1. Great talk! Your site is an excellent resource!

    Any suggestions for community hospitals that doesn’t have such ready access to unthawed plasma? Should we empirically give PCC (in Canada we have the 4-factor version)? Our goal is obviously to stabilize the patient (as much as possible) and send them to a trauma centre. If we are using PCC in this setting instead of waiting for the FFP to thaw, is there any literature on how much to use or when to repeat the dose (i.e. after how much units of blood)? Or is this all uncharted territory?

    I appreciate your thoughts.

    • Yeah, evidence isn’t great, but I think after 4 units of blood, I would hit them with your PCC.

      you can check out:
      Critical Care 2009, 13:R191
      Eur J of Cardio Surgery 2001;19:219
      Eur J Anaes 2008;25:784
      British Journal of Anaesthesia 102(3):345-354

  2. This is a great lecture as usual.

    I listened to this lecture back-to-back with your reversing coumadin in head bleeds talk, and although it may pertain more to your prior lecture, I’m curious to know what you do when you send an anticoagulated patient with minor head trauma home. Do you have them hold (or reverse) their coumadin given the risk of delayed bleeds or just chance it?

    I’ve been intrigued by the idea of delayed imaging in these patients for a while. I tend to CT when they hit the door then observe for a few hours before d/c. I think my neurosurgeons might stroke out if I called them with a positive study that had been in the ER for 6+ hours. My rads would likewise bleed into their brain if they had to read a study at Tzero and T6hours. I’d like to hear what the community thinks?

    Anyways, sorry to hijack, but in regards to this lecture, I found it practice-changing, and legit speaker of the year material.


    • Yep, two cts are tough. I think the argument to make to the neurosurgeons is that in a pt with a perfect mental status, there is no way they would have rushed to intervention anyway.
      Obviously if your pretest is high, you need to get the zero hour ct, but unfortunately those are the pts most likely to have the delayed bleed.

    • At many centers on the west coast, including mine, it is the practice to obtain a delayed (4-6 hour) CT on minor head trauma patients on Coumadin with INRs >1.5. One trauma center in our town admits all for 24 hours. At my place, we keep them in the ED and repeat the CT. If they are supratherapeutic with INR > 3-4, those patients get admitted by the trauma service. Not alot of science behind this but it is a common practice in my community. We follow a similar pattern for patients on Plavix but are inconsistent with aspirn patients.

  3. Anthony,

    That’s good to know. I think that’s great patient care. that’s far from the current practice in my shop, unfortunately, but hopefully we can change some minds along the way.

  4. Scott,
    Really cool stuff. I’m a PA student interested in Emergency Medicine in Chicago and a vet of a couple of tours with the Army in some bad places. I like that your not afraid of bringing some of these products up for discussion. I’m trying to catch up with your podcasts and got to this one and wanted to write in.
    Some of the recent studies published in Military Medicine have talked about tourniquets and their incredibly safe use with even prolonged durations (check out the new SWAT-T tourniquet). They don’t use crystalloid over there, only colloids in the field. Topical hemostatic gauze like Quikclot has been shown many times over that it works amazingly well temporarily. And check out the MATTERs study on tranexamic acid.
    I know your all about getting the best upstairs medicine downstairs, and the stuff they have been using overseas is not the ideal products and interventions. BUT for rural/wilderness/field/prolonged extraction medicine, this stuff saves lives. Most of it makes it into my pack when I’m camping or hiking. Keep up the good work and I’ll keep listening.

    • Thanks for listening, Joe. As you continue through the podcasts, you will find much about MATTERs and the other things you have mentioned. Glad to have you on board.

  5. Like Joe, I just finished this while digging through the archives. Great lecture, really helps reinforce what I’m learning as a medic; less is more. However, I was intrigued by the role that calcium plays during fluid resus; any thoughts on a prehospital role for that? It’s not being discussed in any paramedic textbook or class that I’m aware of…


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