#FOAM

Included below is a summary of numerous blog posts and podcasts that discuss the sometimes controversial issue of permissive hypotension or minimum volume resuscitation in the bleeding trauma patient.

The Basics

• Idea of keeping BP low in traumatic hemorrhage to avoid “popping the clot”
• Based mostly on data from animal trials and penetrating trauma in humans
• Common practice in most major trauma centers in USA
• The exact approach still remains controversial around the world

Disclaimer: These are highlights as interpreted by the author of this article and should not replace listening to the original podcast or reviewing the background research.  Posts are in chronological order and many of the below podcasts go beyond the scope of permissive hypotension. […]

Does End Tidal CO2 correlate with PaCO2 in Traumatic Brain Injury?

Your neurosurgeons and trauma team have accepted a transfer to your hospital for intensive management of a trauma patient who presented to a small community hospital with a traumatic subarachnoid hemorrhage and epidural hematoma after being involved in a motorcycle accident.

While the patient is in the ED, the neurosurgeons recommend maintaining eucapnea for the patient since while there are no acute signs of herniation.(1)

Can you use the end tidal CO2(etCO2) or do you need to rely on arterial blood gas (ABG) measurements to maintain PaCO2 between 35-40 mm Hg? […]

Why is it important to aggressively and appropriately manage rib fractures in elderly trauma patients?

Recently, an 82 year-old male suffered a fall from standing, striking his left posterior flank against a cinder block, sustaining fractures of the left 7th-11th ribs with displacement of the 8th-11th ribs, causing a moderate L hemopneumothorax. After placement of a chest tube, drainage of the hemothorax, and reinflation of the L lung, the patient was then transferred to our facility “for management of his rib fractures”. Given that this patient was going to be managed non-operatively, I found myself wondering why would this patient require transfer for such a seemingly common problem among trauma patients. Rib fractures are present in 10% of all traumas, and in 30% of chest trauma specifically. After assuming care of the patient, I quickly began to realize why this patient was given such a high level of attention. […]

Concussion is a type of mild traumatic brain injury (TBI) that classically occurs in sports-related incidents but can be due to any traumatic force to the brain. The term concussion stems from the Latin word, concussus, which means “to shake violently.” While sport is the most common cause of concussion in children, the most common causes of concussion in adults are falls and motor vehicle accidents. Young children have the highest rate of concussions in all age groups. […]

Rapid evaluation and management of the sick neonate is a required skill for the emergency physician. Here we present a brief but comprehensive strategy for resuscitating and stabilizing the critically ill neonate as well as some mnemonics for help remembering the differential diagnosis.

Case Scenario:
A 38-year-old male with a history of hypertension and an unknown heart defect status post repair in infancy presents to the Emergency Department with acute onset chest pain, dyspnea, and diaphoresis.  He had a similar episode at another hospital 1 month prior that resolved after “some medication.”  He denies drug use.

An EKG is obtained in triage, and is shown below.

The patient’s blood pressure is 120/70.  He is alert and oriented, and speaking in full sentences although dyspneic with respiratory rate in lower 20s and O2 saturation 98% on RA.

Clinical Question: Which pharmacologic agent is most effective for termination of monomorphic ventricular tachycardia?

Thanks to Reuben Strayer for letting us ask him anything. He covered resident education, how to think like an ED physician, practice pearls including ketamine analgesia, chest tube insertion, awake intubation and much more. Follow him at @EMUpdates or check out his latest work on emupdates.com.

We’re grateful to Mathew Miskimon, MD PhD for providing this morbidity and mortality (and improvement!) case from Janus General. Includes a nice discussion at the end on the systemic factors contributing to the outcome.

A diagnostic dilemma from the case files of Janus General. The presentation of this clinical zebra is provided by one of our esteemed editors, Adaira Landry, MD (@AllAroundDoc).