Podcast 95 – Thomas Scalea on Cutting-Edge ICP Management

Thomas Scalea is a legend! He is Physician-in-chief at the Shock Trauma Center in Balitmore. He started the EM program at Kings County in 1991. He is also an excellent doctor and a wonderful person. At the 2012 EMCrit Conference, he gave an amazing lecture on the cutting edge techniques they are using at Shock Trauma for intracranial pressure (ICP) management.

For the basics of ICP Management, check out this prior podcast.


Here is a pdf of Dr. Scalea’s Slideset

Audio-Only Version

Need just the mp3? Right-click here and choose save-as.

Now on to the podcast…

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  1. CAsey says

    Wow, what a great talk.

    Dr Scalea really makes the stats come to life with such great cases!

    This stuff really makes sense when I recall cases where the severely injured patients did not seem to follow the traditional “rules” of resuscitation.
    There is so much we do not know / are not aware of – trauma is a really complex disease, so many interplaying factors.

    Thanks for sharing this Scott – it is the sort of talk I think we will look back at in 10 years and say: “that is what Tom was saying back then…”

  2. says

    Hey Scott,

    My mind kind of asploded when I heard this talk. Fantastic stuff by Dr. Scalea!

    Maybe we should just randomize high ICP head injuries to a single incision from chin to umbilicus vs. none? Just put in the trach, crack the chest and do the laparotomy all at once.

    Thanks again,


  3. Mitch page says

    mind= blown This was arguably the best emcrit ever. It was phenomenal
    Dr.Scalea is one of the best lecturers I have ever heard!

  4. David Hersey says


    Very interesting. Next time I am in the ICU I am going to chat with our Neurosurgical Team about this.


  5. Andy M says

    Interesting stuff. Dr. Scalea must be general surgeon with trauma/critical care/EM training and/or background? Curious…

    Keep up the good work and the interesting cutting edge discussion/topics

  6. Mike T says

    Well, I guess I finally figured out what I want to be when I grow up. Thanks Scott! (and Dr. Scalea of course)

  7. Minh Le Cong says

    thanks Scott and Tom. intriguing stuff!

    Tom sort of mentioned it during his talk but no one else has commented so I will!

    What about DECRA trial and lack of proven benefit of decompressive craniectomy ?
    My only thougt is that perhaps craniectomy alone is like converting a closed tension pneumo into an open sucking one?
    My point is that anecdote is fine until you run a systematic trial that shows no benefit to theory. But must say Tom’s words make a lot of sense…;-)
    We should get him over for SMACC 2014..along with Dutton 😉

  8. Philip K says

    This is really cool! From a prehospital/critical care transport perspective, what are people’s thoughts on passing an NG/OG tube with gentle suction as a way to decrease intra-abdominal pressure in a patient with high ICP? What about an impedance threshold device?

    • Philip K says

      Edit: An ITD would reduce intra-thoracic pressure, not intra-abdominal pressure as the wording in my question implies. My bad.

    • xerxes1279 says

      I don’t think that prehospital it would make any difference. Increased intraabdominal pressure mostly comes from bowel edema in the setting of aggressive fluid resuscitation. I can’t imagine that gastric distension contributes too much. Maybe if the person had a small bowel obstruction and then was severely injured it might help. Otherwise, most patients will not spend enough time prehospital to be resuscitated to the point that their abdominal compartment pressures increase, and even if they did, a gastric tube is unlikely to do much.

  9. Clinton says

    Pretty incredible stuff, thanks so much Scott and Thomas… It’s amazing how appreciating the physiology can open up whole new avenues of therapy for some of our most difficult patients, and I look forward to seeing where this goes in the future. Keep up the great work!

  10. Michael says

    Phenomenal lecture. If I had a ridiculous amount of money I would put a good deal of it towards scouring the medical world for speakers like you and Dr. Scalea, and making a TED-like production out of your talks.

    (on a side note, I think the first eleven minutes of recording from the adjacent bathroom was to test our resolve and worthiness of the material to come)

  11. Adam O'Brien says

    Hi Scott – has Dr Scalea published on this topic? His talk was very emotive – I couldn’t help thinking about the demise of some young people I’ve cared for with head injuries.

    It was great to meet you at CF2013.


  12. Mike Jasumback says

    Ok, I am a bit late to the show on this, but……

    I got a bit of a tingle up my spine listening to Dr. Scalea talk about the work going into the brain trauma index. R. Adams Cowley did the same thing for general trauma/critical care when setting up ShockTrauma back in the day. Not sure if this falls under “all things old are new again” or “forget nt our history, lest we be doomed to repeat it”

    Great lecture either way


  1. […] Poly-compartment syndrome reflects the interplay between pressures in the intracranial, thoracic and abdominal compartments. Examples include increasing ventilator pressures to manage injured lungs which can increase intracranial pressure (negatively impacting on concurrent brain injury), and the relatively new technique of reducing intracranial pressure by opening the abdomen. (There is a great lecture by the pioneer of this technique, Thomas Scalea, over at EMCrit). […]

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