Good afternoon, and thank you everybody for joining us today on our complex trauma case study. My name is Christopher Ruiz, I'm the Vice President of Trauma Services at Doctors Hospital of Augusta. And I'd like to introduce Dr. Maynes. He's currently the Trauma Medical Director of Centura Health Trauma System, which includes 18 designated trauma centers in Colorado, with experience from a level four all the way to a level one trauma center of experience. Today's prescription is a typical day at your trauma center. It's lunchtime and your pager goes off. You verify with the ED that they have one patient on their way unstable and EMS will arrive in approximately five minutes. There's no other information that is known at this time. Please follow Dr. Maynes as he reviews this case, the literature, and how it can be applied to your complex case studies. Test your decision making and treatment modalities during this webinar. You never know if this could be your next patient. Please feel free to share comments, experiences and other questions in the chat box that I will refer to at the end of the presentation. Now for Dr. Maynes, thank you. Thank you. Okay, so we, we have no relevant financial disclosures. So I'm going to start with the scene presentation. This is a 35 year old female belted. She was in the passenger seat with a seatbelt on but both feet up on the dashboard. High speed frontal impact. You see the vital signs here. So, look, heart rate is 115, O2 saturation is okay, GCS is 14, airways patent, no lateralizing findings, abdomen is tender with a seatbelt sign, and the pelvis is also non tender, there's no external hemorrhage. Now I'm going to ask some questions regarding what you would recommend to the folks at the scene. So, the location here is five miles to a rural level three trauma center. It's 70 miles to an urban level one trauma center. There's clear weather, and there's afternoon traffic in the urban area. So the patient's extricated, they start an IV, mask O2, O2 saturation is okay, they put a collar on, increased abdominal pain, 20 minutes into scene time, blood pressure is now down to 95 over 70, respirations are 22, heart rate in this case is still about 120, and on O2 mask. So the patient's given fentanyl for pain, and now the blood pressure is 80 over 60, heart rate's 122, still saturating okay, and a little more sedated but responds to verbal stimuli. So, my first question is, what would you recommend for scene airway management? So here are your choices. We've opened the poll. Let's see what folks think. We had a variety of answers. The majority answer was to continue the mask O2. There was some sentiment to do RSI. Bagging somebody who is still awake and talking is a little difficult. Eye gel basically requires the same meds. So let's talk about where we are at the scene. This is a patient who has a seatbelt sign with a major mechanism and a tender belly. So certainly you're worried about truncal hemorrhage in this case. The average time for definitive hemorrhage control in the OR is about 120 minutes. And that's what prompted some major organizations, the US military, for example, to put hemorrhage control on par with airway. The Wilderness Medicine Society has a mnemonic march which puts massive hemorrhage ahead of airway. And here is the curves of death associated with time to truncal hemorrhage. And mortality per minute on both of these curves, this is from the prompt trial from the military and the proper trial, and what you see is a relatively consistent curve. And when you compare that to Howard Champion's curve, it's basically the same curve. And what's superimposed on there is the scene time, the yellow star is time to the ED, and the red star is time to definitive hemorrhage control in the operating room. And this is out of the National Trauma Database. It included 55,000 patients. And what you see there is that 120-minute timeframe to definitive hemorrhage control compared to the bleeding to death time, median of about 35 minutes. So when you think about time to hemorrhage control and its scene considerations, you're going to want to compress compressible hemorrhage, truncal tourniquet or junctional tourniquets, temporize non-compressible hemorrhage, pelvic binder, permissive hypotension, limit crystalloid. Remember, RSI shock is a relative indication for intubation, not necessarily an absolute. So limiting the scene time in favor of achieving truncal hemorrhage control is always a consideration. When you look at the San Diego RSI trial, this was a trial 20 years ago, but it was one of the few trials that looked at not can we do it in the field. We know we can. In fact, our EMS colleagues are really good at intubation in the field. They hit the mark about 95% of the time on either the first or the second try. Can we do it? It's really not the question. The question is, ought we do it? And in this San Diego trial designed to look at TBI, what they showed was it added on average six and a half minutes of scene time. And there was also inadvertent hyperventilation, episodes of hypoxemia and hypotension, all of which were bad for TBI. And they discontinued that trial early until they could look for causes. And how this is pertinent to truncal hemorrhages, that's six and a half minutes. And six and a half minutes is pretty generous. Our experience is that it's quite a bit more time than that. And do you want to burn six and a half, eight, 10 minutes doing an RSI when you're on a 35 minute countdown to a death from truncal hemorrhage? So the next question here is mode of transport and destination. So remember, you've got a level three center five minutes away. You've got a level one center about 70 miles away. And the question is, do you go by ground to the level one? Do you go to the level three? Do you call a helicopter to the scene? And what's the destination there? Or do you try to get this patient to the level one and rendezvous with the helicopter coming from the level one that carries whole blood and plasma on the helicopter? So those are the choices. There's no clear right answer here. And we're trying to take a look at what everybody answers. You know, 68% said answer E. So the landing zone with rendezvous. The next most frequent choice was ground to level three. And all of the others had some sentiment for doing so. So let's talk about that for a second. So when you compare helicopter versus ground scene transport, there are a lot of considerations other than just speed. Part of it is the added expertise from the flight nurses and whether or not their resources might be better than the resources on the ground. So, for example, a lot of helicopters are carrying TXA, whole blood, liquid plasma. And so that capability, the added experience for intubation by the flight nurses, although, as I said, our EMS folks are really good at intubation in the field. And then comparing the helicopter, there have been some studies that look at how fast the helicopter is going to the scene versus ground. And basically, when there's more than 10 miles or more than 30 minutes to the destination, some of the studies have actually shown that the helicopter might be faster. But I think there's clearly some choices here. It depends on the capabilities of the rural level three. What do you have there? And whether or not you think you can get to definitive hemorrhage control by going to the level three or versus a little bit longer transport time with a rendezvous to try to get to the level one. But what really gets you to the OR quicker? And what resources do you have to apply to the principles of management in this case? I don't know, Chris, you have some comments on this? Yeah, it does depend on kind of the area and location that you're from. Some institutions, especially ACS centers, don't have the availability of any kind of flights coming in and out. Some of my questions, especially with the availability of Roboa, is in regards to how do we assess our patients, whether it's in regards to a FAST or CAT scan with abdominal injuries? Classically, we're trying to evaluate the FAST to see if there's any potential for that patient to be expedited straight to the operating room. But there might be some missed injuries. So what would be your feedback as to how do we assess appropriately for that truncal hemorrhage? And what is the next step for our patients? Yeah, so that's great. In Colorado, we have two of our, actually three of our rural centers, rural level threes, have Roboa right now. And they're primarily being used for major pelvic fracture hemorrhage because our time for inflation of the Roboa in zone three is quite a bit longer than it is in zone one. We haven't really transported anybody with an inflated zone one. With regard to CAT scan versus FAST, I think it has to do with the instability of the patient. You know, death begins in CAT scan, but there are some papers out there that we're going to talk about here in just a few minutes that look at whether or not a marginally stable patient is better going to CT scan or better just FAST and then OR. Let's come back to that one. Sounds great. So, also on the helicopter that was coming to rendezvous from the level one center was whole blood. And there's been a lot written about whole blood resuscitation. There's a lot of sentiment around the country right now that that is superior. Here's the difference in components where you've got one to one to one on the right side versus whole blood on the left. In every category, you get more of what you're looking for. And really, you're trying to reconstruct whole blood with component therapy. So, a lot of us around the country these days feel like the whole blood is better for resuscitation if you can actually get it. And here's one paper that shows emergency use of low titer O whole blood is superior in terms of outcome. And this is from 2020 in the Journal of Trauma. So, question three, you're going to transport this patient. What's your target for blood pressure? All you have is normal saline. And so the question is, what's the target blood pressure for normal saline administration in this patient? Do you do full resuscitation in the scene? Do you do an intermediate level with permissive hypotension in the 85 range? Or do you let them drop all the way down into the 60s and just give them as little fluid as possible? So, we're opening that poll. We'll see what people say. So, the majority are saying blood pressure 85 target. Small numbers say let it go all the way to 60. You know what, that might be what you would do in the military. A lot of times in the military, they're given tiny boluses of crystalloid or colloid at the scene. And just putting a finger on the radio pulse or watching meditation. And for those young military guys, a target blood pressure in the 60 or 70 range may be okay. I don't think that's okay for the general population. There's also sentiment to raise the blood pressure to 120, particularly if you think you've got a brain injury, then permissive hypotension may not come into play. Let's talk about the literature associated with that. So, crystalloid resuscitation is now on the outs. And we're trying to limit crystalloid as much as we can. Here are all of the bad things that crystalloid does. Everybody knows about the triad of death, right? The coagulopathy, acidosis, and hypothermia. And normal saline does everything bad for that triad of death. So essentially, you're giving people cold acid when you're trying to resuscitate them with crystalloid. The permissive hypotension question, this actually came up in 1994. And the folks in Houston did recognize that patients were doing worse if they got full resuscitation in the field with penetrating truncal trauma. And they postulated that they might be popping the clot by blowing the blood pressure back up to 120. You bleed down to 60 or so. And you may slow the bleeding enough to form a clot. But if you blow it back up to 120, you pop that clot. And they also thought that you were running more blood in and then just bleeding it back out, causing the need for a lot more replacement. So that was their hypothesis on this. And when they looked at the results of this study, what they showed, the people that got resuscitated to a normal blood pressure back in the field actually had a worse mortality and a worse morbidity than those that got delayed resuscitation. Now, when you go back and look at the original data from that study, the delayed resuscitation group only got about 375 cc's of crystalloid, whereas the standard resuscitation group got 2,500 cc's. And at that time, a resuscitation strategy for major trauma was to blow in crystalloid and then start blood after two liters. Or if crystalloid was all you had, you kept blowing in crystalloid until you can get to some place that actually had blood. And I think part of the thing that drove the outcome here for those patients that did worse with full resuscitation had to do with the volume of crystalloid. We would never recommend giving high volume crystalloid anymore. And I think they were so anchored on crystalloid resuscitation that they didn't realize that that was probably one of the major drivers of this. The next question is, what would you do with TXA in this case? So would you give one gram, bolus, and a drip over eight hours, or just the gram? No TXA, wait till you get to the trauma center? Or would you give two grams of TXA? So we'll see what people think about that. Okay, so we have kind of a scattered gram, although a narrow majority said one gram followed by another gram over eight hours, which is really the standard. A lot of EMS agencies aren't carrying TXA, so you don't have that ability, so the answer may be none. A lot of EMS agencies don't want to mess with the drip and just give the gram up front. And there are a few centers around the country right now that are giving two grams. So let's look at the literature associated with that. So when you talk about trauma coagulopathy, we know that there is a consumption and dilutional component, shock and inflammation, acidosis, hypothermia, all play into that. But we also know that there, we talk about the endotheliopathy of trauma. And we know there's an endothelial mediated hyperfibrinolysis that can occur. And it's seen in about one third of major hypotensive trauma patients. And it results in about a 60% mortality because you can't stop the bleeding, because people dissolve clot as soon as they make it. TXA reverses this. There's also another phenotype that people talk about. You know, we have the spectrum of thrombosis and thrombolysis. Every biologic system is a self-regulatory system. So whenever we start making clot, we try to resist that by dissolving clot. And you can have dysregulation at either end of the spectrum. And there's a smaller number of patients that will develop fibrinolytic shutdown rather than hyperfibrolysis. That small group of patients results in microvascular thrombosis and has a higher mortality as well, but that's a lower percentage of patients. TXA could potentially exacerbate this, but like I said, you have to play the percentages, and the majority of patients are going to have hyperfibrolysis. So if you really don't know, you may want to go ahead and give the TXA at the start of a massive transfusion. And here's thromboelastography. Now, what you're seeing here, the left side of this, the SP is the fibrin burst, it's the time to development of the clot. The angle that you see the alpha angle going up there is the time to maximum clot amplitude. And then you see a clot that forms that's pretty strong. And then as you play that out to the right, the clot strength begins to go back down to zero. And that's hyperfibrinolysis. And that's what it looks like on the thromboelastogram. You should make a clot and keep it. TXA is what reverses this hyperfibrolysis. So the molecule is a lysine derivative. It does not promote thrombus formation. But what it does is it inhibits both normal and over-exuberant thrombolysis. And it's a competitive inhibition of the conversion of plasminogen to plasmin. It's very powerful. Amicar was the one we used before, that had been around for 50 years used to cardiac surgery to slow bleeding. But this is eight times more powerful in that term, has a very high safety profile, there are a few potential complications, but not many. There's some, you know, there's, there's some systemic symptoms, nausea, vomiting, there's, there's the potential to aggravate seizures, because it may lower the seizure threshold. But that's a tiny number of patients. And so the TXA dosing, generally is recommended, one gram over 10 minutes followed by an eight hour drip, that was the majority of the answers. The pediatric dosing is here. And this all came from the CRASH-2 trial, which was published in 2010, randomized trial, 270 hospitals in 40 countries, with 20,000 patients who were either bleeding, or clinically judged to be at risk, and the primary mortality was outcome. All cause mortality in that that study was 16%, compared to 14% in the TXA group. And the vascular occlusion events in that study showed no difference between the TXA group, and the non-TXA group, the maximum benefit in survival was seen at one hour, if you got beyond three hours, there was actually an increase in mortality. And that was not explained by thrombosis events. So it was a little unclear why the added mortality, but it occurred if it was given after three hours. Now that the study had a lot of weaknesses in it. And when you look at that study, the number needed to treat which which we think generally is an important number was 65 patients to see the benefit of the effect. Now the MATTERS trial from the military was a different study, those were patients actually bleeding and receiving blood. And that was in Afghanistan, the primary outcome again was mortality. And the massive transfusion group again was defined as 10 units within 24 hours. So the unadjusted mortality in that study was quite a bit different, improved by TXA. The MTP group with TXA even had a higher benefit, it reduced the mortality by half in the MTP group. There was in fact, a higher rate of thrombotic events in the TXA group, but the number needed to treat to show mortality benefit was only seven in that study. So clear benefits showed in that study. So the use of TXA in the military, the TCCC has come out with recommendations, and their recommendations are two grams slow IV push or IO of TXA, and also to give it for severe TBI, that's the crash three trial, I won't get into that. But and then the civilian pediatric dosing. So those are the recommendations from the TCCC. So any of those answers would essentially have been correct. So this clinical course patient had masco to their small saline boluses to a target blood pressure of 85. They decided to transport to the landing zone with rendezvous to the helicopter carrying whole blood and plasma destination was another 20 minutes away by air to the level one, whole blood was administered with the missive hypotensive target, and the gram of TXA was given. On activation at the level one center, they went directly to the OR. That center has a direct to our resuscitation room. And the blood pressure on arrival was 120 with a pulse was 120 with a blood pressure of 90 over 60. Lactate was four, there was no hyperfibrinolysis on thrombo elastography. But remember, they'd already gotten TXA. No external hemorrhage. RSI was performed by anesthesia. They did a femoral a line for possible revo a placement, but none was needed. They had a positive fast scan for small to moderate hemoperitoneum. Chest x ray showed no blood in the chest, pelvis didn't have a practice fracture pattern, fast was negative. And there was no external hemorrhage. So the question is, what are the next step? And this, this goes to Chris's question a few minutes ago, would you go to laparotomy? Would you do a damage control laparotomy? Would you would you do a CT scan? Would you do a zone one revo a and then laparotomy? Or would you do a trauma CT scan to incorporate CT angio in the neck and brain, which is which some of our centers are doing? So those are the questions. We'll see what everybody says. So the majority of people. Well, first of all, there was no 50% majority answer. The damage control laparotomy was for was first with a smattering of the others. So let's talk about Chris, that goes to your question. What do you think? You know, I think for this patient, I would want to do the damage control laparotomy. And you know what, I think that would be that would be the standard answer. And that's what most people did. So let's let's talk about that for. So in the last in the last few years, there have been a couple of papers, one, one by john Holcomb, one by gene Moore, that looked at and Holcomb had a whole bunch of other well known authors, Eileen Bulger, and Marty Shriver, who's our TCA board chair, that was, you know, part of the prompt group. And what they looked at was what what happens to patients who may have been a little hypotensive, but stabilized to some extent, and were projected to remain stable. And the answer was you had a fair percentage of the time you're able to avoid laparotomy by doing that. So there is a consideration to go to CT scan, but I think it takes a lot of judgment, a lot of experience to do that. And you really have to design it for the patient that's in front of you. So what are the predictors of instability in that situation? And of course, if you have a large hemoperitoneum, that's somebody who may become unstable. If you've got a short time from injury to evaluation, they're on a trajectory to crash and death begins in CT scan. So you probably don't want them there. If the presenting hematocrit is less than 30, increasing tachycardia, large or arterial extravasation of solid organs on CT scan, or if an experienced physician has a really bad feeling about it, all of those, you kind of have to trust your gut instinct. And all of those would lead you to go to laparotomy rather than go to CT scan, but certainly there is a place for CT scan. So the CT findings on this patient. Now, this center has chosen to incorporate CT angio of the neck and brain to look for blunt carotid vertebral injury whenever they do a pan scan. And that's, that's something we'll discuss a little bit later. But what was found here was a grade four spleen with extravasation, liver and kidney injuries, hemoperitoneum, there was a grade four meaning total occlusion of the right carotid. Blood pressure remained in the 90s, heart rate was 115, with small volume blood administration. In this center, the trauma resuscitation area has a large trauma OR, it is adjacent to three other rooms, a full on biplane angio room, a hybrid vascular room, and a 64 slice CT scan, all of them in very close proximity, and all of them with a large enough room for the resuscitation team to go. So in this, this case, here's the findings. So you had a relatively large liver injury, you see the spleen cracked in that one view, but then you see a lot of blood around the spleen with areas of extravasation in this view. And then you see here, the, the grade three, the grade three kidney injury on the left, but appearing to be contained with injury of the fascia. Here's the carotid scan. And what you see there, the red arrow is the proximal internal carotid artery. And you see that it's, it's widely patent. And then you and then you see it disappear as you go farther up into the into the skull base. So what you have there is a total occlusion from a carotid dissection. So the management here was they decided to go to angio, which was right there, the team goes with them, they've got the femoral A-line deployed just in case they need to go zone one or BOA. And, and so you've got so they do main splenic artery gel foam embolization, they did a liver angio, which really didn't show active extravasation. And they decided because the kidney was contained in Gerotis fascia, that no further treatment was needed in that. So they went to, to the ICU, permissive hypotension targets were relaxed, they continued blood resuscitation to the TQIP MTP termination guidelines, which include hemoglobin 10, normalized lactate. And then the question is, what do you do for the BCI, BCVI injury, and they plan to start anticoagulation when the hemoglobin stabilized. So next question, you've got a grade four total occlusion. Do you start aspirin, aspirin plus Plavix? Do you start heparin? Do you and when do you start heparin? Or do you do a catheter based thrombolysis and try to get that that artery open? So those are the choices. Here we go. All right, again, a whole bunch of different answers. The the most common answer was only 37%. And that was to start therapeutic heparin within 24 hours, if the hemoglobin stabilized. Now I'm going to talk about the literature supporting doing that. 81 milligram aspirin was high on the list. There was some consideration for catheter based thrombolysis. And so let's talk about that a little bit. So so here is a paper. Again, this is, this was in the Journal of Trauma just recently, and it was talking about universal screening for blunt cerebral vascular injury. Now, Gene Moore wrote a paper along with Walt Biffle many years ago, that talked about blunt carotid vertebral injury as being the unrecognized epidemic, and we thought it represented about one 10th of 1% of all major trauma. And as the screening criteria evolved, we became more and more liberal with the use of CT angio. And the question was, should it have been a catheter based angio? Or should it have been, should it be CTA to diagnosis? Or should it be MRA? And we've kind of settled on a 64 slice or better scanner, CTA as being the diagnostic procedure choice for this. And then the question is, what subsets of patients should have screening for BCBI. And we started out with the Denver criteria, then we had the modified Denver criteria, we had the Memphis criteria, there was a paper written entitled, what are we willing to miss. And we have continued to expand the indications for doing screening for blunt carotid vertebral injury, we've added mandible fracture to that group, any mechanism that really produces a torquing of the neck. Now, we see a few of these injuries simply from chiropractic manipulation. And we see, you know, a couple of those a year. And and so it doesn't take a lot of trauma to cause an injury to the intimal lining of the carotid vertebral arteries. So this paper looked at adding that to the to the screen to any patient who was getting a pan scan. And so Maryland shock trauma, we do that in my institutions. And we've identified quite a bit more the paper by Dr. Holcomb and his group at the University of Alabama showed a seven or 8% incidence of BCBI whereas previously, we thought it was only about 3%. So Dr. Scalia's group out of shock trauma in 2015, did a subset analysis of their grade four carotid injury. And what they showed was about a 50% stroke rate, as compared to the 20 or 30% stroke rate of other grades of injury. And so they're so they felt like the risk benefit weighs in favor of reducing stroke risk, you really can't fix the stroke. If you early anticoagulate and get spleen bleeding, you can take the spleen out. Now we've had some recent recent cases at one of our level one trauma centers that also showed a very high stroke rate associated with grade four vertebral injuries. Those are harder to diagnose, but can also be quite debilitating for posterior circulation stroke. So what we've begun to do is early anticoagulation in that first 24 hours if we can, you know, the Western Trauma Association did a time to stroke study. And in that study, more than half of those strokes occurred in the first 72 hours. And a number of them occurred on the way into the hospital. Interestingly, in that study, there were 16 centers and 14 different treatment algorithms. And Memphis did a study a few years ago that looked at what was the stroke rate for carotid and vertebral injuries. They showed about a 20% stroke rate for vertebral about 30% carotid. And they identified an improvement in the risk all the way down to about 4% if treated by any mechanism. So there's been a there's been no consensus across the country for how do you treat that. But I think a lot of us are becoming more aggressive with the grade four injuries, starting early full anticoagulation. That was reflected in your answers and also in what we're doing in a lot of our centers in my system. Chris comments. I actually think that's that's a great approach. We're a little delayed sometimes on starting that anticoagulation. We don't see a lot of strokes happening, but the potential to occur is higher, you could always go back in and do angioembolization for any kind of additional injuries that you see. But great point, you can't go back and fix a stroke. All right, so here's the course, hemodynamics, crit stabilized lactate normal neuro heparin protocol, and the neuro heparin protocol that we use is one that doesn't use an upfront bolus, but has full dose heparin, and very carefully monitors the anti-10A and really does pretty well. We've seen few bleeding complications. However, this patient 24 hours later, hematuria increases, hemoglobin drops, CT shows a kidney injury that required renal angioembolization. And they did a coil embolization of a segmental vessel, got the bleeding stopped. The patient stabilized and heparin was restarted. The patient ends up doing well, she had asymptomatic small emboli with tiny cerebral lymph arcs that did not really produce any functional defects. So that was the course of that patient. So now let's take a step back, because every decision we make is based on experience. It's based on how the patient looks at the scene. It's based on detailed knowledge of your system. What do you have at the level three? What do you have at the level one? What's the actual speed to be able to get there? There are many, many decision points. This patient could easily have gone to the level three center by ground. So let's take a look at what that course might have looked like using the same patient information that we had. And so we'll go from there. So again, high speed MDC, here were the vital signs at the scene. And now the decision is made to go to the level three center. So the patient arrives at the level three center. It would have been a trauma team activation. The surgeon response time is 30 minutes. The OR and anesthesia response time for a level three is 30 minutes. This patient had gotten fentanyl, arrives with a heart rate of 122, heart rate of 80 over 60. Still with the mask O2, lactate was up to four. OR and anesthesia was notified and they were still 25 minutes away. There was no thromboelastography, no interventional radiology and no roboa available at this facility. So on hemorrhage evaluation, there was no external hemorrhage, the airway's intact, breast sounds are equal. RSI was performed by the ED, dropped the blood pressure a little bit, increased the heart rate a little bit. FAST was positives for small to moderate hemoperitoneum. And again, the other compartments where you can bleed to death were negative. So patient comes in, you evaluate the five compartments where you can bleed to death, chest, abdomen, pelvis, proximal, long bones are the first four. The one that is often overlooked is the floor. The floor is a very large component. You can put a lot of blood on the floor. And we used to sit there and watch a liter of blood hose out of the scalp while we were dealing with airway first. That's why most of us have put hemorrhage control on par with airway. And if you've got enough personnel to manage things simultaneously, that's clearly the best option. But what you have here is you've got, your truncal hemorrhage is coming from the abdomen and not from other sources. So the next question is, surgeon arrives, the OR is still 10 minutes away. MTP is started based on the ABC score. That's what TQEP recommends. All of you recall the ABC score for initiation of massive transfusion being blood pressure less than 90, heart rate greater than 120, positive fast or penetrating mechanism. So this patient had two of the four, which gets you an initiation of MTP if you believe you have truncal hemorrhage, which you believed you had here. So MTP started. I would always give a gram of TXA at the initiation of MTP, unless you're one of the centers that gives two grams. This center used FFP, not liquid plasma. It can be up to 40 minute thaw time. So you start PAC cells for the massive transfusion. You start whatever components you have and try to duplicate the one to one to one that you get with whole blood. But here we had PAC cells and that was started. FFP was still about 25 minutes to thaw. No platelets are available. So you give a gram of TXA at the initiation of blood resuscitation. And the question is, what next? So would you call the helicopter and try to transport? Would you go to the OR or would you go to CT scan? And the other thing I would say about CT scan, most of our rural scanners, we don't have the protocol loaded on that to do the CT angio at the same time. You can do the trauma pan scan. You can do the non-contrasted head and cervical spine. And then you can do the CT angio of the neck and brain and then very quickly scan for the venous phase, chest, abdomen, pelvis, that would be part of the normal pan scan. So a lot of centers can do the CTA protocol as part of the pan scan, but it requires some experience and really careful timing. And a lot of the CT techs in the rural hospitals just don't have enough experience to do that very well. All right, so the answer to this poll, again, this time it was go to the OR for a damage control apparatumy. The second most common answer was helicopter to a level one. And then the third most common was CT scan. So they went to the OR here, and I think that's probably the best thing to do. The reason to evaluate whether they might remain stable and get them to CT scan is so that you can do angioembolization and avoid the laparotomy. But here you've got a patient that is bleeding, positive FAST scan. And I think this patient, I agree that this patient probably needs to go to the OR. So here were the findings that we already know were present. And so this was the operating room findings. We had a grade four spleen with bleeding. The grade three liver was bleeding. It just wasn't arterial bleeding. The kidney was contained in Gerotis fashion and did not expand. You still had hemoperitoneum. Blood pressure was fairly soft with tachycardia, and you had active blood administration going on and a lactate of four. So the next question was, you're in the operating room in a level three with that situation, what are you gonna do for a procedure? So here are your choices. The splenectomy versus splenoraphy question always comes up. And then if you've done the splenectomy, do you just keep that patient at the level three or do you send them on to a level one? Anyway, so here are your three choices. Chris, this goes back to your thoughts about this. What do you think? Right answer, splenectomy, splenoraphy, transfer to level one? This is a very difficult question. I would probably go with the splenectomy and then treating them at their center, maybe keeping them there, stabilize them because taking them depending on the duration of time to get to that nearest level one and go straight to DOR, you could have a lot of complications inter-interfacility transfer. Yeah. So anyway, so the majority answer here was splenectomy, pack the liver with Kaolin impregnated gauze, that's the quick clot that we've been using, and then leave the abdomen open and go ahead and transfer to level one. So damage control apparatumy, that's sort of the classic. Splenoraphy was a thing. And we started doing non-operative management of solid organ injury back in, oh gosh, in the 80s in Toronto is where this first started with children. And splenoraphy was a thing for a while. And if you've got a little crack in the spleen and no big deal, then I think it's okay. But if you've got multiple other injuries, I probably would not be doing a splenoraphy or trying to treat the liver without packing. And there's some sentiment that we've overused open abdomens in trauma. And so there's some sentiment that if you get in and the patient's relatively stable and you've got some minor things that you can repair, maybe you ought to repair them and close the abdomen. But a lot of level threes really don't have the depth of personnel to keep a sick patient in the ICU, particularly with the attendant potential complications of somebody who's been in shock. So I think most level threes would want to transfer this at some point, although there are a few level threes that have advanced capability that might decide even to keep an open abdomen. So it's not the easiest question. I think my first choice would have been like most of you, C, do the damage control laparotomy. So let's talk about the key elements of damage control resuscitation. When hemorrhage cannot be controlled rapidly, then you do temporary measures. Now you've already compressed compressible hemorrhage. You've got external hemorrhage, you're gonna compress that. Then you look for the four compartments where you can bleed to death, chest, abdomen, pelvis, proximal long bones. So you want to institute temporizing measures. So things like tourniquet, things like pelvic binder. And then you exercise damage control resuscitation and permissive hypotension, limit crystalloid, trigger initiated MTP, TXA. We've talked about that. The next step in damage control resuscitation is a damage control laparotomy. And you can apply those principles to the abdomen, to the chest, to vascular. We do temporary vascular shunts sometimes. You can do temporary hemorrhage control in the chest, pack it open and send them on to a level one. So there are a lot of instances where you would use that outside the abdomen. But in this case, you're talking about a damage control surgery for the abdomen. And that is to do those procedures that are necessary and quick, but don't dink around in the OR with somebody in shock. So primary hemorrhage control. So pack the liver, take out the spleen and delay definitive operation to another time when the patient's been completely stabilized. And then contamination control. You know, you've got bowel injury. You may reset segments of the bowel, leave them in discontinuity, stapled off. You certainly don't want to try to sew bowel back together in the patient in shock. That's guaranteed to fall apart. So, and again, those are judgment calls. What's the degree of shock? What's the lactate? Is the patient having, did somebody start the patient on pressers? So there are a lot of considerations in that. But in general, you don't want to try to put things back together. You want to prevent abdominal compartment syndrome. So you leave it open and you go back to the ICU. You warm and resuscitate, restore survivable physiology. And we know that staged multiple procedures in these cases are probably safer. Now, in fairness, we probably use open abdomen procedures more in acute care surgery in septic patients for source control. But we still use it occasionally in these kinds of patients. And certainly if you're in the level three center in contemplating transport. So in summary here, there are always choices and consequences in these complicated situations. Now, in this case, the patient went to the level one that that patient could have crashed and died in route. But it allowed them to do a more advanced level of damage control resuscitation with whole blood and lipid plasma. In this case, angioembolization avoided the laparotomy. It allowed for early diagnosis and treatment of the carotid injury. But the consequences of that were kidney bleeding, which required intervention. The ground to level three, the downside is limited blood plasma, no platelets, no IR, no CT angio available. It required a laparotomy and then an additional transport. On the other hand, this patient didn't bleed to death and there are certainly advantages of more rapid hemorrhage control achieved in this situation. So I think the bottom line is most of these questions had no clear, correct answers. And it takes experienced personnel. It takes folks who really could take a look at a complicated situation, who know the literature, who know the pathophysiology and try to make the right decisions in a very short timeframe. And part of our ability to do that comes from conferences like this and comes from a detailed quality review with a loop closure and refining your ability to make these kinds of decisions. So with that, I'll stop and entertain any comments or questions. Dr. Mains, thank you so much for that presentation. I wanna give you a virtual round of applause for that because that was amazing. Really triggers some thought in the inside as to how we care for patients depending on our geographic location and the areas of treatment. Coming from where I initially was in New York, every hospital is very close. So the duration of time and transport between the scene and even hospital to hospital is very short. But I just do have a question while we wait in the comments and chat section, if any others come in, in regards to fluid management, especially for pre-hospital education, what would you advise as a preferred fluid management for patients with those truncal injuries? I know we spoke a lot about normal saline, but between normal saline and LR, difference in pH and osmolality, what would you suggest that we educate our pre-hospital providers for that early fluid management along with that low maintenance of blood pressure? Great question. You know, all of the militaries around the world have a preferred list of fluid resuscitation. At the top of that list is whole blood. At the bottom of that list is LR. Nowhere on that list is normal saline. I was given a talk to rural EMS guys on a tiny little community in the mountains in Colorado, and I had an EMT basic in the audience. I was talking about normal saline being cold acid and talking about the pH of normal saline being 5.5 when you might not expect it otherwise to be that. And I had this EMT basic raise his hand and started explaining to me in great detail why the pH of normal saline was 5.5. Turns out his first job was a PhD in chemistry. And so you never know where you're gonna learn stuff. But, you know, there's a lot of sentiment that LR is buffered. It's not quite as bad. Plasma light is one of those things that's considered. Really, the optimal resuscitation is whole blood or however you can approximate that with component therapy. That actually takes me to the next question. With whole blood versus our one-to-one-to-one ratio, I know a lot of institutions are trying to transition to that whole blood, but could you give us some insight related to cost and half-life pertaining to whole blood? Well, whole blood's 21 days. And really not a ton different than PAX cells. And I think the whole blood ratio and I think there have been probably a dozen papers in the last two or three years showing benefit to whole blood resuscitation. So if you, but there's a limitation to being able to get it. We had to fight a lot of battles in my system to get it, but all of our level one and two trauma centers, our single really high volume level three have whole blood. All of our helicopters carry whole blood in addition, well, one unit in addition to liquid plasma. So you don't have to thaw it. And then a PAX cell unit to continue. So I think to the extent that you can, the cost is not terribly different. It's a little harder to get. A lot of centers are, I don't know of anybody whose wastage is really high. If they're high volume centers, then the wastage of whole blood is really not very high across these systems. So there are a lot of considerations with that. And certainly one-to-one-to-one is good. And if you don't have all of the components, then whatever you have. So if you've got blood, start blood. And we talk about massive transfusion, but really massive transfusion isn't massive. That implies you dump everything in all at once. But in these patients we're trying to resuscitate, you wanna use blood as your primary resuscitation fluid, either blood or components. And you wanna modulate that rate of administration to the end point you're trying to achieve, which in this case is permissive hypotension. And when I wouldn't do that would be brain or spinal cord injury. But I think it's really important that you understand modulating that rate of administration so that you're not over resuscitating on the other end. Understood. All right, let me just check the chat. Amber Sparks says, excellent presentation. Lisa Hines, excellent. Enjoyed this very much. Deborah Clark, very interesting and educational. Thank you. Cecilia Romero, excellent. Thoroughly enjoyed it in the interaction with the polls. Pam Cook, great information. Thank you so much. Wendy Wagner, mahalo for addressing both the level one and level three treatments and care for the same patient. Aloha. And Oresti Romero, thank you for reviewing supportive literature. Excellent presentation. So again, thank you, Dr. Mayne for your presentation today. It was excellent. All right. Well, thanks everybody. Enjoyed it. I hope we can do it again soon. Let me just see here. Any other questions? Do you have other indications for whole blood beyond trauma? Great question. There's indications for OB hemorrhage, for GI hemorrhage. You know, the literature has not quite caught up with those. The clear benefit I think is supported by the literature in trauma. I think the others will catch up because the pathophysiology principles are the same. Excellent. I think that's it for the questions, Dr. Mayne. Again, thank you again for your presentation. Very knowledgeable and influential on the matter and look forward to seeing you soon. All right, Chris, thank you. Thank you.

complex trauma

case study

trauma center

fentanyl

decision-making process

scene airway management

tranexamic acid

TXA

resuscitation fluid