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5 < Back Critical Care Resources Society Guidelines CHEST Guidelines. Topics addressed include: Acute Respiratory Distress Syndrome (ARDS), venous thromboembolism (VTE), and liberation from mechanical ventilation. Antithrombotic Therapy for VTE Disease: Executive Summary (2021) SCCM Guidelines. Topics addressed include: Surviving Sepsis, management of pain/ agitation/ delirium, nutrition, critical-illness-related corticosteroid insufficiency, etc. Infectious Disease Society of America. Critical Care Nutrition. Nutrition guidelines and bedside tools (i.e., Nutric score). European Society for Clinical Nutrition and Metabolism (ESPEN). References ICU One Pager. "Critical care education one page at a time. Simple, free, & open source." High-yield clinical topics condensed into single-page reference cards. Other topics addressed in more detail include point of care ultrasound (POCUS) and COVID. The Bottom Line. High-yield journal article summaries focused on the diagnosis and management of critically ill patients. Critical Care Reviews Newsletter. Weekly update on the most up-to-date literature. Register to receive the email weekly. Life in the Fast Lane [LIFTL]. ICU providers provide educational resources for EM and critical care, including EKG interpretation and the Critical Care Compendium. REBEL EM. Journal reviews, tutorials, and other educational tools. Focus is emergency medicine, but plenty of cross-over with critical care. Stanford Critical Care Educational Resources. Free education resources hosted by Stanford Medical School. University of Maryland- Critical Care Project. Critical Care Now. Deranged Physiology. Antibiotic Coverage Diagram [image] EM-Crit Project. Parent website of the Internet Book of Critical Care and PulmCrit. The Internet Book of Critical Care (IBCC) PulmCrit - blog entries on practical ICU topics. Venous thromboembolism and anticoagulation management Anticoagulation Provider Toolkit Anticoagulation Desktop Reference Anticoagulation in Non-valvular Atrial Fibrillation Anticoagulation in Venous Thromboembolism DOAC Bleeding Management Anticoagulation in Pediatric Venous Thromboembolism Periprocedural Management (DOAC) Periprocedural Management (Warfarin) Cardio Nerds Infographics A Guide to Temporary Mechanical Circulatory Support in Cardiogenic Shock Inotropes Pulmonary Embolism Management Anticoagulation for Atrial Fibrillation/Flutter Push-dose vasopressors Push Dose Pressors: Your Quick & Dirty Guide emDOCs: Push-Dose Vasopressors: An Update for 2019 Scott Weingart: Push-dose pressors for immediate blood pressure control Tutorials Edwards Science Clinical Education. Free access to clinical resources including quick references for hemodynamic monitoring and oxygenation assessment of the critically ill. Quick Guide to Cardiopulmonary Care. Hemodynamic Optimization. Perioperative Goal-Directed Therapy. ScVO2 Monitoring. Thromboelastography. Diagrams of TEG and ROTEM, explanation of methods and variables. Previous Next

1 < Back Textbooks General Surgery: Scientific Foundations Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 21st Edition, 2021. This is the detailed explanation of the science behind the practice of surgery. This is the basic science textbook I used during residency. Mulholland and Greenfield's Surgery: Scientific Principles & Practice. Previously known as "Greenfields". General Surgery: Beyond Basic Science Cameron's Current Surgical Therapy. 13th edition, 2019. Short chapters with high-yield information on every topic in General Surgery. Must-have for later in residency. Trauma Mattox Trauma. 9th edition, 2021. The trauma surgery bible. Highly recommend. Critical Care Marino ICU. 4th edition, 2013. The ICU bible. Highly recommend. Civetta, Taylor, & Kirby's Critical Care Medicine. 5th edition, 2017. A detailed explanation of physiology, diagnosis, and management. Finks Critical Care. 7th edition, 2017. Slightly less detailed than Civetta. Excellent book- not too simplistic and not painfully detailed. Evidence-Based Practice of Critical Care. 3rd edition, 2019. Reviews the literature regarding specific high yield critical care topics. Surgical Critical Care Therapy: A Clinically Oriented Practical Approach. 1st edition, 2018. Essentials of Mechanical Ventilation. 4th edition, 2018. Previous Next

< Back Pre-Peritoneal Packing When: blunt pelvic trauma with hemodynamic instability. How: 1. Low vertical midline incision, stop a short distance below the umbilicus. 2. Split rectus, retract laterally, the peritoneum is just behind the rectus. 3. Slide hand directly under the rectus- palm toward peritoneum and back of your hand toward rectus. Bluntly dissect laterally toward ASIS. 4. Retract rectus anteriorly, use your other hand to place rolled laps in the potential space you just developed [This how-to guide was designed in response to a query from @obcast ] References Smith WR et al. Retroperitoneal packing as a resuscitation technique for hemodynamically unstable patients with pelvic fractures: report of two representative cases and a description of technique. J Trauma. 2005 Dec;59(6):1510-4 Filiberto DM and Fox AD. Preperitoneal pelvic packing: Technique and outcomes. Int J Surg. 2016 Sep;33(Pt B):222-224. Previous Next

Critical Care Medicine. Trauma Surgery. Evidence-based medicine. Doc on the Run. Medical Literature. Welcome to Doc on the Run! A look into the life and mind of an Acute Care Surgeon Sharing the knowledge and wisdom gained after 38 years of life (and over 20 years in medicine). For those who want to learn about the specialty of Acute Care Surgery , you will find insight into the profession, both from personal experiences and citations from articles and websites. For those interested in the medical profession, particularly surgery, you will find career management tips , including networking and mentorship . For learners (students, residents, fellows), you will discover a wide array of educational resources, including recommended educational resources , tutorials on a multitude of topics, a collection of didactic lectures and quick reference guides , an ever-growing library of literature reviews , and clinical vignettes . For fellow Acute Care Surgeons, please consider collaborating and sharing your experience and wisdom with the next generation. For the bibliophiles, check out the constantly expanding list of book recommendations .

< Back Shot in the Chest- Aortic Occlusion A 30-year-old male sustained a gunshot wound to his left lower chest/ upper abdomen. On arrival, his heart rate was in the 50s with weakly palpable carotid and femoral pulses. Significantly hypotensive. Penetrating wound to the left lower chest wall with an occlusive dressing in place without ongoing hemorrhage. Initial workup and management? Assess mental status. Secure large-bore peripheral IV access and start massive transfusion. A rapid ultrasound of the chest and abdomen revealed fluid in the left chest, right upper quadrant, and no pericardial fluid. We placed a left chest tube with minimal output. Still hypotensive…treatment options? Resuscitative thoracotomy. Urgent OR if vitals improve with resuscitation. REBOA. A rapid secondary survey revealed a previous midline laparotomy. This would likely impede rapid access for aortic control during laparotomy, so REBOA was placed through a right femoral artery cutdown. With inflation of the REBOA, he had a return of cerebral perfusion with spontaneous movement of his extremities. He was transported emergently to the OR. We encountered massive hemoperitoneum and extensive dense intra-abdominal adhesions that prohibited easy access for a supra-celiac aortic clamp. There was ongoing hemorrhage despite REBOA. Other options to control intra-abdominal bleeding? Procedures directed at source (compression of the liver, splenectomy, etc). Aortic occlusion above the injury- stops all perfusion below the level of occlusion. This can be done from the chest through a left anterolateral thoracotomy or below the diaphragm (supra-celiac clamp). The patient underwent left thoracotomy for aortic cross-clamp. There were no obvious intra-thoracic injuries. Intra-abdominal injuries included a large Zone 1 retroperitoneal hematoma and left diaphragm injury, injuries to solid organs (liver and pancreas) and hollow viscus (stomach, small bowel, and colon). Management of massive sub-diaphragmatic hemorrhage Aortic occlusion decreases distal bleeding and redistributes blood volume to the myocardium and brain. This leads to a reduction in sub-diaphragmatic blood loss. Traditionally, this is accomplished through an open approach, either via thoracotomy or laparotomy. Concurrent with the expanding use of and comfort with endovascular approaches, endovascular occlusion of the aorta (REBOA) has been re-introduced as a less invasive approach. General indications Traumatic life-threatening hemorrhage below the diaphragm (non-compressible torso trauma) in patients in unresponsive shock Zone 1 (distal thoracic aorta)- control of severe intra-abdominal/ retroperitoneal hemorrhage, or for traumatic arrest. Zone 3 (above aortic bifurcation)- severe pelvic, junctional, or proximal lower extremity hemorrhage. Mixed results regarding clinical outcomes. Essentially the same time to aortic occlusion as resuscitative thoracotomy. Not shown to be significantly quicker at obtaining aortic occlusion than resuscitative thoracotomy. Brenner M et al. Joint statement from the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) regarding the clinical use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Trauma Surg Acute Care Open. 2018;3(1):1-3. Previous Next

< Back Machete Attack- Neck Trauma A 42-year-old male was brought from an outside hospital after sustaining deep, extensive penetrating wounds to the neck and forearms. When he arrived at the hospital, we noted defensive wounds on his forearms and a deep laceration across the anterior neck. The report from EMS was that the patient was assaulted with a machete. What are the management priorities? Prioritize primary and secondary survey and treat life-threatening injuries first. Don't be distracted with impressive wounds. Secure the airway and control active hemorrhage. He was initially seen at a small community hospital, where an endotracheal tube was placed through the tracheal wound, and then he was transferred to our facility. He was rapidly transported to the operating room for evaluation. What structures need to be evaluated? Vascular structures (carotid arteries, vertebral arteries, jugular veins) and upper airway/ digestive structures (esophagus, pharynx). The head and neck team was consulted, and they evaluated him in the operating room. The wound's extent was explored thoroughly. Surprisingly, there were no injuries to the vascular structures, and the injury was isolated to the airway. The endotracheal tube was exchanged for a formal tracheostomy and a stent was placed in the upper airway to prevent luminal narrowing while the repair healed. The wound was closed in layers. Management of Penetrating Neck Trauma WTA Algorithm Anatomy Zone 1 Clavicles/ sternum to cricoid Zone 2 Cricoid to angle of mandible Zone 3 Angle of the mandible to the skull base Hard signs- airway compromise, massive subcutaneous emphysema/air bubbling through the wound, expanding or pulsatile hematoma/ active bleeding, shock, neurologic deficit, hematemesis. Soft signs- hemoptysis, blood in the oropharynx, dyspnea, dysphagia, dysphonia, subcutaneous air, chest tube air leak, non-expanding hematoma, bruit/ thrill. Hard signs or hemodynamic instability→ ensure airway and transport to OR. No immediate operative indications? Depends on symptoms and the zone of injury. Zone 1 and 3- CTA to rule out vascular and aerodigestive injuries; assess the trajectory of injury. Injury→ repair. Concerning trajectory→ triple endoscopy (laryngoscopy, bronchoscopy, and esophagoscopy). Zone 2- symptomatic→ OR. Asymptomatic- serial exams or imaging. Operative approach The most common incision for exploration of neck wounds is along the anterior border of the sternocleidomastoid (SCM) muscle. Exposure of Zone 1 and 3 are more challenging and endovascular adjuncts are useful. Zone 1 may require median sternotomy with extension along the SCM. Zone 3 requires mobilization of the mandible. Zone 2 can be approached with a transverse cervical collar incision with SCM extension. - Tracheal injuries are repaired with monofilament absorbable suture. - Esophageal injury- debride unhealthy edges, ensure full exposure of mucosal defect, repair defect (single or double layer), buttress with SCM, or strap muscle. Place drain. - Combined tracheoesophageal injury- repair, and ensure repairs are isolated with interposition of a well-vascularized muscle flap. Previous Next

< Back Getting Involved Getting involved in your training program and hospital is crucial for your professional development and growth. Here are some tips to help you get started. - Be open to opportunities to get involved early and embrace small projects. Even if a project seems insignificant, it can lead to bigger opportunities. Don't hesitate to accept requests to help write a paper, design a research protocol, or participate in a committee. These small projects can open doors for more significant roles and responsibilities in the future. - Be proactive and take the initiative to get involved. Talk to your mentors and program directors about your interest in participating in projects or committees. Ask for guidance on how to get involved, and don't be afraid to express your interest in specific areas. - Get involved in research. You don’t have to have a strong research background to contribute to ongoing projects. If you have specific research interests, seek the advice of someone with a similar interest and collaborate with them. Different faculty members will have their individual strengths and passions, which are frequently apparent after you interact with them. If you partner up with someone who has a similar interest, they will be able to guide you and lend their support to your project. Training programs frequently have requirements for research and have a framework for supporting involvement in ongoing projects. Research requirements are often a part of training programs, so take advantage of the support and resources available to you. Also, keep in mind that there may be ongoing research projects at your hospital that you can contribute to. - Attend department and hospital level conferences. Grand rounds, morbidity and mortality (M&M) and case conferences are invaluable learning opportunities. Conferences that review complications or deaths are invaluable learning opportunities. They are also a good platform for developing performance improvement projects. Many patient incidents are multifactorial, and there are frequently systems issues that can be addressed to minimize repeat events. - Join committees. Committees are a great way to learn about the inner workings of the hospital and contribute to important decision-making processes. They also provide a venue to meet colleagues in other departments and gain valuable networking experience. - Talk to people. Reach out to your mentors, program directors, and research staff about other opportunities that may be available. They can often provide valuable insight and connections that can lead to new opportunities and projects. After you have explored the opportunities to get involved in your program and hospital, it’s time to widen your professional network. Expanding beyond your hospital will help you stay current with industry trends, discover new opportunities, and establish relationships with colleagues and mentors. One way to do this is by participating in surgical organizations at the national level. Here are some examples: - American College of Surgeons (ACS). The ACS offers membership and participation opportunities starting in medical school. As a member, you can take advantage of educational programs, networking events, and leadership development opportunities. Fellowship in the ACS (FACS) requires board certification, and it is a prestigious recognition that can enhance your professional reputation. - American Association for the Surgery of Trauma (AAST). AAST is the premier national organization for the field of acute care surgery (trauma, surgical critical care and emergency general surgery). There are numerous opportunities for involvement in research and professional development. Membership requires FACS status. However, the organization recently added an associate membership category, which offers younger surgeons an opportunity to participate in the AAST's activities and programs. - The Eastern Association for the Surgery of Trauma (EAST). EAST provides leadership and development opportunities for young surgeons who are actively involved in the care of injured patients. The organization offers ample opportunities to get involved in committees, research projects, mentorship, and leadership roles. This is far from an exhaustive list, but it is a good starting point for young surgeons to explore how they want to develop their network. During my Acute Care Surgery fellowship, I was able to get involved in various research projects and initiatives that allowed me to further develop my expertise and knowledge in the field. At the start of my fellowship, I developed a research protocol that evaluated the impact of legislation on the opiate epidemic. This project allowed me to delve into a critical issue facing the healthcare industry and explore potential solutions to mitigate the epidemic's impact. Shortly after, I attended a department committee that updated our clinical practice guidelines. As we discussed some recent patients with rib fractures, I saw the importance of updating our thoracic trauma management guidelines. I partnered with one of the faculty who had a particular focus on rib fracture management and we worked to optimize our protocol for caring for these patients. This led to multiple opportunities, including an IRB protocol and two manuscript submissions on operative rib fixation. I also had the opportunity to co-author a book chapter on Intensive Care Unit (ICU) management of blunt chest trauma and a manuscript on the use of opiates in chest trauma. During a meeting with one of the research directors in our department, I was able to learn about opportunities to get involved in ongoing projects. This led to me joining a group working on coagulopathy in traumatic brain injury. Through this project, I was able to contribute to a literature review submission and co-author a research manuscript submission. I was also able to present our findings at a national conference. My program director was a strong supporter of and actively shared news about opportunities that could further my career development. One of these opportunities included writing an essay that allowed me to publish and present at a conference. After reading my essay, a critical care physician reached out to connect and invited me to participate in testing a tool for resuscitation in austere environments. This was a unique opportunity that allowed me to apply my knowledge and skills in a new and challenging setting. Overall, my Acute Care Surgery fellowship allowed me to explore different avenues in research and develop expertise in areas that I am passionate about. It also enabled me to collaborate with other experts in the field, broaden my network, and gain invaluable experiences that served me well in my future career endeavors. Previous Next

Overcoming barriers while teaching and being humble as a consultant Tackling the expertise bias < Back Overcoming barriers while teaching and being humble as a consultant Why is it so hard to remember what it was like before you knew the things that you now consider fundamental, basic knowledge? If you are a teacher, which includes school teachers as well as everyone responsible for passing knowledge to others, self-reflection on how you relay information and assess comprehension is paramount. One common challenge is overcoming the "curse of knowledge". The curse of knowledge takes hold and becomes a hurdle when the teacher/ instructor assumes that their audience has the same background knowledge and should be "up to speed" without significant delay. In other words, there are many things you do every day that you consider obvious and second nature. It is exceedingly easy to be quick to judge your trainees for not recalling or readily grasping those concepts. How has this manifested itself in my experience as a teacher in the ICU? Caring for patients with a wide breadth of physiologic derangements is a rich environment for interactive real-time learning. Invasive mechanical ventilation is a perfect opportunity to learn about respiratory physiology. Learning how to pick the right mode/ settings and how to make adjustments to optimize each patient's oxygenation and ventilation (while avoiding further lung injury) is key to good critical care for the patient that requires respiratory support. My understanding of mechanical ventilation was the culmination of many hours and long months/ years spent reading, preparing lectures, tinkering bedside with ventilators, engaging in dialogue with experts, and just immersing myself in the weeds. At some point, and I have no idea when it was precisely, it finally clicked. I didn't become an omniscient guru. But after enough practice, the fundamental concepts finally became solidified in my mind, and managing ventilators has become second nature. Ventilator management is a cornerstone of ICU care. Whenever there are patients that require ventilation beyond perioperative indications, I capitalize on the opportunity to teach. Even though I'm acutely aware of how much work (seemingly endless hours of work) went into learning the finer points of ventilators, it's still hard to remember what it was like before I understood. Please note- this phenomenon is NOT limited to in-person teaching. This barrier can infiltrate lectures, manuscript writing, and a variety of other forms of communication and interaction. Another situation relevant to the medical profession- the consultation with a specialist. If you're on the receiving end of the consult, it can be easy to fall into the trap of assuming everyone should have the same knowledge you have. It's crucial to remember that you are an expert in YOUR field- if the physician calling you had the same knowledge, you would be obsolete. So how do you overcome this hurdle? Here are my suggestions 1. The first step is to acknowledge that your interactions can be impacted by your bias. You know more than your students, or the person that's calling you for a consult. More specifically, you know more about what you're teaching your student and you know more about the clinical situation than the person consulting you. That's why you're the teacher and the consultant. 2. Take time to reflect on how you interact when teaching- do you rapidly become impatient, roll your eyes, reply with condescension or snark, or simply look at your students like they're idiots? Pause in real-time: it doesn't have to be awkward, and I'm sure your audience will appreciate a moment to pause and think. 3. Take the opportunity to put the shoe on the other foot. Reflect on what it was like when you were learning- as an intern struggling to remember how to replete electrolytes, a young resident in the ICU struggling to understand ventilators, or even a young attending struggling in a high-stress operative case. How would you want to be approached/ treated? Previous Next

< Back Pancreatitis UpToDate Patient Education Patient education: Acute pancreatitis (Beyond the Basics) Patient education: ERCP (endoscopic retrograde cholangiopancreatography) (Beyond the Basics) Source: UpToDate Images: Pancreas Anatomy Previous Next

< Back Pain and Anxiety...pending Management of Pain and Anxiety Previous Next

< Back Who Is Our Patient Population? We take care of critically ill and injured patients. Here are just a few examples of the different patient scenarios we manage. We are available 24 hours a day, 7 days a week. Therefore, we often receive consults for various other surgical disease processes outside of what is listed here. Trauma Penetrating wounds from gunshot wounds, stabs, or assaults from any material that breaks the skin and causes bleeding or significant tissue damage Blunt injuries from falls (roof, ladders, etc.), motor vehicle accidents, bicycle accidents, pedestrians struck by vehicles. Non-accidental injuries (abuse, inter-personal violence) Surgical Critical Care Critically ill trauma or emergency general surgery patients. Patients undergoing complex or high-risk surgical procedures or requiring intensive care unit (ICU) admission. Complications from procedural interventions. Intra-abdominal catastrophes. Airway emergencies- patients who are unable to be intubated and require a surgical airway. Emergency General Surgery Appendicitis, Cholecystitis, Diverticulitis. Bowel ischemia or bowel obstruction. Soft tissue infection- necrotizing soft tissue infection. Surgical airway or enteral access- tracheostomy for ventilator dependency and percutaneous endoscopic gastrostomy (PEG). Previous Next

< Back Unusual Case of Peritonitis A 23-year-old male presents to the ED with several days of abdominal pain. He is otherwise healthy and denies any other symptoms. On exam, he has diffuse peritonitis, but no other obvious findings. He is tachycardic with a heart rate in the 110s-120s. His blood pressure is 100s/60s. No significant medical or surgical history. No remarkable events recently. He had plain films of his chest and abdomen. Plain film of the chest and upper abdomen What's going on? Differential diagnosis? Perforated hollow viscus- gastric or duodenal ulcer, bowel obstruction leading to perforation, procedural complication (EGD, ERCP). On further questioning, the patient endorses a recent soccer game during which he blocked a goal and was hit in the stomach. Unsure if it was the soccer ball or a kick to the stomach. He then had a CT of his abdomen and pelvis. CT of the abdomen and pelvis, representative slices What's going on? Diagnosis? Intervention? Free air (pneumoperitoneum) and free fluid are consistent with a perforated hollow viscus. No clear source on the CT. This requires abdominal exploration. We proceeded with exploratory laparotomy. Found liters of succus. There was a single perforation of the small bowel that was resected and anastomosis was performed. The abdomen was closed and a drain was placed. Intraoperative Findings Management of Peritonitis from Perforated Hollow Viscus The hollow viscus refers to the gastrointestinal tract from the esophagus to the rectum. Pain associated with hollow viscus perforation is classically acute onset, constant, severe, and worse with movement. The peritoneal lining of the abdomen becomes inflamed in reaction to the leaking enteric contents. This is a surgical emergency. The diagnosis can be made with the visualization of pneumoperitoneum on an upright chest x-ray (lucency under the diaphragm). A patient with peritonitis and free air requires surgical exploration. A CT scan can help identify the underlying pathology, but is not mandatory and should not delay operative intervention. Non-operative management is reserved for the patient with a sealed perforation (example- retroperitoneal duodenum) or a patient who is a prohibitively high-risk operative candidate (example- patient on palliative or hospice care). Cultural differences Not all cultures have adopted the practice of Western medicine. In some cultures, people still seek advice and medical care from traditional healers. Unfortunately, this can delay treatment if a patient requires operative intervention. Some of the treatments provided by traditional healers can also lead to further injury. This patient with a small bowel injury was seen by a traditional healer several times before he was finally brought to the hospital. The marks on his skin are the result of a practice of cutting the skin to heal the cause of his abdominal pain. Another patient was brought to the hospital for a severe infection of his genitalia. By the time he came to the hospital, his infection was so extensive that he required a debridement of a large portion of the skin in his perineum. He had been seeing a healer who was treating him with a topical solution that had essentially burned his skin, so in addition to the underlying infection, he had severe tissue damage. Previous Next