Category Archives: Tips

Antihypertensive Treatment In Acute TBI

Yes, we know high blood pressure can be bad. Over the long term, it can accelerate atherosclerotic heart disease and pound away at the kidneys and brain. And when it is acutely elevated to critical levels, it can lead to stroke.

But is it always bad in trauma? Trauma hurts like hell, so it’s no wonder than many of our patients (not suffering blood loss of course) are hypertensive.  But how often have you seen this scenario occur:

An elderly patient fell from standing, striking her head. She is brought to your ED by ground EMS. She has a GCS of 8 (E1 V3 M4) with a BP of 200/130 and pulse of 56.  This meets your trauma activation criteria and the team assembles to meet the patient.

As you move her onto the bed, one of your colleagues calls out for some nicardipine to control the pressure. Is this a wise move? Remember the First Law of Trauma:

Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.

What else can cause hypertension and bradycardia in your trauma patient? In this case, certainly a subdural or epidural hematoma.

And why is that happening? Because the intracranial pressure is elevated from the space-occupying lesion. Remember the formula for cerebral perfusion pressure (CPP):

CPP = MAP – ICP

Where MAP = mean arterial pressure and ICP = intracranial pressure.  Normally the MAP is around 90 torr and ICP is about 10 torr. Thus, the normal CPP is approximately 80. The range is 60  to well over 100 torr, and flow autoregulation keeps brain perfusion constant over this range.

But let’s say that we are psychic and know the ICP of our patient to be 60 because of a large subdural hematoma. Her current CPP is 150 – 60 or about 90 torr. What happens if we start her on a nicardipine drip or some other antihypertensive medication? We can certainly normalize the blood pressure to 120/80. But now her CPP drops to 90  – 60 = 30 torr!

Congratulations, you have just shut down circulation to her brain!

Bottom line: Think first before calling for antihypertensive medications in patients who may have increased intracranial pressure. You may be sabotaging the only mechanism protecting their brain while you are calling your neurosurgeon for help. Your top priority is to get them to the CT scanner while permitting that pressure. If it turns out that there is no evidence for pathology that would lead to increased ICP, then turn to the antihypertensive agents to help protect against stroke. 

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Best Of AAST #13: Work-Life Balance

Okay, so this abstract is a bit more on the touchy-feely side. But it is extremely important because it speaks to the balancing act we all have to perform in order to achieve a satisfying harmony between work and everything else.

Older generations of surgeons threw nearly all of their energy into work, and ended up with lesser amounts of involvement with their family and everything else outside of work. At the time, , though, people seemed to be (mostly) satisfied. That’s just the way it was.

But now, there is much more emphasis on a healthy lifestyle, and this includes a healthy delineation of work and not-work. An AAST-approved survey was sent to the membership which tried to parse out the various factors involved in work-life balance, happiness, and burnout.

Here are some very interesting factoids:

  • Of more than 1300 questionnaires sent out, only 291 (21%) returned them (wish I had a sad face icon here)
  • Only 43% were satisfied with their work-life balance
  • There was no difference in satisfaction based on age, sex, or practice type
  • Here are the factors that set the satisfied surgeons apart from the dissatisfied:
    • Early (<10 years) or late in career (>20 years)
    • Fewer hours spent at work
    • More hours spent (awake) at home
    • Enjoy their job
    • Enjoy their partners
    • Better at saying no or delegating work tasks
    • Feel they are fairly compensated
    • Engage in hobbies (86% vs 68%)
    • Exercise regularly (49% vs 20%)
    • Eat a healthy diet (74$ vs 48%)
    • Get more sleep (7 hrs vs 6 hrs)
  • Despite getting the same amount of vacation time, the satisfied surgeons actually used it
  • Dissatisfied surgeons reported significantly more feelings of burnout (77% vs 39%)

The authors concluded that trauma programs should concentrate on optimizing the modifiable factors listed above to improve satisfaction and decrease burnout.

Here are my comments: Well, I don’t have many, nor do I have any questions for the authors. This is a purely descriptive study that paints a general picture outlining what seems to be important in enhancing satisfaction with one’s career path. It is an interesting read, and outlines many of the factors that influence this. I’m sure it’s not all of the factors, but they hit the big ones.

All trauma professionals should look at this data and read the final manuscript. It may help you make changes to optimize your own work-life balance and career satisfaction.

Reference: Modifiable factors to improve work-life balance for trauma surgeons. AAST 2020, Oral abstract #50.

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Trauma Education In The COVID Age

Trauma education has gotten significantly more difficult in the face of the Coronavirus. In-person education offerings like ATLS and PALS courses, TNCC courses, and major trauma conferences are routinely being cancelled or delayed. And many of them have decided to move to a virtual format.

Until early this year, I traveled around the country as a speaker for numerous trauma education conferences. The bulk of these have been cancelled for the remainder of the year. A few have opted to try an online format, and I will be giving several online talks in the coming months.

The American Association for the Surgery of Trauma (AAST) has converted their physical meeting in Hawaii to a virtual one (sigh). I will definitely be participating anyway!

Here are two conferences I will be speaking at, using the new virtual format. If you are in need of some quality education, check them out:

Virtual Excellence in Trauma Care Conference
Intermountain Medical Center – Salt Lake City UT
September 17-18, 2020
Presentations:
1. Keynote Address: Massive Bleeding Associated With Pelvic Fractures
2. Trauma Mythbusters
Registration Info: click here
Brochure: click here

Stormont Vail Trauma Symposium
Stormont Vail Hospital – Topeka KS
October 16, 2020
Presentations:
1. New Trends in Trauma
2. Mobility of the Trauma Patient in ICU
Registration and brochure: available soon

And if your hospital or organization is interested in putting your own grand rounds or other educational conference together, I am now focusing on providing presentations via telepresence.

Please check out the FAQ on my speaking engagements by clicking here.

Granted, telepresence is not the same as being there in person. It’s so much nicer to meet people in person, and it’s much more satisfying to make that more personal connection. But in-person conferences won’t be in the cards for a while. In the meantime, I hope to see you all soon via WebEx or Zoom! Please reach out!

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Video: Keeping Up With Your Literature

Every trauma professional at any level of training and expertise knows that it’s so important to keep up with new developments in your field. To that end, I created a video five years ago that described a super-efficient 5-step system for staying abreast.

Well, time passes and technology changes. So I’ve updated this classic with new recommendations and some refinements to the technique. I hope you enjoy! And please leave comments and recommendations on YouTube!

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Whaaat? Stuff You Sterilize Other Stuff With May Not Be Sterile??

When one works in the trauma field, or medicine in general, we deal with the need for sterility all the time. We use equipment and devices that are sterile, and we administer drugs and fluids that are sterile. In surgery, we create sterile fields in which to use this sterile stuff.

In the past few years, we’ve come to the realization that the sterility we take for granted may not always be the case. There have been several cases of contaminated implanted hardware. And a few years ago, supposedly sterile injectable steroids were found to be contaminated with fungus, leading to several fatal cases of meningitis.

An article in the New England Journal of Medicine brings a bizarre problem to light: microbial stowaways in the topical products we use to sterilize things. Most drugs and infused fluids are prepared under sterile conditions. However, due to the antimicrobial activity of topical antiseptics, there is no requirement in the US that they be prepared in this way.

A number of cases of contamination have been reported over the years:

  • Iodophor – contamination with Buckholderia and Pseudomonas occurred during manufacture, leading to dialysis catheter infection and peritonitis
  • Chlorhexidine – contaminated with Serratia, Buckholderia and Ralstonia by end users, leading to wound infections, catheter infections, and death
  • Benzalkonium chloride – contaminated with Buckholderia and Mycobacteria by end users, causing septic arthritis and injection site infections

Bottom line: Nothing is sacred! This problem is scarier than you think, because our most basic assumptions about these products makes it nearly impossible for us to consider them when tracking down infection sources. Furthermore, they are so uncommon that they frequently may go undetected. The one telltale sign is the presence of infection from weird bacteria. If you encounter these bugs, consider this uncommon cause. Regulatory agencies need to get on this and mandate better manufacturing practices for topical antiseptics.

Reference: Microbial stowaways in topical antiseptic products. NEJM 367:2170-2173, Dec 6 2012.

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