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
- First listen to Richard Dutton on his vision of hypotensive resuscitation.
- Next, listen to one of the Crash2 authors, Tim Cook, to discuss the use of tranexamic acid in trauma.
To Close
Turf wars about who should lead trauma team are sign of immature trauma system (and immature specialty) IMHO @docib @DrRehn @Swisstrauma
— Karim Brohi (@karimbrohi) August 12, 2012
What do you think about ACLS and Traumatic Arrest? Comment below…
Additional New Information
More on EMCrit
EMCrit 323 – New Trauma Resus Insights with Prof. Karim Brohi(Opens in a new browser tab)
EMCrit 197 – The Logistics of the Administration of Massive Transfusion(Opens in a new browser tab)
EMCrit Podcast 36 – Traumatic Arrest(Opens in a new browser tab)
EMCrit 135 – Trauma Thoughts with John Hinds(Opens in a new browser tab)
Additional Resources
You Need an EMCrit Membership to see this content. Login here if you already have one.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
- EMCrit 385 – Eye Trauma I – Retrobulbar Hematoma, Orbital Compartment Syndrome, and Paracanthal Decompressions - October 5, 2024
- EMCrit Wee – Did this Really Just HAPPEN? – The HAPPEN Trial Hot Take – NIPPV for COPD - September 29, 2024
- EMCrit 384 – The Vascular Guy on Vascular Access - September 23, 2024
Scott
Another excellent podcast covering some of the major issues were faced with when dealing with the severe trauma patient.
Keep em coming!
Kane
thanks brother
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
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.
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… Read more »
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… Read more »
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… Read more »
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… Read more »
Thanks for the feedback.
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.
Prof Karim whispers and blurts out during talk making it difficult to follow ,I hope he maintains the tempo of talk next time.sound quality is also bad for such a great and important Topic