All right, good morning. Thanks for joining us this morning. My name is Julie Valenzuela. I'm a trauma surgeon currently at Ryder Trauma Center in Miami we're very busy and Probably see more operative trauma for a blunt and penetrating trauma at Miami We have a TICU a trauma ICU that's separate from our SICU. That's separate from our MICU my training again in Newark your proverbial gun and knife club, and then I did my Fellowship at Vanderbilt, which again is a high-volume trauma center With all of my training I very much took for granted what it takes to provide good quality Care and so all of the concepts I'm going to go over with you Seems to me like this is standard, but my first jobs coming out of fellowship were at a community hospital That was a brand new level two trauma center. And so some of these concepts were not in place My last job was a level one trauma center in Queens, New York We saw bad bad trauma is a lot of penetrating trauma, but it's not an academic center It's pretty low resource for where we were and our anesthesiologists were not critical care trained So we were having to do resuscitation from both sides of the drape So these are important concepts that to me I'm spoiled by because I'm in a very well-resourced Center But in reality, there's only a handful of level and trauma centers nationwide, right? Majority of people getting their care are at community hospitals So it's very important to understand some of these concepts and how to bring it forward to your institution No disclosures the objectives So why do we talk about this? Unfortunately trauma remains a leading cause of death, especially for the young worldwide and the leading cause of preventable death is Hemorrhagic shock now the leading cause of death is actually traumatic brain injuries But once the brain is injured, there's not much I can do about that, right? We're already in the mode of preventing secondary insults and secondary injury, but someone dying from exsanguination That's something we can hopefully do something about So when it comes to the initial evaluation management, this is all based on ATLS I do not have the time to go over the ATLS, but the main Principle is that you have a systematic approach and how you're going to examine this patient from top from head to toe And what are the main priorities you want to identify and treat immediate life-threatening conditions the main ones We really need to worry about airway making sure you got a secure airway tension pneumothorax cardiac tamponade hemorrhage Kind of simple but that's where your attention really needs to focus on and this is why it's important to focus on the adjuncts the adjuncts help you to triage quickly and And that you don't have a lot of time ideally, yes, maybe you can make it to CAT scan at some point But you've got your ultrasound to help you identify for triaging the cavities chest x-ray pelvic x-ray And when we say that we mean portable x-rays, right? Having a tourniquet pelvic binder wound packing plus minus rubo depending on how advanced your center is When you're seeing patients in my mind as a trauma surgeon whether I'm seeing patients in the trauma Bay Emergency room ICU because you never know at what stage you're getting those patients at I'm Constantly thinking of my mind immediately Does this patient need the OR IR or ongoing ICU care and to this point from a systems? standpoint wherever you are The trauma Bay and the ICU should be an extension of one another Remember resuscitation is a concept not a place So if you're in a mixed med-surg unit, and you don't typically just see I you know trauma patients And I would hope that kovat has taught us something make sure you've got scalpels chest tubes plurivax Ios Pelvic binder. These are equipment. That's essential a Belmont rapid infuser These are essential equipment that should not just exist in your trauma Bay or emergency room Make sure you have it available within your ICU because even if you don't know how to do it when you're calling the surgeon Don't expect them to have that equipment with him or her. I Think the main pitfalls I see in in mixed med-surg units and is Inadequate IV access okay, so this is very important when you're dealing with trauma patients, and this is part of the ATLS training also Not activating massive transfusion protocol quickly enough Not mobilizing your interventional radiologist or mobilizing your surgeon quickly enough, so you're dealing with bad hemorrhage You're dealing with you know doing all the resuscitative movements without again keeping in mind Where do you need your patient to be that means if you're starting blood transfusions? You better have in mind about who you're calling next to stop that hemorrhage So That early phase we are all focused on restoring that blood volume Optimized tissue perfusion correct the coagulopathy while we're managing the life and limb threatening injuries What is massive transfusion the first couple of definitions don't matter they're all for research purposes the one that's clinically meaningful If you're having if your patient is more than three units of blood in the first hour and still unstable Well, let's talk about how massive transfusion even came about we had a long understanding of the lethal triad and our initial thoughts and coagulopathy were Were due to our bad practice right we used to flood our patients with crystalloid So we thought we're popping the cloud we're making them cold and we're diluting the clouding factors now This all holds true, but in the early 90s We started having a better understanding of this massive cascade that gets set set off at the time At the time of injury so even before anyone gets a drop of crystalloid or anything There are certain subset of patients who have this acute coagulopathy of trauma and this has been independently associated with mortality and a prolonged ICU stay So in the early 90s as we're starting to have a better understanding of this acute coagulopathy of trauma Where our military is very busy and they start bringing back some information from abroad and they were doing two things Now the Navy was already very well-versed in doing damage control And I've done this training where you basically try to temporize your goal is not to do a definitive fix You got to temporize your ship get safely back to shore for the definitive fix So the military surgeons were doing the same thing. They were only doing the essential portions of the surgery So basically incomplete surgeries, but they're doing two important things stop the bleeding and get control of contamination I'll go over that a little bit later But the second thing they were doing was giving blood sooner and they were giving it a higher ratio So they came back from deployment and said, you know, we should start giving blood in one-to-one-to-one ratios It starts looking more like whole blood There was not a quick uptake. They said, you know what? That's our retrospective data There's survival bias and so nobody took it up readily This led to the first study the PROMED study. We were are looking at things Prospectively and people who are needing higher pretty large volume transfusions when they are given at higher ratios They did have higher better survival So then question became well, what's the right ratio? Is it one-to-one-to-one one-to-one-to-two? We still don't really know what that magical ratio number is however, those who got the higher ratio that balanced resuscitation one-to-one-to-one meaning RBCs plasma platelets they show that they were able to get hemostasis sooner So this became the critical studies that kind of forced us to create massive transfusion On doing it in a balanced way When we have patients and unfortunately in the United States We have a bad problem with gun violence and we have patients who need a lot of blood very quickly So the American College of Surgeons started developing what we call the massive transfusion protocol. This is a free guideline That's available to you off of our website And so it tells you on how to create a massive transfusion protocol and the key components of it and so the idea is that you want to get blood to your patient in a Systematic fashion where you don't have to keep asking for it It just keeps coming and that they're giving it to you in a balanced ratio already So you don't have to do the thinking this has been shown to improve mortality and also actually reduce wastage of blood products Now a very key important aspect of massive transfusion protocol and and this Probably MTP really didn't come about like when I was a med student it didn't exist probably really until like the 2000s and start taking an uptick and a key component is Understanding what the triggers are and every institution is different about what triggers you're going to use These are the most commonly used triggers. So if you have a patient who's hemodynamically unstable They've got obvious bleeding that hasn't been controlled yet by but needs surgery or embolization You're still needing to transfuse your patient and again as we've mentioned that ABC score this came out of Vanderbilt and if you have two or more of this it Likelihood is very high that you're going to need massive transfusion Other scoring systems the shock index has also Been well validated and very popular amongst EMS To let you know whether your patient's going to need massive transfusion also presence of pelvic fractures and long bone fractures There are other scoring systems, however, they're much more cumbersome These are really nice a ABC score and the shock index and using clinical parameters. These can be easily done at the bedside and And that doesn't take too much mental math and you don't need extra laboratory value So these are very nice to use now. The question is do we really need a scoring system? So they've looked at this and maybe it's not better than Gestalt like as Clinicians were pretty good when seeing someone's very unstable, but using the ABC score does allow us to activate MTP much sooner and why does that matter? Another study out of Vanderbilt showed that every delay every one minute delay in getting that transfusion started portends an increase of 5% mortality for your patient When It comes to damage control and and remember that you can give all the blood you want But unless you get some sort of control of the hemorrhage, it doesn't matter So you need to get your patient to the surgeon to the operating room or the IR suite? And there are two things that we're trying to do surge control or embolization sometimes both And then contamination control when we say contamination control surgeons. We don't want stool Gastric content suckers pouring into the abdomen. So we end up just stapling things off We just take sections of bowel out. And so you're going to hear this term leaving people in Discontinuity because we're not there to try to put people back together We're only dealing with the damaged parts getting rid of it over sewing it packing and that's it Who should get damage control surgery, so those are patients in physiologic distress They're acidotic. They're coagulopathic. They tend to have like significant polytraumatic injuries These are the ones that you're still doing MTP and I can't can't stop it and especially if you think your Operative time is going to be more than 90 minutes My target time is about an hour in my mind. And so if you're anesthesia critical care, I tell my Anesthesiologist tell me when I'm at 30 minutes that lets me know I have another 30 minutes to figure out how I'm going to get damage control surgery done So That means we're doing a lot of temporary closures and shunts So patients are going to come to you looking like this either where we just close skin We put bags over it or special dressings just to temporize and cover the bowels The top two pictures are vascular shunts again. There's no time for fancy repairs you just put a tube into the two ends and tie it off and Then You can leave any cavity open The bottom two pictures are ED thoracotomies where again We don't have time to do a formal closure and we use similar wound vac You know fancy dressings to keep it covered that top right? It's hard to tell but patients kind of laying sideways That's a clamshell thoracotomy and there's a plastic bag just covering the chest I've certainly done sternotomies and just left plastic coverage and and bringing them to the ICU I've also brought people to the ICU with a pelvic binder rubo in place waiting for waiting to get them to IR So you can get them at various stages looking at all sorts of complex anatomy coming at you All of this put together is What we now understand to be damage control resuscitation and surgery strategy Okay, so when it comes to damage control resuscitation, so if you're not a surgeon This is most of you are you know doing this damage control resuscitation really that balance ratio blood component That's your massive transfusion protocol, OK? So it's been widely adopted in all hospitals. Know it. Know your triggers. Know the name of your surgeon. Those two should go together. If you're activating MTP and know the triggers, then you should also have IR and the surgeon's name in your back pocket. You want to limit crystalloids. Studies have shown that even a liter of crystalloids increases your mortality significantly. And again, we talk about permissive hypotension. So when I know I have a trauma patient, especially penetrating injuries that's below the neck and I'm not worried about a traumatic brain injury, I will specifically ask my anesthesiologist, I want you to target a blood pressure more like 80s, maybe 70s, until I can get surgical control. So if you're on the trauma bay or if your patient's all of a sudden unstable in the ICU and you're waiting to get that patient mobilized to the operating room or IR, then as you're doing your MTP, you may want to slow the roll just a little bit to keep their pressure in a sweet spot. Because again, if you make it too high, you're only just exponentially making that hemorrhage worse. If there's concern or known traumatic brain injuries, we don't know the magical number of how hypotensive the brain can tolerate, but we most typically target about systolics of 90s to 100s. And again, we want to do a staged care. This is not the time for complete operations. We're only doing what's absolutely necessary, mostly to stop hemorrhage. Now the adjuncts I'm not going to go too much into because my colleagues got a fantastic talk about it. TXA is probably, it's been shown to improve mortality. And if you're going to give it, give it within three hours. The one thing I'll say is most massive transfusion protocols include TXA, but not everywhere. So again, it's very important for you to know your own institutional protocol so that you know if you have to order it on your own. When it comes to viscoelastic testing, TEG versus Rotem, there's some data to strongly support it, some maybe not that effective. The general consensus is if you have it, use it. And then anticoagulation reversal strategy. So obviously if someone's taking blood thinners, you want to try to reverse it, right? But the more important question is, can we use those certain agents even when patients aren't taking anticoagulants, right? So before we were hoping that factor seven was that holy grail, and that's kind of fallen out of favor. And now the same questions arise about the four, three and four factor PCCs, the pro-concentrates. And the recent study, the pro-coax study just came out within the last two years showing that it's not effective, but the question still remains. And there's still an actual ongoing study that's multi-institutional trial that's currently undergoing in the US looking at the same question and the use of four factor PCC in trauma patients who are receiving MTP. We used to say never use pressors in trauma patients, only blood products or crystalloids. And this has clearly also fallen out of favor. I think now we have a much better understanding of the complexity of vasoplegia and the host of factors that cause it. And so even if you might have adequately resuscitated the volume, they're still vasoplegic. And so now there's a definite understanding of push for judicious use of levophed and vasopressin and some trauma centers pushing the vasopressin within the trauma bay, like from the start of the trauma. So when this gets to the ICU, remember there are patients where if I've had multiple gunshot wounds, I don't have time to do a secondary. I barely get to do the primary. I'm just rushing to the operating room. There are patients that you might get that responded to resuscitation, were able to get a CAT scan, and then they bring them to the ICU, but then they maybe become unstable. You don't know at what point you're gonna get your patient. At any point, things can change. And so for trauma patients, things are very dynamic. So you have to do your primary survey from as soon as they arrive and reconfirm your primary and secondary survey. And remember, some of the patients didn't get a complete evaluation. Half my patients, like if we're running to the operating room or IR, there are multitude of injuries I completely understand that I probably missed and need to evaluate for once the patient's a little bit more stable. You have to have a general idea of get a good sense of where, you need to understand what their pre-ICU course was because when they arrive in your ICU, you need to have a sense of where they are physiologically and how long it's gonna take you to capture them. And most importantly, you gotta ask them, okay, did you activate MTP? Is it still active? When can you deactivate it? Or I've certainly had this happen where I thought I've done a stellar job in the operating room and I'm bringing them back and I've already deactivated it. But by the time they get to the ICU, they're all of a sudden unstable and having to reactivate MTP because we weren't quite caught up enough or maybe I missed something. So again, our main goal is to break that lethal triad. I think one of the things that when you don't deal with trauma patients day in and day out, people underestimate how important it is to warm your patient, okay? You have to get your patient warm. And so all efforts need to be made to try to remove any wet clothing and warm your fluids. Having a Belmont, again, these are things that typically, my experience in lower resource centers and where they don't do trauma day in and day out, this is often lacking and some don't understand the importance of this. So the end points of resuscitation. How do we know when we've paid off that oxygen debt? Well, sadly, despite all of our advancements in ICU care, we still use the same parameters, right? Blood pressure, heart rate, urine output. We have the maps, the CVP, using medical records, using mixed venous oxygen saturation. None of this has changed in many years. I think the biggest adjuncts that have been helpful now, maybe a fluid check, but really it's the ultrasound at the bedside to do real live serial assessments to see how fluid responsive someone is, how they're responding to your resuscitative efforts. And most importantly, if your patient remains in shock, it's a very good use to figure out, is it cardiogenic? Is there new fluid in the abdomen or the chest? And there's ongoing hemorrhage that you need to address. Then we know about the metabolic end points. So again, we know that lactate, if it's high, if you're starting with a high lactate, their mortality is high as well. Slow clearance of lactate, if it takes more than 24, 48 hours, that also portends poor outcomes. For me, for my very, very sick trauma patients, sometimes I will check the lactate every two hours to make sure I'm trending okay, and my resuscitation's on point. For most critical, not the most lethal critical, but critical patients, I'll check it about four to six hours. And again, if it's not trending in the right direction, I am very quick to go back to the bedside and figure out if we're missing something. And then of course, the hemostatic end points, and this is kind of like the new, it's not new, but now we say it's end points of trying to correct that coagulopathy. And again, remember, there's no single value. There's no holy grail. You gotta use all of these points, because the whole point is not only to pay the oxygen debt, right, but we wanna try to avoid over-resuscitation, and we're still not quite great at that. And so you gotta use all of these end points to try to help guide your resuscitative efforts. So once we restore the normal physiology, hopefully you're gonna be able to do that within the first 48 hours. This is a time we go back to complete our surgeries. This is a time when you can tell orthopedics and any other consultants, now it's okay for you to do more of a definitive fix. Otherwise, everything else is on hold. What are the pitfalls? The pitfalls are many. With massive resuscitation, we get massive electrolyte abnormalities, and that's something you wanna look out for and correct quickly, especially if you've got ongoing resuscitative efforts in your ICU. Again, the biggest problem for some of the really sick patients is a coagulopathy or it's a surgical bleeding, and sometimes I can't even tell, and sometimes you're stuck at the bedside and asking your surgeon, maybe you need to come to the bedside and even do a bedside laparotomy or evaluation to figure out if it's just coagulopathy or if they need an actual surgical hemorrhage control. And for the non-surgeons in the room, sometimes it's really hard to tell because I'll have left drains or the wound vac and it's just pouring out and it looks like you've missed something, but what we're talking about is when someone's profusely coagulopathic, all the surfaces are just oozing. What we're looking for is, is there a vessel that we didn't tie off? Is there a missed injury that we didn't address? And sometimes it's very difficult to tell. Do not be afraid to call your surgeon or IR back to say, hey, maybe you need to relook or re-angio to better evaluate. And then if your patient has ongoing shock, maybe it's not due to trauma or hemorrhagic shock, maybe they ingested toxins and we oftentimes put this way in the backbone of our minds and missed compartment syndrome. So especially with massive resuscitation, our patients are at increased risk for compartment syndrome, especially if they had a vascular injury, they're coming in with shunts and they didn't do a fasciotomy, you better make sure that you're constantly checking the compartments. When we leave those temporary abdominal dressings on, it does not, just because that fascia is open, it's still possible to get abdominal compartment syndrome because if you're still flooding your patients with products and their bowels swell, that dressing we put on may still not be lax enough to allow that bowel to breathe. So the late phase. So we've done a great job, we get through the first 48 hours and this is where I have to tell families, now comes the hard part. This is when we're dealing with multi-organ failure, ARDS, all the late complications that really I think most of you, again, have mastered, we're very good at this part. Our goal is to get the patient to this part so then we can deal with the late complications. I will say for the surgical patients and trauma patients, keep in mind that there's a host of other complications you need to try to keep in mind and that's your anastomotic leaks, intra-abdominal infections, surgical site infections. So anytime you're dealing with a surgical patient, really day five to seven, when they're starting to get septic, that should be top of your mind. And in fact, if they've received a lot of resuscitation, they're still in your ICU, expect that complication. I always tell families, we're on day five to seven, I'm expecting a complication. I'm expecting something bad to happen and it does happen typically. I will very briefly mention two patient populations. Elderly are flooding our ICUs, in the MICUs as well as our TICUs. I will say the main takeaway point and this I go over in my talk that's available online. The problem is that they're very fragile and they decompensate very quickly and they have a host of other medical problems that complicate your ability to manage these patients. So I would say the biggest takeaway is have a very low threshold to admit them into your ICU and keep them there. Okay, they may look okay initially, but if they decompensate on the floor, it's very hard to capture them. So most level one trauma centers have very, we have lowered the threshold for ICU admission for geriatric population. The other population is a pregnant patient, right? We all know all the physiologic changes that makes it difficult to airway, difficult to access, procedures are more difficult. But every time I give a talk on trauma and pregnancy, the one thing that I'm always surprised by is my main takeaway point is always, if you wanna save the fetus, you gotta save the mom. But everyone focuses on this, which I'm always surprised about is that ACOG, which is the OB-GYN Association, as well as every trauma association says, do not delay your CAT scan. I know we love our traumagrams, right? But if you were gonna scan your patient if they weren't pregnant, that's the same indication to scan your patient if they're also pregnant. The injury and the concerns of the radiation to the fetus, the risk is actually quite low if you look at the ACOG paper. And so the most important takeaway point that I've learned from giving the talk on trauma and pregnancy is do not delay the scan. If there's some, because again, if you wanna save that fetus, you have to save the mom. And there's some information that that CAT scan is gonna give you that you can't get otherwise. As far as new frontiers, what's old is new. We're gonna hear a whole lot about whole blood is coming back into favor. And now that we are much more liberal and doing damage control surgery and leaving abdomens open, DPR is coming back into favor. This was done long time ago. Now it's coming back and showing some physiologic benefits. And we'll probably hear more about that. And that's it. Thank you for your time. Thank you.

Dr. Julie Valenzuela

trauma care

trauma centers

massive transfusion protocol

damage control resuscitation

elderly trauma patients