We're going to be talking a little more about trauma at this point. Some of the things that we will be discussing are not necessarily things you can implement at your own institutions, because it kind of depends on what institution you're working in and what's kind of going on. But they are sort of best recommendations for all trauma patients in general and could potentially show up on certain exams. So what's new? I wouldn't say a lot of this is new, but it's certainly novel, newish. So most of you heard about eFAST already. If you don't know already, we are using less crystalloids in the trauma patients, balanced blood product use. There's a lot more damage control resuscitation for specific reasons. TAG, again, is being used over, and Rotem as well, over things such as INR and other kind of coags. Is it perfect? No. Is it better than the other ones? Yes. So it's definitely less bad. And TXA is a very controversial thing that, again, is going to be dependent on your institution, the resources, and the protocols that you guys have set up. So again, the beginning of trauma is the same as any shock. It's your ABC, and you add D and E to that. If any of you have taken ATLS, you should know this kind of well off by heart. The airway, breathing, and circulation are the same. Disability involves a rapid GSS score, as well as looking at some other specific things that may be a problem or could cause an immediate issue to your patient. And exposure means, essentially, that although you want to keep the patient warm, you really have to do get sort of the patient's clothes and everything off so you can take care of any possible injury. Again, remember, the issue with trauma is to stop bleeding, stop bleeding, and stop bleeding. Unlike surgery, excuse me, sepsis, taking the patient for resuscitation prior to going to surgery may not be an option, because you can't stop bleeding by just giving blood products. So these patients, unlike other types of shock, may require immediate transfer to the operating room, where that's the best they can get, and anesthesia will deal with it. You have to basically stop the bleeding, stop the bleeding, stop the bleeding. Again, airway, it's typical for sort of what you see for other ones. Most times, rapid sequence would be indicated. Chest tubes, again, the answer is no longer 36 French. Actually, you could actually justify on your boards using a 28 French, whatever you're comfortable with. But there have been some very good studies showing that for both blood and certain other thick sort of things that could come out, that a 28 French is just as good. IV access, again, as we talked about, large gauge, 18 if you can get them. Two, intraosseous access has been well-proven by the military establishment and is being used in most hospitals at this point. If you don't have one, I would recommend at least trying to bring it in for your code team. It's a lot better than getting sort of stuck while someone's doing CPR while you're trying to get a femoral line and the body's bouncing all over the place. It hasn't been approved for certain things, but it certainly can be used for CT scans. And although it's not perfect, when you use a rapid transfuser, it seems to be able to work reasonably well for that as well. Of course, it's a temporary line. But again, these are temporary things you're doing to save a life. Tourniquets, again, it's not something you guys would normally deal with unless you're in the trauma bay dealing with that kind of stuff with specific training. There are specific things you are sort of required to do in order not to lose the leg. But this can, again, it's been shown by the military that this can prevent death. And the eFAST, again, adding on the lung components while you're down there, if you're facile with this sort of thing, will allow you to sort of add a component before you even get the x-ray that may allow you to intervene on the patient. Just to plug, there's an ultrasound course coming up, SCCM, very soon, which can teach you in all these techniques. OK, I'm not going to go through all these, except for the fact that this has been on every exam you'll probably ever take since medical school and will continue to take, or APP school, or pharmacy school, or wherever you are here from. Best thing you can do, I guess, is just sit down and kind of memorize it. Sit down one night and kind of do it. Same as you do with certain QT prolongation drugs and other things that you've got to remember, certain waveforms that you're going to have to remember on the ventilator that still kind of come up on your boards. So there's class 1, class 2, class 3, class 4. And again, I don't make the board questions, but I still hear about sort of, this patient demonstrates blank, blank, blank. What class sort of hemorrhage is this? This is some other sort of things that kind of go into it. This part's a little bit more likely to show up, I think. But this is important as well. The urine output will also show up. The respiratory sort of rate and other things may not be sort of on the question as much. OK, what else has sort of come out? Reboa, this isn't going to be something that you guys necessarily do, but it is quite useful to understand it. And it's certainly changed the amount a surgeon kind of has to do, you know, opening the chest, as we used to say, and thump, do all these kind of things. The problem is how many of those patients you actually get alive to the operating room and then back to the ICU is somewhat limited, especially with the way we clamp. This is a more sophisticated, I would say, way of trying to accomplish the same thing. And although it's still being studied for this, that, and the other, overall, I think it's been adapted by many level one trauma centers. And it's a pretty simple concept. You know, same way we do balloon pumps. We can do ECMO. We can do these things. Why couldn't we just put a little balloon in there to temporarily stop blood flow to wherever you're trying, wherever the exsanguination is occurring, and then when you get operative control, then you can release the balloon. Clearly, it has to be done rapidly. You will need either multiple x-rays or some sort of fluorescence to make it work without hurting the patient. But in those places that can do this or have hybrid rooms, it's been relatively successful. I don't think you're going to have to memorize the algorithm. Again, unless you're a trauma surgeon, it's not really that important. But understand there is one that, like ECMO, you just can't use it on anything, anyone, anyone who comes in. There's sort of a thought process to what needs to be done. And you sort of have to have the resources to be able to do it rapidly and conduct it. This is something that usually comes up. It's sort of the death triad of coagulopathy, acidosis, and hypothermia. This is what you're always trying to avoid when the patient comes in or rapidly correct. So again, don't leave your patient frozen. The room should be hot. Blankets should be used even after exposure once you know what's going on, appropriate resuscitation, and avoiding coagulopathy, which tends to come rapidly. They talk about using shock when a patient demonstrates blood products for three or four hemorrhagic shock. Now, actually, a lot of places are recommending that you start with blood products for any brief form of shock that's kind of going on. A lot of it's going to be dependent on your environment and what your trauma surgeons sort of believe or don't believe. But it's very clear that, at least when patients are in some form of hemorrhagic shock, early use of blood products over crystalloids overall seems to be associated with an improved outcome. You're going to be asked questions about can I use the MTP, whole blood, et cetera, et cetera. I think, in general, the data is showing that whole blood is advantageous. The problem is it's a very limited resource. So you can't just go in and start questioning things or asking your blood bank for things or something, especially at the time of the trauma. It's not the time to address this. So what you need to do is what's within your hospital's massive transfusion policy that's already been established or what's available to you at the time. We, at Florida, have some whole blood available. But again, I would say it has to be ordered by attending. We only have a certain number of units. And it can be only used in certain circumstances. Again, some people believe in a one-to-one-to-one ratio for the blood product transfusion, especially if you're giving the massive transfusion protocol. Your blood bank should have something already figured out with what you're allowed to get and how those coolers kind of show up. And my advice is that's better than nothing. And it's better than we're crystalloid. So do that. And then, if there is a committee that you want to get on to discuss current data about how to change it or what resources are available, that's probably the best way to go about this. Did you have a question? Yes, I'm sorry. What are the instances in which you've been giving whole blood and not hemorrhagic shock? It is from hemorrhagic shock trauma. But again, who defines that when the piece, like not everyone comes like Monty Python exsanguinating right in front of you. So how you determine that has to be by a senior boarded personnel. Because again, it's a very limited resource. And I think Dr. Kaplan wanted to add something to that. This now is what you'll find in emergency rescue teams protocols. Now I get a microphone. Now you're doomed. So emergency rescue team protocols, it doesn't matter whether it's OB rescue or it is the upper GI hemorrhage rescue pathway. As long as some person is using some metric, they get access to whole blood. And that's perfect. It's a great place to start. In fact, they've done this so commonly in Norway that their rescue helicopters are only stocked with whole blood instead of component therapy because they can put more units on board and they get a much more rapid and more robust resuscitation with less overall product use. It is a little more difficult, but some places will stock the buddy transfusion kit so that if, in fact, your hospital is involved in a disaster, you could do just that when you cannot get blood products to come in. Yeah. And of course, everything Dr. Kaplan said is correct. But again, my recommendation is most of your transfusion directors, transfusion bank directors, want to do this. So try to work with them to at least come up some way to create availability rather than sort of arguing with them about why it's not there and blah, blah, blah, because that's not going to help them at all. They have to make as much out of the product they can get survive as long as it can get. Again, blood drives are great, but it's still a very limited resource. Just to go back, I think, again, if you don't have Tegger Rotem, again, probably most of you should have the availability to do something like this. We already sort of had a protocol presentation on how to read those. You will be asked probably a question on that. Easiest way, again, is to either memorize it. Most of us are a little lazy, because whatever hospital system we use kind of gives us the number that's sort of in an area that allows us to not have to interpret all the curves that kind of come out. And of course, you can always use the sort of wine glass versus martini glass interpretation, if you look on Zoom, to sort of give you an idea of what's fibrinolysis as opposed to what requires FFP, et cetera, et cetera. TXA in a pre-hospital setting. OK, that again, it's the data on TXA is going back and forth, back and forth, back and forth. If it's given in the right population at the right time after trauma, it seems to be beneficial. If it's given too late and indiscriminately, it could actually cause more harm than good. I cannot give you a definitive answer on this, except, again, to work with your pharmacists to go through the data and come up with a protocol that will work with your institution and how it goes. I cannot tell you that every institution gives TXA in the same manner. I think only the Army and the military services probably have something like that set up, where they have the capability of getting it in the field as possible. It's not as easy as you think, kind of like when you've heard the FFP trials that they do in Pennsylvania. It's not as easy to actually get that resource for every state, given different regulations, different rules, and things that are going on. So again, I would work within your hospital system to know what the protocol is, enforce that protocol, and if you feel it's not evidence-based, work within the system to try and change that. OK. Again, for hemorrhagic shock and trauma, again, your main point is to stop bleeding. That's what ATLS is basically about, temporized bleeding to get definitive care. Most places have issues either in the extremities, chest, abdomen, retroperitoneal pelvis, and into the thighs. And you could have multiple liters of blood in the thighs before you get a compartment syndrome, so it's something you have to have a high suspicion for. When you do trauma, if you're in the ER, or somehow this person gets early shipped up to your ICU, it is a team sport. You need to run the team. Resuscitation is important. Again, if you think you're going to need more than three to four units, it's time to consider massive transfusion protocol, and make sure everyone who needs to know knows that this patient is in hemorrhagic shock. Again, we've moved towards less early crystalloid use. That doesn't mean you can never use it, or if a patient doesn't look terribly bad, or whatever, but needs some volume resuscitation, that's appropriate. But if you suspect hemorrhagic shock in the setting of trauma, we have moved more towards giving blood right away. Again, what is a balanced ratio? There's a lot of arguments. As Dr. Kaplan said, whole blood is probably our best nature. Nothing can do better than nature. But again, I would, given limited resources, you need to work with, again, what your blood bank gives you, and what you have set up. TXA, again, I would, again, caution you for its indiscriminate use. I would say that you should, again, look up your own protocol, and see exactly when it's appropriate, and how to use it. Fibrogen, fibrinogen analysis, in addition to TAG, should be something you're looking at, which kind of helps you with fibrinolysis. If you wait, number nine is basically, if you wait for it to happen. Doesn't mean you want to do things indiscriminately. I keep saying that. But if you wait till it happens, in hemorrhagic shock, it's too late. Again, I would caution people who potentially are going to, let's say, IR, and have established active exsanguination, without appropriate, potential even, airway, and IV access. Because by the time they get down there, even though they look great in front of you, everyone says, look, they're great. They're 21. Everything's fine. They go down there. And then the poop hits the fan. So there are places, like in Florida, where our angiosuite, and our interventional radiology is in the anesthesia bay. So we actually have a luxury of having all those people there right there, unlike other places where you may be sending them six floors away in another building to be dealing with hemorrhagic shock. So hemorrhagic shock will sneak up on you if you're not paying attention to it, and you need to be ahead of it. And I think that's really what it's just trying to tell you. Like any form of shock, base deficit and change in lactating urine output can be a good guide at the time to see where you are. OK, so first question. Restrained patient is transferred to the ED after a T-bone motor vehicle collision with a heart rate of 110, stock blood pressure of 90, and a respiratory rate of 35. He reports left shoulder pain, shortness of breath, left-sided chest pain, and left hip pain. The most concerning of these is, OK, raise your hand if you believe number one. OK, raise your hand if you believe number two. Raise your hand if you believe number three. And raise your hand if the hip pain's the worst thing you're worried about. OK, not that many people raised their hands, so it's a confusing question. But again, you've got a patient. We talked about our ABCs. So there's nothing here in the question to indicate that they can't talk, or they would have told you, and you don't get to go back and forth. So you have to kind of interpretate what they're saying. What you did end up with was shortness of breath and a little bit of shoulder pain, and an extremely abnormal respiratory rate. What's our normal 20, which is a try breathing 20 times a minute. That doesn't happen. So 35 is quite rapid, right? So of all the things you've seen, especially if you were to memorize that table that kind of came out before with the types of shock or whatever going on. Now, this isn't necessarily hemorrhagic shock, but sort of the respiratory component, I think, is the one you would address immediately given the history and given the part of the abnormality. Again, this could be some form of hemorrhagic hemothorax. It could be a tension pneumothorax. It could be some other injury specifically there that you could deal with immediately as part of sort of an ATLS ABCDE workup to save that patient's life. That is the answer. Sorry, there wasn't a sort of thing right there. So then we do a secondary survey. Secondary survey is very important because everyone gets all excited. They do all the normal ABCD things, and they sort of start walking away. And you forget there are other things that you really have to go through from head to toe to see what exactly is wrong with the patient, how you're going to triage that patient, and you may miss something that's very important. A person could be actively exsanguinating from a wound that you didn't see as part of the initial ABCs that you can address in this secondary survey. There may be other issues that, again, need to be dealt with. So we're not going to go through it all, but it is a head-to-toe physical examination. As they say, eyes and fingers in every orifice. This should be chaperoned. It should be. That's sort of the law now. So instability, it's always a question when you do ATLS. Something went wrong. What do you do? You go back to A. So you just start over. So if all of a sudden everything was fine, and then the nurse is screaming, pressure's 60 over 40, start over. Stop looking at their fingers. Stop doing this, that, or whatever, pressing on their belly, and go right back up to the head and start over again and see what's going on. And then, of course, there's ample history. We'll talk a little more about that in the end. Two things also as part of your survey that you should always be considering. Again, if it's a female, no matter how old, within reason, you should be sending a pregnancy test as soon as you're able to obtain urine. Tox screen is up to you and sort of how your hospital deals with those sort of things. Antibiotics. A single dose of antibiotics is typically indicated for any dirty wound. It does not have to be broad spectrum. Most people don't have resistant pseudomotus in their soil. But also, again, kitchen knives are all dirty. So there's probably something on there that you need to consider. Can be what you, again, your hospital uses, but a first generation cephalosporin if they're not allergic is usually acceptable. Last thing is please don't forget tetanus. We can assume some things in our college students, certain kids a certain age, but you can't assume that your patient is up to speed on that. Most ERs are very good about making sure you get that, but any dirty wound, any dirty injury, that's something that really needs to be addressed as part of this secondary tertiary survey you'll see before the patient moves on. Of course, none of that takes priority over shock. And all that kind of goes out the window to later if your patient is hypotensive. We already sort of talked a little about the e-fast. We don't need to kind of go through the whole sort of thing. But the whole point of the fast in general is to allow you to make the decision of whether a patient should go straight to the operating room based on intra-abdominal bleeding. It can also allow you to do interventional things on the pericardium and heart if they're needed to save the patient's life immediately. And again, the e-fast, by using the lung aspect of it, you can identify certain potential life-threatening issues before you can even get a chest x-ray expediting treatment of the patient. This includes but is not limited to attention pneumothorax. OK, so ample. Again, when a patient's in shock, it's not the time to ask if they're BRC1 positive or something like that. You need to kind of go through what's important. So key would be allergies, key medications, vital past medical history, last meal. I think we were joking last night that some of the Denny's may not be going on for as much longer. But every trauma patient you see in the middle of the night has either had fourth meal or Denny's or something like that. They're always going to have a full stomach, which is why it's also important that you consider using rapid sequence in these patients every time you go, if you have to intubate them. You just have to assume they have a full meal, full tummy. And then you want to get the events and environment related to the injury. Again, if you have a blast injury from a burning house, they've been on the ground for, I don't know, 12 hours. That's important to know for rhabdomyolysis. They may have carbon monoxide poisoning. There's all sorts of things you could get rapidly from either the family member, the patient, if they're able to converse with you, or the ambulance personnel that can tell you immediately that may alter how you do your first couple of steps on the patient. We still get pelvic films. It's really important. You can see an open book right there on the right. Again, there's really no way to replace this. It has to be done. Again, it can affect specifically what you do, whether you put on a binder, how you sort of create an algorithm of who gets what, who's going to be treated for certain sort of things. And again, a lot of bleeding in the pelvis can absolutely occur, even if their upper body is looking OK. So this is still part of your ATLS algorithm. Why do we do a tertiary survey? Because again, you get sort of all the excitement. And none of this ever happens sequentially. You never get like the one patient. Then you can kind of go to the next patient. Then you go, everything's happening all at once. God forbid you have a mass casualty event. Patients can be hurt if you don't go through everything systematically. But you've got to do it when you've sat down. You're not in the OR. You're not running around like a lunatic. And you have a chance to look at this patient from head to toe and go through all the check boxes and make sure you haven't missed anything. You could miss a delayed pancreatic injury. You guys, I think, had something previously on that for the trauma with what's going on with the seat belt sign. You can miss spine things that can paralyze a patient forever. There's all sorts of things that you need to go through. So either you or someone in your team should be sort of, a lot of us actually have a checklist that we do as part of our tertiary survey to make sure that it's all been gone through at least within 24 hours so we don't miss these kind of things. And a lot of it's important, too, because all the adrenaline may have worn off. They may have new pain. Or some of the things, the drugs and the drug alcohol intoxication may have worn off. And now they can tell you a little more about this, that, and the other that may have been missed. So again, I don't think this would be necessarily a tertiary survey as a question on your boards. But it's absolutely something you should understand. And if you're part of a team that takes care of these patients, you should actually have a protocol that helps you institute this after all the acute issues have been addressed. Again, who should do this? Someone who's well-trained in what goes on. At our institution, it usually ends up being the trauma nurse practitioners who have been trained and certified in how to do this properly. But again, it can be residents of a certain level who have been trained properly. Or it can be you, the physicians, who make sure this is OK. And again, just things change the day after where all of a sudden pain shows up, doesn't show up. Neck pain occurs. Things that could be terribly life-altering for the patient that you need to sort of investigate. OK. Damage control resuscitation. We used to spend hours and hours trying to fix everything. And then we would close the patient. And then we had tons of ARDS. We'd have lots of coagulopathies. You saw the death triad. We would get compartment syndromes in the belly, renal failure, all these terrible things. So what we tried to do is figure out a balance. And that balance is maybe we leave them open, intervene as much as we can the key issues, and don't sit there focusing on resuscitating them in the OR where it's cold. And you can't do all the things you want to do because of the environment. Get them back to the ICU. Resuscitate them appropriately. Be in an environment where the nurse can keep them warm and address key issues. Now, that being said, leaving someone's belly open for a week is also not a good thing. So you have to have the ability. I think Dr. Kaplan was mentioning, you've got to be able to get these people on the OR schedule. You should have a team that can get this patient within 24 to 40 hours back on the OR schedule so they can have definitive care. Usually at that point, you are putting bowel that you've resected back together. They're not on high-dose pressers anymore. They've been volume resuscitated or blood product. Things have been normalized. They're no longer in a coagulopathy. That doesn't mean necessarily that you should leave all blood vessels not addressed. You may need a vascular team or a good trauma surgeon that also does vascular at this day and age to be able to fix certain things that you just can't leave. Certain arteries just can't be left bleeding or stomped on. They deliver oxygen to major areas, and they may have to be fixed immediately. But that doesn't mean you go into, if you have bleeding veins from an open book pelvis, which will happen, you go in and start trying to fix all the veins. You pack that off, you get out. There's certain things you don't mess with, as Dr. Kaplan mentioned. You don't mess necessarily with the pancreas at that point or do a definitive procedure unless it's absolutely necessary. Yes, there is a trauma whipple. Do people get that immediately? Not necessarily. You sort of leave an open belly, get out, come back in, see what's viable, and then come up with a better plan. Lots of things you can do now. They have lots of coagulation and heating packets from the military that work quite well. Just be careful. Again, we do a lot of retroperitoneal packing, abdominal packing. And again, you can sort of combine these with Angio to sort of, if you have a hybrid suite now, to sort of do a one-two punch to try and stop bleeding as fast as possible with your interventional radiologists. And again, with your trauma orthopedic individuals, this may be the time to do external fixation and some other sort of things. If you've done a damage control, it doesn't mean you're out of the woods. They can still re-bleed. If they're actively bleeding, you're going to have to do something about it. You have to stop the bleeding. End of story. Again, a lot of this may or may not be sort of your forte, because in the ICU, a lot of this is dealt with at ER. Like, what's a high-risk mode? What should you be looking for? Was the patient thrown from their vehicle? These are sort of things that normally have been dealt with when they arrive to the ICU or the neuro-ICU, those sort of things. But it's important, again, to understand exactly what's kind of going on so that you can have an idea of what's more likely to cause damage and what's not. Traumatic head injury is a huge deal. You do need to make sure that you don't miss any of this. Again, people are drunk. People have a lower GCS. People may just be in shock and can't respond. And you're not going to necessarily get the perfect neuro exam. So in an area that can do CTs, I would say most of these places, it's sort of become the norm for a head-to-toe examination, unless you can use common sense, where it was a person just had a witness fall, and they didn't hit their head. Or they were, unfortunately, just shot in their belly. It was witnessed, and they didn't fall down. These are things where, no, you don't necessarily have to do a pan scan for that. You treat what's going on. But for most blunt trauma, where you can't get a good story, you don't know what's going on, and they're very sick, usually you're going head-to-pelvis. OK. Again, I don't think spinal injury risk factors is something you should understand. But again, I don't think it's going to change your management in this case. And I would also say that you just have to have a high suspicion, high suspicion, high suspicion. And again, I don't think there'll be a question specifically about this on some sort of board exam. OK, so question two. 65-year-old man is found at the bottom of the stairs with a scalp laceration. So here we go with the data again. We have a stock blood pressure of 110, heart rate of 100, respiratory rate of 18. So so far, you're like, meh. Oh, but look, now we've got a GCS of 8. Now, why is that important? What's that kind of a cutoff for when we're sort of examining patients? Yeah, this is where you start thinking, I've got to put a tube into someone because they can't handle themselves. Glasgow Coma Scale, again, it's one of those things you should just memorize and be able to use, top of your head. There's no easy way out of it. Just do it. Which provides the best chance to avoid a secondary brain injury? So this is one of those ones where it's kind of a, you're saying, hey, look over here. Look over here and see what's kind of going on. But what do we do with every trauma patient when we see them, regardless of what they told you? ABCs, right? So until you establish ABCs, nothing else is going to work. So who thinks we should? It makes sense, right? Let's do a measure to prevent cervical spine injury. Of course, right? But is that the first thing you do for someone who is now a GCS of 8? Probably not, right? 3% normal saline bolus, that is definitely a part of TBI management in some places. Hypernatremia, certainly not what you're going to do first thing on the scene or first thing in the ER. Airway, that seems like a good thing. Anti-seizure prophylaxis, yeah, that seems to be the norm for most TBIs now, at least a week. I mean, it varies from neurosurgery, neurology, neuro-CCM from institution to institution. But three is probably the least bad choice or the best option of the ones you have. So it is. So again, don't get tricked. ABCs, then go to the other stuff. Damage control resuscitation. So when do we use it? I think we sort of discussed some of that. I think some of the most important part to talk about this is the concept of permissive hypotension. This is used by most militaries in the world, including the Israeli Defense Force, the British Army, the American Army, when someone has certain injuries, such as extremity injuries or even aortic injuries that are actively exsanguinating. And it's sort of the concept of don't pop the clot. And what you found is for up to one to two hours, you can have someone with a systolic somewhere in the range of, I don't know, it varies, but maybe you could say a MAP of 40, 45. As long as they're perfusing their brain and kidneys enough that they don't actively start exsanguinating from one of the other injuries. So that's your concept of permissive hypotension. Sometimes we actively do that when you also get these transthoracic aortic sort of dissections. And you guys already talked about how beta blockade for sheer stress is the first thing you want to do. But also you do, before definitive treatment, often you'll have permissive hypotension. Vascular won't be telling you to keep it above a certain level. Vascular surgery said, I'd like you to keep it at a certain level. So potentially, it just varies. Systolic blood pressure of 90 until we can figure out exactly what we're going to do or not do with this patient. Medical management, placing a stent, taking them for the whole nine yards. OK. We're not going to talk again about MTP specifically. Again, I don't think anyone's going to ask you about the study or which ratio to use. I just think we all realize that now a balanced approach is better. And you should work again with your blood transfusion bank to see what is available for you. And as Dr. Kaplan said, if you can get whole blood for hemorrhagic shock, that's great. And that should probably be one of your first thoughts if you can get it. Again, this is sort of the tag that has already been reviewed by previous talks. Again, TXA is an antithrombolytic. Again, I've seen study after study after study. If anyone wants to comment on that, that's fine. But right now, it's still a little unclear exactly which patient population and at what time it should be used. I would say if it's very early after the trauma and you have active fibronolysis, this is probably something very good to use. That's also probably true in almost any operating room that you have today with sort of what's kind of going on. But again, if you're a certain amount of time out and you give it, you're actually more likely to induce clots, which can lead to other problems, rather than fixing your specific issue. TTE, again, this isn't trauma-specific, but it can be very helpful. I think most of us are actually functional in this. If you're not, hopefully you should be. And again, plug the course that's coming up, the CCM sort of thing that's going on. And we are a little bit out of time, so I'm actually going to end there. And if you have any questions, I will answer them now, or I'll be here all afternoon to answer any of the questions you have. Thank you, Dr. Eckman.

trauma care

eFAST

damage control resuscitation

ABCDE approach

Reboa

massive transfusions

TXA