Trauma ICU Rounds

In this episode we sit down with the Chief of Trauma, Surgical Critical Care, Burns, & Acute Care Surgery at the University of Arizona, Dr. Bellal Joseph, who share with us his thoughts and research findings on hot topics including frailty, geriatric trauma, leadership, and more. Timestamps: 00:12 Introductions 01:30 What is frailty? Your physiologic NOT chronologic body. 06:58 Injured elderly trauma patients can have good outcomes 07:30 Trauma specific frailty index 10:48 Failure to rescue 13:57 Geriatricians and the trauma surgeons 15:08 4Ms-What Matters, Mobility, Mentation, Medication 16:48 Geriatric cohorting/wards 22:24 ACS geriatric centers of excellence 29:35 Brain Injury Guidelines (BIG) 38:17 The importance of teamwork & servant leadership 40:28 Imposter syndrome 43:19 Leadership considerations 45:25 Final thoughts References: Joseph B, Friese RS, Sadoun M, Aziz H, Kulvatunyou N, Pandit V, Wynne J, Tang A, O'Keeffe T, Rhee P. The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons. J Trauma Acute Care Surg. 2014 Apr;76(4):965-9. doi: 10.1097/TA.0000000000000161. PMID: 24662858. Joseph B, Obaid O, Dultz L, Black G, Campbell M, Berndtson AE, Costantini T, Kerwin A, Skarupa D, Burruss S, Delgado L, Gomez M, Mederos DR, Winfield R, Cullinane D; AAST BIG Multi-institutional Study Group. Validating the Brain Injury Guidelines: Results of an American Association for the Surgery of Trauma prospective multi-institutional trial. J Trauma Acute Care Surg. 2022 Aug 1;93(2):157-165. doi: 10.1097/TA.0000000000003554. Epub 2022 Mar 28. PMID: 35343931.v Joseph B, Pandit V, Haider AA, Kulvatunyou N, Zangbar B, Tang A, Aziz H, Vercruysse G, O'Keeffe T, Freise RS, Rhee P. Improving Hospital Quality and Costs in Nonoperative Traumatic Brain Injury: The Role of Acute Care Surgeons. JAMA Surg. 2015 Sep;150(9):866-72. doi: 10.1001/jamasurg.2015.1134. PMID: 26107247. Joseph B, Pandit V, Sadoun M, Zangbar B, Fain MJ, Friese RS, Rhee P. Frailty in surgery. J Trauma Acute Care Surg. 2014 Apr;76(4):1151-6. doi: 10.1097/TA.0000000000000103. PMID: 24662884. Orouji Jokar T, Ibraheem K, Rhee P, Kulavatunyou N, Haider A, Phelan HA, Fain M, Mohler MJ, Joseph B. Emergency general surgery specific frailty index: A validation study. J Trauma Acute Care Surg. 2016 Aug;81(2):254-60. doi: 10.1097/TA.0000000000001120. PMID: 27257694. Support the show

In this episode, we talk all things critical care the one and only, Dr. Jean-Louis Vincent aka. JLV. This episode is a MUST listen. We touch upon the evolution of early goal directed therapy, measures of fluid responsiveness, optimizing oxygen delivery, and the importance of integrating data points versus examining them in isolation when caring for our critically ill and injured patients. This and MUCH MUCH more in arguably one of my favorite episodes to date!! Timestamps 00:00 Introduction 01:21 What happened to SG catheters and should we use them? 04:05 What decreases mortality in critical care patients? 05:30 When to transfuse critical care patient? Use your brain! 08:55 Measures of tissue perfusion and fluid responsiveness 09:36 JLV breaks down the Rivers trial 10:36 Recent EGDT papers 10:54 How to optimize O2 delivery? Late ScVO2, dob challenge, and fluid challenges 13:21 Dynamic measures of fluid responsiveness 13:46 CVP as a relative value 15:14 Passive leg raising (PLR) as a measure of fluid responsiveness 21:20 JLV's take on therapeutic nihilism 24:45 Don’t isolate; integrate! 26:46 Navigating the future of critical care – JLV’s thoughts on AI in the ICU 29:55 Rapid fire hot topics in the ICU – Yes or No -Metabolic cocktail -Corticosteroids for septic shock -Albumin and Lasix or Lasix alone PCT/CRP and sepsis/Abx Resources: International Symposium on Intensive Care and Emergency Medicine (ISICEM): https://www.isicem.org ISICEM Chats Platform: https://www.isicem.org/e-chat/index.asp Articles: Passive leg raising:five rules, not a drop of fluid! https://ccforum.biomedcentral.com/articles/10.1186/s13054-014-0708-5 The fluid challenge https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-03443-y Blood lactate levels in sepsis: 8 questions Vincent JL, Bakker J. Blood lactate levels in sepsis: in 8 questions. Curr Opin Crit Care. 2021 Jun 1;27(3):298-302. doi: 10.1097/MCC.0000000000000824. PMID: 33852499. We should avoid the term "fluid overload" https://ccforum.biomedcentral.com/articles/10.1186/s13054-018-2141-7 EGDT in the Treatment of Severe Sepsis and Septic Shock https://www.nejm.org/doi/full/10.1056/nejmoa010307 A Randomized Trial of Protocol-Based Care for Early Septic Shock https://www.nejm.org/doi/full/10.1056/nejmoa1401602 Support the show

In this episode, we discuss the overarching importance of AVOIDING iatrogenic harm in the ICU with arguably one of the world's leading experts in critical care medicine, the one and only, Dr. Jean-Louis Vincent aka. JLV. Tune in as Dr. Vincent shares with us the importance of having a systematic, problem-based approach to patient care delivery which, of course, involves giving our patients a FAST HUG every day! Time Stamps: 2:10 LA Critical Care and Differences between Europe versus USA 4:04 COVID, Modern tech and bedside care 5:32 ICU Rounds – How I do it 6:00 Team Based ICU Care 7:56 Modern advances in critical care 9:55 Problem-based approach in the ICU 13:18 FAST HUGS 14:00 Feeding 14:36 Analgesia & Sedation 15:46 Thromboembolic prophylaxis 16:25Head of the bed elevated 17:17Ulcer prophylaxis 19:22Glucose control 20:48 Tube feeds, yes? Ulcer ppx , no. 22:30 Outro Support the show

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

"Getting patients resuscitated through sepsis, septic shock, and hemorrhagic shock is not the end...it's the beginning." In this episode, Dr. Brakenridge from Harborview Medical Center joins us to discuss PICS and the impact of this syndrome on our critically ill and injured patients and their families. Also referred to as the Post-Intensive Care Syndrome, Dr. Brakenridge shares with us the evolution and results of translational research into this now well-recognized morbid condition which often occurs in the setting of chronic critical illness. From the importance of breaking the cycle of "sepsis recidivism" to the. application of the SCCM A to F bundle, this episode is a MUST listen for those of us taking care of patients in the ICU. TIME STAMPS 00:12 Introduction 01:46 What is PICS? The role of chronic critical illness (CCI) 05:13 Phenotypes vs. endotypes 06:47 The role of biomarkers in PICS 08:50 When does acute critical illness turn into CCI? 10:14 Risk factors for PICS 15: 07 Prognostication and determining patient trajectory 18:32 The Glue Grant Experience: Genomics of Injury 22:48 Hemorrhagic shock resuscitation: Then and now 25:33 Sepsis recidivism & avoiding secondary insults 29:08 ICU delirium 31:55 The role of early mobilization 32:41 The impact of catabolism in sepsis 34:50 Is there a role for anabolic steroids to counteract PICS? 37:52 What's ahead in terms of PICS translational research? 39:44 Cytokine and immunomodulator therapies 41:49 Final thoughts RECOMMENDED READINGS Brakenridge SC, Wang Z, Cox M, Raymond S, Hawkins R, Darden D, Ghita G, Brumback B, Cuschieri J, Maier RV, Moore FA, Mohr AM, Efron PA, Moldawer LL. Distinct immunologic endotypes are associated with clinical trajectory after severe blunt trauma and hemorrhagic shock. J Trauma Acute Care Surg. 2021 Feb 1;90(2):257-267. Efron PA, Mohr AM, Bihorac A, Horiguchi H, Hollen MK, Segal MS, Baker HV, Leeuwenburgh C, Moldawer LL, Moore FA, Brakenridge SC. Persistent inflammation, immunosuppression, and catabolism and the development of chronic critical illness after surgery. Surgery. 2018 Aug;164(2):178-184. doi: 10.1016/j.surg.2018.04.011. Epub 2018 May 26. Sauaia A, Moore FA, Moore EE. Postinjury Inflammation and Organ Dysfunction. Crit Care Clin. 2017 Jan;33(1):167-191. Stortz JA, Murphy TJ, Raymond SL, Mira JC, Ungaro R, Dirain ML, Nacionales DC, Loftus TJ, Wang Z, Ozrazgat-Baslanti T, Ghita GL, Brumback BA, Mohr AM, Bihorac A, Efron PA, Moldawer LL, Moore FA, Brakenridge SC. Evidence for Persistent Immune Suppression in Patients Who Develop Chronic Critical Illness After Sepsis. Shock. 2018 Mar;49(3):249-258. Support the show

In this, our 50th episode, we are in Austin, TX, for the Annual EAST Scientific Meeting where we are joined by Dr. Bryan A. Cotton who shares his expertise and knowledge regarding the use of whole blood (WB) in trauma patients. From the use of whole blood in prior military conflicts to the design and successful implementation of one of the only prospective randomized controlled trials of modified whole blood use in trauma patients, Dr. Cotton provides an incredible overview of the potential benefits of whole blood or as he refers to it - "the dying blood product". Also covered in expert fashion are the role of other hemostatic products and strategies including tranexamic acid, fibrinogen concentrates, and a plasma first resuscitation strategy. Time Stamps: 01:16 The rationale for whole blood & a 1:1:1 transfusion strategy 04:24 Military experience with WB: What's old is new again! 05:44 Modified WB vs. Component Therapy RCT 06:02 Leukoreduction of WB 07:00 Type-specific WB 09:38 Platelet function in WB vs. aphaeresis platelets 11:58 Warm fresh WB vs. cold stored 12:55 The whole is greater than the sum of its parts 15:02 What do we mean by low-titer WB? 19:14 O+ vs. O- WB & the potential for alloimmunization 24:39 Transfusion reactions & safety of WB in trauma patients 25:40 Prehospital WB for the win 27:32 LITES Network 28:27 Hemorrhage control, 1:1:1, viscoelastic assays, cryoprecipitate & fibrinogen concentrate 32:00 BAC's thoughts on tranexamic acid (TXA) 34:47 BAC's thoughts on hypertonic saline (HTS) for COVID-19 38:51 Final thoughts & future directions Recommended Readings: Cotton BA, Podbielski J, Camp E, Welch T, del Junco D, Bai Y, Hobbs R, Scroggins J, Hartwell B, Kozar RA, Wade CE, Holcomb JB; Early Whole Blood Investigators. A randomized controlled pilot trial of modified whole blood versus component therapy in severely injured patients requiring large volume transfusions. Ann Surg. 2013 Oct;258(4):527-32; discussion 532-3. Williams J, Merutka N, Meyer D, Bai Y, Prater S, Cabrera R, Holcomb JB, Wade CE, Love JD, Cotton BA. Safety profile and impact of low-titer group O whole blood for emergency use in trauma. J Trauma Acute Care Surg. 2020 Jan;88(1):87-93. McGinity AC, Zhu CS, Greebon L, Xenakis E, Waltman E, Epley E, Cobb D, Jonas R, Nicholson SE, Eastridge BJ, Stewart RM, Jenkins DH. Prehospital low-titer cold-stored whole blood: Philosophy for ubiquitous utilization of O-positive product for emergency use in hemorrhage due to injury. J Trauma Acute Care Surg. 2018 Jun;84(6S Suppl 1):S115-S119. Sperry JL, Guyette FX, Brown JB, Yazer MH, Triulzi DJ, Early-Young BJ, Adams PW, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Witham WR, Putnam AT, Duane TM, Alarcon LH, Callaway CW, Zuckerbraun BS, Neal MD, Rosengart MR, Forsythe RM, Billiar TR, Yealy DM, Peitzman AB, Zenati MS; PAMPer Study Group. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018 Jul 26;379(4):315-326. doi: 10.1056/NEJMoa1802345. PMID: 30044935. Yazer MH, Jackson B, Sperry JL, Alarcon L, Triulzi DJ, Murdock AD. Initial safety and feasibility of cold-stored uncrossmatched whole blood transfusion in civilian trauma patients. J Trauma Acute Care Surg. 2016 Jul;81(1):21-6. doi: 10.1097/TA.0000000000001100. PMID: 27120323. Websites: LITES Network https://www.litesnetwork.org Southwest Texas Regional Advisory Council https://www.strac.org/blood Support the show

In the second episode of a two-part series, Dr. Mattox shares his insights and thoughts on hot research topics in trauma in need of investigation. Additionally, he helps us to envision what acute trauma management may look like in the future, while also sharing with us how his book (and one of my ALL-TIME fave surgery books!), Top Knife, came into being. From lessons learned to lessons in need of learning, Dr. Mattox has all of the bases (and basics) covered. Time Stamps 0:00 Introduction 00:12 "The resuscitation is the incision." 00:44 Welcome & Announcements/Call to Action 02:24 Whole blood is good but.....what should our endpoint of resuscitation be? 03:05 Drones in the prehospital setting 08:03 Reimagining the ER 08:57 General Surgery training: Then & now 10:00 Top Knife, Trauma, Rich’s Vascular Trauma 11:33 How Top Knife came into being – Saturday mornings, coffee, Mary Allen & a tape recorder 16:57 To operate or not operate? 22:11 Mattox Vegas TCCACS 26:11 Final thoughts: ”There’s always a better way." Support the show

We. Are. Back!! After a (brief?!) hiatus, we are launching 2022 with a 2-part series with the one and only Dr. Ken Mattox. In this episode, Dr. Mattox shares with us his thoughts on what the modern general surgeon should look like and how we as surgeons differ from our medicine counterparts. Additionally, we review the history of modern trauma resuscitation, the paradigm shifts that have occurred as it pertains to permissive hypotension, as well as the technological advances that have occurred over the last century that have improved care of the critically injured patient. This is an episode not to be missed! Time Stamps 00:12 Welcome & announcements 04:21 What does the modern "surgeon" look like? 07:48 The interplay between technology & surgery 10:15 Serendipity & Dr. Mattox's early career 11:28 Finessing & integrating clinical practice with research opportunities 13:45 The 2 most impactful advances in trauma care during the last century: the microchip & organized trauma systems 17:00 Dr. Mattox's thoughts on REBOA & intravascular control/treatment techniques 22:32 MAST pants: lessons learned 25:18 Elevate the BP with MAST and fluids? Increase the mortality!! 26:30 Permissive hypotension 27:06 Vasopressors in the ER?! Hypotension is teleological!! References Bickell WH, Pepe PE, Wyatt CH, Dedo WR, Applebaum DJ, Black CT, Mattox KL. Effect of antishock trousers on the trauma score: a prospective analysis in the urban setting. Ann Emerg Med. 1985 Mar;14(3):218-22. doi: 10.1016/s0196-0644(85)80443-1. PMID: 3977145. Bickell WH, Wall MJ Jr, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994 Oct 27;331(17):1105-9. doi: 10.1056/NEJM199410273311701. PMID: 7935634. Hirshberg A, Hoyt DB, Mattox KL. From "leaky buckets" to vascular injuries: understanding models of uncontrolled hemorrhage. J Am Coll Surg. 2007 Apr;204(4):665-72. doi: 10.1016/j.jamcollsurg.2007.01.005. Epub 2007 Feb 23. PMID: 17382227. 2022 Mattox Vegas TCCACS https://www.trauma-criticalcare.com/tccacs/program/ Support the show

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

In follow-up to a recent pro-con debate on the use of pre-hospital pelvic binders, we explore the why, when, and how of pelvic binder placement. From the indications to post-placement considerations and importance of a multidisciplinary approach to the management of these life-threatening injuries, this episode of Rounds is a great addition to Season 1 Episode 24 Hemodynamically Unstable Pelvic Fractures with Dr. Clay Burlew. Time Stamps 00:12 Welcome 02:52 Learning Objectives 03:43 Introduction 05:58 Initial Assessment & Management of Patients with Suspected Hemodynamically Unstable Pelvic Fractures 09:54 Young-Burgess Classification of Pelvic Ring Fractures 12:00 Indications, Technique, and Considerations for Properly Placing a Pelvic Binder 17:30 Hemostatic Adjuncts in the Management of Patients with Hemodynamically Unstable Pelvic Fractures 22:13 Take Home Points 23:11 Outro & Call to Action Support the show

In this episode, we sit down with Dr. Carlos VR Brown from the Dell Seton Medical Center at the University of Texas to discuss issues relevant to both junior and mid-career trauma & acute care surgeons. Topics covered include: military-civilian trauma, finding one's niche in academic surgery, work-life balance, and learning from our mistakes. As I prepare to enter a new phase in my academic surgical career, the timing of this interview could not have been more perfect. This episode is packed with career pearls and words of wisdom that are not to be missed! Time Stamps 00:12 Introduction 02:37 Welcome Dr. CVR Brown 05:39 When did your interest in trauma surgery begin? 08:26 Military versus civilian trauma surgery 11:16 Carlos Brown is a Hero (No Matter What He Says) 13:18 Military & advances in clinical knowledge 14:29 Research & the importance of mentorship 15:04 The path to academic surgery: LAC-USC 2002-2007 17:45 Mentorship and research 20:31 Coming home & the opportunity to build 23:33 What is really important in a job? People, place, and family 26:32 “If you build it, they will come” BUT you need to surround yourself with REALLY GOOD people. Oh, and time management is also essential! 28:08 If you don’t have to be at work, leave! And go do the things that bring pleasure to you outside of work. 30:25 “We all make mistakes….” 31:36 Ask yourself, “What’s the best fit for both your career and family?” 32:51 Outro and call to action Links: Carlos Brown is a Hero (No Matter What He Says) https://www.texasmonthly.com/articles/carlos-brown-is-a-hero-no-matter-what-he-says/ Support the show

Massive upper GI bleeds can be intimidating and lethal. An expeditious, multidisciplinary approach is required to improve survival and optimize patient outcomes. Time Stamps: 00:12 Welcome & Introduction 01:55 Goals & Objectives 02:29 Common Etiologies & Differential Diagnosis for UGIBs 05:15 Initial Evaluation 10:52 Initial Management 15:38 Indications & Timing of Endoscopic and Non-Endoscopic Interventions 18:19 Forrest Classification of Peptic Ulcers 20:43 Indications & Timing of Surgical Interventions 21:30 Surgical management of Bleeding Peptic Ulcers 23:40 Take Home Points 25:10 CTA Consider becoming a Patron of the Show! Support the show

Our first in-person interview since the start of the COVID pandemic! Join us for National Stop the Bleed Day as Dr. Kenji Inaba from LAC+USC joins us to discuss management of penetrating cardiac injuries, the Los Angeles County Hospital Emergency Response Team (HERT), and recent updates to the Stop the Bleed campaign. From the utility of FAST to the diagnostic (and potentially therapeutic?!) role of subxyphoid windows, this episode has it all and is not to be missed! Also, remember to check out Season 1 , Episode 11 - National Stop the Bleed Day & Tourniquet Use in 2020. Support the show

Join us as we discuss surgical management options for the difficult gallbladder. Is it better to open or proceed with a laparoscopic subtotal cholecystectomy? If the latter, fenestrated or reconstituted? What's the difference?! This week on Rounds, we have several guest professors join us to discuss their perspectives and experience on managing patients with a difficult gallbladder. Joining us from Texas (and favoring subtotal cholecystectomy) are Drs. Sharmila Dissanaike and Michael Truitt. Drs. Angela Neville and Jessica Keeley from California discuss the merits of converting to an open cholecystectomy for patients with a difficult gallbladder. Also, joining us is Dr. Christian de Virgilio, who co-moderates this lively and educational podcast episode alongside me. Support the show

Bowel obstructions may be due to mechanical or functional causes. Although acute colonic pseudo-obstruction (ACPO) falls into the latter category, we must ALWAYS rule out mechanical causes for massive distension of the colon. In this episode, we make our way down the GI tract and discuss the pathophysiology, risk factors, diagnostic and therapeutic considerations for what Dr. Ogilvie coined "Large-intestine Colic" in 1948. Support the show

Whether due to occlusive or nonocclusive obstruction of the arterial inflow or obstruction of venous outflow, acute mesenteric ischemia (AMI) continues to be associated with high mortality rate. Early recognition based on a high index of suspicion is critical to early diagnosis and intervention, particularly among patients presenting with pain out of proportion to physical exam findings. In this episode, we discuss the pathophysiology of AMI, together with common causes, the initial clinical presentation, and management strategies for patients with this life-threatening and elusive surgical disease process. Support the show

Rare. Morbid. Lethal. NSTIs area group of infections which result in aggressive tissue destruction, systemic toxicity, and can involve any layer of the soft tissue. The key to successful management (like so many disease processes) is having a high index of suspicion together with administration of early, broad-spectrum antibiotics and surgery. Support the show

Dr. Scott Weingart joins us on Rounds to discuss a topic that's of great interest to the both of us - surgical cricothyroidotomy. Tune in to hear how Scott's approach to performing a cric has evolved over time and why "trauma surgeons are the worst people to learn crics from?!" From 3 strikes and your out to the use of bougies, this episode covers all things cric. Also check out Episode 23 of Rounds "Surgical Cricothyroidotomy: How I Do It". Even better go to: https://emcrit.org/emcrit/surgical-airway/ and review the FANTASTIC content that has been put together by Scott and his team at EMCrit. Support the show

What are the determinants of mean airway pressure? Is too much PEEP ever a bad thing? In this episode, we review determinants of oxygenation in mechanically ventilated patients and discuss the benefits and risks of high versus low PEEP strategies, as well as the utility of lung volume recruitment maneuvers. Check out our previous related episodes 1, 3, 6, 10, and 36. Support the show

Back to the basics! In this episode we review the evolving criteria, etiologies, and pathophysiology of ARDS. A brief review of ventilator induced lung lung injury and initial vent setup provide the groundwork for future episodes exploring how to troubleshoot the vent and therapies for ARDS that have been shown to improve oxygenation and mortality. Please check out Episodes Support the show