An Interview on Severe Trauma with Karim Brohi

Yearning for some trauma aren’t you?

Today I got a chance to interview Karim Brohi (@karimbrohi). He is a trauma and vascular surgeon in London and runs the incredible Trauma.org site. Dr. Brohi has consistently been on the cutting edge of hypotensive resuscitation, hemostatic resuscitation, and massive transfusion.

Dr. Brohi’s Lecture on Hypotensive Resuscitation

Dr. Brohi gave an amazing lecture on hypotensive resuscitation. I highly recommend giving it a viewing.

You can view the lecture here;

or on the trauma.org site.

Here are the questions that remained after watching that lecture:

What is the MAP goal you use for resuscitation of unstable hemorrhage patients?

What are you doing with your suspected intracranial bleed patients with concomitant hemorrhage on call today?

What do you think of Dutton’s idea of high flow, low pressure resuscitation using solely FFP/Blood as resus fluid and fentanyl to cause sympatholysis?

Traumatic Arrest

Is there any role for closed chest CPR in arrest from hemorrhage. If not, why is it so pervasive amongst EM and Gen Surg doctors? How do we abolish this practice?

Any role for drugs?

Do you bother with cross-clamping?

Check out this previous podcast on traumatic arrest.

Massive Transfusion

Are you using any of the scoring systems or instead, gestalt?

Are you using TXA? If so, when and in which pts?

When does TEG or ROTEM enter the picture?

Hypertonic saline?

Tell us a bit about Cryostat?

More Podcasts on the Above

To Close

Did you Like this Post? If so, then retweet it…

What do you think about ACLS and Traumatic Arrest? Comment below…

Now on to the Podcast:

You finished the 'cast,
Now get CME credit

Already an EMCrit CME Subscriber?
Click Here to Get CME Credit for the Episode


Not a subcriber yet? Why the heck not?
By subscribing, you can...

  • Get CME hours
  • Support the show
  • Write it off on your taxes or get reimbursed by your department

Sign Up Today!

.

Subscribe Now

If you enjoyed this post, you will almost certainly enjoy our others. Subscribe to our email list to keep informed on all of the ED Critical Care goodness.

This Post was by , MD, published 2 years ago. We never spam; we hate spammers! Spammers probably work for the Joint Commission.

Comments

  1. Kane Guthrie says:

    Scott

    Another excellent podcast covering some of the major issues were faced with when dealing with the severe trauma patient.

    Keep em coming!

    Kane

  2. Alan Vukusic says:

    Dr. Brohi. Excellent presentation of the topic. I work in British Columbia where the transport times are often significant (hours) to delivering definitive investigation of and control of active hemorrhage. Our rural sites transfer to two Tertiary/Level 2 Trauma centres from a wide geographic area.

    You suggest a MAP of 50-65mmHg in the order of 20-30 minutes and emphasis on emergent bleeding control. If the rural patient will wait hours for hemorrhage control, can you suggest a MAP target during transport?

    Thanks
    Alan Vukusic, CCFP(EM)
    Clinical Trauma Director
    Royal Inland Hospital
    Kamloops, BC

  3. Well….. what about prehospital treatment of traumatic cardiac arrest? Opening the chest is usually not an option…
    PHTLS says either call the code, or do external chest compressions.

    • I think prehospital compressions are fine if bilateral finger thoracostomies have already been tried and they are not delaying for one instant transport to a trauma center.

  4. Hi Karim & Scott,

    First off great podcast and discussion. Thanks for puuting a huge area into a clear and concise presentation. Great to hear that in all likelihood it is probably fair to manage penetrating and blunt haemorragic shock the same way in terms of fluids and targets.

    Karim, in your Trauma Masters presentation, you highlight evidence that shows the detrimental effect of both high volume crystalloid and possible pleiotropic effects of the crystalloid. I work at motorsports events where storing blood products (including albumen) is impractical, so not an option, and transport distances can be significant (similar issues to the state ambulance services). Some events are held around the corner from a major trauma centre, so you could argue to simply protect the airway, defer IV access and beetle over to the resus bay forthwith. For others, the transport time might be an hour or more and travelling without IV/IO access would make you nervy.

    Given the possible pleitropic concerns for crystalloids that you outlined in your presentation, while starches (esp >200kD) are looking a bit shaky in sepsis right now, is there any reason to think that limited volumes used in prehospital trauma resus might be an option? Or does it boil down to crystalloids may not be great, but while en route to definitive therapy, they are the best we’ve got right now so just don’t aim to normalise BP numbers?

    Secondly, near the end of your presentation you say prior to contolling the bleeding point permissive hypotension is the way to go, but once the bleeding is controlled go aggressive on the fluids to correct the markers of hypoperfusion (lactate, etc). Does this statement need to be qualified perhaps? By the time the bleeding source has been controlled, one would imagine there is already a degree of endothelial dysfunction established, so while the tap may be stopped, the inflamatory damage may already have started. Therefore the risk of capillary leak is still there and if you go nuts with the fluid you’ll still end up with morbidity probability. So perhaps the concept should be similar to the aim of EGDT (if not all the methods) in sepsis, that one would resuscitate to a target within a timeframe and then ease off. I don’t disagree with your statement and perhaps I’ve misinterpreted it, but I think it needs to be qualified a bit.

    Finally, can we access more of your trauma Masters talks somewhere? That one is great.

    Thanks again

  5. As always very provocative and enlightening interview. It seems there was a lot of emphasis on the limited role that closed chest compressions have in traumatic ( hemorraghic ) arrest. I was always under the assumption that the only situation in which a thoracotomy helps was for release of tamponade. Dr Brohi felt that your case of an exsanguination from neck bleed needed a thoracotomy. To be clear , is it felt that open chest massage is THE way to go for an empty hemorrhaged heart? If this is true, then shouldnt it follow for the medical patient who arrests from a massive GI bleed or RP bleed than they too should have their chests cracked?

  6. Scott and Karim,

    Just catching up on my EMCrit podcasts and wanted your opinion on the mixed head and abdominal trauma patient. Where I work I do both tertiary care emergency medicine and rotary wing transport. I recently had that was brought to a smaller ER approximately 1 hour flight from our centre. On arrival she had CT confirmed facial fractures, SAH, and likely DAI. She also had a positive abdominal FAST for free fluid. Her initial blood pressure was 60/40 when I arrived. En route back to our hospital we transfused her 4u pRBC but she still had a pressure of 60/40. My concern was if I leave her pressure at this level she will have had over an hour of poor cerebral perfusion and while she may survive the abdominal bleeding she would likely have a very poor neurologic outcome. However, if I were to add vasopressors to increase her MAP and improve her CPP I most likely would increase her intra-abdominal bleeding and possible exsanguination from that.

    I decided to continue the blood and used a nor-epinephrine infusion to increase her to a MAP of 60. Our receiving trauma surgeon was relatively critical of this decision, and I was curious as to your view.

    The patient ended up having her spleen embolized which stopped her bleeding but died two days later in the ICU as a result of her head injury. In this case it is likely that she would have had a poor outcome no matter what was decided, but I value your opinion on any possible future similar cases.

    • To my mind, you made a good decision in a circumstance without much evidence. MAP of 60 is very reasonable and is unlikely to pop the clot, while giving some degree of cerebral perfusion. of course we would do it differently if we had all the products at our disposal, but you don’t so i don’t think it is a bad call. i don’t think you made the spleen bleed more. what norepi can do however is decrease tissue perfusion and make coagulopathy worse. probably better to give some calcium next time and see if you can maintain bp. other option is some hypertonic saline.

  7. DocXology says:

    My take is that the majority of evidence for minimal fluid resuscitation occurs in trauma networks where transport times are relatively short. To try to extrapolate this to rural and remote situations would be dubious. It concerns me when we immediately try to generalise observations from a quaternary centre with a well organised retrieval system. We need more research.

Trackbacks

  1. […] EMCRIT Karim Brohi interview […]

  2. […] An Interview on Severe Trauma with Karim Brohi a true champion of the trauma, him and Scott discuss the in’s and out’s of traumatic arrest and massive transfusion, and where we are today with these concepts. […]

Speak Your Mind (Along with your name, job, and affiliation)