Okay, thanks for coming everyone to the third annual critical care case records of the joint trauma system This is the third year of us doing something like this where we review cases that we've seen over the past year sort of described and recorded in the joint trauma system and the DOD trauma registry and so Unfortunately, there are Service members who are still getting hurt Even though combat operations have slowed we have Service members getting hurt on a week weekly basis if not daily basis So, please keep them in your thoughts So just some housekeeping. My name is Kevin Chung I am in a medical intensivist and the chair of medicine for the Department of Medicine at the Uniformed Services University And My co-moderator Lee Cancio director of US Army Burn Center, San Antonio, Texas okay, so before we go into the slides and introduce our panel members If you are on med Twitter, feel free to live tweet throughout this entire Session. However, I ask that you Respect the photos of the individuals and do not tweet photos There are some gory pictures as well. So please Be mindful and don't tweet those photos if they appear gory to you It's not going to be going to be appropriate for Twitter So thanks a lot So this is My co-moderator and I are going to go through this case our usual disclaimers These are actual cases that we've seen at our military treatments facilities and so just That and then our distinguished panel members that you see in front of you are Colonel Jeremy Pamplin medical intensivist and director of TATRC Colonel retired John Oh trauma surgeon at Penn State Hershey Matt Borgman lieutenant colonel Matt Borgman pediatric intensivist and chief of pediatric critical care at Brooke in San Antonio and Colonel Todd Rasmussen who was our Speaker yesterday in one of our sessions the Peter Safar memorial lecture vascular surgeon and professor and associate dean of clinical research at USU if I could ask each of the speakers to just Elaborate on that very brief introduction and tell me a little bit about yourself Dr. Pamplin, you want to start? Sure. I'm Jeremy Pamplin. I am a medical intensivist spent a good portion of my career at both Madigan Army Medical Center and San Antonio Military Medical Center now Brooke Army Medical Center again I was the director of the surgical ICU there and the burn ICU and have gone in the direction of Research at the telemedicine advanced technology Research Center looking to develop advanced medical technologies for the future the support for medical support for the future battlefield I'm John Oh spent 20 years in the military just retired in 2017 I retired as a chief of general surgery at Walter Reed National Military Medical Center, and I'm currently a trauma surgeon at Penn State Hershey director of the surgical critical care Division as well as a fellowship director for surgical critical care and Matt Borgman So I've been in San Antonio now almost 10 years. I'm soon to be joining Kevin and Todd here at at USU So I'm looking forward to that this summer Research interests have been in trauma and resuscitation and Delving into as well as simulation and some ECMO work at our Center My name is Todd Rasmussen and I am Now at the Uniformed Services University. I'm an attending vascular surgeon at Walter Reed I Have been the director of the combat casualty care research program. That was a is a large program. That's administrated out of Fort Detrick, Maryland I've been the deputy commander of the Institute of Surgical Research with a number of friends and colleagues on the stage and Before that I did my vascular surgery Work out of San Antonio both at Wilford Hall and then through multiple deployments downrange. So, thank you and Goes without saying that all panel members have extensive experience downrange in various settings from roll two to roll three Okay, so rules of engagement for this session We're not providing any tactical strategic or operational information. So we're not going to talk about those things Especially OPSEC stuff We encourage audience participation Throughout the session. We're gonna have Sort of mini breaks where we're gonna encourage Participation. I know that there are some a lot of experts in the room. And so we would love to hear from you those of you in the audience who Have comments and questions about certain treatment strategies that we employed in this case This is a complex case as complex as I've ever sort of heard about or experienced personally in my 15 years in the ICU So that's I mean we worked 10 years in the burn ICU. So That says a lot. It's a very very complicated case with no really no right answer you know the folks downrange did the best they could to take care of the patient and the patient's still alive and so You can't argue with success but there are a lot of Points that we're going to discuss that can be controversial Alright, so if you are not familiar with the Continuation or the continuum of care in combat casualty care. This is a brief introduction buddy aid Rendered by the service members that are fighting alongside our service members That's considered role one usually Non-medical providers provide this kind of care Role two and sometimes you have obviously special ops Medics and so on and so forth role two is a limited a surgical facility for surgical team Where you're gonna have limited blood product transfusion create capability so on and so forth role three is a more Elaborate Operation where you have Specialty representation ice an ICU with an intensivist ICU nurses mechanical ventilators and so on and so forth role four is a Hospital that we have in Germany where many of our patients from the Middle East get evacuated to prior to getting evacuated To the states and then roll Walter Reed is an example of role five facility. That's a typo So this is your location. You're in a forward operating base It's a role to facility this is for the panel. I'm gonna give you some time to think And this is your capability there are two general surgeons one CRNA at this sport surgical team You have a sauna site available ISTAT availability no x-ray. You have a total of 20 units of packed red blood cells some Low titer whole blood as well and Capability to initiate a walking blood bank. You've pre-screened a bunch of folks This is your trauma bay in the role two And your operating room pretty much it's the other side of the room Okay, so this is our case and You know, we're gonna sort of this is a very complicated case as I said So we're gonna take it a step at a time so point of injury approximately zero four hundred this service member who happened to be in a Ranger unit 33 year old was on patrol when the the patrol hit an IED shrapnel Went into a grenade that was located in his waist And so that detonated the grenade on the service members waist Massive soft tissue injuries With a huge defect in the right hip and leg ensued Obviously a right also a right mangled extremity So at this point Kevin was was he mounted or dismounted dismounted so he was on foot patrol and As I said the shrapnel went to his grenade that was on his belt and exploded so Knowing that do we have any medics in the audience? Okay, knowing that we don't have any medics here before you What are some of the things that you've seen medics do in the field? That could help a patient like this and I'll just open this question up to the entire panel Turnicates and direct pressure. What's that? Turnicates and direct pressure. Okay, turnicates. Stop the bleeding So, you know, you're you're you've encountered That would be good if you could hold pressure on one area, but this is a massive hole a shark bite What what types of You know dressings that you have available And I think to be packing it with quick clots Anything else at the point of care, but you're thinking about just to just to back up one step I don't know the context of what was going on. You know, it's an IED blast. I don't know if there are enemy combatants in there. I don't know if there's an enemy combatant. I don't know if there's an enemy combatant I don't know if there's an enemy combatant. I don't know if there's an enemy combatant in the area, of course, the first step is, you know, care under fire, and if that's what's going on, the most important thing to do is obviously return fire, and then to start stabilizing the casualties. So I don't, just, it should go without saying. Yeah, that's a very good point. There are not, the unit is not under attack. There is a medic that's embedded with the Ranger platoon, and he was on site to render care. Kevin, there's a couple of new devices that I think you're probably aware of, and I've honestly not seen them used a lot, but I certainly know they've been developed for this, potentially this pattern of injury, and that's the JET or the SAM tourniquet that are sort of the pelvic binder with pneumatic cuffs that include the femoral arteries for high complex dismounted or proximal, complex dismounted blast injuries of the lower extremities and perineum, so those in combination with, you know, quick clot or topical hemostatic agents to, and those devices that I mentioned can do two things. One, they can, you know, bring a pelvic fracture back to approximate it or reduce it manually, and then they can occlude the femoral artery if the injury in the hemorrhage is too proximal for a tourniquet. I guess I'd also be thinking of, you know, IO, access, and probably ketamine, you know, depending upon hemodynamics and the patient's overall status, so that access, pain control, topical hemostatics or hemorrhage control. So very good, so ketamine, something that's being used quite a bit, downrange now, and IO. I mean, this guy, I think that's the quickest way of attaining IV access. So anything else, any other drugs, or, I mean, are you thinking about transfusion at this point? I guess the question would be your, you know, how quickly can you transport, right? I mean, you know, they have, you know, we are deploying a TXA product, and, you know, hopefully we'll have one that will be easier to use in a situation, but a lot of the medics, especially in those ranger units, have TXA available to give at the point of injury. I guess the question is, are you gonna, you need to balance that with getting them, you know, how far are you away from that role to how quickly can you get them on a vehicle? Do you wanna, you know, stay in play or scoop and run, right? So, but administering a TXA and the question of how easy or quickly can you do that, not limiting your ability to get them back to that role too, is I guess the question. Okay. And I think this team, I don't know what the timeframe is for this particular injury, but certainly now the ranger medics are all carrying at least one unit of actual threshold blood. It's available to be, you know, used in the field. And I would imagine as soon as they have IV access and they have at least started or controlled hemorrhage as best they could, they would be starting to transfuse that. And most of them are starting to think now, depending on the evacuation needs, about the next, you know, evolutions of care and starting to think about whether or not they're gonna need additional resources and in terms of buddy transfusions. I'm guessing we're gonna start getting into talking about that later. Okay. So, blood is available. How many of you would give any crystalloid or if you had available, Hespan? Okay, good. So these are actual notes from the Joint Trauma System Conference we have every week. And so please excuse Dr. Cancio and I, some of this, some of these terms. We tried to interpret and we can't. But these are the notes from the presentation. And so we're gonna go right off of them and see exactly what happened on the ground based on the reports that we received on the ground. So this is a 33-year-old male, IED grenade was on the hip, detonated, sustained injuries to the right upper extremity, right lower extremity, right pelvis. There was a cat tourniquet placed in the right upper extremity. A cat was attempted and placed in the right lower extremity. Again, just massive soft tissue injury. They happened to have a junctional tourniquet that they utilized along with hemostatic dressings. The panel sort of described that. And for the audience, we did not have this capability 15 years ago. 15 years ago, this would have been just gauze, plain gauze that we were trying to achieve hemostasis with in the point of care. They did establish an IV. They tried a sternal IO, but was able to get a left AC IV. They applied manual pressure to the abdomen. Did a needle chest decompressions on both sides and was able to place the right chest tube. Gave the patient TXA. So the units are carrying TXA, especially the special ops units. Had ketamine available that they gave IM. They gave some IV, gave some calcium and then sedatives. The unit, believe it or not, was carrying cold stored whole blood. So that was nearby. And also, there was a walking blood bank program that they had trained, the unit had trained. So a couple of the service members in the unit put out their arm and gave blood. And so here we are at an hour after injury. Blood pressure of 60 over palp on the radial. Respiratory rate of 20. And they have an end tidal CO2 capability. And after all these interventions, the patient is getting reassessed and they're trying to clamp an artery, all this stuff. This is a picture of the pelvic inguinal or junctional tourniquet they utilized. And it was really just an improvised tourniquet. They did not have the current technology that's available. It's not been widely adopted yet. But as you can see in this situation, it could be helpful if utilized with hemostatic agents. So the patient was called for a Medevac. So here we are, almost two hours later. We're into this. A humeral IO is placed. Patient gets two more units of cold stored whole blood. That's just amazing that they're able to do that. And then again, another repeat decompression. Gets Invance, ketamine again, another gram of TXA, manual pressure to the pelvis and abdomen, and then arrives to the roll two. Kevin, his airway, I'm sorry. Okay, we can talk about that in a second. So this is the roll two trauma bay. And this is what you're seeing in front of you. Okay, so imagine yourself for the couple of surgeons in the panel. You're the trauma, you're the head of trauma at this roll two. Patient comes in two hours post-injury. The blood pressure is 60 over 40, 140 heart rate, respiratory rate of eight, satting 67%. GCS is three, a little sluggish, cold and pale, diminished right breast sounds, weak carotid pulse. Don't really need that information. Absent right upper extremity pulse. It's completely mangled and has a cat tourniquet. And getting O2 and via nasal airway. And they're trying to bag mask and ventilate him. Chest tubes placed bilaterally has a positive FAST. So for Dr. Oh and Dr. Rasmussen, what are you thinking at this point? I'm thinking this patient looks like he's very close to arresting. So several concerns I have. One is I have to rapidly triage all my cavities for hemorrhage. It's fantastic they were able to get two chest tubes in. But I'm still concerned that he may have a massive hemothorax that's just not being drained by his chest, by the chest tubes. I still have to rule out blood in his abdomen and not just fixate on the most obvious source of hemorrhage obviously, which is gonna be these massive extremity injuries. So they have a FAST and, I'm sorry, you said positive FAST, that mean his FAST was positive for abdominal fluid? Yep. I'd also FAST his chest and do an E-FAST because I could probably get that faster than a chest X-ray. And if he's not intubated, I'd be, what I wanna do is resuscitate him as quickly as possible with blood and whole blood if I have it before I intubate him. Because as soon as he gets that paralytic, he's gonna arrest. Dr. Rasmussen, do you have anything to add? Well, I agree with those points. I guess what comes to mind here is this is a, they've done a, this is a great example of a successful sort of permissive hypotension approach. I mean, they've, in this case, he's two hours after injury and he may be close to arresting, I agree, but he also may have just sort of found that a good spot for now. So I think you can gain really quickly a little bit more information with looking at his pericardium and his chest with the FAST exam, maybe a quick chest X-ray. He may not need, it'd be interesting to see how much he would need to be intubated as far as paralytic or even sedation. So he may not need that. I guess what, I'm tempted to just, you know, the Brits would talk about, what'd they call that, they would just go straight to the OR in Bastion. Yeah, right turn resuscitation. They just go right to the OR. And this is, you know, I can't see all of his injuries. I don't know, have all the information, but this strikes me as somebody of really quick, very quick time in the recess room and just get him or her, I guess him, to the OR and do these things. The other thing that comes to mind probably is getting him prepped and maybe femoral artery access for a boa catheter or getting him prepped for a rapid laparotomy and clamping of the aorta in case or when he does arrest. But I think they've done, and this is a good example of what seems to be, either with skill or luck, Providence, they've done a nice job after two hours of permissive hypotension. So if this guy is fading, what are your options? I mean, do you do an ED thoracotomy in a Roll 2? Or are you going to prefer the Roboa? Well, if that question is still for me, I mean, I think it would depend on his chest. I mean, if he had- I know what Dr. Rasmussen's saying. Well, you'd need to have a, you know, you'd really want to make sure to John's point that his chest is negative. He doesn't have effusions in either of the thoraces or he doesn't, and that he does not have any blood in the pericardium. And then I think it depends upon your resources and your comfort level and skill set. I think if you sort of have a team that knows what Roboa means, and you can get a pretty quick femoral artery access with a, you know, micropuncture kit, and you have that available, then certainly Roboa would be a reasonable approach, at least getting access and positioning, you know, yourself to inflate the balloon in case he does arrest. But similarly, you know, for a long time now, we've also been without Roboa, and, you know, having his chest prepped and being ready to do thoracotomy and clamping. If he arrests, that's a viable alternative as well, especially, certainly if he has a hemothorax or hemopericardium. So I think it depends upon the skill set and the comfort level and the training of the group. Just out of curiosity, how many surgeons in the audience, if you could raise your hands? So keep them up if you would do an ED thoracotomy for decompensating patient. I mean, I think in this case, you know, he hasn't arrested yet, and this is the thing, right? So this is the debate, and I don't think we have an answer. In order to do, really, an ED thoracotomy, you really have to wait for the patient to arrest, and then you're reactive, and then you've got to open a large body cavity and push the lung out of the way and lose, you know, reserve, pulmonary reserve and clamp the aorta, and that is fine. That can be done, but it is certainly reactive. You know, okay, now the patient's arrested and we're in as bad a situation as possible. Let's do a reactive, maximally invasive maneuver. As opposed to just in a controlled manner, in this case, getting femoral artery access and being ready in a proactive manner, potentially to prevent arrest altogether. You know, it's, again, as I said when I started, we don't really know the answer to that. Every patient's better, or every patient's different, but it is certainly sort of the crux of the debate, I think, at this point. And I think it's important in this kind of a forum, too. We glanced over a little bit of the, you know, two hours of time that took them to actually get to this location. You know, there's a lot of battle drills and there's a lot of work that went in. I think I counted five units of blood that were actually transfused by probably one or two individuals in that far forward location while they were doing many other things. And it really highlights the priority of kind of teamwork and battle drills and training to make sure all the folks that are around them are doing the things that need to do in order to be able to do that type of advanced care to even get them to this point. And we're talking about the, you know, the surgical control of the underlying problem right now, but there are other things that are ongoing right now being done by other individuals, and particularly that anesthesiologist or CRNA that was there. I don't know what the split was, but those individuals are probably working on either managing the airway or potentially controlling the airway without medications and hopefully getting more access and delivering more blood product. That's a great point. So this patient would have died in Central Pennsylvania with a similar injury, right? With two hours transport time. So just going back, I think some of the life-saving things that were done were large volume, well, not massive, but large volume blood transfusion prior, but they also did something really great, which is they gave calcium. And I can't even remind my anesthesiologist to give calcium during a massive transfusion. We've seen this multiple times where they get cardiomyopathy from hypocalcemia. But the patient is still in extremis right now, and what I'm looking at is a positive FAST scan. So I'm where he's exsanguinating into his abdomen. So my personal preference is if I've triaged the chest with an X-ray and I'm FAST, I would take him to the OR and immediately get in his abdomen and control his aorta sub-diaphragmatically. Control the hemorrhage in the abdomen and then address the extremities. Okay, that's a very nice discussion. Okay, so it turns out they have a roboa capability at this role too. This was in October or September of last year. So just recent. They placed two cortis on both sides and then rapid sequence at the basin. A few minutes later, we have more calcium. ANSEF and Tdap is administered. So at this point, I mean, I think we've talked about some damage control priorities. Anything to add for the surgery itself? The only thing I would point out, and having talked to a number of junior surgeons and critical care providers in these situations over the last numbers of years, this is gonna be a hard operation. I kind of forget that. I think we're all, we sit on nice chairs like this in a nice auditorium and we think about our fellow getting started and we have good lights and we have good retractors. This is gonna be a hard operation. And I think if I recall knowing a little bit about this case from what I have heard and in seeing of other cases, it's hard. They don't have, you don't have a fellow, you don't have another surgeon, really. You have an orthopedic surgeon. Yeah, and- Any orthopedic surgeons here? So it is, I think trying to do things, Kevin, to your point of thoughts about the operation itself, you know, things that can be done to provide you sort of a quote-unquote an extra set of hands or to make that operation as possible, as feasible as possible, because it's just hard. You don't have, not likely to have good lights. You're not likely to have good retractors. You're not likely to have another set of hands. And that goes through my mind now more as I think about these cases. And now, at this point, they're done by brilliant junior surgeons that are downrange now. So, but it does come to mind, I think. Okay, well, it was a difficult surgery from what we're hearing on the conference call. Right upper extremity was debrided. A vascular shunt was placed in the distal and proximal brachial artery. The right flank was debrided with some bleeding control achieved. An X-lap was performed. Sigmoid colon had a serosal tear that was repaired and it was just packed. So there's another part that goes along with that surgery. As soon as they go to the OR, I mean, this guy has the potential to consume all resources available at this small location. So someone, as they've gone to the OR, is now working on figuring out how to either get more resources or ideally send him someplace else. You know, while right now, the volume of casualties is much lower than it was. And these are oftentimes just one-offs. I don't think that should be the lesson going forward, which is the purpose of these kinds of talks. And the next round of folks need to also remember this is the potential for one of many, right? And going slow or not thinking about how to move on quickly will always cause challenges for the next patient to come. Makes you think about the Somali incident, right? It was the shark bite, you know, that happened right before the incident, which completely drained all their blood products. So, I mean, an essential piece. And they didn't have a walking blood bank back then. No, he could easily use up all 20 of your red cells. Yep. So these are some pictures, some photos. I don't know if there's anything to comment on, Dr. Rasmussen. I mean, is this futile here, trying to do? Well, I think as the audience knows, and probably some that are, gosh, more experienced at this than I am, but I think at this point, it's damage control. I mean, it looks awful. But to Jeremy's point, I think, you know, the decision of whether or not that's futile at this point, you know, at least for, sure, it looks futile, it looks bad, but I think stepping through it, if you can identify the sides, both severed ends of the brachial artery, try to put a shunt in and cover it and manage it at this point. If it's not bleeding, just leave it. And then move to the next awful extremity and do the same. So it's likely to be futile. I don't know at this point that that decision needs to be made at this, you know, this is really a fluid situation. But right now, if it's not bleeding, I would try to manage it, shunt it, and then move to the next one, recognizing that if I can't control the bleeding or, you know, that it could be amputated, but. So this is two hours in. Yeah, and this is a general surgeon managing this patient, presumably. Sure, I mean, so you mean, absolutely. It wouldn't be, if the, the challenge is the amputation's not easy either. And so it's gonna take some time and resources. And if you've got a hemoperitoneum and all that's going on in the belly, I would leave it like that. I would cover it, manage it. If you need to, leave the tourniquet on it and don't mess with it, because you're gonna get into a rabbit hole trying to do a right upper extremity amputation in that situation, and you're gonna be misprioritizing and maybe creating bleeding that you didn't need to get into. So it's likely futile, but at this point, I'd leave a tourniquet on it, cover it, and get to other priorities, because there are many here. So here's more pictures of his lower extremity. Extremity photos. This is in the rule three here. So this is some information about the patient in the rule two facility. There was a VBG that was done, pH of 7.18, PCO2 of 50, and base deficit or base excess minus six. You got ionized calcium that's relatively low. Has gotten a couple of amps, or amp of bicarb, a few amps of calcium chloride. They put a roboa in, and as I said earlier, and roboa's been in for a total of 110 minutes. What do you think about that, for the panel members? This is intraoperative information? Yeah, intraoperative roboa, inflated. I mean, it took them that long, obviously, to save the guy's life and do the things that needed to do, but you know, what is the optimum time a roboa balloon can be inflated before you start seeing the consequences of... If you have direct visualization, can you also take it down, look, see what's happening up on... That's my understanding in this case that it was, you know, I don't know the details, but I have been in on sort of the JTS discussion of this a couple months ago, was that it was put in to provide afterload because they felt the patient was going into a terminal rhythm and was going to arrest. So they felt like either clamping the aorta or putting in a balloon was going to be necessary to prevent, you know, exsanguination and cardiac arrest. And then I think my understanding is that that was done, that there were assessments made intraoperatively trying to bring the balloon down or, you know, the other thing that we know is come off the aortic clamp. I mean, they're in many ways very similar, but that the patient didn't tolerate coming off the clamp or didn't tolerate having the balloon down and so it was re-inflated is my understanding. So it wasn't my understanding, and again it's as good as it can be, I guess I wasn't there, but is that this wasn't inflated and forgotten, you know, this was placed for immediate afterload support as a damage control maneuver to help them amidst this complex case. And when they would let it down, the patient would not tolerate it, so they'd go back up. I think the point that you're also trying to get after is the duration, and it's just not clearly stated for the audience, that you know, the duration of time that it was up, whether it was down for brief periods of time or however, you know, however long it was taken down for, the total duration of time obviously is an ischemic injury to a whole lower body. And that time is money, and the longer you have obviously ischemia that size of that portion of the body, the more downstream challenges you're going to have in terms of multiple organ failure, even potentially coagulopathy when you allow the blood to be reperfused, and it's a whole bunch of other challenges that can come on as you allow the body to be reperfused after that duration of ischemia. So the the rule of thumb that we use is 45 minutes for aortic cross clamping, and there's a lot of animal studies that kind of bear that out. That's when you start getting ischemia reperfusion injury. So 45 minutes is just a rule of thumb. So I totally understand why they kept the robola up, especially if he kept getting hypotensive and trying to rest wherever they took it down, but one strategy we used, again a camp bastion where we saw a huge volume of these dismounted blast injuries, they have massive pelvic injuries, is we actually got rapidly in the abdomen, and then we walked the clamps down to the common iliacs. And in this case, perhaps they could have moved a clamp down to the right common iliac where his extremity injury was, where he was likely exsanguinating, then they could have taken the balloon down. But the other advantage of the zone 3 borboa is you're not getting nearly, I don't think as much gut ischemia as you would with a thoracic aortic clamp, but I mean this is just, this is one of the side effects of using something like a roboa, and now you're gonna have to be prepared for the reperfusion injury that's gonna happen. And I think we're tempted to say, well this is similar to just Dr. O's clamp, you know, right, so he's gonna do an immediate laparotomy and put a clamp in the superceliac artery, or I'm superceliac aorta, and we're tempted to say it's the same. It's sort of the same, but it's also different. In the case of a quick immediate laparotomy with a superceliac aortic clamp, you don't have a sheath in the femoral artery. And I think, you know, that's gonna probably play out here. So it is a little bit different. The ischemia reperfusion of the, below the clamp of the balloon is the same, or very similar. But what you have with the roboa catheter is a seven French sheath in the femoral artery, which that ischemia time probably is also increasing the risk of perisheath thrombosis, you know, clot forming around the roboa sheath, which you don't have with a superceliac clamp. You know, so they're similar, but they're not exactly the same. I'm sure it's gonna play out, otherwise you wouldn't be presenting it. I guess, we'll see. So the patient ends up getting, at this point, 11 total units of cold stored whole blood, 26 units of fresh whole blood from from his buddies, and then some PAX cells, 16 units of PAX cells and FFP. Without this whole blood, do you think this patient could have survived? No. No platelets on the fob. Yeah, right, no platelets. No cryo. So we're continuing this case into roll three. The patient arrives six hours later. Amazing that they did all that in that shorter period of time. Just heroic effort. You could see blood pressure of 158 over 100, heart rate of 114, patient's intubated, has minimal time in the trauma bay, but blood transfusions are continued in the emergency department and continued into the OR and brought directly into the OR. In the OR, there's a transhumeral amputation that's completed. They say it's just, you know, it's point of no return. IND of the right hip. They perform a right hip disarticulation there, right there and then. Right flank debridement, repair of the right external iliac vein injury that was there. Another, it was just packed, but XLAP ascending and sigmoid colon sorosal tears are repaired. Rigid proctoscopy is done and there's, it seems to be normal. And then the verboa sheath and catheter are removed. And so at this point, the patient comes rolling out to the ICU, to Dr. Borgman and Dr. Pamplin. What are you thinking now? Surgeons have saved his life. What are you going to do now? Don't mess it up now. It's time to take a nap. I mean, these guys have done a great job and I really appreciate their help. Created a mess. Presumably, CCAT is activated. So, you know, probably some of our decision-making is going to be thinking about, you know, when is, when is, are we going to be able to get this patient out? But, you know, I think we hit a lot of the damage control resuscitation principles already in terms of, you know, good balance for resuscitation, the giving of calcium. You saw the temperature there that was normal. So that was, you know, not to be forgotten, especially in that pre-hospital time. But it was 98, I think, coming out of the OR. So now it's just dealing with the consequences, right? So it's potential ongoing transfusion needs. You know, we do have thromboelastography at some of our role threes. We might be able to do that. You know, reassessment of, you know, depending on our lab capability, reassessment of transfusion needs, electrolytes, you know, and looking at the multi-organ failure from the potential ischemic injury, right? So is he going to pee for us? We're going to have to deal with that. You know, what is his lungs are going to look like? Are we going to deal with an ARD situation? So, presumably, all that's going to happen given that degree of injury. Yeah, I think the principal takeaway is that his stability after the OR is temporary and is really, is an evolving process. You know, he may not be, you know, sick right now, but he's likely to progress to increased illness from a multi-organ, you know, standpoint because of the ischemic time more than probably anything else. And even, although I will say, you know, now that we have moved to component, you know, a higher ratio component therapy and increased use of fresh whole blood or even cold-stored whole blood, you know, the inflammatory injury that we used to see when crystalloid was added to that mix is much, much less than it once was. So without the ischemic time, like this guy, if he just had the superficial soft tissue injuries and he consumed, you know, a whole bunch of, even it was a multi- extremity injuries and they had been controlled with tourniquets and he had gotten an equivalent or similar blood product resuscitation, you know, he might actually not look too bad for a while just because of that type of hemostatic resuscitation. It's really the ischemic time that we've seen here that's going to become a problem moving forward, I would think. I would think about the things that we've missed, right? So now does he need, he probably needs a CT scan, his head and his spine and his thoracic aorta. I mean, you know, who knows what else is there. So I'd be thinking about some sort of CT scan and then get out that ultrasound and be looking at what we missed. And I think in the era of Riboa, if they took the sheath out, I think, you know, looking at the femoral access site with the ultrasound while you either refast, you know, the ultrasound is a great tool. I mean, you guys are probably better at it than I am, but I would be, you know, trying to really look at things that we may have missed while we wait for his oligary and his pulmonary failure and these other things, and probably include a CAT scan. Just to show that our perception of what's sick is completely skewed. This person is not sick, but that's because we deal with a lot of sick patients. So in the World 3 in the ICU, there's a continuing massive transfusion. The lower extremity has, the wound back has large output. Four to six units of blood transfusion is necessary every three to four, or 30 minutes to 45 minutes. There's, you're starting to go up on your vent settings. PEEP is 15, FIO200 percent, and patient is starting to desat. We've all seen, many of us have seen this. So at this point... Did he have a TAG anywhere in there? TAG is cooking, but you're having trouble with oxygenation at the moment. Okay. John, would you see, would you CT him? Or would you wait? I think at this point I would, I would wait. I'm worried about his oxygenation, so I think the first thing I would do is start going up on his mean airway pressures to try to help him oxygenate. And from what you know, what you have available in a World 3, and what, what are you thinking? I mean, can you, what capabilities do you have? All I got is PEEP. How about you guys? The rest of the panel, some thoughts about vent management? And we have a full, you know, a fully capable, you know, role, you know, pretty much modern ICU ventilator in a World 3, and you can really pretty much use almost any, you know, strategy on a ventilator that you want. You know, presumably this guy's still largely sedated and paralyzed. I would probably go with your traditional low tidal line, you know, approach with at least moderate PEEP to begin with, and then, you know, kind of see how things play out. Presumably they're going to not play out in his favor. And we're going to be thinking about more advanced care, and that more advanced care in, you know, today's day and age is getting people ready to come and help you. And, you know, I don't know when it's going to happen, but presumably if his lungs continue to get worse, and we're going to want to move him out of the role three in the next 48 to 72 hours, that's going to involve probably an acute lung injury rescue team and ECMO. And that's, you know, those, it's never too early to start getting a team ready to start thinking about coming to get that if you're going down that path. Are you calling for the ECMO team now? I don't think so. I think we're just, that's in the back of the head as you're trying, you asked about the capabilities that are available. The standard capabilities for regular ICU are available, but you don't have, you know, you can't transfer them down the street. You have to transfer them across the world. So it takes that team a while to get to you, and you have to start thinking about that reasonably early. It doesn't mean that they're coming. It just means that you need to be prepared to get them ready when you think that you need to pull that trigger. I would say it's not wrong to call them. I mean, was it 209-116-ECMO, right? Can you, can the audience, can you talk about that capability? What is that? Yeah, so that's the, I mean, that's the hotline that goes to the Brooke Army Medical Center, to the ECMO team there. You can also, you know, fire up the burn team, too, for, no pun intended, for getting out for our burn casualties. But, yeah, I mean, you can think about it as an ECMO consult, right? I mean, just as, you know, we saw, you know, for an ECMO referral center, just like in CSER and whatnot, I mean, it's a good chance to both get them ready, get them on the radar, because, you know, just getting people to pack and get ready, it takes time spinning that up, right? So, again, that kind of activates, get people prepared, so they're at least thinking about it and making some initial steps to make a trip. Additionally, depending on, you know, there's a wide variety of experience, and certainly it's an opportunity for the provider at the bedside to talk through the event management, right? I mean, there could be some other things, you know, what is my particular event doing? Can I do APRV? Can I do inverse ratio, you know, with the stuff I have on hand? So, you know, I think it helps with that dialogue, gets people activated and thinking about it early. And I think that, you know, as long as he is still having evidence of bleeding, it's important to recognize that we're not giving this guy crystalloid. That's not going to make his lungs any better. So, you know, the number one thing we've got to figure out is why is he still bleeding, and how do we stop that, and only giving the appropriate resuscitation during that period of time, because that will make his overall trajectory better. So, moving on with this case, in the ICU, a new seventh French sheath is placed for another Ebola because there's continued bleeding, and that is inflated for another 30 minutes, decreasing bleeding from the flank, and now you're not giving blood, you know, six units of blood every 30 minutes. There's a walking blood bank that's initiated again in row three. Four units of whole blood is given over the course of the evening, and norepia started. I think at this point he's starting to get sick. Stable H&H, ABG, and CBC. Post-injury day one, the patient is brought back to the operating room. Repeat IND of the right upper extremity and right flank are performed. The right shoulder is debrided and closed. Abdominal cavity, without any hemorrhage, and is closed, but you notice that the right femoral artery is without pulse, and intra-optis thrombectomy is performed. The roboa sheath and catheter are removed because they notice that there's decreased distal pulses. So all along, the vent is weaned, and so are the pressors. The blood cultures pop up positive already for gram-positive cocci, and so this is what the foot looks like, and I think I'm gonna punt this to Dr. Rasmussen. Yeah, I mean, it looks like it's ischemic. I mean, so I think, you know, depending upon the patient's overall condition, then I think he, you know, needs to have, it sounds like they did a, they explored the left common femoral artery, but they need to do more work, or we would need to do more work on that left lower extremity, you know, with an arteriogram or re-exploration and thrombectomy, probably a below knee. Oftentimes, in these cases, you can't, one cannot perform an adequate thrombectomy from the common femoral, so actually exploring the below knee popliteal artery is sort of the second choice, so that one can selectively do a thrombectomy in each of the tibial arteries. Often, you just can't, you know, trying to do that from the, from the groin or the common femoral artery is a sort of a half-court shot. It's hard to, it's, you're too far away, so cutting down directly on the below knee popliteal to do selective tibial thrombectomies looks like that's, that would sort of be the default thing for me. I wouldn't probably mess around with anything else because the foot looks ischemic, and it sounded like this patient had thrombus in the left common femoral artery, they just didn't, weren't able to clear thrombus more distally. What about prophylactic fasciotomies? Sure, yeah, good point, really good point. At the end of that, below knee popliteal exploration and selective tibial thrombectomies, then doing a prophylactic fasciotomy of the leg would be a good idea. I agree. Is that pretty standard care? Well, I'd leave that up to others. I mean, that would be standard care, you know, in our, in our hospitals here, and if the expertise, you know, you mean the fasciotomies? Yeah, I think so. Yeah, and we, I think downrange, you have to be very liberal with them because they're gonna get on a plane for up to 12 hours, and you can't do fasciotomies, at least not adequately, on the, on the back of a plane. The, the challenge is, and I, you know, I know this is a sort of, the discussions accommodates sort of a little bit of, I don't know, controversy, or, you know, we can talk openly. The challenge is what standard of care treating that foot at the role three, and without, I guess, you know, one can't be critical of this life-saving sort of heroic effort, but, but it does come to mind, you know, with, with the, the scenario at the role three, you, you've had to do a thrombectomy in the left common femoral artery. You did that. Presumably, the thrombus is out of left common femoral artery, but the foot still looks like that. The, now we, now you need to explore the below knee popliteal artery. That is not, that's, that's, it's bad. There's thrombus. That scenario is one of incomplete thrombectomy and a, you know, profoundly ischemic foot. It's challenging, you know, it's easy for me to say, but, you know, are our, you know, general surgeons, or, you know, is the whole team on board with that, and do they have the experience? John, I don't know what, you know, you train a lot of general surgeons, and you're in this field, I mean, probably more directly than I am. I mean, what, what are your thoughts about that? Because I think that probably wasn't done here. Yeah. I don't want to. That's not a core competency for general surgery anymore. Right. Obviously. So, the place I learned it was actually in 2007 in Baghdad, and we saw a lot of upper and lower extremity vascular injury, but that's where I learned how to do the old-fashioned on-table angiogram, and figured out how to pass catheter distally. Right. And you got to go below the popliteal trifurcation, or I'm sorry, I mean the trifurcation to do an adequate thrombectomy. Right, because what you'll see with the, the angiogram from the common femoral is there'll be flow to the popliteal. You've successfully, you know, you've removed thrombus in this SFA, but now the sort of the three-point shot or the half-court shot, you can't reach it with a thrombectomy catheter from the groin, so then you have to go below the knee. And I won't, without trying to spoil the case, I believe, if this is the case I'm thinking of, that necessary procedure was done 16 hours later at SAMHSA. You know, and it's, it's a difficult thing because it's, you know, we've... Just accessing the popliteal artery is, is not easy. It is not easy, and, and it's, it's very difficult to comment on those things without sounding critical, because it's, you don't want to do that. We've been through 15 years of, yeah, trying to be, to be professional in these venues, but it is a challenge for the younger general surgeons that we're sending down range. You know, as you just pointed out, it's not a core competence. I mean, we need to... It speaks to why we're doing this, right? Yeah, yeah. I mean, they, they save this guy's life. Yeah. So we send all of our general surgery residents at Penn State to the ASSET course, which is a phenomenal course that teaches you how to do things like access the popliteal artery, which I think is great. So if I could, since it's not a core competency of general surgery, is there a need for additional competencies for the military general surgery? Absolutely. Yeah, and I think Mark Boyer is working on that ASSET course, ASSET Plus, that has military competencies added to it, which I think open vascular procedures is going to be a huge one. Yeah, so from my understanding, there was not a vascular surgeon at the role three at that time. Yeah. So these are general surgeons doing the best they can. The, the issue of this infection, I think that's also just important to note, I don't remember seeing antibiotic on there. I had, right before you started moving on, I was about to talk about we all should probably add antibiotics, but you know, that's a, that's kind of a thing that we would all, would, I was assuming was kind of already done, and we didn't specifically comment. So on that first round out of the OR, that is really the intensivist job to really go through, and system by system, just like we always do, make sure you haven't missed something. So it's not just missing the injuries, it's missing the, you know, standard medical things that you need to make sure you have applied to that individual. We were still working on lungs and resuscitation at the time, but it's, that's also the time when you cross all your T's and dot all your I's with things like antibiotic therapy. So presumably we've looked at his head at some point in time with all this as well, or gotten some sort of neurologic exam after that first OR that he's able to, you know, still be with us. So the patient is shortly weaned off pressors. In the operating room, the left foot is modeled without any signals, and so they do a cut down, and a thrombectomy is attempted, but it appears to have one vessel runoff. There's a four compartment fasciotomy done. This is what the foot looks like. So they did, they did do it downrange? Yeah. Yeah, I mean, great, you know, awesome. Right. You know, because it must have taken the Asset Plus course. Or been trained by John O. So total blood products in this patient up to this point, in the pre-hospital setting, we're talking about ten total of cold stored whole blood, and some fresh whole blood. In role two, you got this much. Role three. So in total, we're talking about a hundred and eighty three units of blood for this one patient. And so as you think about this, Dr. Boardman, would you like to comment? Specifically, you know, I'm interested in, you know, the cold stored whole blood. That's a relatively new thing that we started doing. Is that just as good as fresh whole blood? I mean, should we continue to do this? What are your thoughts? Well, you can go back a slide just for that. You're just spalling here. I just don't want to look at my face here. There we go. Don't tweet that out. Yeah, so, gosh, so just, I mean, ten units of blood pre-hospital. It's just, you know, pretty dang remarkable, right? I mean, again, we're starting to do a little bit of that in the States. You know, in San Antonio, we have, now we have whole blood pre-hospital with, you know, set strategically as part of the EMS system. You know, I think, you know, I mentioned briefly before, but, you know, it's gonna be difficult to get this out everywhere, right? I mean, I think there's huge potential for just a freeze-dried plasma product in lieu of this. But in terms of cold, to answer your question, in terms of cold stored whole blood, you know, we need a Dr. Kapp here, who's, you know, this has been a lot of his life's work, but, you know, you know, when I do my little competency for transfusion and there's, for blood products in our hospital, you know, there's that big no-no of putting platelets or whatever in a cooler, right? You know, it can't, you know, it's a no-no. They all die when they go in there, but, you know, but, you know, I think what he's shown and, you know, a variety of his work is that you're actually not only restoring the functionality of those platelets, because those old studies were just done on platelet counts, but the functionality that was restored, but also there's potentially decreased inflammatory response. We need to think about blood as a living thing, right? And so if it's kept warm, I mean, fresh whole blood is different because it's given, you know, right away, but if it's stored and kept warm, as we are doing with platelets, you know, there's this ongoing inflammatory response happening. And so being cold-stored is actually mitigating that, so I think there's, you know, certainly an advantage for this casualty by receiving that. You know, we also didn't mention ongoing, well, we're not sure if TAG is available, but, you know, considering ongoing TXA, you know, if there's continued bleeding and, you know, not, you know, giving us shrapnel and oozing that's going on to help with that. But, yeah, and that's just a remarkable mass of transfusion, right? Do you think this person could have gotten this kind of transfusion 15 years ago? Possible? So, I mean... Not that much whole blood, right? Yeah. That's, you know, that's all brand new, and, you know, and I think about, you know, purely if this was a, I mean, platelets are not available here, right? Or there's some, but if this was all, quote, one-to-one-to-one, without all that whole blood, they would have gotten a whole bunch more of the material in the, you know, the preservative material in those individual units as opposed to getting whole blood, where it's much less of that preservative material, which is, you know, certainly better for this casualty. What we're missing on this slide, and it really probably should be, I mean, I think many of us have started included on the total blood product transfusion is calcium, right? I mean, there's no way this guy didn't get a whole lot more calcium than we once gave before, especially with that blood transfusion. And, you know, keeping track of that as if it was part of the resuscitation is something we are doing much better at. I have a question about the calcium. Are you giving that, do you give that to a target range? Is that, or do you give it... Well, pre-hospital, it's just empirically. So, yeah, the rangers that were trained to do that, it's just drilled into them. I mean, they're doing, right now, they're trained to do that fresh whole blood, you know, so not the cold store they had there, right, but the fresh blood that they gave. They can give that from under 20 minutes, so 10 minutes of kind of donation aspect and then 10 minutes of administration. So they got that under 10 minutes. So, in order to do that, you got to, you know, drill, drill, drill, drill, right? And part of that drill is giving calcium, so that's given empirically. Is it, and how much per, is it, do you train, you know, giving a certain amount per 10 units of blood, or is it... Yeah, it's all protocolized. I can't recall offhand. I think it's two grams, four grams up front? Oh, no, no, no. It's a gram at a time, as far as I know, but after every, essentially, four units, I believe is what we're at. And then once you get to the hospital, we're a little bit more, you know, lab maybe dependent, but it's hard to know. I don't know that you can give too much calcium to somebody who's actively bleeding it out on the floor, right? You're not really trying to, you're just trying to make sure that what is available is working, and it's, you know, rapidly being lost as well, just like all the other parts. Right, you know, I think we need a, you know, I think we're, here, we're definitely, I think, a little too attuned to, you know, checking ionized calciums, keeping it above 1.1 or whatever, but in this, in this type of setting, you know, certainly should be given empirically, you know, as the patient's bleeding. So, in addition to this whole blood, I applaud them for getting close to the Borgman ratio here, one to one. Okay, so this is what the CT scan, they finally have a chance to do the CT scan after the, this heart tick, and patient's stable, quote-unquote, and here's what reconstruction looks like after the washout. They try to pin as much as possible, do what they can. So, prior to transfer, a heparin is initiated for that thrombus, and then a vent is further weaned. They added meropenem and amphotericin, and then CRT is started. The panel comment on that. What was the indication for dialysis? The potassium was 7. Good idea. CK was beyond, above limit, the high limit of detection. They diluted it 10 times, and they could still, they still couldn't detect it, or it was just too high. So, massive rhabdo. So, is that something that is available in the Rule 3? It used to be, yes. Now? Depends, right? Certainly, the theater, the theater hospital, the theater Rule 3, where we evacuate out of, we now have that, I think, fairly routinely in place. I don't know that we always have an individual there that knows how to effectively order the CRT, but, you know, we certainly have telemedicine support available to help with that if needed. It's, you know, if you have acute renal failure with hyperkalemia, this is the best option available to do it. It doesn't need to be done with, you know, systemic anticoagulation. It can be done with regional anticoagulation. It can be done with adequate anticoagulation for a period of time, you know, assuming the person is able to, assuming that it doesn't clot too quickly. This challenge with this person, he's still fairly inflammatory, so he's likely to need some at least regional or circuit anticoagulation. We could probably debate all day about the value of, you know, replacement therapy, high volume replacement therapy, circuit changes related to using that mode of, that modality to try to help with rhabdomyolysis. Probably not the purpose of this talk. Some people might do it, some people might not. So you're absolutely right. Whoever spoke up in the audience, I can't see from here, it's so bright, but some Roll 3s have this capability, but it's not written into the field hospital manual and equipment set. And so that's something that we are working on. There are some in the community that feel like we don't need that capability, but I think this case highlights the fact that yes, we do need it. So it turns out the ECMO team was called because they were unable to oxygenate the patient and they, the ECMO team launched prior to the patient getting better. When the ECMO team got there, the patient had improved, but because of the hyperkalemia, they decided to start CRT and continued it in flight. I'm just gonna go directly to the picture. So this is in the back of a C-17 and they have the impact ventilator and here's the next stage, no financial connection. And this is something that we do have the capability to do in flight with the ECMO team and we've done two other cases like this where we do CRT in flight. This is Dr. Mason. He's the ECMO director and he jumped on the chance to get on this mission and thought he was gonna do ECMO, but decided to do CRT instead. For 19 hours, they managed the patient in the air somewhere in the middle of the Atlantic. They did a mid-air refuel because they didn't have time to land or just couldn't afford to and they were able to get to San Antonio in 19 hours. Okay, at this point I'm gonna take a brief pause and open it up for questions to the audience. This is now transition between role 3 and 4 care and then before admission to Brooke Army Medical Center. No questions? You want to jump right in? So, the Rule 3, you should be able to do definitive hemorrhage control. So it's no longer the hypotensive resuscitation is more for the pre-hospital environment. I think at Rule 3, you can assume that you have hemorrhage control. And I think what's happening now is the patient's actually septic. And that may be a big reason why he's hypotensive. But just going back to CRT, I mean, they showed in Korea that dialysis in theater improved outcomes. Why is it still not on our MTO? I don't know the answer to that. That's a very good question. It's incredible. And I've explored this myself personally. And one of the arguments that they always bring up is, hey, we had a just-in-time dialysis team model ready to go during Iraq and Afghanistan in its heyday. And it was never utilized. So why are you saying all of a sudden that you need renal replacement therapy capability? Just they're not thinking about what's in the literature and everything else. I will say that there's all the other things you've got to think about as an intensivist. When they're in the ICU, if you're hypertensive, in a trauma case, and you're on a ventilator, and you're not getting, and you're getting some sort of medications, one of them should clearly be pain medicine. And it would only be something that would come to the forefront of my mind is, does this person, not necessarily sedated, but are they getting adequate analgesia for their injuries? Okay. We're going to continue this case with Dr. Cantillo. Thanks, Dr. Chung. So the patient arrives at Brooke Army Medical Center. And the patient, at this point, to summarize, has bilateral pneumothoraces. He's got a fracture of his right iliac pelvic wing. He's undergone an attempt at open reduction internal fixation. He has undergone a hip disarticulation. He's got the right external iliac artery injury, the right lower extremity traumatic amputation, the right upper extremity injury and amputation. He's got massive soft tissue injuries, a little burn. He's undergone some excision, debridement. He's got sigmoid colon injury, which has been repaired. At this point in time, as stated, he's got acute kidney injury, rhabdomyolysis, bacteremia. And his left lower extremity is still ischemic, attributed to complications of reboa placement. Physical examination at that time shows no double or single signal in the left foot. The pelvic flap is dusky. His SATs are fairly poor, but he's only on 50% FiO2. He's got a couple chest tubes. He's got a huge VAC. He has a base deficit of 5.8, a high lactate, a high CPK, he's coagulopathic. He's got a low white blood cell count and he's thrombocytopenic. This is a picture in the operating room upon arrival to Brooke Army Medical Center. You see the big VAC and the necrotic-looking pelvic flap. Close-up of the wound. This is a problem wound. I think we could all agree. You see wires through the ischium, attempted ORIF. We can see a ligated external iliac vein and artery in the midst of the wound. This is the upper extremity stump on presentation showing some ongoing necrosis. Surgical options at this time, considering specifically the left lower extremity, doctors, would you perform a left below the knee amputation, isolated limb perfusion, an arteriogram? Would you perform operative debridement and VACing of the rest of the wounds, leaving the left lower extremity for later? Would you do systemic anticoagulation and serial exam of the left lower extremity or some combination of the above? Can I ask, what do the muscles look like in the left leg through the fasciotomy wounds? Are they? They look dusky and poorly perfused. I would amputate the left leg. It sounds like it's killing him. I mean, I agree that it sounds like it's contributing to his complicated picture. So I think he should have it amputated. I know what, yeah, go ahead. I was just going to say, you know, the intensivist says something's dying, I need a surgeon. It may be a leg. He's got a lot of other injuries. It's got a fairly extensive look. It can't just be his leg. Yeah. Well, sure. He's got maybe some other items, but if leg is the focus, and that's the only place we find that's dead, then he's not getting better right now, and he should be, and something's not getting adequate perfusion. So the patient underwent isolated left lower extremity limb reperfusion with Heparin and CPT-PA in an effort to salvage that limb. That success was ultimately unsuccessful in that Doppler flow was momentarily regained and then lost six hours later. Subsequently, the CPK increased from 5,500 to 20,000 by the next day, and he underwent the left below the knee amputation along with a completion hemipelvectomy. The specimens from the completion hemipelvectomy and the remaining wound at that operation after the hemipelvectomy. Meanwhile, an infectious workup was initiated or continued. Vancomycin, meropenem, and amikacin were administered. Blood cultures came back positive from theater, enterococcus sensitive to vancomycin, and then blood cultures came positive for carbapenem-resistant enterobacteriaceae, specifically New Delhi metellobetalactamase 1 E. coli sensitive to amikacin and colistin. The practice against invasive fungal infection was begun as per protocol using liposomal amphotericin B and voriconazole. On the 21st, ambizome was stopped, and on the 24th, histopath came back, and the ambizome was stopped because the wound started to look cleaner. But on the 24th, histopath from the 19th of August, an interoperative specimen demonstrated from the right shoulder angioinvasive fungus in both viable and non-viable vessels, specifically broad 90-degree angle branching with few septae in the organisms. Interestingly, fungal cultures were subsequently negative from that surgical specimen. So for this situation of apparent angioinvasive fungus in a blast-injured patient, would you resume the ambizome and continue the voriconazole? Would you add other antifungals, stop the antifungals? Would you also continue amikacin, replace with colistin, or give both for the MDME coli, some other antibiotics? Or would you just take the patient back for repeated wound debridements, doctors? Yeah, I was going to say, I'd call that guy right there. The first step is probably getting to the operating room. And the answer is? Right. Yeah, a couple of comments about the antibiotics. The histopath you described sounds very much like aspergillus, right? It could conceivably be scutosporium. But so any septate hyphae with angioinvasion, probably aspergillus, maybe that. Vori is the only reliably active drug against scutosporiosis, and it is the drug of choice traditionally for aspergillosis. So I would keep the voriconazole on board. I'd probably ditch the amphotericin. I'd probably add an echinocandon, like mycofungin. I'd probably find the toxic dose and use that. So it'd be like 150 of mycofungin. That wouldn't have any activity against sceeto, but there's some soft data that that can augment the benefits of voriconazole for invasive aspergillosis. But ultimately, it's going to be, obviously, debridement the best you can. As far as the treatment of the other two things, this actually illustrates, interestingly, he got empiric ertapenem, which I know is a common practice in prolonged field care settings, but I would respectfully discourage that as empiric perioperative or kind of point of injury prophylaxis in someone who's got evacuation within the short term. And this guy illustrates a good example of it, because he promptly grew out three things that are resistant to, or not grew out, but demonstrated three infections that are resistant to carbapenems. And this is the experience we had in OIF and OEF with highly resistant Dastanetobacter. The prophylactic agent should be cefazolin. And cefazolin and cold steel are your prophylactic agents of choice for infection. So probably what I would do for that metallobeta-lactamase producer, that NDM1 carbapenemase-producing E. coli, is tentatively I would use a combination of Avicaz, of cefazidime avibactam, and then aztreonam. These isolates tend to produce multiple beta-lactamases, of which NDM1 is just one of them. Aztreonam is resistant to hydrolysis by NDM1, which is handy. But then you have the avibactam on board as kind of a suicide molecule to mop up the residual ones. You could use colistin. Polymyxin B has better pharmacodynamics than the critically ill. And I would use that preferentially instead of colistin. If you're stuck using colistin, amikacin isn't going to get into any of that tissue. It'll help clear the bloodstream better, but it's not going to kill the infections. And then vanc for enterococcus is fine, but enterococcus is not the thing that's going to kill them. I hope that helps. Thank you very much. Dr. Lindberg, burn surgeon, I had a patient who ended up with fungus, right angles, and it turned out to be mucor, and in that case, your only choice is surgery. And what I learned to do was send any tissue, debridement tissue, to the path lab and have them stain it, because I got the result back faster than cultures. And so I could debride the culture, send it for fungal staining, and within two days, I'd know if there were still fungal elements there. So every two days, I could take him to the operating room and know that I was getting clean margins rather than waiting for culture results. Very good. Thank you. So, interestingly, both antifungals were stopped, and the rationale for that, personally, to be frank, I probably would have continued antifungal therapy. The operative decision, the decision was made based on the appearance of the wounds. The patient went back multiple times for debridement and inspection. The right upper extremity stump was clean, and what appeared to be angioinvasive infection was effectively extirpated surgically. The patient was given colistin for the E. coli and the amikacin was stopped, continued to receive vancomycin for the enterococcus. The bacteremia cleared. However, the patient was diagnosed with sacral osteomyelitis based on intraoperative bone cultures from the 23rd of August. The patient received cephiderical anticycline for four weeks as treatment for that sacral osteomyelitis. Doctor, would you have any comments about that new cephalosporin? These images show the continued progression of that right flank wounds. There was an abscess in the left gluteal region which also grew out some E. coli, surgically drained. This shows stump of the right common iliac artery at its origin on the aorta where it was resected. On the 4th of September, in response to septic-appearing physiology, the patient underwent a PET scan, demonstrated apparent inflammation of his sembromembranosis on his left lower extremity stump. Then upon incision and drainage, it was found to have chronically inflamed muscle with no infection. So that was ascertained to be a red herring. This shows gradual efforts at wound closure. On the 10th of September, the patient underwent placement of bone cement over the right border of the hemisacrum. You can see also the extraperitoneal rectum in the wound. Subsequently, the patient underwent some autografting of the muscles. Bone cement is intact, the rectum is still in view. Alloderm was applied over the rectum. Integra was applied over the sacrum. By the way, he's got a stoma over his anus due to a period of incontinence. That's not a true stoma, it's just a stoma bag. Further improvement in the appearance of his wounds. This is the appearance of the Integra after removal of the silicone layer and right prior to autografting. This is day of discharge on the 2nd of December. Well-healed wounds in this area, remaining sort of opening there in the region of that gluteal abscess shown previously. Here he is doing some rehab in the intensive care unit. And here he is starting ambulation in the gym. And subsequently, he was fit with prosthesis for his hemipelvectomy. So I think the injury was in October, so November, December, so about two months. It was a pretty decent recovery rate. This man walked across the parking lot from the hospital to the Center for Intrepid in order to go to therapy. So you know, I told him, you're an inspiration to me. In any event, in early 2020, the patient was readmitted to the hospital for left lower extremity amputation revision. And therefore, he was non-weight-bearing for the first time in several months, you know, in a couple of months. He had to be a prolonged chair or bed rest, and he developed severe low back pain during this period of time. With frequent ER visits for severe pain over a two-and-a-half-week period. He did not have any numbness, weakness, or loss of sensation to his residual limb or lower body. He didn't have constitutional symptoms or other evidence of an infection. His labs were normal. Rather, the pain was attributed to rotational stress on the spine due to a lot of sitting and twisting while sitting. In the emergency department, he received toroidal rubaxin, gabapentin, and oxycodone, and he could not be weaned from narcotics. For this increasing chronic pain problem, doctors, would you admit him to the ICU for pain management to include opioid detoxification and a ketamine reset? Would you evaluate him for revascularization of that residual left lower extremity? Would you perform a lumbar puncture, obtain an MRI scan or CT scan, or some combination of the above? I think I need more information, so I think an MRI and a CT would help. So the patient was admitted to the ICU for ketamine reset, which is a form of opioid detoxification. Indeed, an MRI without contrast was obtained, and it demonstrated possible L5S1 osteomyelitis and discitis. The following day, he had an MRI with contrast, which confirmed that, and also showed no epidural abscess. A couple days later, he had a CT scan, which again confirmed that. He was treated with vancomycin and zosyn. This is the MRI, which shows that osteomyelitis and discitis at L5S1. This is the CT scan. I think you can appreciate how those vertebrae look chewed up. So your options for this osteomyelitis, which for all I know had something to do with the original sacral osteomyelitis, would you place a PICC line for prolonged antibiotic course and repeat imaging in a month? Would you do an LP, perform a biopsy of the disc, perform a laminectomy and discectomy, perform a partial corpectomy of L5 and S1 and discectomy, or call an orthopedic surgeon or a neurosurgeon? I think he's going to need a PICC for prolonged antibiotics, and then I call the spine surgeon. I think the real key is, you know, doing this empirically is potentially fraught with error because, I mean, you really need to get a culture of this based off of historical antibiotic resistance and understand what you're actually dealing with. So to not try to, you know, get some, certainly you can start with some easy cultures. You may get a, you know, a blood culture that gives you a reasonable answer, but that may not make him better until you really understand what the source, what the inciting organism is. So the patient underwent an L5-S1 disc biopsy, and it was positive for the same NDM E. coli. The zosyn and vancomycin were stopped. The colistin and tigacycline were resumed. On the 5th of February, he underwent an L5-S1 discectomy and a partial corpectomy. I'll show that in a second. And he was started on avocasin-astreonam with sensitivities to the esophageal recall pending. During that surgery, interventional radiology placed a breast biopsy-type needle into the inner space to facilitate the surgical approach through the previously operated flank. They found a 75 percent disc destructive infection. They did the discectomy, they debrided the bones, and they placed a cage. Here's the sort of needle localization of the target surgical approach. This series of images shows the insertion of the strabiculated cage and its gradual expansion under fluoro. That's the cage going in, and this is the postoperative CT scan. So postoperatively, the patient was transferred to the Burns Center ICU for intensive inpatient rehab and critical care. He continues to recover with increased tolerance to rehabilitation and upright posture. A checkerboard analysis demonstrated synergy for the combination of avocasin-astreonam, and the plan is for an approximately eight-week course of antibiotics. And he's in the ICU. He's not critically ill at this point in time. Next question. I would add that probably being in the Burn ICU, the big advantage there is just the remarkable physical therapy, occupational therapy team that you have there for this kind of patient. And they're doing it with not just this kind of patient, but as well as the complex Burns and even the ECMO patients. They're getting up and walking. So it's a remarkable team that is an essential piece of his care. Absolutely. This case really highlights for me that outcomes in general is more than just live-die. There are lots of other things that go along with patient recovery that needs to be optimized in and outside the ICU. Any other questions or comments from the audience or panel members? Okay. So for the sake of time, I don't think we have enough time to go through the entire next case. I'm going to call an audible and just end early if that's okay with the audience. But before we do that, I just want to acknowledge a few folks. This would take us an hour, so I don't want to put you through that. Well, we could just ask the panel members, okay, diagnosis, treatment. We should have had a skip ahead option in our PowerPoint. Yes. Dr. Chung. There's the lupus part, Dr. Pamplin. Yeah, he was afraid about that. Well, there's nothing to be afraid of. You know, the point you made, Dr. Chung, about the outcomes after a major injury like that, it's very important to me because we got to the point in that man's recovery where he had a huge setback featuring intractable pain. And so from the standpoint of full recovery and rehabilitation, he was now a failure. So I think the importance of that long-term approach to the care of these patients is 100% on target. So this is really just a reminder that a lot of people really contributed to the case that we just discussed, and it took an entire multi-D team to make this patient get to where he is today. We also want to acknowledge Margarita Carter, who was instrumental in getting us this information, and then Colonel Jen Gurney, who could not be here today, unfortunately, due to her deployment. She's currently somewhere in the Middle East. Do you guys know where? Afghanistan. Afghanistan. And she typically moderates this session for us and basically is the founder of this entire concept. So I want to give a shout out to Jen Gurney. And you can tweet this picture. She's getting an award for being the best colonel physician in the Army. So a huge honor that basically a top doctor in the Medical Corps being given by our former Surgeon General. So we also want to thank the esteemed panel members for their participation. I hope I didn't make you guys too nervous. But your answers were tremendous. And thank you for Dr. Cancio for co-moderating this session with me. Thanks for coming, everyone. And you're out early. Thank you. Awesome.

critical care

improvised explosive device

role-two facility

rapid assessment

blood transfusion

surgical team

ongoing monitoring

ventilation management

severe lung injury

combat environment

antibiotic therapy

osteomyelitis

multidisciplinary team