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Welcome back to Behind the Knife. This is Patrick Georgioff, trauma surgeon at Duke University, and today is another installment of the Big T Trauma Series. So the Big T Trauma Series offers clinically oriented material that focuses on how best to care for traumatically injured. and critically ill patients. So past topics have included things like transfusion medicine for the trauma surgeon.
gun violence, neck trauma, and a whole lot more. You can find the whole series on our website and app. And this series gets its name from the University of Texas at Houston Memorial Hermann Red Duke Trauma Institute, one of the busiest trauma centers in the entire. country. And today we're joined by Dr. Teddy Cusio, one of my former co-fellows, now faculty at UT Houston, and Dr. Jason Brill, Trauma Medical Director for the U.S. Indo-Pacific Command, also one of our former co-fellows.
And we have an extra special guest, a new father from four days ago, Dr. Jared O'Reef, who's currently a first-year fellow at UT Houston. Jared, are you surviving the birth of your child? Yeah, it's been tough, but we're getting through it. And I think the kid's just lucky that she took after the looks of her mother, not me. Otherwise, she'd be in trouble. So I'm excited you guys are all here. Teddy, why don't you tell us what this episode is all about?
All right, I'd be happy to. So we have compiled a list of scenarios that we would consider pitfalls and trauma. These are cases that the wrong decision leads you to stand up in front of a podium. at your M&M. One of my favorite quotes from training, and I say this all the time to the residents is, the eyes did not see what the mind does not know.
When you step back and think about it, you realize that principle is really core to all of our training and the basis for this episode. It's really important to know what you're looking for or you're never going to recognize it. Yeah. And of all of the episodes aired in the big T trauma series, pitfalls are fan favorites. So we have compiled a list of.
slightly more complicated and maybe some not so obvious scenarios that we have all experienced. I promise everyone here has seen this at one point or another. And we think that the BTK community would benefit from hearing. Even if they aren't obvious at first, again, we've seen them. And so you can play detective as we go along and maybe predict what we're about to describe as a pitfall. Because again, we've seen them either happen or...
All right, pitfall number one. Jared, you are in the trauma bay receiving a 25-year-old male who's involved in an MBC. He has the following vitals. Heart rate's 130, systolic blood pressure 100. Oxygen saturation is 90% on a non-rebreather and he has a GCS of 6.
A primary survey is performed. There is concern for airway protection due to his GCS of six. He's got decreased breath sounds on the left and palpable femoral pulses. A quick secondary exam reveals seatbelt sign along the lower part of the abdomen and a left ankle deformity. He has two 18-gauge IVs already in place, and blood is on the way. A chest tube is immediately placed. There's a rush of air and about 300 cc's of blood without any bleeding thereafter.
Fast exam is negative. And chest x-ray confirms absence of a hemo or pneumothorax and shows your well-placed chest tube. And a pelvic x-ray shows pelvic fractures without an open book. So in order to protect the airway and improve oxygenation, the patient undergoes uncomplicated rapid sequence intubation, unfortunately. He codes shortly thereafter. Now, Jared, there are a number of problems with this scenario, some more obvious than others. Let's go through them. What do you think?
Yeah, this patient is in hemorrhagic shock until proven otherwise. I think when we performed our rapid sequence intubation, we took away the patient's sympathetic tone. That combined with the introduction of our positive pressure ventilation, we also decreased his end diastolic filling pressure and cardiac output. That's what caused him to arrest. If I could have this one back, I would resuscitate with blood products first.
I think this is a really good example of when CAB, meaning circulation, then airway, then breathing, trumping the traditional ABC. Yeah, you've got it, Jaren. So the military has been pushing treatment of exsanguinating hemorrhage before addressing airway and breathing for quite a while. So we call this X-ABC, so exsanguinating hemorrhage and then airway breathing and circulation. And I think the wider community is catching on because in the next iteration of ATLS, the 11th edition.
there will be recommendations to resuscitate with blood products whenever possible before intubating a patient in hemorrhagic shock. For a little bit more on this, check out episode 730, A Circulation-First Approach to Trauma Resuscitations with Drs. Disunike and Farada for more on this topic.
Yeah. And a quick plug. So if you use our website or an app, you can easily search for episodes. So we now have over 850 episodes. So you can search by keyword, by topic, by series, et cetera. It's really easy to find compared to Apple or Spotify or whatever you're using as a running list. So Jared, this case also highlights the importance of a rapid and complete. primary survey with the appropriate use of adjuncts. And remember that trauma patients
They die from TBI and hemorrhagic shock. Yeah, that's right. This patient presented on the farther right end of stage three hemorrhagic shock, which can bring with it confusion and anxiety, which may be mistaken for altered mental status secondary to his head. Yeah, it's important to remember that airway is certainly critical, right? Nobody here is arguing that we throw ATLS.
the window that algorithm is important but airway doesn't exist in isolation in other words yes you've secured an airway but if you've forgotten the rest of the abcs yeah it does you no good just to have the et2 in the right position, right? That's only part of the story. So somebody with a stab wound to the neck or a large TVSA burn, yeah, that's a true seconds count airway emergency.
Go ahead and secure the airway right then. But when the patient has sources of bleeding and they're satting in the 90s, maybe start a resuscitation first rather than killing them with a bolus of purple fall and a paralysus. Now, I think this is a really important concept, especially if you don't see these type of patients very often. But it's important for listeners to think about that C is the new way. This is especially true in penetrating trauma.
We often mask, ventilate patients from the ED to the operating room, and we very adamantly try to not intubate these patients. in the ED and wait till they're in the OR prepped, draped with a knife ready before they get intubated. Yeah. This will be great with the 11th edition of ATLS, the X.
A, B, C, D, E. Again, X for exsanguinating trauma patients. Think about resuscitating before intubating. So that wraps up trauma pitfall number one, intubating a patient in hemorrhagic shock in the ED, causing them to code. No good. All right, next scenario. Jared, 60-year-old female. had a ground-level fall, also with a GCS of 6 in this scenario, and is otherwise stable. The patient is given rocuronium for a paralytic and intubator.
So the patient gets trauma scans and the head CT shows a 0.8 centimeter subdural hemorrhage. There's four millimeters of midline shift. Jared, what is the subtle pitfall here? Yeah, I think my neurosurgery colleagues are going to be not so happy with me for this one when my intern consults them from the CT scanner. Because the first thing neurosurgery is going to want to do after reviewing the imaging is examine this patient off of sedation, the keyword being off of sedation.
My rockeronium decision is probably going to delay that 45 minutes to an hour. If she emerges with the worst exam, that's fine. Yeah. In this case, I would probably reach for a shorter acting paralytic like succinylcholine because the rapid offset of about five minutes. allows for much faster monitoring of mental status off of sedation compared to something longer acting like rocuronium and really potentially jails you for a crucial time period.
I know this episode is going to be after the ab site, but I feel like... If you talk about succinylcholine, you got to remember the abcite question, right? It always has a risk of hyperkalemia. So we got to remember to be careful for patients like end-stage renal disease. burn patients, even like crush patients. Stuxencholine is a depolarizing paralytic agent that can cause a large efflux of potassium.
So if you knew that the patient had a fistula, I would definitely avoid it in that situation. But in the absence of those contraindications, it's good for head injured patients, as we talked about, because it's fast off. Yeah. In general, if you're looking to do a rapid sequence intubation, the vast majority of patients, except for the very few that Teddy mentioned,
are going to tolerate succinylcholine just fine. And it's going to be much better for you in trauma world to be able to reevaluate that patient. And then you can also use either essentially ketamine or automidase. So if you just pick your favorite, pick a ketamine. Pick Etomidate, whatever you like better, get that dosage figured out in your mind, and plan on giving the vast majority of your trauma patients succinylcholine, except in special circumstances, you're going to be well on your way.
Yeah, I guess we should mention Rocky Runyon does have a reversal agent. So if you've heard of Sugamidex, normally that's our anesthesia colleagues that have. more ready access to that. It may or may not be available. And the emergency department does come with the cost monetarily. So that's why it's locked up sometimes. Really, I think if you need that. Ask your anesthesia colleagues for help if you need access to it, because it can be something that if you didn't realize, oh.
there is a head bleed and we need to reverse this, that might be an option for you. Or let's say you weren't able to use succinylcholine, that this patient was on their way to dialysis when they fell and blocked their head. and you have a contraindication, well, maybe you give them rock and then just reverse it afterwards. Sure. All right, so pitfall number two, we want to avoid using a long-acting paralytic when intubating a potential TBI patient as this prohibits rapid repeat neurologic exam.
All right. The next one. This is a juicy one. It's ripe for chaos. It's the trauma. Sabotage lurking at every corner. Yeah, absolutely. Yeah, admittedly, this is a skill that I'm still acquiring in Chicago, where I did residency at Mount Sinai. Accepting a transfer wasn't really a thing because a level one trauma center is at least every half mile with 19 being in Cook County alone.
compared to Houston, where there's only two and only one with the helipad, a.k.a. UT. And my first thought was, yeah, big deal. You talk to the transfer center and accept the transfer, but they tend to be fraught with booby traps. Yeah. And this is not to say that every transfer is a pitfall. I would say the vast majority of the time, 98% of the time, there's no issue.
And in fact, it's much more common, and there is research ongoing in this topic, more common to find yourself scratching your head and asking, why do we need to transfer this stable patient? Probably could have been taken care of at the sending facility. But in any case, you do have to be on the lookout because even if it only happens a few percentage points of the time, when you encounter a good fall, it can be.
The way I think about this, we have to assume that the provider managing patient has the patient's best interest in mind, right? Nobody would ever assume. But they may not really have the resources to manage them. And so as level one trauma centers, that's where we step in. Teddy, what are some of the more common pitfalls that you see when it comes to transfers?
And I think this is definitely a skill, right? Because if we don't teach this in training, then you become an attending and all of a sudden it's like this brand new thing. But one of the things that I've learned for sure is acuity, right? So I can't tell you the number of times. that I've accepted a stable patient, quote unquote, who arrives like peri-arrest or they're, quote, stable, but they're on a norepi infusion. By the way, that doesn't count as stable if they're on pressers.
You should always be ready for whatever condition they're going to come in, right? Even though they're a transfer, they can still be acutely ill. So you should have all your equipment as if they're a fresh trauma right off the street. So lines, tubes, blood. Everybody should be there ready to handle whatever rolls through the door. Yeah, Teddy, I think that advice is great. Treat every trauma transfer as a new patient.
just like EMS brought them to you. Not that things may have not been done to them already, but I think starting from square one and doing everything you would normally do for a new patient is great. My level of vigilance is always a little higher for these patients, and I really try not to get biased by what the transfer center told me or what I heard through the grapevine or even maybe sometimes what the sending provider tells me. So here's an example.
So I hear about a pelvic fracture and they don't have an orthopedic trained trauma orthopedist over there. And so they need to send the patient because of the pelvic fracture. so that we can fix it at our level one facility. Great. So that's why I accepted the transfer.
But then the sending facility forgets to tell me, let's say, about a pulseless lower extremity from the dislocated knee that was reduced at the outside hospital. Oh, yeah. And they also have gross hematuria from this bladder injury. Right. So they also, let's say they saw a bullet on chest X-ray and the found down patient and forgot to mention that. I think if you treat these patients like they are fresh traumas, then you'll catch these things that we.
are designed to catch, but not all of these sending facilities are always going to load the boat and give us the correct story about the page. Yeah, I think a common one that I've seen, especially here at UT, is just incorrect imaging when they arrive in the ED. We're told that the patient is, quote, pan scanned, but then you upload the imaging with radiology.
And all of your CT scans head to toe are without contrast. And a super common one is that they're missing a pertinent scan that the standalone facility may not have known to get, like a CTA neck when the patient has a seatbelt sign across his chest. This is also a common board scenario that I ran into while studying for my oral board exam. When the examiner gives you incorrectly phased studies or studies without contrast.
and there'll be a patient that'll go to some company that'll scan. You had to tell it to look for cancer or something like that. And your examiner will be like, okay, here's the scan. And you have to ask and say, what phases? Was it with IV contrast? If you don't, that's pretty much an automatic fail. So this is a pitfall that goes beyond trauma transfers. Any thoughts on the patient who's been operated on at an outside hospital before it gets transferred over?
Yeah. I recently had firsthand experience of this one. I had a patient who had a splenectomy done after a gunshot wound at another hospital, and they had to transfer them to us because they also had a brachial artery injury. So we were focused on the brachial artery. But at the same time, the patient was decompensating from missed intravedonal injuries. So we had to reopen them. So I think, yeah, more operating. But so I think listen to what the outside facility.
tells you, but also verify when they get there and treat the patient, right? Yeah, I did have fun shunting the brachial while Teddy and my co-fellow played misinjury bingo in the belly. Yeah, I'm glad you had fun with that. Somebody did. Yeah, I'll get on a soapbox for a second. I think asking the right questions when accepting a transfer is absolutely critical. And it is incumbent upon you as the accepting surgeon to do.
Don't depend on the sending facility to know what you want. And they may not see trauma ever. And so they really are depending on you to be the captain of the ship. Vital signs, maybe including some trends, what drips they're on, the labs that you want to hear about, imaging, and as Jared mentioned, the phases and how that imaging was done. Maybe they know the past medical history at the sending facility because they've seen this patient before and there's an anticoagulant or something.
And then I always ask for a complete list of injuries, not just the ones that they can't handle at that facility and want to transfer for. And then when you know those, okay, so what interventions have been done for those and how's the patient responded? I would say all of those are fairly critical questions that you may not be able to get a hold of that facility or that provider.
By the time this patient arrives, potentially several hours later. So the way I think of gathering this information is how would I present this patient to my team and sign out the next. And I always prefer to get that information from the treating surgeon or if they're not available, the emergency medicine physician. Whoever is the primary person taking care of that patient.
I'll mention in Hawaii, this is a state standard that's mandatory every time that there's a physician to physician turnover. But I understand that practice patterns vary. You don't always have time to listen to this entire story. But I would say if you don't. have due diligence every time you are going to encounter this pitfall at one point or another. Yeah. Well said, Brill. So that's pitfall number three, accepting.
a transfer. And I think I want to add one, one piece to that as well. And I try my darndest every time to ask the transferring provider to ask our transfer center, et cetera. I'm like, double, triple, quadruple, sure. You send those images over, right? They're pan scanned. Those images are done. Maybe they're done correct, completely correct. And so often they come with no electronic transfer, no disk.
No reads. It's an EMTALA violation. Yes, it is. But it's so frustrating. It happens all the time. There are times. Usually we can hunt them down. In this day and age, it's easier to get those electronic transfers more and more, thankfully. But you still end up having to re-scan some of these people. And that's just, it hurts my soul when that happens.
Let's move on to the next case, 20-year-old male motorcycle collision. All right, this patient has intracranial hemorrhage, multiple rib fractures, and they underwent an X-lab with splenectomy. And the patient is known to have a dirty, mangled lower leg. There's mud and gravel embedded in real tore up, exposed muscle. And there's multiple fractures that are obvious in the knee.
in the lower leg. So multiple services are involved, as they often are when it comes to megalostromity, orthopedic surgery, vascular surgery, and plastic surgery. are all consulted, all of whom have taken a look at the leg and they think this thing is viable. They are going to... save the lake. And the saga plays out for the next three weeks. There's aggressive care with take backs for debridements roughly every other day. Unfortunately, the patient developed septic shock.
This leads to multi-organ system failure. Eventually gets an AKA, but the patient dies. Yeah, this is an unfortunate scenario that it's a relatively common start to the scenario. Mangled extremity is something that we all see often, and it's a tricky one, right? It's tricky because...
That decision between life over limb is tough, especially when there's multiple cooks in the kitchen and everyone has one goal and then you have to be the bad guy or girl sometimes and change the goal to save the patient's life. These wounds are often filled with mud and grass and exposed to devised tissue and fractures. These patients that we see, they get debrided and they exfix. They have wound vex and flaps and nerve transfers.
It can be a real mess is what I'm getting at. So how do we wrap our head around that? Jared, are there any like criteria that we can look at for these mangled extremities? Yeah, definitely. There's the mangled extremity severity score or the MESS criteria. This includes ischemia time, pulse exam, age.
level of hypotension, and mechanism of injury. With a score of 7 out of a possible 14, at least being a suggestion that an upfront amputation may be beneficial. However, this is an older scoring system and is more of a rough guideline than actual practice these days. We have advancements in wound care, surgical capabilities combined with skin substitutes. It's not uncommon for a limb with a score of a nine or 10 to be saved or at least an attempt at limb salvage to be made.
And I think adding to this, what makes this so difficult is that amputation is a tough decision, especially when you haven't had a discussion with the patient. You don't have the patient's family available. Let's say they've remained intubated after even their initial debridement, right? So that's really difficult to take on by yourself. Really, they are made on a case-by-case.
basis. And I think there comes a point in time when the patient's overall prognosis takes priority, right? So life over limbs is something that's not a difficult of a concept to comprehend, even though the actual practice may be much more. complex. Another question that I will often ask is, okay, the leg can be saved, but what functionality will that limb offer the patient? And fortunately, we...
We're in the United States where generally we do have good prostheses. Certainly there are exceptions to this overseas. You save the limb no matter what because somebody with an amputation is an outcast, right? So this can get even more complex when you're not necessarily within the United States boundaries. Yeah. These are tough cases, but we have to remember absolutely that the trauma surgeon is the quarterback. And sometimes we need to push for an amputation for the benefit.
of the patient. And as you said, Brill, it can be hard to know or feel confident in your decision, especially really early in the patient's course. And whenever possible, I would certainly recommend loading the boat, right? If time permits, have a few trusted partners, take a look. And it also depends on what kind of resources you have at your institution and what level of interest and expertise you have from other specialists like orthopedic and vascular surgery.
Some have a great deal of interest in managing these tough mangled extremities, and some certainly do not. And you can finally consider a time-limited trial. for the severely mangled extremity Because what you don't want to do is find yourself in this situation where you're converting from a BK to an AK because you waited too long. Or in the worst case scenario, like this one, where the patient ends up.
And so to that end, Jared, what did we miss? What was the pitfall that we actually missed here that led to this patient's death and can occur in these grossly contaminated mangled extremities? Yeah, in this case, the pitfall would be a missed fungal infection. Yeah, I think this is a perfect example of the eyes may not see, but what the mind does not know, right? If you don't know to think about a mold infection, you're never going to see it.
So like these patients that even if you get an upfront damage control amputation, But then they keep going back to the OR for consecutive washouts and their skin or muscle is necrotic. After they just got debrided to healthy tissue and you have another take back with necrotic tissue and another take back with necrotic tissue, you should start thinking about mold and start empirically treating with antifungals.
for a diagnosis if you send it to pathology it's going to take forever right for them to see that grow in the lab but we have become more aggressive at our shop. We have a protocol where we send the specimen fresh to pathology, and they look at it under the microscope in real time for hyphae to diagnose a fungal infection. a frozen specimen just like they do in the cancer world so
I like that, Teddy. Don't forget to specifically send that sample from the OR. You have to ask the right questions, make sure it's tagged correctly. If you have any concerns, reach out directly to Pathology and say, hey, I need to look for mold. If you don't know what you're doing, just say, what do you want me to do? how do i label this how do i send it check for mold please
Yep. And I guarantee that your facility has a pathologist on call somewhere that can help you with that. Yeah. With mold, you have to be aggressive in those initial take backs. And there's another pitfall at the end. where you are getting close to formalizing the amputation. But really, you can only do that when you have several additional washouts that didn't need any further debridement and the wound bed looks great. Only then should you start to formalize and say, yes, we're done here.
Mold is another thing that I only saw after arriving in Houston, and it really is impressive how quickly it spread. Aspergillosis counts in this category that is prompt treatment. Yeah. All right, there are ups up, pitfall number four. Do not find yourself playing limb over life and think mold if you find yourself debriding muscle and skin on daily take backs. And of course, these are often polytrauma patients.
where keeping a non-functional limb can be very burdensome to the recovery. It's a tough decision. Load the boat and think about all the different aspects we just covered. Okay, scenario number five. Our last scenario is a 33-year-old male who presents with a four-centimeter stab wound to the right of her quadrant. The patient is hemodynamically stable. and taken to the OR for diagnostic laparoscopy, which was converted to laparotomy for primary repair of the splenic flexure.
and small bowel resection times one. Five days later, the patient has a persistent and severe ileus, nauseated, vomiting, not passing flatus. CT scan is obtained and it shows small bowel herniating through a right upper quadrant defect, Jared. C'mon. We missed a... Yeah, missed one, huh?
Yeah. Oh, boy. This one is a little embarrassing. It appears that somebody got excited that they caught a case and forgot to close the traumatic ventral hernia from the knife that went through the abdominal wall. And now this patient has an incarcerated ventral hernia. Yeah, so close to perfection yet so far. Yeah. Close only counts in horseshoes, hand grenades, nuclear war. Not in surgery, though. So think about it. We close 12 million report sites for Coley's and Appy's.
and you have to remember a stab wound especially the one the size in this scenario is four centimeters so fun fact an oreo is 4.5 centimeters so it's not insignificant I'm glad you know that, Teddy. I learned something today. So Patrick, how would you fix the hernia?
Yeah, there's a couple ways. You can do it open, certainly. You already have a stab wound. Maybe if it's big enough, you could look through that stab wound to examine the bowel for viability that's stuck in that incision. In this case, again, having already addressed the primary injury.
Sometimes you might need to extend the skin a bit farther to get down to the fascia and take a good look at the bowel. And if the bowel slips back in, you can always put a scope in a fresh stick or you can even place the port in the mood and insufflate that way. And once bowel viability is confirmed, I would just close the defect in interrupted fashion with PDS or Maxon sutures.
If you are doing it at the initial case, you can do from the inside and from the outside. And who knows if that's better in the end, but it makes you feel better when you have all that PDS and Maxon in there. Yeah, I guess I don't know that I would count that as a missed injury, but it's definitely a pretty close one. Yeah, certainly a missed opportunity. Yeah. In the words of Dr. Brian Cotton, disappointments. We've all heard that.
All right. Some of us more than others. Pitfall number five. We forgot to close a traumatic ventral hernia. The devil is in the details and these things do in fact matter. So that wraps up this episode of the day T trauma series pitfall episode number three. We hope you enjoyed it. Jared, take us away. Dominate the day. This episode of Big T Trauma was sponsored by Teleflex, a global provider of medical devices. Learn more at teleflex.com.
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