Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

This patient has undergone a significant trauma and physiologically, there'll be a lot of changes. Um uh So I'll start with, uh, well, the top, on the top that there's a cytokine storm, there's a whole host of cytokines which are released when someone has poly traumatized, uh these cause inflammatory response within the body, which can lead to all of the other things such as hypothermia, leaky capillaries, um uh acidosis. Um This patient's probably had significant blood loss as well, uh from his injuries, followed by any surgery that he might have had. Um, we can't see anything above his uh sort of uh abdomen level. So we don't know if there's anything else going on above but significant blood loss. Uh And that can lead to um acidosis. Um It can cause uh coagulation abnormalities um with a loss of uh platelets, uh leak pillories. Um and he must have been resuscitated with, well, hopefully blood, but if he was resuscitated with uh fluids, then he'll be, he'll be human diluted. Um That's about all that comes to mind. Yeah. So we'll be having talks on the coagulation pathway and talks on out loss. Um Yeah, I think you used all of the words there. Um In terms of calculation, you talked about the platelets, but you might also talk about the consumption of fibrinogen when you start adding all these words together and the phrases consumption of fibrinogen and the cytokine storm, the examiner sits there goes well, I'm not going to go into too much depth. It seems like he knows what he's talking about. You shouldn't hope they don't ask you what cytokines are going. But if you construct a sentence out of most of those words, then you can get the physiological response to trauma in one or two sentences. Okay. And it is this, it's whether we do um early definitive care or damage control orthopedics and it's that whole cytokine storm that then leads to the leaky capillaries, which leads to as J was talking about the him a dilution. So you've got to give them twice as much fluid to be able to resuscitate them because half the amount of fluid is going into the third space. A lot of the fluid is going into the lungs and gradually drowning them. And that's the problem with the, the trauma response. And what we want to do in all everything we do is to mitigate it. If you put type a therm eah and blood loss and acidosis together, what do you get happening as sources blood loss again? Kagle upsy. Yes, coagulopathy. Okay. And we call that the bloody spiral of death. Uh Yeah. OK. Who else is coming up to the exam? Hassan? What have you, what do you see there that we've done to mitigate their physiological response to trauma? You might be a mute. Hassan. No, maybe not. I can't hear you. Can you hear him? No, I can see your face coming up. Which means you must be talking. I think I'm not used to medal but I can't hear you. Yeah, it's his, my friend's not working for some reason. It was working earlier. Yes, I heard him earlier. Who else is coming up to the exam? And Ebert show you there, see you flipped a pin in for some reason but uh Mr Brandis, I'm not, but I'm happy to go. That's it. Tell us what we've done here to mitigate the trauma response. Um So you've done um well, stabilization of the long bones without doing definitive fixation. So minimal izing uh the physiological uh trauma being caused the patient. So rather than doing the major operation, you reduce the physiological hit. The second hit, I suppose. Yes. At last you got the word second hit in a lot of the exam is about constructing your phrases and constructing your sentences. And if you say to me second hit and as such, we've done what we've done here is avoided definitive fixation. And for long surgery minimizing the second hit, I mean, you're really up there, aren't you? Okay? Keep talking. Um So Yeah. In the, in this context, it's um minimizing second here in order to avoid uh leading into uh multi organ systemic uh multi organ failure, essentially. Um And then after this, the patient can be stabilized on, on uh I T U. After which, when physiological parameters have improved, they can return to the for definite fixation. Okay. So how have we done that? How did we minimize the second episode by being quick and efficient with our surgery? What else have we done as other things done? Uh I mean, long bones have been stabilized which will minimize hemorrhage. Um fasciotomy have been performed in order to minimize stop there. So, what is the the stabilization of the long bone fractures achieved? Um So this is partly him hemorrhagic control reduces blood loss from, from long bones. Yes, reduced blood loss. What else? Uh It also facilitates um uh positioning of maneuvering of the patient for any other surgical intervention that may be required in general surgical intraabdominal um surgery and the like. Okay. What else? Um um I'm not sure what else. OK. Minimizing pain, part of our physiological response to trauma and that constricts, our capillaries and sends our autonomic system haywire is pain. Um If you talk to Roman, uh Addenbrooke's, the NCC consultant is very much the idea that we need to stabilize the long bones to stop that paying generation. Although there on our see you and they're ventilated and they can't tell us, they're in pain. Their body is still telling their brain they're in pain and then their brain is releasing sata cons and the hormones and signals to the rest of the brain causing the rest of the mischief. Hmm. And so by stabilizing the long bones, one we minimize or reduce the amount of blood loss and we reduce the pain response. What else might we reduce? Use the word might um, I suppose you can also you might also reduce risk of uh injury to your vascular structures as well if you okay produce secondary injury to other structures that are close by. Yeah, I must say if you haven't taken out your property elottery when you first break your femur, you have to be very unlucky when someone's rolling you gently a nice view, but there's always a potential. Okay. Anything else? Um I'm not sure what else. So what do we think causes the leaky capillaries and the ARDS adult respiratory distress syndrome, the subset of multi organ failure? Um uh I'm not sure. So fat embolism. Alright. Okay. So it's thought and I use the word thought that by stabilizing the long bones, we have less leakage of fat into our systemic blood system, which then circulates around our body and therefore minimizing the effect of fat embolism embolism syndrome. How much of it is that physical fat being in our blood, you know, these little glow Biggles, that's what we see it as or how much is it, is the pain or the associated stuff that goes with it? We don't know. Okay. So we've stabilized the long bones. Let's go through that again, to minimize blood loss and allow the clot to form who possibility of fat and embolism syndrome and to minimize the pain response, knowing that pain generates uh physiologic response. Uh centrally, what else have we done there that you can see? Um So you've always done fasciotomy. He's on, on both legs as well. Yes. So sometimes you'll do them because you have the have a compartment syndrome. You've actually measured them occasionally, they have an eminent compartment syndrome. If they've got horrendous leg injuries, you'll do it prophylactically and that's to avoid further injury from devitalized muscle. And what comes under the decompression of fasciotomy as well when we think about the multiple e injured patient, um I suppose it's, you also reduce the risk of rhabdomyolysis and rate of toxic. Uh Yes, good. Anything else? Um What goes with the DS in the multi injured patient in terms of the priorities of treatment? Um We'll come to it. You see the prehistoric element that J never talked about that's on this actually, see at the C clamp that's also on kids. And so in terms of the physiological response to trauma, uh when you start out, what is the physiological response to trauma, you need to sort of get a whole lot of those words in as quickly as you can. And then you need to start talking about damage control orthopedics and how you minimize the second hit, either from prolonged surgery or being exposed to the elements like this in theaters and becoming hypothermic acidotic. And with him a dilution leading to the power of death, uh these sort of phrases and, and language that you want to be using when you're talking about it. Um This was the whole idea of the first hit. A second hit that came out 1983 tranqui spoke about it. The try model distribution of death. The fact that we die when we either on the road because of an unsurvivable injury, but like a pulmonary uh artery rupture like Princess Di or we die within the first hour. Um uh And then the third distribution was that we would die too with the late weeks later, from that Satya Con Storm, from that physiological response to trauma that lead to the leaky capillaries and to the ARDS and gradually dying on the ICU. The second hit is a again a concept of this idea that any further insult, whether it's uh infection on the ICU, whether it is dead muscle or bring compartment syndrome, um whether it is just movement of a broken leg, disrupting the clot again, um leading to more fat being released or due to the uh response to pain. Um adding more of a stress on the body and obviously the biggest hit of all hits is an orthopedic hit in terms of surgery. And then when is this theoretical threshold, which if we go above, in terms of our inflammatory response, that we will burn out and fade away, that we will achieve a, a ceiling uh that we can't recover from. Now, the problem is at the moment anyway, is no one really knows where that level of head sits. So we haven't been able to quantify it on a physio physi physical level. Iii too long bones and one broken forearm or two liters of blood loss. No one's been able to give it a total physical injury. This is 100% chance that you're going to get to that theoretical level and subsequently, any further hits. We've tried to look at the cytokines. We've tried to look at the inflammatory markers, interleukin six and tried to then prognosticate it unfortunate hasn't really got into any sort of clinical practice. And so we don't actually use the level of inflammation in someone's body or someone's blood or the cytokines as a measure of how much stress they're under. But more a response to resuscitation. And that's what the last set is all about. It's not a cytokines, it's a response to resuscitation. It's whether you're going for an aerobic or aerobic respiration. And so the reason we live or die in response to trauma relates to serves the systemic immune response syndrome relates to cars, the counter anti inflammatory response syndrome. And this is a process that comes in a few days later, sort of calming down the inflammatory response. And very much what decides whether we live or die is our response to a given hit is our response to blood loss. And that inherently dependent on our genes. And that's why the Viking is sitting there. Do you have blood loss genes? Are your genes made to clot? In other words, if you stabbed or do you have blunt trauma genes and head injury genes that are there neuro protective? So for a certain injuries, someone being stabbed or a certain injuries, someone being crushed by a car, different people will have a different inflammatory response and be able to recover differently. And so it's all these three features, the systemic immune response, the counter anti inflammatory response syndrome and your genetic uh ability to deal with trauma that decides whether you live or die and how you respond to it if you haven't read it. Uh This is a good article uh from 2006, which was the beginning of damage control orthopedics. Prior to this, it was all about early definitive care. And then as we learned this idea of the uh trauma physiology, the concept of the first hit and the second hit that we then started minimizing it. Uh Thanks in 2000 uh in the 2006, 2007, 2008. Uh we talked about the lactate. Now, the lactate isn't really a cytokine. It is just about whether your cells are, uh, aerobic or anaerobic metabolism. It's not directly a measure of the severity of your injury because there are some people who will resuscitate better and there are some people who are resuscitated better. Um, but it was showing that if you had a lactate of less than 2.5, you had a low mortality and if you had a higher lactate higher than four, you had a sort of 18 to 20% mortality. And that's where the lactate sort of came in. What it showed was that people who had a high lactate were more likely to die. And it became from that this sort of a traffic light. Uh 2.5, less than 2.5, you could go ahead and do whatever you wanted. Around 2.5, you watch the trend more than 2.5, you stopped completely. Uh When clunky started talking about the try model distribution of death, um I see us were relatively not primitive, bad choice of words. But since the introduction of the major trauma centers, since more and more people have been given access to high level I C U K. We've lost that third mode contribution. We've lost the try model distribution of death. It's now come down to a bio motile distribution. In other words, you either die on the side of the road or you make it a hospital and then die within the 1st 24 hours because there are people that are dead, but we keep them alive. One to see whether we can harvest their organs to, to let their family come to terms with it and just to see which way the dust is going to settle. But generally, we know those patient's uh that are going to die within the 1st 24 hours and they second mode of distribution that delayed deaths due to the beauty of the intensive care units. And the beauty of uh resuscitation has dramatically reduced. Also our knowledge of uh the trauma response and how to mitigate those injuries has again uh led to people living longer. Now, this side of uh the evolution from early total care, too early appropriate care. This change came around 2014, a little bit based on values paper 2013. And if you're coming up to the exam, it is worth digging out these papers and reading them, they will go into a little bit more detail that I can in the uh 45 minutes that I've got. But you want to read them and how we evolve from early total care to damage control orthopedics, too early appropriate care. So that when you're talking in your exam, when you're approaching a patient, you've got a level or depth of knowledge behind just the headlines. And the value in 2013 showed that there wasn't anything perfect that we accepted the 2.5. But due to the better understanding of orthopedic surgeons of that second hit in the physiological trauma due to the increased capability of intensive care units. Uh one to support the organs or two, possibly even replace the organs um to support respiratory care to put some on ECMO. Um we've been able to push up that level of lactate um to about a fall, but there is a little bit more than just the lactate. So you could pass on a lactate or four, but you would want to know a little bit about the ph and so you would want to P H more than 7.25 or basics s less than five, you don't want it more than five. Um and those are the sort of parameters you'd be using, making your decision in the modern trauma system on whether you're gonna go for damage control orthopedics or whether you're gonna go for early appropriate care. And often in your clinical decision making you fluid, it's not absolute DC. Oh uh early appropriate care. You would deal with one injury and then deal with the next and then deal with the next and then deal with the next clinical case is always the best. So here we see a patient with a head injury, base of skull fracture, nasal bone fracture, APC pelvic injury, right? Super condo fema and open tibia, open tibial plateau and a Beimel YOLO ankle fracture, who's coming to the exam intubated through the window and there's his X rays. Hassan, you're coming to the exam. Can you talk yet? I see your face coming on the screen or your mark on coming on the screen but I don't hear your voice. Anyone else coming at the world? Are you there? Said deneche, are you there? I'll go ahead from now, Mr Ran. Ran random. What do you who just flash on the screen? Anyone's face? Just shout at your your microphone um Here. Okay. If you're they're not. Actually I really don't, I just don't wanna keep asking people who want there, John, you popped up. Hassan, you popped up and I couldn't hear you. Hi, I'm back. Can you hear me now? I can hear you now. Hasan. Thank you. You're coming to the time. Yes, I am. Yes, indeed. Okay. So here you've got a 20 year old with multiple injuries. Um What are your priorities? And how do you approach it? So, patient will have to be managed according to the A T L S protocol. So lifesaving uh injuries would have to be addressed first, airway, breathing, circulation, uh disability, next. So pairs of skull injury that's uh hi concern for uh respiratory associated problems. And uh this would have to be a month of the Supreme approach was an aesthetic team. So uh starting from the top, this patient, well, uh um might need intubation by means of fiber optic intubation was addressing the stability for the C spine. Um that might as well need to include assessment for the cervical spine, whether that needs just um stability with where's blocks or does the patient need? Hello and pins and there's a bone fracture that is of uh that's priority if the patient is not acutely bleeding for that, if it's already intubated, um then the check that the chest is not associated with this injury by means of um CT scan processing, there is no hemithorax or pneumothorax or any mediastinal life threatening injury, but it's not listed there. So, coming down this uh APC pelvic injury. So there's an unstable with uh synthesis. If it's dire status of uh more than two centimeters closely by looking at it, he's got a pelvic binder which seems to be above the level of the greater trochanter. So it might not be addressing what it needs to be doing. So it will bring the pelvic binder down to the level of the G T. Um. Um patient will need a CT scan with contrast and that will give us a good idea of the three dimensional injury or geometry of the fracture and any associated him at home or ongoing uh intrapelvic bleeding that might need addressing by uh our colleagues from the interventional radiology if it's uh continuously blushing or bleeding, um coming down to the right supracondylar to fema and right tibial shaft fracture open. So this is a fly flying knee and unstable. So this will be in need to be addressed by an external fixator and at washing and providing the that open tibia wound fracture might need prophylactic fasciotomy on that side. If it's uh concerning clinically or evolving swelling or other element can be used as well. Inter operative lee is to measure the compartment pressure with uh arterial line, uh transducer but very low threshold to do a a prophylactic fasciotomy. The left ankle is a Beimel, you're a fracture if it's in grossly acceptable position. So that would be an option for back slap and manipulation under anesthetic because this will be the list of the concerns. So it's a complex uh injury. We'll need to assess the patient lactate uh trend to see they're able to go for damage control our spirits approach or they need to be resuscitated further until they're more stable. To have the first part of the surgical intervention. Okay. And, and adding antibiotics, of course, according to the post four guidelines and addressing the uh anti tetanus prophylaxis for the open fracture. Okay. Um Everything you said is absolutely right. I can't fault you. Um But the question was, what are the priorities? Um And how would you choose which one is the higher priority? I got a little distracted when you started talking about halos and pins. Um There's no cervical spine fracture in there. Um Kindly to stick to the question a little and tell your answer to what they're asking you. Um There was a little bit about an outline, measuring, you know, you need to give them your knowledge. You've obviously got your knowledge and so your priorities are defined. Absolutely. I love your answer in the beginning to identify life threatening injuries and deal with those injuries as they're identified base of skull fracture, likely to be of dealt with in terms of airway and breathing. Um with intubation, nasal bone fracture, unlikely to be uh anything in terms of priority. Definitely, the APC pelvic injury would be high on my level of priorities both for circulation under HLS in terms of bleeding, but to reducing the systemic uh effect for the 1st and 2nd hits of trauma by producing the blood loss and uh reducing the systemic response in terms of then leading on to respiratory problems. In terms of uh leaky capillaries and uh breathing problems. The long bone fractures, the super condo a fema and the tibial shafted belchatow again would be priorities in terms of circulation for bleeding and for minimizing the trauma response. And as such, these would be my high protease by manual ankle fracture. I would stabilize relatively quickly with non operative treatment in the back slab. So that's how you sort of thinking on the way you go and then you move your way down two D. So if you haven't read this article, it's a little bit old now, but aspects of current management, the surgical priorities and how this is the article was a little bit about how you choose what you do to reduce that trauma response. So stop the bleeding, reduce the inflammatory response, remove all of the devitalized tissue, prevent ischemia reperfusion injury. So if there has been a vascular injury, if it's uh more than six hours, then think clearly whether you want to revascularize that limb and providing pain relief and what it really comes down to. Sorry, I need to just jump forward a few slides is the DS. So most times it's easy to justify your prioritization on ABC airway breathing and circulation. Bearing in mind that the long bones and pain contribute to your trauma response and a little bit to breathing in the long term, although it may not kill you immediately. And then after that, when you get down to the D's, you need to be talking about the bride decompress and decontaminate and that's kind of where I was going to seb. And so we've done the external fixators to deal with principles A and B in terms of not a sorry B and C breathing and circulation in the long term. But then we also want to debride, decompress and decontaminate any tissue so that they don't get a further second hit due to dead muscle uh rhabdomyolysis or possibly infection. For. Who else was that? G uh Jihan, did you uh can you hear me tell me a little bit about, yes, I can tell me a little bit about those vac dressings. What do you think the backdrop things are basically in place in the Fasciotomy that was performed on the leg and they uh basically uh form a function of a negative uh fresh addressing uh if there's any uh bleeding or uh we're in the legs, it will, it will try to essentially uh that away. Yes. Okay. Um So there was an open right tibia economy and with the tibial plateau was open as well. So they may be there for fasciotomy is, but they also there for the um uh open fractures. Um And tell me a little bit about the controversies of negative pressure, wind therapy and open fractures. Um I think um I think the points against it uh would be uh if it's an open fracture uh potential, it could be bleeding. So you could be encouraging uh blood loss through negative pressure. Um uh I can't think of anything, nothing else other than that or it'll be taking away, you know, like uh uh factors that uh that are pro healing. So it will basically, you know, stop the fracture from healing. Uh I don't know if that's very important the acute setting. Uh But that's the only two. I. Uh Okay. Okay. So you're thinking that actually the back might increase the blood loss and continue that bloody spiral of death. You're thinking that the back might actually taking the humi d eight hours for whatever fracture you've got. Is that what you're mentioning? Yeah, that's right. And what problem and what trial looked into that? I don't, I don't know. Sorry. Okay. Good. Uh You apologizing. We don't know. And that's good because that's why uh we'll get to. And what basically happened for this patient is they won't for gradual reconstruction uh gradually turning in from a series of external fixators to internal fixation over time. So uh when you come to the trauma response, you want to minimize the trauma response of blood loss, you want to minimize the trauma response of secondary injury, you want to minimize the pain response um and uh reduce the amount of potentially and then they use the words potentially that, that that's being released. Although the uh sort of visualize it, don't we? That when you put an X weeks on, there's less shaking of the bones or less fat going into the circulation, I'm not too sure how absolute it is. Um We've talked about the parameters in terms of uh your ph greater than 7.25, your basics s or 5.5 and your lactate of four. No one to my knowledge at the moment is using um actually cytokines uh as a measure of the degree of inflammation. The other thing to consider when you're doing the multiple India patient and making the decisions is looking at um those parameters I talked about but also any associated head injuries. Um, they don't tend to do as well, any associated chest injuries and an associated an abdominal injury. Um, coming up to 37 I'm going to have to be going in a moment. I just want to get two negative pressure room dressings a little. Um, so yeah, there used commonly because they are very functional. They are very good. They are very easy. I don't think they increase the blood loss unless you've got a spurting artery in there. Um, there's been a number of trials looking at uh negative pressure wound therapy dressings. That's just 20,012 where they show that actually using negative pressure wound therapy dressings, you reduce your infection rates from 20% down to 8%. Now, that's a high infection rate. I don't know about you. Um, or where you work or where, uh, the rest of you may work. But it's, yeah, that's a high infection rate. I mean, uh, we see a few infections following tibial fractures, but we certainly don't see up to 20%. And this was when they were doing back in 2002, 2007, they were dressing the wounds until they healed. Um And so most of those wounds were going on to secondary uh healing. Um And in this next study that came, they were doing the same sort of thing. They were doing negative pressure, wouldn't therapy until the practice healed. And that then led to this trial. So you would want to be reading about this trial. Uh The wolf trial came out in the general, the Macon Macon Medic Association in 2018. And they looked not just at infection because infection is not the end point. They were true professors. They looked at function. And so they did look, look at union rates and they looked at uh functional outcomes. And what they showed is that there is no difference between standard dressings and negative pressure wound dressings. There's been a few articles since then, systematic reviews and meta analyses that have actually counted that articles suggesting that you are better to do rap dressings, it still remains a little bit open. Um Just be careful when you read the articles. Um It's very much uh what they were hoping to do with the VAC. Were they doing the VAC to damage control like we do mostly in the UK or certainly within East anglia and then doing a complex reconstruction or plastic surgical reconstruction to close the wound or were they using the vax to actually close the wound and dressing it with the VAC for week one and week off? Um I think the bottom line, I think the way I would approach the negative pressure wound therapies, I would quote the wolf trial and say no difference in function, no difference in outcome, no difference in infection rates. But for nursing care and for practicalities of dealing with open wounds or fasciotomy wounds. I, uh, would use a vac dressing. Uh, the last thing and this is probably the biggest thing that has reduced the trauma response to patient's is the establishment of the major trauma centers and centralizing trauma care. Um, Hussein will be talking a little bit in the moment about, um, uh, massive blood loss and the coagulopathy of trauma. Uh, since they've started putting blood products onto the ambulances, since the ambulances have been able to get to the patient's faster and get them into the hospital faster. We've dramatically reduced that first hit, um, and dramatically reduced the physiological response uh to trauma. Any questions? I see there's three comments in the chat, something gone wrong. Well, trout whilst waste our CT as well. Jason, what's the West trial? Um, hi, this is another are CT done by Matt Costa which was published in uh 2020. Uh, and again, it said that, um, there's no difference between your infection rates between, um, um, negative special therapy and standard with treatment. I, I have to read the details to tell you more, but I just read the conclusion and, and tell you the conclusion. Yeah, I just read it whilst we're talking about it. Okay. Great. I'm gonna have to go look that up every day is a school day. Anyone got any more questions before we start about the blood is power of death. That'll cool. Who's running tip. Uh, yeah. Sounds like no more questions at the moment. So, we move on to the bloody spinner of the death. Mr Van Rensburg. Just a link on the, on the chat. Okay. That's what I should have called. My talk. The West. W I h what is wh stand for? Oh, man. Math. Uh huh. The findings of the study do not support the use of negative pressure, wind therapy and patient's having surgery for major trauma to the lower limbs. Yeah. Why do we still do it then? Definitely because I don't want people to mess with the wound. Uh, when you put a standard dressing on it just peels off it soaks in the bed, then people are walking doesn't make a difference. Allegedly, not allegedly. Those are, those are pragmatic trials. Yeah. Are you using conventional dressings? No, my comment to Matt when he set up the will cloud, he was a registrar the same year as me was the worst thing that can happen is it shows no difference. Um Yes, there's lots of reasons why the standard dressings do a little bit bit about the same as the vac dressings. Um, we tend to abuse the vac dressing is a little but it's certainly for nursing care, patient care, tolerability of the people around. Uh, it is nicer but, but, but he does say on the, on the wist that the outcomes were the same. But however, the cost of uh negative pressure therapy is higher and therefore they don't, don't recommend the use of negative pressure therapy. It's not actually a clinical problem. It's a cost issue that, that he's mentioned. Yeah, like I said, the worst thing that you come out of that trial was that it makes no difference in outcome here. And then they start looking at the money. Correct. Yeah. Well, they haven't beaten us with the stick yet. So, no, that's why we should kind of forget about it and then continue using uh someone told that patient that they feel she clipped. Have fallen off. The what? Sorry. So she clips on that. Actually the pill of this. Yeah. The last time you picked it up, it was on a CT boss. I had to go and tell them, ok, well, they may not be full. She clips, there may be something else. Okay. Thank you for the invitation. Um Sorry, it was a PDF fire. Have another more interactive one. Have a good day. Thank you. Thank you very much like All right. Right guys. Uh So do you want to carry on? Do you want a break for a few minutes? Can you see my presentation? We can see it? Cool. What do you guys want to do? Um I'm happy to carry on. I don't know what everyone else. All right, let's carry on then. Uh So we're going to talk about bleeding and resuscitation. Um It's important comes up in the exam. Um, we'll talk about some interesting stuff but we'll get, we'll cover the basics that you need to know for the exam and we'll talk about when it might come up in the exam. It's quite a big topic that can come up in lots of different places and then some strategies to answer and get as many marks as you can in the exam. So, uh, we're going to cover the clotting cascade, which is a little bit boring basic science. See, but I've tried to keep it simple um and relevant and hopefully it will be one of those things that you get right. That's why we're doing this. Um And then what happens in the trauma patient, there's some new things uh that might be new to your hope. Um Then how to resuscitate with what products and then what surgical adjuncts we can do to for hemorrhage control. And then we've got a couple of cases to discuss. Okay. So trauma is leading cause of death, know that. But hemorrhage accounts for about 40% of all trauma deaths and it's the leading cause of preventable death. Understanding. It is important for both clinical work and the F R C s. Uh the bleeding topic comes up uh in basic science and trauma adult path and in your M C Q s uh in the clinical setting, it could be an interruptive bleed, a major, major trauma or a pre op risk assessment. So, if you haven't seen this at some point when you're getting close to the exam or even in your early ear's start looking at these videos bike went on. Um, they're, they're brilliant. Uh So if you go through it, this one's about 15 minutes long, um, you just go through the clotting cascade and each drug and where it works on the clotting cascade, it just makes everything click. So, um, we're going to briefly go through that and excuse my uh handwriting, which I did on my I've had for my, my F R C S notes. So, clotting cascade is made up of this pathway. There's an intrinsic pathway, an extrinsic pathway and they share the common pathway. So, starting with the extrinsic pathway, you get tissue damage and you get release of tissue factor, which then activates factor 7 to 7 A and that helps convert into the common pathway 10 to 10 A. In the intrinsic pathway. You get tissue damage, endothelial collagen stimulates 12 into 12 A A which then goes on to uh 11 to 11 a nine into nine A and then down 10 into 10 A. Okay, eventually you get to prothrombin, which is to, that gets activated to two A which is thrombin and thrombin is your clot. Okay. Um Sorry, fiber in is your clot. So thrombin goes onto fibrinogen to fiber and fiber in is basically your clot. Um that clot is broken down by plasmin. Um and we'll go through how different drugs interact with these. So, um the way heparin works is it promotes anti thrombin three and anti thrombin three works uh on the pathway between um pro thrombin and thrombin. So it inhibits uh that it promotes that area. So you get reduced thrombin. Uh and it also inhibits uh 10 A and to a low molecular weight heparin inhibits 10 A. So does Apixaban, rivaroxaban and Edoxaban. Um dabigatran works as a to a inhibitors. There's a thrombin inhibitor and takes a works on uh plasma. So T X A is a clot stabilizer. So every time you have an injury, the way that plasma works, every time you knock yourself, you develop a small, little bit of a clot. What plasmin does is break down that clot because otherwise you'd be forever clotting. Um And it's your form of regulation. Um What, what T X A does is up, regulate this process. And so tissue plasminogen activator promotes plasminogen to plasmin and the plasmin uh prevents the breakdown of fiber into fiber and degradation products. So, what T X A does is it's a competitive inhibitor of tissue plasminogen activator and therefore, it reduces plasmin and prevents fiber analysis. So it's a clot stabilizer. The opposite of that is a clot buster, which is what streptokinase is okay, which is what you'd use in. Aske emmick. Um Lim uh what the vascular surgeons use or and stroke care historically. Um So what that does is up regulates plasminogen to plasmin. So you get increased fiber analysis and so it's a clot. Buster Warfarin works on vitamin K on a vitamin K dependent pathway. So what that means is you get vitamin K and that gets converted into reduced vitamin K and the reduced vitamin K is needed for gamma carboxyl ation of the glue tannic acid and the glue tannic acids essential for the clotting factors 279 and 10. And so, Warfarin affects those clotting factors. So that's a common question. Um And by doing that, you get um anticoagulant at the anticoagulant properties. Now to reverse that, we give vitamin K but that takes a long time to work and to reverse. And so if you want a quick reversal of Warfarin, you give those clotting factors in the form of oct appliques or bury plex, which is recombinant to 79 and 10. Okay. So you just instantly incident clotting factors. Uh and Warfarin works on, as we said on the intrinsic extrinsic and common pathways uh reversal, vitamin K can take time. So that's the basic sciences. Bit, we're gonna talk about resuscitation techniques. Um That stuff you just need to know I would watch the Kuantan video. Um It's just really nice summary um resuscitation techniques. So, components of blood, okay packed red cells, we know red cells platelets, we know FFP are clotting factors and cryo is clotting factors and fibrinogen. Okay. So, sources of hemorrhage on the floor and four more. Yeah. So blood on the floor in the chest, the abdomen and the pelvis and in the long bones. So who wants to tell me about the triad of death? Anyone? Yeah, I'll go fine. Um So you're trying to, so you try to death these three primary components, acidosis, hypothermia and coagulopathy. The problem of which, well, firstly, they cause you to die, but secondly, they contribute to each other. So, hypothermia will contribute to your coagulopathy and your ass tosis. Um and basically perpetuate each other um acts promote hemorrhage, essentially. Yeah. Absolutely. And so that's kind of what the traditional teaching is. There's a, probably a bit more to it which we're gonna go through in a second. But what the triad of death or the theory of that triad of death is is that um that happens over time, you have your trauma, then you get cold, then you get acidotic, then you get coagulopathic and you use up all of your cutting factors. Then we give you blood products and we give you uh the line and you become diluted even further and through dilution, uh you become more coagulopathic and the spiral continues. Um And that's been the traditional teaching, but there, there's a bit more to it. So the one of the things that isn't well taught is um this, there is an acute coagulopathy of trauma and this was um work done by Kareem bro, he at Barts Health um at the Royal London and what they did was look at their polytrauma as that came in. So they had 1000 and uh they had like 1800 cases and then they had full data for 1088 of them. And what they looked at was those patient's with a really high injury severity score. Um, they had a coag screen that was sent ASAP and they looked at what they're, whether they were coagulopathic at the time and whether the injury severity had anything to do with it. And so what they found was the mean, uh coagulopathy was present in 20 for almost a quarter of patient's. If you broke that down in terms of injury severity score, the ones that had an injury severity score of under 15, 10% of them had an acute coagulopathy over 15, it was a third. And if they were really probably injured, like the patient that L V R was showing with X fixed from pelvis to toe tip, 70% of them or coagulopathic. And so major traumas, an indent independent risk of coagulopathy, it can happen as quickly as within 15 minutes. Um And so the quicker you start treating that and reversing it, the better the theory, the theory is the better the outcome. So the classic teaching of giving two bags of salty water in a patient who's multiple e injured, um is unlikely to make as much of a difference as if you were to give blood products. And so we're moving away from the A T L s, give salty water, then start blood, then do this. And we're giving blood much earlier and blood is being given by the hems teams, uh products have been given by the hems teams. So the idea is that if you reverse that coagulopathy early, you will avoid the complications of major trauma. And what we know is that this paper showed that patient's with an acute coagulopathy of trauma. Well, four times likely to die, four times more likely to die, have a higher rate of multiple organ dysfunction and would have a longer stay on I T U. So if you can intervene earlier, you can reduce all of that trauma burden. Okay? Has anyone? This is, this paper is from 2003. So it's almost 20 years old. But until I came across it when I did my masters in trauma, um has anyone heard of this? It's not well taught, never heard of it before. It makes a lot of sense though, right? It does. Okay. So how do we resuscitate? And with what? So as we were saying, the A TLS approach with two liters of Saline is, is pretty old school and that giving blood products, the terminology for that is he static resuscitation and that's pretty much the gold standard now. Okay. So what I would what you should say in your exam is this is a multiple e injured patient and they usually give you some parameters and they'll give you some crazy parameters like they're, you know, heart rate, 1 40 BP, 60 systolic. So, you know, they're great for shock, they are severely uh injured. Uh and I would manage them with hemostatic resuscitation in a 1 to 1 to one ratio and everyone says 1 to 1 to one ratio because they know they've heard the headline. But does anyone know the evidence behind it? Anyone there? Okay. Uh So initially it was observational data uh from the wars in Iraq and from uh the wars in Afghanistan and what they looked at was um survival mobility and it improved in the military setting. And then they then said if it worked in the military setting, then a young guy that's come off their motorbike and is completely smashed to pieces is very similar to a soldier who's been blown up by an idea uh in terms of physiology. So improving that ratio might help in the civilian population. And so the multiple studies came out and the one to know about is the proper trial, which is this okay? So this was I think 2015 and what they did was it was an RCT in America. They looked at 12 level one trauma centers where they had 680 multiple injured patient's and they randomized them half of them got blood products in a 1 to 1 to one ratio, half of them got blood blood products in a 1 to 1 to two ratio. And um what they found that the patient's in the 1 to 1 to one ratio, achieved homeostasis and experienced uh fewer uh fewer deaths due to exsanguination within 24 hours in the long run. If they survived, it made no difference uh in within 30 days. So what gave, gave no, made no difference over into overall mortality. But if you, if you died of bleeding, you were more likely to survive if you've been given a 1 to 1 to one ratio. And so that's why we give 1 to 1 to one ratio in a bleeding patient. Um uh because it reduces the mortality in the uh 1st 24 hours and therefore reduces the morbidity and reduces uh uh further complications. So, as we were talking about, we give prehospital blood. Um And before they used to have a few packed red cells that they would start uh on the helicopter. Uh then now looking at actually starting the transfusion early. Uh And so they give a, they give FFP and packed red cells. And this multi center study was looking at um whether you give FFP and packed red cells versus packed red cells alone. And essentially what they found is the patient's had reduced mortality again in the short term, if you give FFP and packed red cells. And the idea goes back to that acute coagulopathy of trauma. So if you've got an acute coagulant coagulopathy of trauma, the sooner you intervene, the sooner you reverse that coagulopathic, the, the quicker you get them out of that spiral of death. Okay. And so giving FFP and, and bloods on a helicopter while they're bleeding out is only gonna um in the, in the long run, okay. Um In terms of where we're going with this, it takes us to full cycle. We're looking at whether you give whole blood for trauma um which includes platelets, FFP and um and cry, which is essentially what we're doing but in separate samples. So the theory is why don't we all just put it in one bag and it goes through every trauma patient in one bag. Um What we, what we the way we administer it is don't just hang it up as a drip. Uh sorry, just one sec. He won't go back. Ok. Awesome. Hold on. Mhm. Sorry. Uh just bear with me one sec. So it'll just take a minute to uploads anyone have any questions? We'll wait, sorry. Um So just on, you know, when you get patients come in, we activate major hemorrhage, obviously there's protocols in each individual hospital. Um So I mean, I think about, I think six months ago something or other we had this patient jumped off a bridge, unstable pelvis, spinal injury, etcetera, etcetera. So we actively major hemorrhage and we put in 12 units red cells, I think maybe one of FFP and they sort of stabilized and E D was saying control and saying maybe we don't, you know, we can pause major hemorrhage. Now, were you in the D G H or you in an M T C? It was uh you know, last year. So, uh yeah, whatever we call it. Um Yeah. So do we proceed with just pump the entire 1st, 1st pack in or should we wait? You know. So you, it depends on your patient, right? And so you monitor their physiological response and we'll go through how you can monitor their physiological response and how you can adjust uh titrate their uh anti coagulation. Oh, they're quite, they're, they're resuscitation. So let me just if the slides will work now. So for whatever reason they won't go back. But let's see. So what I wanted to show you was a Belmont transfuser. Has anyone seen those before? Not anything I've heard of it? Yeah. So in major trauma, uh here this is a Belmont transfuser. Okay. And so what this does is you basically hang your bags of blood products. So your, your red cells, your what your FFP and everything and your platelets and it basically fills it all up in this bucket or this chamber and then pumps it as quickly as you want it to or it will go. So if you've got someone who's bleeding out really quickly. Um, then this is way better than a pressure bag or someone's bag or whatever and it frees people up. So this is what you should have a major trauma call when you have a major hemorrhage. Um, this is what you should have in theater when you've got a major hemorrhage. Um, because if you don't have this, you're not going to be filling up as quickly on the top end, potentially. Um So that's what I wanted to, to show you. So next time you're a major trauma call, have a look out and see what this is or if you're in a in theater in a bleeding pelvic case. Um Then that's the kind of stuff you want on standby. So we talked about uh this and this and then the crash profile. Um Does everyone know the crash trial? So has, and that's called a Belmont rapid transfuser. Um Does anyone know about the crash trial want to go through it? So this is a little bit old. Um uh But it's, this comes up in the MCQ, I think now came up, keep on UK and it's one of those trials where you just need to know it because it was such a big deal. Um There are a few quirks to it. So it was a massive study, 40 countries, America, not one of them because they didn't believe in it. Um Over 20,000 patient's all adult trauma, patient's at risk of bleeding and they were randomly assigned within eight hours of their injury to either T X A or a matching placebo. All cause mortality was significantly reduced with tranexamic acid. Um And the risk of death due to bleeding was significantly reduced. Uh There was no increase in V T. Uh mortality was higher if T X ray was given three hours after three hours. So ideally, you want to give it as soon as possible. Uh No one could really explain why giving T X A after three hours uh increase mortality. But it's probably to do with where the patient is in terms of their coagulopathy. Um So you need to know the crash to trial both for the vibe ear's and probably now for the MCQ is there are, will be a few questions and it will be things like um giving, you know, giving Tranexamic acid after a, after three hours and you've got no one in MCQ that you can't go, you shouldn't give it acutely after three hours. So, uh anyone heard of wrote him or Thrombi Elastography, heard of it? I don't know what it, I don't know anything about it because I don't think we used it in uh knowledge, did we? No, I don't think they did it in many places. Even in a days. They don't uh use it much. They do at the London. Um So Rotem is a bedside test. It's a bit like doing an A B G. And the idea is it tells you what the, what's happening with the clock. Okay. So it characterizes the coagulopathy and you get these funky graphs. Um And based on that graph, you know what they're deficient in. So you'll know that they're deficient in platelets, they'll need platelets, you'll know that they are um fiber analytic. So they will need some T X A. Um and it allows you to fine tune your resuscitation, okay. Um And just like you do an A B G and put up the machine, it's a machine like this, you take your aliquot sample and you put it in the machine and it gives you a chart and then some one clever goes through it and tells you what products you need. Now the time where this becomes really useful or more useful is in the, in the patient's that you're really going to struggle with. Okay. So you give a massive hemorrhage protocol, you give pack a, you give pack be they're still bleeding, they're on their way to I R but they're still bleeding. And it's like now what do I give? What do they need? And that's when you start getting hematology input and you start um thinking about whether you have things like Rotem available to you to guide your resuscitation and you kind of make it tailored and bespoke to that patient and what they need in that situation. Um And so it's just an extra tool to um to know about. You will definitely not need to know anything about how to interpret it. Um But you need to know that it exists, I guess. Um Interestingly, uh in most uh studies related to trauma, it hasn't been able to show that it's improved outcomes as such. There's been a couple of studies that have um but a systematic review, this one in 2014 didn't show that. Um I think it made a huge difference. It definitely works in liver transplant where there's major hemorrhage and in cardiac surgery, it's um it's been shown to, to save lives and improve um transfusion requirements and therefore I T U stays so surgical management, the bit that we can do. Um has anyone heard of? Right to the source? Not a clue. Okay, fine. So this came out in 2011 and it was written up by Nigel Tie who's a colonel in the British Army and he was placed in Camp Bastion at the time. Uh I was an S H O in Birmingham at the time. So we did this regularly in Birmingham. Um for the really sick patient's, the term right turn resource is based on the floor map of Camp Bastion, which you can see in the left top corner. Um So the patient comes in, they've been blown up by an IED, they come through and recess is on the left and in front of you and to the right of resource is the operating theater. And if a patient is that unwell, that they can't even make it to resource, they will go straight to theater and resuscitation will happen in theater. Whilst at the same time, I'm in control surgery. Okay. And so these are the sickest patient's. And I've done this a couple of times at Adam Brooks and I've done this a few times in Birmingham where there's literally nothing. You can't do anything in recess anymore. You need to stop the bleeding and you can't do that down there. Um And so 11 of the things that you can, one of the criteria is if they've got a complex airway injury, um, and they need a surgical airway if they've got severe blast lung and need advanced ventilation. Uh, if they've got a penetrating torso wound and their systolic BP is below 80 um, then it's not a mystery. They need a laparotomy. Um, at the same time as being resuscitated. If they've got multiple limbs amputated above the knee or above the elbow, they're gonna have a significant arterial injury that management. Um And if they've got an obscure pattern of injury, but there really unstable, then you need to go somewhere where you have all options available to you. Okay. Um Once you get into theater, it's the goals of right turn resource is to provide a definitive airway. Um, uh, consider mechanical ventilation. Uh, you get circulatory access to bilateral trauma lines. Uh you run that level one infuser, the Belmont infuser. Uh you get invasive monitoring so you get an art line, uh you control the environment so you warm the theater, you warm that you use a bear hugger. Uh You do immediate hemorrhage control. Okay. So, inspection of tourniquet uh tie off vessels that are bleeding, uh pack any wounds and then the abdominal guys will do thoracotomy, knees, uh laparotomy, he's uh a proximal aortic control pericardotomy to release tamponade, uh and cardiac repair, hilar lung twists to stop uh pulmonary hemorrhage. Um and you can do all of that in theater, the, the vogue in the civilian setting. So in parts of Candida and in parts of Switzerland, for example, they'll have a hybrid sweet. So the sickest patient will come into theater where they've got a built in CT scan. Er So whilst you're resuscitating, you get your trauma ct, your trauma CT is being red and uh your prepping the patient's torso. So you've got the chest, the chest, the prep the abdomen and then the radiologists will go right. He's got uh he's got a splenic rupture that's bleeding. And so you open the abdomen and you packed it do damage control laparotomy and that's all happening at the same time. Um So that is like the future within the constraints of the NHS that's not likely to happen anytime soon. Um But similar sort of thing does happen Uh So I know that Adam Brookes, we've done, uh we've put them on the pelvic table, for example, we don't know where they're bleeding and I are will come into theater and we'll do it on Table Angio. Uh And we'll work out whether it's the chest or the abdomen. And we decide, and the trauma surgeons will decide what they're gonna open and we'll stabilize long bones and they go to NCCU. Um So it's, that's thought of sort of thought process in the really multiple injured patient's that you're going to be thinking about is that decision being made in pre hospital settings before the patient even lands in, in the department when they decide to for right turn or it depends who it is, right. So if they are a d consultant who's on the hems trolley and they're, they're like, I really don't think this guy's gonna do anything or they've got, for example, uh significant head injury and blown and blown pupils and the non obvious bleeding anywhere else, they're pretty obviously got a head injury, then they will go and have a CT scan and go straight to theater um for neurosurgery to the craniotomy, for example, as the CT is being read up okay. And at the same time, they'll do the trauma sand and they'll work out whether he's got bleeding in the abdomen because what you don't want to do, spend a couple of hours dealing with his head injury and realize that he's bleeding out in his abdomen. Yeah. Cool. That makes sense. Yeah. So this is what's done in Cambridge and this was published by the OT you consultants in uh injury. Um and it's Cambridge polytrauma pathway. So patient lands in the emergency department uh unstable, they need surgery and the indications for that are uncontrolled hemorrhage, an ischemic limb compartment syndrome or grossly contaminated open fracture, they'll go to an out of hours theater, okay. Um If they're well enough to have a trauma CT, they'll have that first. If after they have the trauma CT, after they have the trauma CT, there is a consultant MDT for these code red patient's okay. So different places call it different things. Um at the Royal London patient's that bled out loads are called code reds. Um So uh you get intensive care or an anesthetist, the surgical specialties and the radiologists, they all have a chat and they say this is the main problem and then they decide altogether when to, to deal with that problem. So if it's something that stop bleeding, but we'll need intervention at a later date. For example, it's a pelvic fracture that is now responding to uh resuscitation and they have not bled out and there's no blush on the CT scan. Um Then you can keep the binder on sit tight and definitively fixed during daytime. If they're really unstable, then they need surgical management. Okay. And this is the massive hemorrhage protocol from the east of England. Uh So the triggers are 40% loss of blood volume or four liters in 24 hours, two liters and three hours or more than 100 and 50 mils per minute. Okay. Um So get senior help. Do your A B CS, get IV access, uh start resuscitation, start giving the products. Okay. So we're gonna talk about pelvic bleeding. Has anyone been involved in pelvic bleeding? Does anyone want to talk through their experience? And what happened? Because it is scary when it happens? Uh So, yeah, I mean, we've had some pretty bad pelvis is obviously acknowledge um which have been associate with hemorrhagic or not entirely sure whether it's always from the pelvis itself. Um But also we approach with our A T E and we actually a major how much protocol once we identify that there is human Dabiq instability, um pelvic binder should be on well, when they arrive, if not, then we need to apply that and ensure it's at the correct level. Uh and a century well, aggressively resuscitate the patient with our, with our first pack pack. A. Um So I think uh I think Mr Rowe covered this in one of his previous pelvic trauma talks. But I think obviously your then determining whether patient is responding, transient, responding or not responding at all, non responder. And that's going to help determine what we're going to do in terms of uh what the necessary intervention is because if they respond, that's great. We need to keep the, sustain them and make sure there's no either identifiable cause of hemorrhage. Um But if there's, if they're transient responding, then it's possible they need, we need help from the interventional radiologists. Um They're made to look for any bleeding vessels and coil them. Um And if they're not responding at all, then it's a case if they need to get to theater and probably pack them. If that's if the pelvis is the main source of their, of their hemorrhage essentially. Yeah. And that's, that's basically, it's, that's what we're gonna talk about. So pelvic bleeding, the majority of pelvic bleeding's venous, okay. So 85% of it is venous. And as Hassan mentioned earlier, when he was asked about sacral fracture, um it's the presacral plexus really that, that gets torn, shredded and bleeds and bleeds a lot. Um Arterial bleeding is less than 10% of the total population. Um But in the patient's that are hemodynamically unstable, it's an arterial bleeding, about 50 to 80% of patient's. So if you've got a patient with a pelvic fracture who's hemodynamically unstable, there's a reasonable chance that they've got an arterial injury, okay. And that could be a major artery in which case, they're not going to be around for very long. Um Or it's gonna be a fairly large artery that you've got a bit of time, but to deal with, but you can get there, you got to deal with it quickly. Okay. So, uh those include um superior gluteal vessel, pudendal um and the corona mortis, uh you can also bleed from the fracture ends, okay. Uh which bleed quite a lot. So management is him a static resuscitation, pelvic binder and MDT approach. Okay. So, uh interventional radiology, does anyone know what selective or nonselective is? Um So it's essentially whether you go after the, if they can identify a specific vessel, that's the uh or the leak, the leaking vessel, then they can embolize that or coil it specifically. But if not, they just go higher upstream non selectively and just block the whole thing off. Uh Yeah. So if you, if you're doing this, you're doing it to save their life. Um If you can see that it's one particular branch, um it's pretty cool. They just put a few coils in, it turns off the tap. It's amazing. It's better than opening up their abdomen and doing damage control. Laparotomy is. Um But sometimes you just see a load of contrast leaking and you can't see where it's from and they're becoming more and more unstable. And then really the only option is to get a proximal control. Okay. And so you get proximal control and you tie off their I'll yaks or the internal iliac. Does anyone know of any problems that can aka this can be an M C Q? So problems with nonselective embolization is uh, the internal iliac, we'll get tied off and, uh, you basically end up with, you could end up with beautiful necrosis, sexual dysfunction, um, and uh problems related to that. Um, with regards to uh whether, how, how much of an effect that has, uh, it's a bit controversial because actually if you've only done one side, you still got some collateral supply from the other side. And not every patient will have gluteal crosis after embolization. Um Even if they do the reason you're doing it is to save their life. So it's a small price to pay, I guess, pelvic packing. Okay. So anyone done it? Seen it silence just on the one of the Cadillac models, but not, haven't seen it yet real life. So, because of COVID, we haven't run the, we haven't done the, the canned of Eric course for a while now, but it's a really good course. Um And we'll get you to, we'll get you guys to do it when we run it again. So just waiting to get some funding and organize it. Um But essentially, it's not particularly hard. It's a useful skill to know in most places. If you work in a major trauma center, you'll have the help of a trauma or general trauma surgeon who can help you if you're a pelvic surgeon. Um then the time you're gonna be packing the pelvis is when you have a bleed intraoperatively. Uh or an emergency setting because you need to be there. Okay. Um So lots of people discuss different things so you can go from interventional radiology to pelvic packing or pelvic packing and then to interventional radiology, they're not mutually exclusive. Um Lots of different places uh practice different things. In the UK. The gold standard in most centers is go straight goods to go to interventional radiology if the hemodynamically stable enough. Okay, because pelvic packing is pretty disruptive. Uh and it's pretty destructive, but it's one of those things that you're doing really to save life rather than preserve function. Okay. Places like Denver uh Colorado, they, so they prefer to pack uh urgently. So someone comes in with a pelvic fracture and they're hosing out there persistently, hemodynamically unstable uh and require more than two units of packed. Mattel's they get packed. Um Whereas that happens pretty much every week, Adam Brooks and the Norwich and they don't get packed. Um Most of the time a binder is enough and interventional radiology uh is enough um along hemostatic resuscitation. So in terms of you mentioned, it's out it's destructive. So you need to get around to the back because usually stick a pack towards the venous plexus, what what the structure you're disrupting when you go along. So if you think about your stop approach. Yeah. Yeah. Think about how careful you are dissecting, how you're trying to avoid, you know, the obturator nerve, the uh you know, things like pudendal nerve which controls your sexual function. Uh things like uh the ureters. Mhm. Um Like you don't know where any of that stuff is when you're packing, you just literally shove a packing as hard as you can. Um So you open them up and instead of like in a stock approach where you do a test the incision, you do a midline incision in case they've also got a dumb trauma and they need uh abdomen packing or any general surgical book. Usually put 6 to 9 packs in. You start with the side on the S I injury cause that's where they're gonna have that preset called plexus tear. Okay. So say the left side is down, you start on the left side, you basically grab a back and you shove it along the pelvic brim until you get all the way back into the sacrum. Um whereas usually you dissect out highly affecting your fascia, uh retract the nerve and the bladder out of the way you just kind of get on with it and get it in. It's a damage control procedure, okay. Um So it does have significant morbidity. Cool. Sounds good. Um Okay. So you pack one side, then you pack the other side and uh they go back to the unit. Now what you do there is you stop, you slow down the bleeding, you allow the, the anesthetic team to top up the top end and then you transfer to I T U for further resuscitation and come back another day uh to do what you need to do definitively. So once you got those packs in, are you, what are you monitoring for response or you just get the packs in close? And so there's not really much you can do, right? You just keep packing, packing, packing as much as you can. Once you've packed, there's not like you've just got to, you've got to stop. That's as much as you can do surgically. Um, in terms of um, putting pressure, right? So the you, you're, when you do, when you do, when you pack a pelvis, you should take a hemostatic pause. You need that clot to form. Okay? Because what you don't want to do is keep disrupting the clot. Okay. So the worst thing you can do is what's called the peek a boo. So you put the, you put the packs in and you're waiting, uh, you gotta wait enough time for a clot to form. Okay? If you keep going, is it clotted? It bleeds a little bit more. Is it clotted, bleeds a little bit more? Now, is it clotted leads a bit more, just pack it and leave it okay? And if there's still blood pouring out through your packs, it means packing is not going to cut it. You gotta get proximal control and we'll talk about that in a second. And what options there are? Okay? Cool. Sounds good. So you packed them, there's thought that you'll definitely slow down the bleeding. But whether you stop it enough uh for that to be definitive management, okay. And if not, then they need to go uh to interventional radiology uh to have a have a angiogram and embolization if they can see a bleeding point, um patient's that have packing uh can also have packing if they're going to theater for another reason, for example. Uh So if they're going for an emergency, thoracotomy, for example, and they've got a bleeding pelvis there already in theater. If you, depending on what your resources are, you could pack the pelvis at that point. Okay. Um Again, a lot of places will have options to have interventional radiologist come up to theater um but not everywhere has that option. Okay. So this flow diagram is stolen from uh Pete Bates who kind of suggest this pathway where they're not mutually exclusive. You can do uh interventional radiology and then public packing and public packing and then interventional radiology. Okay. Anyone know what this is, isn't it just very, very major nonselective um uh well, blocking of the vessels, you just block way at the top. Have you heard of the boa a while ago? Didn't read much on it unfortunately. Yeah, this one. So this is a Robo stands for resuscitative endovascular balloon occlusion of the aorta, I think. Um So it's basically a tourniquet and so you get common femoral access, you shovel wire up, you inflate the balloon. And uh if you do it above the bifurcation, it cuts off blood supply to the pelvis and to both the legs. And what that does is, yes, it causes ischemia of the legs, but it turns the tap off enough that you can fill up at the top, have time to open the abdomen and get control of whatever is bleeding, clip it and then let the balloon down. Okay. And it's think interventions like this that are allowing us to save patient's that would have otherwise died. So this is a, this is an example on the board. There's a uh so before the robo, a the BP is uh undetectable and then rub oh A goes up, BP is automatically 98/50. Okay. So it makes a huge difference. It will perfuse your kidneys, your brain um uh and your heart um while buying you enough time temporarily to, to get um control of the bleeding, okay. This is the alternative to cross camping the aorta and that can be done either with a laparotomy or via thoracotomy for a more proximal control. This is a less invasive version of that. There's currently a trial called the UK Ribo trial where these patient's are bleeding out, uh come in. And if they're not responding these, if you're non responders, they'll, they'll send her a bow up uh and then fill up and then try and work out where the bleeding is and let the ribo down. Are they simultaneously blocking high up and above the bifurcation? Or is that just a different levels, depending on where those are, they're, they're showing examples of the different levels. And so obviously, you need to go higher up if you've got an aortic dissection, for example, and you need to, you need to block higher up. It's not without risk at all. But if you're doing this, this is the last chance saloon, right? So if you're doing, if you're doing a zone to block, you might lose your kidneys, you might lose your kidneys and and have problems with, with that respect. So this is a really nice summary. Um and this is the code red protocol at the Royal London. Uh which kind of brings everything, let's say they're on one page. Okay. So if you get a patient, so this is what you should probably structure your major hemorrhage answer uh in your exam. Um So if you get patient with the systolic BP below 90 and they have a poor response to initial fluid resuscitation, they have a suspected or they have a suspected active hemorrhage, you must declare a code red, okay. So declaring a code red, triggers all the on call consultants to be made aware and it triggers uh the blood bank to start sending uh the emergency blood up. Okay. You take your blood, your baseline blood tests and for them they do Rotem as well. Um You uh you bring up pack A and pack A has four units of blood, four units of FFP. There's no platelets or cryo in pack A and that's pretty much the same in most places. Uh If the patient is still bleeding, you request pack be, pack, be comes up and that's got six red, six yellow or FFP, two cryoprecipitates and one big bag of platelets. Okay. And you've got to determine where you've got to have the a team member that is able to go and get those, um, packs in order to give them as quickly as possible. And you'd want a level one transfuser if you're giving that that much in terms of products. Okay. Generally what they advise is they give oh neg blood for women because of the resource antigen and uh positive for men. Um, to make sure they've got enough blood available. Um, if they've not had the usual T X is usually given by the hems team. Now, if they have not had it, they should be getting it soon within three hours of massive hemorrhage. And we've discussed why within three hours, uh, if the bleeding continues, you then got to decide where you're going to go. Okay. So this is where your damage control surgery ties in. This is where you, your polytrauma pathway ties in and you have to decide where you're going to go. What they use a guide uh for resuscitation is uh it's based, is the acronym. Uh Pete Bates is pretty annoyed that it's not Bates. Um but it's blood acid base, uh surgical progress, uh temperature uh and electrolytes. Um So, uh those are the things that you want to look at and correct. You want to keep a potassium less than 5.8 and you want to keep the calcium uh above one. So if a patient has had massive transfusion, they can become hypocalcemic. And uh so after you, when you're requesting packed be, you need to start thinking about giving calcium as well. Okay. Um Once the bleeding is controlled, you've then got to think about what you're gonna do and step down your code red. Okay. Uh That is pretty much it. So understanding co gravity is important, hypostatic resuscitation is key in restoring physiology. You've got to combine it with damage control orthopedics or early appropriate care strategies to manage the being patient using MDT approach. And it's an important topic that come up in many places for the example. All right, any questions, got a couple of cases to discuss. Uh, no questions in the chat at the moment. Okay. Everyone going home already. Uh Maybe. Okay. Awesome. Uh Any volunteers for cases, not a single volunteer? Okay, first, that's fine. Okay. So, uh right. Uh this 34 year old uh comes off his motorbike at 70 miles an hour and lands in your major trauma center, uh how are you going to manage this patient? Um So in the initial phase, I'll assess the patient using an A T E approach. Um as per 80 less protocols was activating the, the trauma team as well. Um Priorities being, identifying and managing life threatening injuries. Uh primarily um well, major hemorrhage in this patient's case. Um The images I have at the moment, I've got a P pelvis demonstrating an open book APC type pelvic fracture. Um And on the ct axial views, I can see what looks like uh some right sided and poor bit of left sided uh hemorrhage as well with what looks like some rib fractures. Um There's no pneumothorax I can see. Um So this patient's got quite a few major life threatening injuries to begin with. Um priority one. So as part of my 80 I'm gonna ensure the patient's large war uh access um resource as we're using major uh hemorrhage protocols. Um I'd like to ensure the patient's got a pelvic binder in situ help control at the level of GTs to control how much from the pelvis and identify any other source of bleeding as well. Um Once the patient stabilized from 80 approach, um then I would like to get well, patient already gone through the, through the CT scanners, but get a full trauma CT from head to toe and uh take things from there essentially. Yeah, good. So you get a, you put the binder on, uh they remain unstable. Uh They, they improved a little bit enough that you got a CT scan. So you got your CT scan. It's an A P T type injury. Um, and uh they have a uh a large pelvic chemo term that is expanding. Um They've also got some blood in their chest and some blood in their abdomen. Mhm. Um Where are you going to go from there? So it sounds like this patient's uh um with the major hemorrhage protocol in in place transfusing 12121. Well, actually with the mid pack A, it won't be 1 to 12 or they'll be red cells and FFP. But this patient sounds like they're not responding. They need surgical intervention and likely they won't be uh stable enough to tolerate going to I I think they need to go to theater. Um So I'd need help from my general surgical, well, general surgical trauma surgical colleagues um as well as going into the pelvis. So, orthopedic slash pelvic surgeons as well. Um Priority is um well, they need to pack, I think the pelvis needs packing. Um So that will be via the mid low midline laparotomy, which can be extended up to the abdomen in order to go into the abdomen as well. So you, you do a midline laparotomy or the general surgeon in midline laparotomy. Also find a sequel. Perth. Mm. Okay. Yes, they want to pull out the stoma? Mhm. Is there anything that you would advise them? Um all the advice? Um where does this term ago? Uh The stone is going to go in there? Sort of its sequel perp it's going to be in their lower write. I'll it fossa region. Okay. So exactly where you want to start making decisions for your pelvic fixation, right? Yeah. So what you, what you would say is the exam is according to both guidelines, I would ask them to make the stoma as high as possible to avoid the surgical field for definitive public fixation. I later day. Right? Okay. Yeah, that's, that's something that everyone call needs to know. Um So if something bad is in and you know, you're not gonna do anything about pelvis in terms of stability and defended fixation. Um But you're gonna need to advise the general surgeons that if uh they need to do a um a stoma that if they could try and make it as high as possible. And that therefore what you don't want to do is have a big bag of poo where you, where you want to, where you want to do clean orthopedic surgery, right? Yeah. So if you can drape it out, that's ideal make sense. Yeah. Okay. Uh fine. So, yeah, you basically end up talking about fixation. Um and uh resuscitation in that either um the key to the virus is basically you've got to be a safe consultant so you get your um you get to, you got to get to your six which is your safe pass very early on and then spend the bus to the Viber trying to push yourself up to seven and eight. Mhm. Okay, cool, cool. Unless someone else wants to do the second case, I think we'll call it a day unless anyone's got any questions, it's like no other questions. Uh fine, I'll hold it.