazing real case from Brazilian doctor, Guilherme Resener. The podcast episode runs through a real case that the HEMS Physician attended to and the quick thinking that took place whist on shift. Within the case we talked about guidelines for resuscitative hysterotomy, when and where to cut, statistics and why there is a need for aggressive interventions for good outcomes. The episode may get you to tears, but will also bring you to love Guilherme for his brut honesty, compassion and dedication to his job.         Show notes  Resuscitative hsyterotomy - Video Dr Sara Gray - 2018 EMCrit Cardiac disease in Pregnancy- 2022 perimortem-caesarean-section- 2018 - Life in the fast lane  

In this podcast, Eric discusses the art of having a "Resuscitative Mindset" when performing advanced airway management with guest host Kevin Collopy. When is it ok to perform advanced airway management rapidly? Is it ever ok? When do we deploy delayed sequence strategies?  Should we always use a "Resuscitative" sequence intubation mindset regardless of our assessment findings?  So much good conversation about all things airway and decision-making. Please like, subscribe, and leave any questions or comments. Contact information for Kevin Collopy Twitter: @ktcollopy Email: Kevin.Collopy@novanthealth.org See omnystudio.com/listener for privacy information.

Contributor: Jared Scott, MD Educational Pearls: Immediate resuscitative thoracotomy can be performed in the ED to gain rapid access to the thoracic cavity in cases of traumatic cardiac arrest Western Trauma Association Society Criteria for ED thoracotomy Blunt trauma +

The FlightbridgeED Podcast has been taken over! Chris Meeks joins us to discuss how the devil is in the details of our RSI procedures! Tune in to learn how applying a high-flow nasal cannula can significantly improve patient outcomes and your workload! Be sure to listen to the end for a huge announcement! See omnystudio.com/listener for privacy information.

Dr. Jeremy Levin and Dr. Megan Quintana discuss Resuscitative Thoracotomy (RT) with Dr. Ronnie Mubang and Dr. Adam Nelson.  They dive into patient selection, application of ultrasound, different institutions' criteria, the clamshell, and some less tangible benefits of RT besides survival.  Additionally, hear their opinion about select patient scenarios and special populations.  And ALWAYS wear your PPE! Supplemental material: Joseph B, Khan M, Jehan F, Latifi R, Rhee P. Improving survival after an emergency resuscitative thoracotomy: a 5-year review of the Trauma Quality Improvement Program.Trauma Surg Acute Care Open. 2018 Oct 9;3(1):e000201. doi: 10.1136/tsaco-2018-000201. PMID: 30402559; PMCID: PMC6203136. 

The hows, whys, logistics, and applications of focused, bedside transesophageal echocardiography performed by critical care and EM providers, with Felipe Teran, assistant professor of emergency medicine at Weill Cornell and director of the Resuscitative TEE Project. Takeaway lessons As a rule, resuscitative TEE is performed in patients with a secured airway. TEE views are not … Continue reading "Episode 43: Resuscitative TEE with Felipe Teran"

In the critically ill trauma patient, optimizing airway, breathing, and circulation is not always as easy as the ABCs.  In this episode, Nyssa and Lisa discuss resuscitative sequence intubation and how it differs from a crash intubation or a delayed sequence intubation. We also consider how to handle the special cases of TBI patients and the combative trauma patient. 

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.  

In the previous podcast, the SMACCForce Simulation Team performed a Resuscitative Hysterotomy in a high-pressured situation. Now, we debrief. Sim is a powerful tool, it allows for healthcare professionals to practice rare medical procedures, to refine team work and to enhance collaboration. Importantly, it provides an opportunity for healthcare professionals to practice responding to challenging situations.  In this episode, the SMACCForce Simulation Team debrief on the learnings and opportunities from the Resuscitative Hysterotomy simulation. For more head to: codachange.org/podcasts

From #SMACC2019 the SIM team demonstrate a Resuscitative Hysterotomy on a pregnant, 36 year old female who was involved in a high speed motor vehicle accident. The catch? She is the surgical registrar and friends with members of the team. Watch or listen as the SIM team guide us through a Resuscitative Hysterotomy in a high-pressured situation. For more head to: codachange.org/podcasts

This week Paul Rees returns to discuss the trans specialty procedure of REBOA. He looks at why it isn't commonly used in PHEM but talks about the situations where it could usefully be incorporated into the pre hospital emergency environment.   Key points from this podcast: Adopt a whole system approach and deliver the patient to a centre who can help to stabilise them Access, access, access, start training now with Ultrasound. Know how to subtly manage the probe to get vascular access with ultrasound. If in a system employing the REBOA system consider the inflation time carefully Resources related to this podcast: Norwegian HEMS REBOA paper (open access) – https://www.ahajournals.org/doi/epub/10.1161/JAHA.119.014394 About Paul Paul Rees is a military interventional cardioloist at Barts Heart Centre in London, with a special interest in circulatory support and resuscitation. He is also a HEMS consultant, flying for East Anglian Air Ambulance. As a Surgeon Commander in the Royal Navy, he is their Consultant Advisor in Medicine, as well as Reader in the Academic Department of Military Medicine.  He chairs the Defence Resuscitation Committee, leads the Defence Endovascular Resuscitation Group and has recently designed and delivered a new capability for treating battlefield haemorrhage. He co-leads the new British Cardiovascular Intervention Society group looking at out of hospital cardiac arrest, and teaches as invited faculty on a number of international endovascular resuscitation workshops. Paul's military background includes active service with submarines, combat deployment with Commando forces, being the airborne MERT consultant in Afghanistan and numerous humanitarian and disaster relief missions including work in an Ebola treatment unit in Africa.  

In this follow-up episode to our discussion with Dr. Scott Weingart of EMCrit, we review the indications for performing a resuscitative thoracotomy, together with the potential application of a circulation first resuscitation strategy, and some intricacies regarding performing a surgical cricothyroidotomy.

Take Home Points This is a resuscitative hysterotomy – focus is on saving the mother first. Delivering the fetus can improve venous return thus increasing... The post REBEL Core Cast 46.0 – Resuscitative Hysterotomy appeared first on REBEL EM - Emergency Medicine Blog.

In this EM Cases Best Case Ever podcast, Dr. Kari Sampsel, Emergency Physician at Ottawa Hospital and Assistant Professor at University of Ottawa, Medical Director of Sexual Assault and Partner Abuse Care Program guides us through an example of a perimortem C-section - a resuscitative hysterotomy at Janus General. She and Rajiv discuss preparation, indications, the procedure, team dynamics and debriefing for this HALO procedure... The post BCE 82 Perimortem C-section – The Resuscitative Hysterotomy appeared first on Emergency Medicine Cases.

This episode is a wrap up covering the highlights from the Tactical Trauma international conference on pre-hospital critical care and trauma. This conference emphasizes tactical medicine, with a panel of experts speaking throughout the 2 days. 0:10 – Introduction to day 2 wrap up 0:40 – Introduction of the panel 1:15 – Mike Abernethy wraps up his session as a moderator on Day 2. Takeaways include Michael Lauria’s discussion on the preoccupation with protocols and guidelines. 2:45 – Three basic concepts include speed, simplicity, and coordination of care. Tactical medicine boils down to how efficiently one can perform these three tasks using evidence based medicine. Take the lessons learned from the military medicine, and a lot of them can be applied to civilian EMS and in-hospital care. 5:30 – One thing to add, is being able to do the basics very well. These basic skills will lay the foundation for new advanced technologies and interventions. 7:00 – Discussion on Mike Klumpner’s talk on medical best practices at MCI’s. The phrase “Just because you can, doesn’t mean you should” is discussed among the panel members. Being able to look at these mass casualty events, their injuries, and intervention with simplistically is the key. An example here includes an anecdote regarding a vascular neck injury, and the ability to ask “Am I making a difference, or am I delaying definitive care?” 9:30 – The panel discusses the criticism of triage in an MCI setting during day 2. One example given is that during most MCI’s, the triage tags were not used including the Boston Marathon bombing, where triage had to ‘go out the door’. Another example is the way the walking wounded are huddled into a corner and sometimes forgotten, while they may be gravely injured as evidenced in the Manchester bombing. 11:40 – FDNY’s new triage protocols include any penetrating injuries between the clavicle and the pelvis are immediate red tags. 12:15 – Breakout sessions with LEO’s who discussed the medical care of the K9’s. 13:30 – The point on situational awareness with the K9 colleagues is discussed. This includes muzzling them early if gravely injured and in danger. 13:45 – Anesthesiology talks about how dogs have a fenestrated chest cavity, and its importance with a tension pneumothorax. The end result is that the resulting obstructive shock may be worse in dogs. 15:00 – Ketamine takes a hit when it comes to pain control with K9’s for multiple physiologic reasons. Morphine IM 30-50mg was preferred for K9 pain control. 15:35 – Currently, it is a felony in the USA to provide ALS to animals if you are not a veterinarian. Propositions for exclusions for EMS workers trained in animal care are in the works right now. One anecdote is during a NC MCI, kid pools were filled with ice for the explosives K9’s, drawing a parallel to firefighter rehabilitation. 18:05 – Psychosocial aspects when providing medical care is discussed along with PTSD learning points. While feelings of anger and hostility towards your patient may be natural, providers must be able to accept that and continue to give medical care. 19:35 – Learning points in PTSD. One interesting finding was that those with minor injuries who received early intervention developed worse PTSD when compared to those with severe or no injuries. This raises questions on mandatory Critical Incident Stress Management, and how it should always be voluntary. 21:05 – Best practices after tough calls in EMS. Debriefing, assessing for safety, and assuring readiness for the next job are the top priorities. Being able to spend time with your colleagues, who have been through similar experiences versus mandatory CISM is discussed as well. 23:15 – The longer people stay in lockdown during MCI’s, the more likely they are to develop PTSD. Data coming out is showing that school lockdowns are causing PTSD in pediatrics. 24:50 – ‘Just culture’ is discussed, as is the importance of making system level changes to prevent errors. Most of the time, it is organizational culture that leads to mistakes, and not just individual mistakes. 26:10 – No non-discoverable mistakes exist in EMS, as opposed to hospital-based medicine. 26:55 – Takeaways from afternoon lectures including penetrating trauma with Dr. Tom Koenig, tactical medicine in mass casualty events with Dr. Matthew Lengua, OB trauma, and blast injuries. 27:30 – Resuscitative hysterotomies in Finland, and other advanced procedures done quickly and in austere environments. Discussing the decision gap, which the is the time from when the decision to perform a critical procedure is made until when that procedure is performed. 33:30 – Advances in resuscitative hysterotomies and thoracotomies, and there are now clear indications for both. However, this does not mean that Top Cover should be eliminated. 34:00 – Takeaways from blast injuries and penetrating trauma, specifically to the head and neck region. Major points include how EMS Physicians can treat some of these patients in the warm zone with critical interventions. 36:00 – Learning points from the lecture on burn care, and the unpredictability of the burn patient. One takeaway is that due to the current school of thought, providers are over-intubating patients with harm. Studies have also shown that escharotomies performed outside of burn centers are often performed incorrectly and incompletely. 39:30 – Use of vehicles as a weapon of mass destruction has become more common recently. A takeaway is that the extent of injury tends to be worse when the attack is intentional, whether using vehicles or other weapons. Logistically, the scene tends to be complex as it generally encompasses are large area. The discussion is brought up again about how as medical personnel, we can empower and train the general public to help. 48:55 – Next steps include teaching our communities the basic skills that have been proven to save lives, and working together to minimize these threats in the future. 49:15 - Conclusion

REBOA is a hot topic in the world of emergency medicine and prehospital trauma care. Join the medical directors for a review of “resuscitative endovascular balloon occlusion of the aorta.” We’ll discuss the basics, the anatomy, the complications and the evidence. Who is doing this in the EMS world and what are their results? We’ll answer that question along with looking to future possibilities as well. References: 1. Brenner M, Inaba K, Aiol A, et al. Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy in select patients with hemorrhagic shock: early results from the American Association for the Surgery of Trauma’s Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery registry. J Am Coll Surg. 2018;226(5): 730–740. 2. Lendrum, Robbie et al. Pre-hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for exsanguinating pelvic haemorrhage. Resuscitation. 2019. Volume 135, 6 – 13. 3. Osborn LA, Brenner ML, Prater SJ, Moore LJ. Resuscitative endovascular balloon occlusion of the aorta: current evidence. Open Access Emerg Med. 2019;11:29–38. Published 2019 Jan 14.

“This one will wake you up; Badness is coming your way” - Sara You might only see this once in a career, and when you do, you and your team need to be ready.  Sara talks physiology, technique and team-based approach to this confronting resuscitative scenario. (19:18)

There are few surgical interventions more dramatic than the thoracotomy - a desperate last-ditch effort to save a failing heart by manual compression. The history of the procedure is a fascinating one, dating back to the 19th century. This became the procedure of choice when a heart stopped, typically during surgery, but was eventually replaced by what we now call CPR. The history of the development of CPR is also covered, and of course, we'll take some interesting tangents. 

Interview with Peter Rhee, MD, MPH, and Bellal Joseph, MD, authors of Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma

Interview with Peter Rhee, MD, MPH, and Bellal Joseph, MD, authors of Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma

Author: Dylan Luyten, MD Educational Pearls:   Resuscitative thoracotomies are most commonly used for treatment of cardiac tamponade and to selectively perfuse the brain and heart in setting of hemorrhage control. Resuscitative thoracotomies are indicated in patients with penetrating injuries who lose vitals in the ED or those who had vitals within the last 10 minutes. Do not perform resuscitative thoracotomies on patients who have no signs of life on scene, asystole as their presenting rhythm, or no vitals  > 10 minutes. Resuscitative thoracotomies are not indicated in patients with blunt trauma  unless vitals are present in ED. Do not perform CPR on trauma patients.   References: Karmy-Jones R, Namias N, Coimbra R, et al. (2014).Western Trauma Association critical decisions in trauma: penetrating chest trauma. Journal of Trauma Acute Care Surgery. 77:994. Seamon MJ, Shiroff AM, Franco M, et al. (2009) Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers. Journal of Trauma. 67:1250.

This podcast is a discussion with Lt Col Jason Paisley MD, USAF, the director of Physician Education at the Center for Sustainment of Trauma and Readiness Skills (CSTARS). The podcast reviews the updated Clinical Practice Guideline (CPG) on REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) for advanced providers. Specifically, it addresses the newer equipment … Continue reading REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) CPG →

Navy personnel with 3d Medical Battalion, 3d Marine Logistics Group, participate alongside Marines in the Forward Resuscitative Casualty Care course.

The vocabulary of elite teams is changing. Understanding the roots of grit, resilience and poise under pressure requires a deep dive into the challenging, sometimes ugly world of our emotions, fear, anxiety and expectations. This is the good news: the science of human performance has evolved as well, and offers insight on how to train for a focused and enlightened team mindset. Emotional regulation, environmental manipulation, stress inoculation, mental preparation -- these are the concepts that define the new resuscitative collective unconscious. In this session, we will discuss how the science of human performance and psychology can inform the development of expert teams, from heart rate and tactical breathing to emotional valence and cortisol surges.

Your most favorite resuscitation items such as oxygen, bolus epinephrine, intubation and cardioversion may in fact be harmful for the pediatric cardiac patient presenting to the emergency department in extremis. Due to the physiology of certain complex congenital heart diseases, the usual resuscitation maneuvers may in fact kill the patient instead of helping. Supplemental oxygen can worsen the pulmonary to systemic blood flow ratio in single ventricle patients and cause them to have rising lactate levels and cardiac arrest from low systemic cardiac output. Intubation and positive pressure ventilation may impede pulmonary blood flow in patients with a Glenn shunt and the patient can become more desaturated. With increasing PEEP and higher respiratory rates the patients will continue to deteriorate and desaturate. Regular dosing of epinephrine boluses in patients with single ventricle physiology who are dwindling (nearly arresting), can actually worsen their systemic output by increasing systemic vascular resistance and promoting pulmonary overcirculation. Cardioversion of a previously healthy pediatric patient might be tempting when you see what looks like a stable ventricular tachycardia. This wide complex rhythm has fooled many people into shocking it. You might in fact be dealing with something else and can make the patient infinitely worse by shocking.

We review a talk by Dr. Sara Gray from SMACC (Social Media and Critical Care) conference in June 2016, Resuscitative hysterotomy, which is the new name for perimortem c-section [1]. In this talk she challenges the "4 minute" rule: if resuscitative efforts following maternal circulatory arrest are unsuccessful, cesarean delivery should be commenced at 4 minutes and completed by 5 minutes to optimize fetal outcome.  Then we delve into core content on pregnancy emergencies using Rosen’s Emergency Medicine (8th edition) Chapter 98and Tintinalli’s Emergency Medicine (8th edition) Chapter 178 as a guide, discussing nausea and vomiting, hyperemesis gravidarum, bacteriuria, and vaginal bleeding in the first trimester. Thanks for listening! Jeremy Faust and Lauren Westafer

This session will review the latest evidence for resuscitative hysterotomy (aka perimortem cesearean section), in light of the latest ACLS guidelines. Is there really evidence for the 4 minute rule? How fast do we need to do this? Terrified of this risky procedure? Come learn some practical tips for getting through this as effectively as possible. No time for the whole podcast? Check out these quick links and references: • http://emupdates.com/2013/10/22/perimortem-cesarean-section-in-the-emergency-department/ This one has many details of the procedure itself. • http://stemlynsblog.org/peri-mortem-c-section-at-st-emlyns/ Great review of the procedure, nice FOAM resources at the end • http://emcrit.org/wee/peri-mortem-c-section/ Includes links to the videos below. • Prefer a review article? This is a great review of the science on maternal cardiac arrest and PMCD (PMID 24797653) • An excellent review of published cases is here (PMID 22613275), describing the details of timing of PMCD as it relates to maternal and neonatal survival

We are excited to welcome back Dr. Joseph R. Shiber, Associate Professor of Emergency Medicine at the University of Florida College of Medicine. Dr. Shiber is currently on loan to us here at the University of Maryland as he completes his Critical Care Medicine Fellowship. He is the first EM/IM/CCM graduate our program ever had and has been making waves in the academic world since his departure. After many requests he has agreed to share one of his most requested lectures: A history of resuscitative medicine.

In this episode we were lucky enough to catch up with Sam Sadek, EM Consultant at The Royal London hospital and HEMS doctor and also Zaf Qasim EM Consultant in Delaware in the United States. Both have been heavily involved in the setup and delivery of REBOA service in their respective posts. In this podcast they share their experience and expertise on the topic of setting up a REBOA service. A huge thanks to both of them as this is a superb podcast for anybody considering getting involved in REBOA. Recent podcasts on REBOA on ERCAST and EMCrit are essential listening and serve as great preludes to our discussion so make sure you check them out. Please pop any comments or questions at the bottom of the page and we will come back with a Q&A podcast on the topic really soon! References Resuscitative endovascular balloon occlusion of the aorta: a gap analysis of severely injured UK combat casualties. Morrison JJ. . Shock. 2014 May;41(5):388-93. doi: 10.1097/SHK.0000000000000136. Resuscitative endovascular balloon occlusion of the aorta might be dangerous in patients with severe torso trauma: A propensity score analysis. Inoue J. J Trauma Acute Care Surg. 2016 Apr;80(4):559-67. doi: 10.1097/TA.0000000000000968. The inflammatory sequelae of aortic balloon occlusion in hemorrhagic shock. Morrison JJ. J Surg Res. 2014 Oct;191(2):423-31. doi: 10.1016/j.jss.2014.04.012. Epub 2014 Apr 13. Resuscitative endovascular balloon occlusion of the aorta (REBOA): a population based gap analysis of trauma patients in England and Wales. Barnard EB. Emerg Med J. 2015 Dec;32(12):926-32. doi: 10.1136/emermed-2015-205217. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Rossaint R. Crit Care. 2016 Apr 12;20(1):100. doi: 10.1186/s13054-016-1265-x. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. Moore LJ. J Trauma Acute Care Surg. 2015 Oct;79(4):523-30; discussion 530-2. doi: 10.1097/TA.0000000000000809. The AAST Prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). DuBose JJ. J Trauma Acute Care Surg. 2016 Apr 5. [Epub ahead of print]

A 5-year-old boy was playing with his older brother in front of their home when he was struck by a car. He sustained a femur fracture, splenic laceration, and blunt head trauma – the so-called Waddell’s triad. On arrival, he was in compensated shock, with tachycardia. He decompensates and needs blood. How do we manage his hemodynamics and when do we perform massive transfusion? Pediatric Massive Transfusion 40 mL/kg of blood products given at any time within the first 24 hours. Adolescents and Adult Massive Transfusion 6-8 units of packed red blood cells (PRBCs) Adults have about 5 L of circulating blood. Not including plasma, one could replace all circulating erythrocytes with about 10 units of PRBCS The best ratio of PRBCs:Plasma:Platelets is unknown, but consensus is 1:1:1. 1 unit of PRBCS is typically 300 mL of volume. The typical initial transfusion of PRBCs in children is 10 mL/kg. Massive transfusion in children is defined as 40 mL/kg of any blood product. Once you start to give a child with major trauma the second 10 mL/kg dose of PRBCs – start thinking about other blood components, and ask yourself whether you should initiate your massive transfusion protocol. The goal is to have the products ready to use in the case of the dynamic trauma patient. The Thromboelastogram (TEG) Direct measures the four components of clot formation. When there is endolethial damage and bleeding, the sequence that your body takes to address it is as follows:  Platelets migrate and form a plug Clotting factors aggregate and reinforce the platelets Fibrin arrives an acts like glue Other cells migrate and support the clot. R time – reaction time – the initial line in the tracing that shows time to beginning of clot formation. Treated with platelets K factor – kinetics of the clot –how much the clot allows the pin to move, or the amplitude. Treated with cryoprecipitate Alpha angle – the slope between the R and K measurements – reflects how quickly the fibrin glue is working. Treated with cryoprecipitate Ma – maximum amplitude – reflects the overall strength of the clot. Treated with platelets LY30 – the clot lysis at 30 min – is the decrease in strength of the clot’s amplitude at 30 min. Treated with an antifibrinolytics (tranexamic acid) Shape Recognition Red wine glass: a normal tracing with a normal reaction time and a normal amplitude. That patient just needs support and monitoring. Champagne glass: a coagulopathic TEG tracing – thinned out, with less amplitude. This patient needs specific blood products. Puffer fish or blob: a hyperfibrinolytic tracing. That patient will needs clot-stablizer. TEG – like the FAST – can be repeated as the clinical picture changes. The Trauma Death Spiral Lethal triad of hypothermia, acidosis, and coagulopathy. Keep the patient perfused and warm. Each unit of PRBCs contains 3 g citrate, which binds ionized calcium, causing hypotension. In massive transfusion, give 20 mg/kg of calcium chloride, up to 2 g, over 15 minutes. Calcium chloride is preferred, as it is ionically readily available – just use a larger-bore IV and watch for infiltration. Calcium gluconate could be used, but it requires metabolism into a bioavailable source of calcium. Prothrombin complex concentrate (PCC) Prothrombin complex concentrate (PCC) is derived from pooled human plasma and contains 25-30 times the concentration of clotting factors as FFP. Four-factor PCCs contain factors II, VII, IX and X, while 3-factor PCCs contain little or no factor VII. The typical dose of PCC is 20-50 units/kg In the severely hemorrhaging patient – you don’t have time to wait for the other blood products to thaw – PCC is a powder that is reconstituted instantly at the bedside. Tranexamic acid (TXA) Tranexamic acid (TXA), is an anti-fibrinolytic agent that functions by stopping the activation of plasminogen to plasmin, and the degradation of fibrin. The Clinical Randomisation of an Antifibrinolytic in Significant Hemorrhage (CRASH-2) investigators revealed a significant decrease in death secondary to bleeding when TXA was administered early following trauma. Based on the adult literature, one guideline is to give 15 mg/kg loading dose of TXA with a max 1 g over 10 minutes followed by 2 mg/kg/h for at least 8 h or until bleeding stops. Resuscitative Pearls Our goal here is damage control. Apply pressure whenever possible. Otherwise, resuscitate, identify the bleeding source, and slow or stop the bleeding with blood products or surgery. How Children are Different in Trauma In adults, we speak of “permissive hypotension” (also called “balanced resuscitation” or “damage control resuscitation”). The idea is that if we bring the adult patient’s blood pressure up to normal, we may be promoting clot rupture. To avoid this, we target a MAP of 65 and look for clinical signs of sufficient perfusion. Adults tolerate hypotension relatively well, and is sufficient until we send them to the OR or interventional radiology suite. In children, this is simply not the case. Hypotension in children is a sign of pre-arrest. Remember, they compensate with an increased systemic vascular resistance and tachycardia to maintain blood pressure. We should not allow children to become hypotensive – severe tachycardia alone should prompt us to resuscitate. In other words, permissive hypotension is not permissible for children. FAST is not sensitive enough to rule-out abdominal trauma. Fox et al in Academic Emergency Medicine found a sensitivity of 52%; with a 95% confidence interval [CI] = 31% to 73%. Often children even with high-grade splenic and liver lacerations can be managed non-operatively. If they are supported adequately, they are observed in the ICU and can avoid surgery in many cases. Unfortunately, a negative FAST cannot help with detecting or grading the laceration for non-operative management. In other words, feel free to use ultrasound – especially for things that we in the ED will react to and intervene on – but CT may help to manage the traumatized child non-operatively. General Guideline for Imaging in Pediatric Trauma CT Head and Neck, non-contrast: in concerning mechanisms of injury, patients that are difficult to assess (especially those under 3 months), those with a GCS of 13 or lower. CT Chest, IV contrast: for suspicion of vascular injury that needs exploration, especially in penetrating trauma. Otherwise, chest xray will tell you everything you need to know in children – especially in blunt trauma. Hemo or pneumothoraces are readily picked up by US or CXR. Rib fractures on CXR predict pulmonary contusions. If you are concerned about great vessel injury, then CT Chest may be helpful; otherwise consider omitting it. CT Abdomen and Pelvis, IV contrast: helpful in grading splenic and liver lacerations with goal to manage non-operatively. Abdominal tenderness to palpation, significant bruising, or a seat belt sign are concerning and would generally warrant a CT. Also, consider in liver function test abnormalities, or hematuria. Extremity injuries: in general can be evaluated with physical exam and plain films. However, some injuries in high-risk anatomically complex areas such as the hand and wrist, tibial plateau, and midfoot may be missed by plain films, and CT may be helpful here. Remember: you can help to mitigate post-traumatic stress and risk for adult healthcare aversion. Summary Massive transfusion in children is at 40 mL/kg of total blood products. Think about it if you are giving your second transfusion to the traumatized child. Do everything you can to support perfusion and avoid the death spiral of hypothermia, coagulopathy, and acidosis. Keep the child perfused with blood as needed, correct coagulopathy, avoid too much crystalloid, and make sure to use the least high-tech of all of these interventions – keep him dry and covered with warm blankets. Do a careful physical exam, and use CT selectively with an end-point in mind – the default is not the pan-scan – evaluate possible injuries depending on your suspicions from history, physical, and lab tests. Become familiar with the relatively new modalities in trauma such as TXA, cryoprecipitate and the emerging technology of thromboelestogram – red wine is good for you, champagne is weak, and a puffer fish is trouble. Selected References Dehmer JJ, Adamson WT. Massive transfusion and blood product use in the pediatric trauma patient. Semin Pediatr Surg. 2010 Nov;19(4):286-91. doi: 10.1053/j.sempedsurg.2010.07.002. Fox JC, Boysen M, Gharahbaghian L, Cusick S, Ahmed SS, Anderson CL, Lekawa M, Langdorf MI. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med. 2011 May;18(5):477-82. Harvey V, Perrone J, Kim P. Does the use of tranexamic acid improve trauma mortality? Ann Emerg Med. 2014 Apr;63(4):460-2. 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. Nosanov L, Inaba K, Okoye O, Resnick S, Upperman J, Shulman I, Rhee P, Demetriades D. The impact of blood product ratios in massively transfused pediatric trauma patients. Am J Surg. 2013 Nov;206(5):655-60. Ryan ML, Van Haren RM, Thorson CM, Andrews DM, Perez EA, Neville HL, Sola JE, Proctor KG. Trauma induced hypercoagulablity in pediatric patients. J Pediatr Surg. 2014 Aug;49(8):1295-9. 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. This post and podcast are dedicated to Larry Mellick, MS, MD, FAAP, FACEP. Thank you for your dedication to medical education, and sharing your warm bedside manner, extensive knowledge and talents, and your patient interactions with the world. Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP

This talk will cover what we should do for patients who are considered too sick to have emergency surgery. These patients provide major management challenges in Critical Care. Do we admit them to intensive care to optimise them prior to emergency surgery or should we get on with surgery and resuscitate them intraoperatively? Should the surgery, if undertaken, be limited to damgae control surgery or operative resuscitation, or should more definitive surgical procedures be undertaken. There often isn't good evidence to mandate a course of action either way so the decision will mostly be based on the treating clinicians opinions. In these complex cases, who should decide? These factors and others will be examined

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

Dr. Simon Walsh from London's Air Ambulance Barts Health NHS Trust gives a talk at SATS Aarhus symposium - Prehospital Interventions By Frontline UK Helicopter Doctors and Paramedics

This interview with Joe Bellezzo is what caused Scott to pursue ECLS. The post Resuscitative ECMO Interview from EMCrit.org appeared first on ED ECMO.

Joe Bellezzo, MD along with his partner-in-crime, Zack Shinar, MD have started an ED ECMO service at Sharp Memorial Hospital in San Diego. I am so jealous! In this episode of the podcast, I get to talk to Joe about how it works.