All right, good morning, everybody. Thank you. There we go. My name is Sean Murley. I'm a trauma intensivist and emergency physician at Grandview Hospital in Southeast Pennsylvania. And I'm really excited for today's session, particularly because we're going to get to hear from a group of experts on crucial, controversial, and relevant topics in critical care. And our goal today really is to just provide you with updates in literature while giving you actual actionable takeaways to take home to make the right decisions for your patients. Now, before we begin, I'm actually very curious to know who our audience is today. So we're going to do a little morning poll, if you will. So raise your hand if you work in a medical or mixed med-surg unit. Okay, a good chunk of our group. How about a surgical or trauma ICU? Okay. Neuro-ICU, any pediatric ICU? Probably not, because this is an adult court. Oh, wow. Okay, very good. All right, here to learn some stuff outside of pediatrics. Great. Cardiovascular or cardiac ICU? Okay. Pharmacy department? Excellent. Nurses? No nurses? Oh, wait, there we go. Excellent. And respiratory therapists? Excellent. Did I miss any groups? Okay. So pretty diverse group, and that's really, honestly, for me, the best part of a conference like this. It's not exclusively geared to one profession, one department, or another. And we really get to have these interdisciplinary conversations to help take care of our patients. All right, here we go. So I'm eagerly awaiting my first financial disclosure, but the only thing I will disclose with regard to my presentation is that I've been on a bit of an artificial intelligence kick recently. Many of the images that I included in my presentation were created with an AI image generator, and it really was a lot of fun to create this presentation. If anybody's interested, I'm happy to talk to you about that, too. So what exactly is my role today? I'm here to be a guide for you through an entire day of learning. As I mentioned earlier, we have an incredible panel of speakers, and they'll be teaching us about a variety of topics. My goal is to link those lectures together with a shared common thread, specifically a patient case. Throughout the day, I'll also use some audience response questions to stimulate thought and hopefully set the stage for the upcoming lecture. Some of these questions will be answered by the lecturers themselves, while others can be found in the course textbook that you'll get to take home. And others are going to be just little topics that we'll learn along the way. Before we continue, let's take a minute to register for that poll. So what you'll do is take out your phone. You can either open up on the browser or on your text messaging service. In the browser, type in that top URL, and if you want to do this by text message, then send a text to 22333 with the text message saying Critical Care 1. No spaces. I don't know about the capitals or not, but you should get a response back if everything goes okay. Also, do you have something to help me go backwards? Any chance? No scroll wheel on here. And then go back. That might be, yeah. All right, so as of now, you probably will not see a question. You may see a question from when I was testing it yesterday, but you can ignore it for now. We're going to come back to it. All right, looks like there is a question that shows up. But we'll, for those of you who did it through the text message service, you probably won't see anything at all. So just sit tight. As I go through my presentation, we'll come across some of these questions. All right. So, we'll start off with the trauma case. And for those who aren't involved in trauma, I hope this is a nice glimpse into the really complex nature of trauma critical care and the multidisciplinary approach that it requires, particularly in the later stages of patient care. But we're going to have some really excellent speakers on trauma and resuscitation. So, I thought this would be a good way to frame that. Okay. So, the case. We have a 25-year-old male who's involved in a high-speed motorcycle accident. He was thrown about 30 feet from his vehicle into an alley. On arrival of an advanced life support EMS crew, they find the patient unconscious and with obvious deformities to his right forearm and left thigh. They also notice the smell of alcohol on his breath. After a quick evaluation with a primary survey, they place a cervical immobilization collar on him, transfer him to a long spinal immobilization board, and move him to the ambulance. They initiate transport to the hospital with lights and sirens. En route, the team initiates a crystalloid infusion, decompresses the left chest with a 14-gauge catheter for concern for tension pneumothorax, and immobilizes the wrap and wraps the forearm. So, this brings us to our very first audience participation question, which you should see on your browser, on your phone, and the answers are listed here as well. It's perhaps an infrequent occurrence in the critical care unit, but when you need to perform a needle decompression, the location is incredibly important for multiple reasons. So, to start us off, and hopefully this is an easy, low-ball question for most of us, and I will disclose, there are two correct answers here, okay? What is the optimal location for needle decompression of the chest? Posterior axillary, second or third, midclavicular, second or third, lateral clavicular, second or third, and anterior axillary line, fourth or fifth. Can we go back one? And let's see if this is going to work. So, for those of you who are on your browser, you should be able to see the results of it come back to you live. And then, let's see what happens if we move to the next slide, if maybe it refreshes, okay, negative. Can we right-click on that and see what happens? No. All right. Well, I guess only some of us get to see the results, but we'll definitely get to see the answers later on. What's going on? Let me see what it says. Thank you for mentioning that. Ty, any thoughts? So, did you, just curious, did you do it on, from the URL or from a text? So, I'm going to ask you to type in the text, and then I'm going to ask you to type in the URL. So, I'm going to ask you to type in the URL, and then I'm going to ask you to type in the text. So, I'm going to ask you to type in the text, or from a text. So, the URL actually shows you the right question. So, maybe we could just, if you could just show, are you able to show the slide again? Can we go back to that, please? Yeah. Thank you. Yeah, and this is probably the easiest way to do this as well, because the question shows up on your screen. You can do this from your computer, from your phone, from a tablet. And I'll say that if you do it on the URL, you can actually see live, like, what everyone, you know, what most of the group, how most of the group answers. So, in fact, we could just tell you what it is. Yeah, and actually, I'm going to, I want to save it because I do have a slide for the answers later. All right, so as, and we'll come back to the answers as we move along through the day. Everybody okay with this URL? Anybody still need it? Excellent. So, on arrival to the hospital, our patient is transferred to the ED stretcher, and the primary survey is started. We're going to hear about that pretty soon. The Advanced Trauma Life Support course, or ATLS, teaches us to systematically evaluate patient, trauma patients with an ABCDE paradigm, which we're all in critical care. We're very familiar with ABCDE and F, and I guess now there are some extra letters there. Although this paradigm is currently in the process of being changed, traditionally, it started with an evaluation of the airway. So, this patient is making gurgling and snoring sounds. The airway doc is concerned about the airway and prepares to intubate, as another team member prepares to place a left chest tube. His blood pressure remains low at 86 over 40, and his heart rate is 132. His GCS is now six, and his pupils are normal. The team cuts off all his clothes. He's quickly examined for any external hemorrhage. He has scattered abrasions, bruising on his chest and abdomen. He's log rolled and examined, and the team finds no abnormalities in his spine. The trauma team activates the massive transfusion protocol and starts by transfusing a unit of whole blood. While the blood is transfusing, the team performs simultaneous intubation and tube thoracostomy. He's placed on a ventilator, and the chest tube puts out about 600 mLs of blood immediately before slowing down. And this brings us to our second question of the day. I'm gonna go forward and go backwards for us. Go back one slide. Yep, perfect. Based on traditional criteria, what threshold of immediate chest tube output would warrant operative evaluation in this trauma patient? As with the previous question, the real answer to this question is in flux, and really depends on the patient's hemodynamics. Recent guidelines have called into question the traditional value, but I think it's important and a good value for us to be aware of. So I'm gonna give you guys a couple minutes to answer this question. It looks like it's updated on the platform. Few more seconds. What's that? Yeah. All right, we'll move on, and we'll come back to that. So a chest X-ray is performed that shows a well-placed endotracheal tube and a chest tube with good drainage of the hemothorax. A pelvis X-ray shows an open book pelvic fracture, and given his hypotension, the team puts on a pelvic binder for him. A FAST exam is positive concerning for intra-abdominal bleeding. Now one last question in this section before we move on. I'm gonna go forward and then backwards. Which of the following is not a component of the assessment of blood consumption score, the ABC score? This ABC score can be helpful with identifying patients, trauma patients in particular, who are at risk for needing activation of massive transfusion protocol, specifically in patients that have two or more of these. So I will wait about 10 more seconds. All right, let's keep moving. So the patient actually responds well to the unit of blood, and it allows the team a chance to go to the CT scanner and identify the patient's injuries. The team quickly reviews the images and finds the following injuries. Numerous rib fractures with associated pulmonary contusion, a sternal fracture, left-sided hemoneumothorax, four centimeter splenic laceration, multiple pelvic fractures, and a right psoas hematoma with active contrast extravasation. Orthopedic surgery and interventional radiology are immediately consulted to assist with the pelvic fractures and the psoas hematoma. And he's moved from the ER to the IR suite, undergoes angiography and embolization. And in the operating room, orthopedic surgery places on an external fixator for his pelvis. He's then brought to the ICU for continued resuscitation. And this leads us into our first lecture of the day with Dr. Julie Valenzuela.

Dr. Sean Murley

critical care

trauma cases

massive transfusion protocol

interventional radiology