< Back Pulmonary Embolism...pending Diagnosis and Treatment of Pulmonary Embolism Previous Next

12 < Back Other Resources Radiology Radiopaedia.org . Open-edit radiology resource, compiled by radiologists and other health professionals from across the globe. How to Read a Chest X-Ray: The Graphic Novel and Drawing Book. Download this “Dummies Guide” to reading chest x-rays and brush up on the basics. Appropriateness Criteria. Evidence-based guidelines to assist providers in making the most appropriate imaging or treatment decision for a specific clinical condition. Acute Right Upper Quadrant Pain Acute Right Lower Quadrant Pain 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

< Back Interpreting Chest X-Rays Developing skill with radiographic interpretation requires practice. Look at every film for your patients. Practice by looking at normal films, then compare between normal and abnormal. For example, compare an image for a patient with a normal cardiac silhouette and compare it with a patient with an abnormal silhouette with a widened mediastinum. This is NOT an exhaustive list of everything that can be seen on a chest x-ray, but is an overview of common pathology that can be seen. How to read a film 1. Identify- correct patient/ date/ time. 2. Identify orientation. Is the projection posterior-anterior (PA) or anterior-posterior (AP)? Is the patient rotated? PA is when the patient stands with their chest facing the x-ray cassette and the x-ray is behind the patient, so the x-ray beam travels from the posterior of the patient toward the plate, which is situated on the patients anterior surface. AP is when the patient’s back is towards the board and the x-ray is in from front of the patient, so the x-ray beam travels from the anterior of the patient toward the plate, which is situated on the patient’s posterior. This is the orientation when a patient is laying supine in the trauma bay. On an AP film, the heart appears enlarged compared to the PA. Rotated- compare bilateral or midline structures, such as clavicles and the spinous processes of the vertebra. If the clavicles are asymmetric or the spinous processes are not midline, the patient is rotated. Structures (ABCs) 1. Airway Is the trachea midline? Are there any opacities in the lung fields- pneumonia, masses, bilateral haziness? Do the lung markings extend to the edge of the chest? If not, and the space area is dark, this is suggestive of a pneumothorax. In contrast, if the space is white, this is suggestive of a fluid collection (hemothorax, infected fluid, etc). Is there evidence of fluid? This depends on the patient’s postion and the consistency of the fluid. Free fluid (fresh hemothorax, pleural effusion) will layer dependently, so if the patient is upright, the costophrenic angles will be blunted. If the patient is supine, the fluid can cause generalized opacity of the lung field because it layers along the back of the patient. 2. Bones- examine for fracture, dislocation, masses (tumor) Upper extremity/ shoulder? Ribs? Vertebra? 3. Cardiac Silhouette size/ contour? Normal is <1/2 the size of the thoracic cavity Evidence of aortic injury? *Bonus- 3 places for blunt aortic injury- aortic root, diaphragm, and isthmus just past subclavian takeoff Widened mediastinum (supine >8 cm or upright > 6cm) Loss of aortopulmonary window Abnormal aortic contour Depressed left mainstem bronchus Left apical capping Left hemothorax Nasogastric tube deviation Widened paraspinal or paratracheal stripe 4. Diaphragm Elevated- symmetric elevation is consistent with poor inspiratory volume. Blunting of costophrenic angle- effusion. Abdominal contents in chest (ie gastric bubble in the left chest)- consistent with diaphragm injury or defect. 5. Everything else Air in soft tissue- many potential etiologies, but common causes include pneumothorax or esophageal/ airway disruption. Air under the diaphragm (pneumoperitoneum)- concerning for hollow viscus injury. Iatrogenic foreign bodies- endotracheal tube, central lines, ports, pacemaker, endovascular grafts, esophageal stents, feeding tubes Non-iatrogenic foreign bodies- swallowed objects Additional References and Images from Radiopaedia.org **Click on Cases and figures and Imaging differential diagnosis on the right-hand column of each page for more in-depth explanations of specific pathology** Radiopaedia Airway Bones and Soft Tissue Cardiac Silhouette and Mediastinum Widened Mediastinum Hemothorax Pneumothorax Nasogastric Tube Position Previous Next

6 Tips to Be More Comfortable with Uncomfortable Conversations Giving Bad News < Back 6 Tips to Be More Comfortable with Uncomfortable Conversations It's not fun to tell families (or patients) that there was a complication, that their loved one died, or that their loved one is not going to survive. But it's a fundamental principle of good patient care, especially in the specialties of trauma and critical care. I didn't become truly comfortable with these conversations until my critical care fellowship. After many years and countless conversations in private rooms, here are my tips on how to develop this skill. 1. Experience. It's uncomfortable, but you should take every opportunity to participate in these conversations, starting as a student/ trainee. - As a young resident, I remember walking with my attending to go talk to a family about an intra-operative complication. I'll never forget the sinking feeling in my chest, the shame that I made a mistake. This was a pivotal moment in my training. My attending didn't have to tell me I messed up. But he knew I needed to see how he handled disclosing to the family members. He showed me that this wasn't something that I should allow to crush my self-confidence. - A few years later, during one of my first trauma rotations, I remember sitting in a small room in the ER as one of my co-residents told a family that their child was the victim of a fatal shooting. I didn't have much experience telling families that their loved one had died. In particular, I didn't have any exposure to telling a family that their loved one died in a trauma bay- a family I'd never met, a family who never had a chance to see their loved one before they died from their injuries. I was initially embarrassed that my co-resident, who was one year younger than me, was more comfortable leading the discussion than I was. But then I realized he had much more exposure to that type of conversation because of his previous trauma rotations. So I took it as an opportunity to learn and prepare myself to lead the conversation the next time. - Two years later, in the ICU waiting room of the same hospital where I watched my (younger) co-resident tell a family their son died, I sat with the mother of a young man who was critically injured. Thankfully, I had much better news. But still, it's not easy to tell a single mother that her oldest son was shot through the chest, and was laying in the ICU, intubated, with an open chest and abdomen. 2. Learn from watching experts. - Everyone has a slightly different style of handling these conversations. I joined my attendings for every conversation I had the opportunity to witness. This included conversations about everything from Code Blue incidents to fatal injuries and end-of-life care. It's important to see different styles, which will allow you to develop your style. Some are more blunt, some are more observant of family dynamics, some are overly talkative. There are some you may choose to not replicate, but it's important to see a spectrum of styles to learn what works for you. - I've watched my MICU attending talk with the wife of a man who came to the hospital with acute cardiac arrest, requiring emergent coronary angiography and intervention, then therapeutic hypothermia. I learned how to succinctly describe a complex situation and support a wife make a crucial decision without pressuring her. - I've watched my trauma attending talk to a family of a young male patient who had died on the operating table. I've watched that talk more than once, unfortunately. And it never got more comfortable. But I learned how to convey devastating news while simultaneously expressing compassion. 3. Practice. - As a fellow, I would often have a pre-brief with my attending and we would discuss key points for the meeting, as well as the goals of the discussion (ie deciding about proceeding with surgery, deciding about comfort care, etc). - When I have younger residents who are having family meetings, particularly one's that I haven't worked with before, I have them rehearse their conversations with me before. I did this as a resident and a fellow, and I still do this with my fellows. 4. Get feedback. Positive feedback is always nice, but true constructive feedback is key to improving. - I've had nurses and chaplains who have joined me for multiple family meetings, and it's always reaffirming to hear them compliment my interaction. - My attendings still occasionally joined me in conversations toward the end of my fellowship. It was always helpful to hear feedback about what was well-received and how I could have been more effective. 5. Once you've practiced, developed your style, and absorbed feedback- don't expect it to always be easy. - Towards the end of my fellowship, I had a particularly challenging case. I had already had countless family discussions and had become very comfortable with being uncomfortable. For a variety of reasons, I was emotionally overwhelmed with this patient's situation- I sat and cried at the nurse's station for a long time. Then I went and talked to my attending and told her I couldn't have the conversation, that I couldn't stop crying. I was hoping she would take over and lead the conversation- I should have known I wouldn't get off that easily. She reassured me that I wouldn't have to say much- I had already established rapport with the patient's family the day before, and they'd be able to tell from my non-verbal communication that I didn't have good news. It was (and still is) the hardest conversation I've had. 6. Don't Stifle Your Emotions (within reason) - Some people would criticize me for expressing emotion when having discussions with families. I do think there has to be a healthy separation, and getting emotionally invested with every case would be paralyzing. I don't cry during the majority of these conversations. However, I'm not a robot, and I still occasionally have patients that affect me on a more personal level. For example, I had one family that came to the very difficult decision to transition their mother to comfort care. Their mother was the matriarch of the family and her children didn't want to disrespect her. She had expressed that she would not want to be kept alive if she couldn't continue to have meaningful interactions and care for the family. I told them that giving them the implicit approval to allow her to die peacefully was probably the greatest gift she could have given them, and I reassured them that they were showing her the ultimate level of respect and kindness by honoring her wishes. That hit me differently because I could feel their pain as I imagined myself in their position. Previous Next

< Back ICU Society of Critical Care Medicine (SCCM): Patient and Family Resources Meet the Critical Care Team Learn about the members of the ICU care team. Patient Communicator Application This free app by SCCM is designed to improve communication between patients, families, and caregivers. Critical Care FAQs Learn about which patients require care in the ICU, what things commonly happen in the ICU, as well as find a more detailed explanation of common medical conditions seen in the ICU. Resource Library The MyICUCare.org Resource Library includes complimentary materials aimed at educating patients and families about the critical care journal, both during an ICU stay and after discharge. Understanding Your ICU Stay: Information and Patients and Families booklet. American Thoracic Society- Patient Education | INFORMATION SERIES Managing the Intensive Care Unit (ICU) Experience: A Proactive Guide for Patients and Families Mechanical Ventilation What is Acute Respiratory Distress Syndrome? What is ECMO? Central Venous Catheter Arterial Catheterization What is Hemodialysis for Acute Kidney Failure? What is Sepsis? Palliative Care for People with Respiratory Disease or Critical Illness Tracheostomy in Adults Living with a Tracheostomy Venous Thromboembolism- Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Preventing Venous Thromboembolism [John Hopkins Medicine: Armstrong Institute for Patient Safety and Quality ] Previous Next

< Back Mangled Extremity- Keep or Cut? A 42-year-old male was struck by a vehicle as he was crossing the street. He was brought in by EMS. He had a depressed GCS and unequal pupils, and he was intubated for concern for airway compromise. He had a significant injury to the right lower extremity with diffuse bleeding, but no active arterial bleeding. Compressive dressings were applied. He had fluid in the LUQ window of his FAST. He was hemodynamically unstable. Initial evaluation and management? Imaging? Poly-trauma patients demand prioritization and quick decision making, and the simple step-wise algorithms designed for each injury in isolation are less helpful. Patients with blunt abdominal trauma and hemodynamic instability require emergent operative intervention. Patients with a depressed GCS and an abnormal pupil exam require emergent CT imaging to define the severity of their head injury and consultation with neurosurgery. Patients with a mangled extremity require a CT scan to define the vascular injury. In the setting of blunt abdominal trauma, a positive FAST and hemodynamic instability, he was transported to the OR emergently. If there was an option for a rapid CT en route to define his TBI, that would have been ideal. But hypotension is associated with worse outcomes for TBI patients, so the priority is stopping the bleeding. We performed a midline laparotomy, splenectomy, and repaired a diaphragm injury. We placed a temporary abdominal closure. Intraoperative Image What do we do about his mangled lower extremity? Consult vascular or ortho? Ex-fix? Amputate? There are several important tasks. Assessment of injury to neuromuscular structures is vital. If possible, rapid restoration of arterial blood flow is beneficial. However, it is vital to evaluate the need for amputation. This decision requires consideration of current physiologic status, co-morbidities, and baseline functional status. It's sometimes a question of life versus limb. Orthopedic and vascular specialists can be consulted, but it is important not to lose sight of the patient's overall clinical status. A brief temporizing procedure to restore blood flow with a shunt, stabilize bony structures, and preserve any remaining soft tissue may be appropriate, but a lengthy vascular repair and bony fixation are likely not ideal. The patient's baseline functional status, social support, and co-morbidities were unknown. Based on the severity of his extremity injury, high injury burden, and need for urgent head CT, my recommendation was for immediate amputation. This decision requires weighing the risks/ benefits of limb salvage (prolonged time in the operating room for stabilization, risk of ongoing tissue ischemia leading to systemic complications) vs amputation (limb loss). Our orthopedic specialists felt they could salvage his limb, and give him a chance to be an active participant in the decision-making. We agreed to a time limit to minimize operative time, so the limb was stabilized temporarily with a plan for ongoing evaluation of the limb viability. Managment of the Mangled Extremity WTA Algorithm Management of patients with mangled extremities remains controversial. Severe scoring systems have been created, with variable success in predicting who requires amputation. In the acute setting, the trauma surgeon must weigh the risks and benefits of limb salvage versus immediate amputation. If the limb injury is devastating (perhaps only hanging on by a small skin bridge), and the patient has other injuries that require immediate intervention, rapid amputation can be life-saving. If the decision to amputate is less clear, a second opinion from a colleague and orthopedics should be elicited. There have been remarkable advances in the ability to restore function to mangled extremities, and discussion with specialties can be very helpful. "Therapeutic advances in the treatment of vascular, orthopedic, neurologic, and soft tissue injuries have reduced the diagnostic accuracy of the MESS in predicting the need for amputation. There remains a significant need to examine additional predictors of amputation following severe extremity injury." Loja, Melissa N et al. “The mangled extremity score and amputation: Time for a revision.” J Trauma Acute Care Surg. 2017;82(3):518-523 The trauma surgeon must maintain perspective on the whole patient- spending hours doing meticulous vascular or nerve dissection/ repair or extensive orthopedic manipulation can be an intolerable burden on a patient with multiple other injuries. 1. Control active hemorrhage. 2. Restore anatomic limb alignment. 3. Assess distal arterial flow→ evidence of vascular injury→ CTA to characterize injury. 4. Assess neurologic function. Unable to control active hemorrhage or there is hemodynamic instability→ proceed to OR. Assess for the need for immediate amputation. Factors to consider: Complex, segmental, severely comminuted fracture. Large circumferential soft tissue loss or massive soft tissue necrosis. Compartment syndrome with myonecrosis. Nerve disruption. Massive contamination. Prolonged warm ischemia >6 hours. Poor distal anastomosis options. No immediate amputation→ intraluminal shunt to re-establish perfusion. Then assess bony and nerve injury. Evaluate risks/ benefits of limb-preservation. Previous Next

< Back Shakshuka- A North African Dish Ingredients 1 large red bell pepper, thinly sliced 1 large yellow bell pepper, sliced 1 red onion, sliced 3-4 garlic cloves, diced ¾ tsp salt cracked pepper to taste 1 tsp cumin 1 tsp sugar ½ tsp smoked paprika ½ tsp chili flakes 3 medium tomatoes diced small ⅓ c white wine or water 1 T fresh basil ribbons or chopped Italian parsley 4 -6 Extra large organic eggs Other optional additions: crumbled feta or goat cheese 1 C browned chorizo ¼ C finely diced spanish style cured Chorizo or Merguez, a North African spiced sausage Instructions 1. Preheat oven to 400F. 2. In a large cast iron skillet, heat the olive oil over medium heat. Add the onion and cook until tender, about 5 minutes. If adding raw chorizo, brown it with the onions. 3. Add the sliced peppers and garlic, and turn heat down to med-low and cook for 5 more minutes, until peppers are tender. If adding the cured spanish chorizo or Merguez sausage, add it now. Add all spices, sugar and salt. Cook for 2 more minutes. Add fresh tomatoes and white wine. 4. Simmer on low for 15 minutes, adding more water if it gets too dry or thick- you want a stew-like consistency. After tomatoes cook down, taste, it should be full flavored- adjust salt and sugar if necessary. Crack 4-6 eggs over the mixture, sprinkling each egg with salt and cracked pepper. Add crumble goat cheese or feta over the top and place in the 400F oven. 5. Bake until egg whites are cooked (about 7 minutes) and yolks are still soft. Remove from oven and top with fresh basil (or Italian parsley). Serve with toast or crusty bread. Veggies sizzling Previous Ready for the oven Yummy! Next

< Back Wound Care American College of Surgeons: Home Skills for Patients Adult Colostomy/Ileostomy - collection of resources to help you prepare for managing your ostomy, including videos and a home skills kit. Your Colostomy/Ileostomy Ostomy Home Skills Kit: Adult Colostomy/Ileostomy Wound Management Home Skills Program Drain Care Jackson-Pratt (JP) Drainage Tube: After Hospital Care [Northwestern Medicine] Previous Next

< Back Cardiac Physiology Cardiovascular Physiology Oxygen Delivery Adequate cardiovascular function is vital to maintaining perfusion to the organs and tissues in the body. Perfusion drives oxygen delivery (O2) and removal of byproducts of cell metabolism (CO2). The amount of oxygen that is delivered (DO2) is a function of cardiac output (CO; the volume of blood ejected from the heart every minute) and the arterial oxygen content (amount of oxygen in the blood). Cardiac output is determined by the volume of blood the heart pumps out into the body with each heartbeat (stroke volume, SV) and the frequency of the heartbeat (heart rate, HR). Stroke volume depends on preload (blood volume returned to the heart), contractility (effectiveness of cardiac muscle activity), and afterload (pressure in the peripheral vasculature that the heart has to overcome to eject blood). Arterial oxygen content (CaO2) is the amount of O2 in the blood that is ejected from the heart. This is determined by dissolved O2 + O2 bound to hemoglobin. Hemoglobin carries O2, and the percentage of Hgb molecules that are saturated (bound) with O2 is determined by arterial blood gas (SaO2, arterial oxygen concentration) or pulse oximetry (SpO2, peripheral arterial oxygen concentration). Pulse oximetry is non-invasive and is a reliable surrogate (as long as SaO2 >90%). The O2 carrying capacity of one gram of hemoglobin is 1.38 (this is a constant in the equation). So this is the first part of the equation: the number of hemoglobin molecules x the % of those molecules that are saturated with O2 x how much O2 saturated hemoglobin can carry . The second part of the equation is the dissolved oxygen (partial pressure of arterial oxygen, PaO2, reported as mmHg). This value is multiplied by the constant 0.003, which is the mL of O2 dissolved per mmHg plasma. This number is infinitesimally small relative to the other half of the equation and it is typically ignored when determining oxygen concentration. This means that the significant modifiable factor in CaO2 is Hgb. Oxygen has to have something to bind to (Hgb) because dissolved oxygen has minimal oxygen-carrying capacity. Oxygen delivery (DO2)= CO x CaO2 Cardiac Output (CO)= heart rate (HR) x SV Stroke volume (SV)= the volume of blood ejected from the heart each heartbeat. Arterial oxygen concentration (CaO2)= [1.38 x Hgb x SaO2] + [PaO2 x 0.003] How can oxygen delivery be increased? One of the components of the equation has to be adjusted. Increase cardiac output. Increase SV- use of an inotropic agent (* medication that increases the strength of the heart contraction), ensure adequate preload (volume resuscitation). Increase HR- use of a chronotropic agent (* medication that increases heart rate). Increase arterial oxygen content Increase blood hemoglobin concentration *See pharmacology below Oxygen Consumption Oxygen consumption (VO2) is determined by how much oxygen the peripheral tissues extract and use. It is the difference between oxygen delivery (DO2) and oxygen return(ed) (SvO2). Oxygen consumption (VO2)= DO2 - SvO2. Oxygen consumption is calculated by subtracting SvO2 or ScVO2 from the amount of oxygen delivered. Venous oxygen saturation (SvO2 or ScVO2)- concentration of oxygen in the blood returning to the heart. Measured with a central venous catheter. *See below under CV monitoring for more details. Cardiovascular Monitoring There are several techniques for monitoring cardiovascular parameters, ranging from non-invasive to maximally invasive. Non-invasive methods include telemetry, pulse oximetry, and blood pressure monitoring. The benefit of these devices is their simplicity of use and interpretation. But these are error-prone, and regarding blood pressure, it doesn't provide continuous monitoring. For more info, see lecture entitled " Hemodynamics ". Arterial lines can be placed to provide continuous cardiac monitoring. The arterial waveform can indicate specific pathology (see Edwards Quick Guide to Cardiovascular Care ). In addition, an arterial line can report stroke volume variation. Stroke volume variation (SVV) is a surrogate of arterial pressure changes with inspiration/ expiration. If the change in pressure with respiratory cycles is >10-15%, it suggests the patient is fluid responsive, meaning they are likely to improve their preload (and cardiac output and blood pressure) with IV fluid administration. Central venous catheters can be placed to deliver intravenous medication as well as provide cardiac monitoring. A central venous catheter can measure the pressure of the blood returned to the right atrium (central venous pressure, CVP), which is a crude measurement of preload and right heart function. In addition, the oxygenation of the blood returning to the right heart (from the head and upper body) is reported as Central venous oxygenation saturation (ScVO2). ScVO2 reflects the balance between oxygen delivery and consumption. Arterial lines and central venous catheters are considered "minimally invasive". A pulmonary artery (PA) catheter is the most invasive device for cardiac monitoring. Similar to a central venous catheter, a PA catheter can determine the oxygenation of the blood returning to the right heart, which is the mixed venous oxygen saturation (SvO2). However, in contrast to the central venous catheter which is located in the superior vena cava (proximal to the right atria), this device is measuring blood oxygenation in the pulmonary artery (from the right ventricle), so it accounts for the blood from the entire body (unlike the ScVO2). Cardiac Pharmacology Vasoactive medications are frequently used in the ICU for the management of shock, heart failure, and other acute pathology. There are several key receptors, and understanding the function of each receptor is the key to using these different agents correctly. Receptors * α (alpha) 1- vasoconstriction * α2- inhibit norepinephrine release from presynaptic neurons * β (beta) 1- chronotrope (↑HR), inotrope (↑Ca in cardiac myocytes ↑contractility), dromotrope (↑cardiac impulse conduction velocity) * β2- vasodilation * Dopa 1- vasodilation * Dopa 2- neurotransmitter release Pharmacologic Agent Classification Each medication has a specific physiologic effect based on its particular mechanism of action. Agents may stimulate or inhibit receptors (see above) or alter the concentration of a key substance (cAMP, calcium, potassium, nitric oxide (NO)). Previous Next

< Back Stabbed in the Right Thigh A 42-year-old male is brought to the Emergency Department as a Level 1 trauma activation for a stab wound to the right thigh. He was hypotensive before arrival, with SBP in the 70s-80s. Estimated blood loss of 500 mL on the scene. On arrival, the patient is awake and argumentative. His blood pressure is 90 systolic. On a rapid secondary survey, there is no evidence of any other wounds. There is a tourniquet in place to right upper thigh. When the tourniquet is released, there is arterial bleeding from the wound and there is no palpable distal pulse. What do you need to do before leaving the trauma bay? Replace tourniquet. Call OR to have vascular instrument set available, as well as massive transfusion, cell saver, etc. Type and cross for blood transfusion. After ensuring a type and cross, we proceeded to the operating room. How do you want to prep and drape the patient? Any instructions for anesthesia? Wide prep and drape to ensure adequate access for proximal and distal control- this includes prepping the lower abdomen for possible iliac exposure. Also, need to prep contralateral lower extremity for potential saphenous vein harvest. Ultrasound localization of the saphenous prior to prepping can allow identification of the larger vein. Anesthesia will need to monitor hemodynamics and volume status and be prepared for volume resuscitation with blood. In addition, they will have to be vigilant for the repercussion syndrome, the metabolic disturbance following the re-establishment of arterial flow (washout of toxins following ischemia). We placed a pneumatic tourniquet on the patient's upper thigh. We prepped and draped from the umbilicus to the knees, and also prepped and draped the contralateral thigh to have access in case a saphenous vein harvest was required for repair. We made an incision directly over the wound and dissected down to the artery. There was a single wound in the anterior surface of the distal superficial femoral artery. Proximal and distal control was obtained after circumferentially dissecting and placing vessel loops. The artery was divided and spatulated. It was repaired with an end to end tension-free anastomosis. Following arterial repair, we performed a lower extremity fasciotomy. Management of Penetrating Arterial Trauma WTA Algorithm Diagnostic Workup Hard signs- pulsatile bleeding, thrill, bruit, expanding hematoma, pulse deficit, cold pale limb. These patients require operative intervention. A few exceptions can benefit from preoperative imaging to document the presence and location of associated arterial injuries: wounds in the thoracic inlet, shotgun wounds in the extremities, and segmental fractures or fractures at different levels of an extremity. Soft signs- history of pulsatile bleeding, wound near an artery, non-expanding hematoma, neuro deficit, weak pulse, proximity injury. These patients need further workup to evaluate for the presence of arterial injury. An ankle-brachial index should be performed, and if ≤0.9, CT angiography is indicated. If ABI >0.9- no further w/u needed. ABI <0.9- CTA. Principles of arterial repair 1. Plan incision to facilitate proximal and distal control. 2. Ensure adequate back bleeding. Fogarty to remove distal thrombus. 3. Tension-free anastomosis. Adequate lumen. Clean margins. Don't create more damage to the vessel. 3. Consider risk/ benefit of heparinization. Systemic dose: 70-100 units/kg IV. Regional dose: 50U/ml x50 mL. 4. Completion angiogram to document repair. There are various techniques for creating an anastomosis, but the basic principles must be maintained. Recently, I was taught a useful technique [Dr. Feliciano, AAST 2020 Virtual Conference] that prevents tension at one point along the anastomosis. A parachute technique, starting with loosely approximated sutures on the back wall, followed by parachuting the two ends close to continue the suture on the anterior surface of the artery. Indications for fasciotomy include prolonged limb ischemia (>6 hours), combined arterial and venous injuries. 1. Feliciano DV. Evaluation and Management of Peripheral Vascular Injury. Part 1. Western Trauma Association/Critical Decisions in Trauma. J Trauma. 2011;70(6):1551-1555. 2. Feliciano DV. Pitfalls in the management of peripheral vascular injuries . Trauma Surg Acute Care Open. 2017;2:1–8. Parachute Technique [Feliciano] WTA Algorithm for Peripheral Vascular Trauma Previous Next

5 Team of Teams New Rules of Engagement for a Complex World - From retired General Stanley McChrystal. Guidance on developing an adaptable, agile, and unified organization. - Changes in the nature of war necessarily lead to changes in leadership and team dynamics. - Given the dynamic nature of current combat, the prevalence of unknown unknowns, and the rapid pace of information dispersion, it is unreasonable for every leadership level to approve every maneuver. - Teams need to be competent and well-trained. But in this current environment, it would be prohibitively cumbersome to require the commander's involvement in every decision while remaining agile and quickly responding to constant changes. In contrast, developing a strong team and providing a common goal, an overarching mission, allows teams to execute, react, and adjust to shifting battlefields. The end state serves as a guide, and the group draws from their training to accomplish the mission. Previous Next