Download Rapid Fire Aaron A. Pugh, PA-C

Rapid Fire
Aaron A. Pugh, PA-C
Physician Assistant, Trauma and Critical Care,
Intermountain Medical Center, Intermountain Healthcare;
Salt Lake City, Utah
Objectives:
• Extrapolate the multivariate approaches in confounding patient case
presentation reviewing several vague or controversial topics and
integrate these additional variables into their own daily practice
• Compare and contrast different methods of treating the same
problem and recognize nuanced care and the broader boundaries
and limits to what we currently know and measure their own
contributions to patient care in a self-reflective way
Rapid Fire Topics
Aaron Pugh PA-C
Excellence in Trauma Critical Care Conference
#ETCCC14 @IMCTRAUMA
Goals of Session
Rapid Fire is the Potpourri in Jeopardy of
Conferences
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discussion of 2 hot topics 30 minutes
discussion of 1 review topic 10 minutes
discussion of 1 ethically challenging topic 10
minutes
Hot Topic #1 REBOA
Resuscutative Endovascular Balloon Occlusion of
the Aorta
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history
indications
technique
review of the literature
challenges and hazards
future
Hot Topic #1 REBOA
History
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Temporary occlusion of the aorta as an operative
method to increase proximal or central perfusion to
the heart and brain in the setting of shock is not
new.
Resuscitative aortic occlusion with a balloon was
reported as early as the Korean War. Despite
potential advantages over thoracotomy with aortic
clamping, resuscitative endovascular balloon
occlusion of the aorta (REBOA) for trauma has not
been widely adopted.
Hot Topic #1 REBOA
Indications
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uncontrolled hemorrhagic shock with damage
control resuscitative methods well under way or
imminent
the alternative is direct cross clamping the thoracic
aorta for proximal control of bleeding.
contraindications are known aortic injury
Hot Topic #1 REBOA Indications
Persistently Hypotensive SBP <90 mmhg
have access to femoral artery
NO
REBOA
YES
Position of REBOA to ZONE
1
to OR for EX LAP
Position of REBOA to ZONE
1
and inflate
NO
CXR:
possible aortic
injury
NO
YES
FAST
POSITIVE?
Pelvic
Fractures
YES
NO
Position of REBOA to ZONE
3 and inflate
Hot Topic #1 REBOA
Technique
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Arterial access
Balloon selection and positioning
Balloon inflation
Balloon deflation
Sheath removal
Hot Topic #1 REBOA
Technique
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Arterial access
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US Guided
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18-gauge hollow needle and 0.035-inch wire
into common femoral artery. The initial sheath
is 5–8 Fr and 8–15 cm long; considered as the
initial sheath
Hot Topic #1 REBOA
Technique
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Balloon selection and positioning
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Position with fluoroscopic
guidance to aortic zone I or III
depending on injury pattern
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Preceded by placement of long
(260 cm) working wire into the
aortic arch
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Followed by removal of the
initial sheath and placement of
large diameter long sheath
over this wire
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Finally, large diameter,
compliant balloon is placed
over wire under fluoroscopic
guidance
Hot Topic #1 REBOA
Technique
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Balloon inflation
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Inflate with fluoroscopic
guidance using mixture of
contrast and saline
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Inflate balloon until it
adopts the aortic wall
profile and then stop and
turn stopcock to maintain
inflation
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Inflation and balloon
occlusion may result in
dramatic increase in
central aortic pressure
Hot Topic #1 REBOA
Technique
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Balloon deflation
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Turn stopcock and
deflate balloon port
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Deflate slowly after
communication with
anesthesia and
members of
resuscitation team
Hot Topic #1 REBOA
Technique
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Sheath removal
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Open exposure or cut down on sheath entry site
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Proximal and distal control above and below the
sheath entry site and closure with 5-0 or 6-0
monofilament following its removal
Hot Topic #1 REBOA
Review of Literature
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several animal models
limited use in humans
plenary paper this year at AAST demonstrating
efficacy and a fair amount of morbidity
several courses and training of trauma surgeons
popping up.
Hot Topic #1 REBOA
Hazards and Challenges
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High (proximal) entry into iliac artery or low (distal) entry into
superficial femoral artery
Assuming groin crease is the inguinal ligament
Inadvertent entry into venous system
Inadvertent movement of stiff wire too proximal or distal risking
injury to aortic root or carotid arteries
Overinflation of balloon and damage to aortic wall
Distal migration of balloon, sheath, and wire with pulsation
against the inflated balloon
Profound hypotension
Loss of desired balloon and wire position
Loss of arterial control upon removal
Ineffective arterial closure
High rate of AKI documented
High rate of amputations
Inflammatory sequelae
MY BIGGEST QUESTION: Time it takes to perform
Hot Topic #1 REBOA
Future
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no adequately powered studies as of
yet
need betterment of current devices
no standard training
no standard acceptance or
recommendations
better follow-up studies
Hot Topic # 2 Acute Traumatic
Coagulopathy
Definitions and Mechanism
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impairment of hemostasis and activation of
aberrant fibrinolysis; hyperfibrinolysis that occurs
early after injury
independent of the usual shit storm already
occurring of:
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acidosis, hypothermia, or hemodilution
thus making things worse
similar to DIC but differs in that it only occurs with
systemic hypo perfusion and a proposed
dysregulation of the Plasminogen activator
inhibitor-1
Hot Topic # 2 Acute Traumatic
Coagulopathy
Definitions and Mechanism
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Current Hypothesis:
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Hyperfibrinolysis is a highly lethal component of acute traumatic
coagulopathy. Plasminogen activator inhibitor-1 (PAI-1) and tissue
plasminogen activator (tPA) are mutually inhibitory, existing in
equilibrium with an inactive covalent complex.
•
Degradation of PAI-1 by activated protein C (aPC) has been
proposed as the initiator of hyperfibrinolysis in acute traumatic
coagulopathy.
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HOWEVER!
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new discovery now exists where there is an observed increased
resistance to exogenous tPA in most trauma patients.
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the normal reaction to traumatic injury is a protective elevation of
PAI-1 and that the cases of hyperfibrinolysis in acute traumatic
coagulopathy are caused by an overwhelming release of tPA from
ischemic tissues in patients unable to up regulate their PAI-1.
Hot Topic # 2 Acute Traumatic
Coagulopathy
Definitions and Mechanism
Hot Topic # 2 Acute Traumatic
Coagulopathy
Treatment
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massive transfusion protocol
TEG directed transfusion
hemostatic agents
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recombinant factor VIIa
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prothrombin complex
concentrate
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antifibrinolytic agents
Hot Topic # 2 Acute Traumatic
Coagulopathy
Massive Transfusion Protocols and Treatment
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diagnosis of ATC means the likelihood of massive transfusion
goes way up. On average they receive 10 units or more of PRBC:
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MTP
defined as more than 4 units of blood related colloid an hour
1:1:1 transfusion goals
predictor of SIRS; MODS; ARDS; and oh yeah death
wide variation among trauma centers with growing trend away
from plasma and toward platelets, PRBCs, and adjuncts initially
taking more priority with FFP being a close backup in an effort
to minimize total volume
LIMITING CRYSTALLOID!
Permissive hypotension TBI vs the rest of injuries
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Hot Topic # 2 Acute Traumatic
Coagulopathy
Teg directed transfusion
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TEG parameters have been associated with
survival while INR has not
Maximal Amplitude correlates to transfusion
need better than standard studies
Better 30 day survival has been
demonstrated
more precise
in vivo vs in vitro (INR)
INR is a sacred cow. yup. that just happened.
Hot Topic # 2 Acute Traumatic
Coagulopathy
hemostatic agents
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recombinant factor VIIa
principle trigger factor for clot formation
initially approved for treatment of
hemophilia
should be reserved for salvage therapy
should be coupled with aggressive
correction go the other 3 issues with ATC
to to reduce prothrombotic complications
Hot Topic # 2 Acute Traumatic
Coagulopathy
hemostatic agents
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prothrombin complex concentrate
enriched with factors II, VII, IX, and X
designed for hemorrhage control in
hemophilia B
rich in Vit K dependent factors
used in rapid reversal of warfarin tx
use in some of the reversal of newer DTIs
again risk of prothrombotic complications
Hot Topic # 2 Acute Traumatic
Coagulopathy
hemostatic agents
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antifibrinolytic agents
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transexamic acid
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CRASH-2 Trial a reduction of approx 2%
reduction of absolute mortality (study
rife with complicating factors
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MATTERs Trial showed reduction of
mortality of 7%
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Despite limitations in these studies:
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Moral: EARLY AND EMPIRIC TX is
cheap and essentially harmless
Hot Topic # 2 Acute Traumatic
Coagulopathy
hemostatic agents
desompressin
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use in correction of platelet
dysfunction often associated
with TBI related coagulopathies
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and can be used in conjunction
with platelet mapping portion
of TEG
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study still very lacking
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Review Topic: Blunt Vertebral Artery
Dissection
Case Study
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56 yo Male with essential HTN nonsmoker
‘Self-Made’ Man
MTN Biking with a helmet
flipped over handle bars ‘arse over
elbows’
POV into ED
Trauma Consult with a mTBI
refusing to wear collar
Review Topic: Blunt Vertebral Artery
Dissection/Occlusion
Case Study
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diagnosed with a small but significant SAH
C1 Jefferson Fracture
concussion
Review Topic: Blunt Vertebral Artery
Dissection/Occlusion
Additional Work Up and Admit
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CTA of Neck shows left grade 1 vertebral artery
occlusion with borderline adequate collateral filling
Review Topic: Blunt Vertebral Artery
Dissection/Occlusion
Admit to ICU
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pt is started on ASA; scheduled for
surgical intervention for fracture
gets up to use the bathroom despite
bed rest orders
has minimal vaso-vagal episode
becomes confused
dysarthria
apraxiac
Review Topic: Blunt Vertebral Artery
Dissection/Occlusion
Additional Diagnostic studies are performed
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MRI/A shows large cerebellar infarct.
Review Topic: Blunt Vertebral Artery
Dissection/Occlusion
Additional Diagnostic studies are performed
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MRI/A shows large R PICA cerebellar infarct.
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patient essentially progresses to a GCS of 6 and
never improved
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at the time of d/c to an LTAC he had the following
problems:
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GI Bleed
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BUE DVTS
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E.Coli Ventriculitis
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Hydrocephalus
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Seizures
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Pneumonia
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Trached and Pegged
Still hadn’t had his neck stabilized.
Review Topic: Blunt Vertebral Artery
Dissection/Occlusion
Screening, Diagnosis
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Blunt Cerebrovascular Injury
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Anatomy
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divided into anterior and posterior
circulations meeting at the Circle of Willis
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variability of collateral flow is what creates
the many clinical presentations
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Anterior provides cerebella
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Posterior provides midbrain, and cerebellum
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Vertebral arteries originate in the subclavian
and are divided into 4 segments
Review Topic: Blunt Vertebral Artery
Dissection/Occlusion
Screening, Diagnosis
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Blunt Cerebrovascular Injury
MOI
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MVC, falls, assaults, head banging, and hangings
with MVC accounting for more than 50%
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very famous case was Roy of Sigfreid and Roy
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pathology is most commonly an intimal tear with
pseudo aneurysm being the second most common
Screening
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Hard: c-spine fractures,
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Soft: skull fx, facial injuries, seatbelt sign, GCS 6 or
less
Diagnosis is made with CTA of the neck
Review Topic: Blunt Vertebral Artery
Dissection/Occlusion
Diagnosis, Treatment
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Blunt Cerebrovascular Injury
Injury Grading
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Grade 1 intimal irregularity of 25%
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Grade 2 intimal irregularity of greater than
25%
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Grade 3 pseudoaneurysm or AV fistula
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Grade 4 complete occlusion
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Grade 5 transection with active
extravasation
Review Topic: Blunt Vertebral Artery
Dissection/Occlusion
Diagnosis, Treatment
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treatment is based entirely from historical
controls and demonstrated morbidity and
mortality in treated patients
Mainstays of Treatment
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anti-thrombotic therapy as injury pattern
allows
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no specific agent, optimal duration, or
end-point
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stroke rates of posterior injury 11-41%
depending on grade of injury
Review Topic: Blunt Vertebral Artery
Dissection/Occlusion
Diagnosis, Treatment
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surgical, interventional therapies
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for grade 2 or greater
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unfortunately most arterial areas are
currently inaccessible
endovascular therapy
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no controlled trials and a fair amount of
stent related complications, but often
done
lytic therapy
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if pts are ischemic and there are no
contraindications (rare)
Review Topic: Blunt Vertebral Artery
Dissection/Occlusion
Followup
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7-10 days
anti-thrombotic tx as long as
the lesion is present
life long ASA
Ethical Topic: the DNR Tattoo
Case Study
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68 year old man with multiple health
problems, drives his car into a stationary
object; then, still conscious shoots himself in
the face.
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arrives via EMS
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obvious facial trauma
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moving all fours
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with imminent airway issues
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mildly elevated BP and HR and this
tattooed on his chest:
Ethical Topic: the DNR Tattoo
Ethical Topic: the DNR Tattoo
the appeal of it
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implies a preference against
resuscitation so strong that the person
has etched the image onto their body.
The tattoo is inseparable from the
body.
Unlike Do Not Resuscitate (DNR)
paperwork or medic-alert bracelets, it
cannot be misplaced, easily removed,
or lost.
Ethical Topic: the DNR Tattoo
the reality of it
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The notion of a tattoo stems in part from fear that
such choices will not be respected. This fear has a
basis in reality
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Study to Understand Prognoses and
Preferences for Outcomes and Risks of
Treatments (SUPPORT), physicians only
understood 46 % of hospitalized, seriously ill
patients’ preferences to forgo cardiopulmonary
resuscitation (CPR)
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In qualitative interviews, emergency
physicians described the emotional and moral
distress caused by resuscitating a patient, only
to learn later that the patient had a legal,
signed, Do Not Resuscitate document that was
not accessible in the emergency department.
Ethical Topic: the DNR Tattoo
WHY IT IS A BAD IDEA
• No safe harbor.
• Open for a wide interpretation in the unconscious patient
• DNR orders, like all medical orders, need to be
reversible. If patients are permanently committed to
preferences expressed at one time, they may be
reluctant to express any interest in foregoing
interventions.
• a substantial percentage of patients change their minds
regarding preferences for attempted resuscitation.
• people underestimate their potential for adaptation to
illness and disability.
• Changing a POLST form or removing a DNR bracelet is
fairly straightforward and free.
• Removing a tattoo is an expensive and time-consuming
process.
Ethical Topic: the DNR Tattoo
Death and Dying and honoring a patient’s
wishes
• For those individuals who do hold strong
preferences against resuscitation, there is a need
for a form of legally binding documentation that
is inseparable from the body.
• Twelve states, including California and New York,
recognize the POLST form as legally binding
orders to forego CPR and other resuscitation
measures
Ethical Topic: the DNR Tattoo
the epilogue
• we crash intubated this patient and resuscitated him
• finding several severe injuries
• severe TBI
• facial fractures
• several orthopedic injuries
• we admitted the patient to the ICU; made contact with
his family and withdrew care at their behest
• he died within hours
Bibilography
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A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients (SUPPORT) Trial JAMA
1995;274(20): 1951-1598
RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA (REBOA) IS A FEASIBLE
ALTERNATIVE TO RESUSCITATIVE THORACOTOMY IN TRAUMA PATIENTS WITH NON-COMPRESSIBLE
TRUNCAL HEMORRHAGE AND PROFOUND HEMORRHAGIC SHOCK Laura J. Moore* MD, Megan Brenner
MD, Rosemary A. Kozar* MD,Ph.D., Jason Pasley DO, Charles Wade* Ph.D., Thomas Scalea* MD, John B.
Holcomb* MD, University of Texas Health Science Center-Houston. AAST 2014 National Conference
Plenary Papers 9-12 Paper 9: 8:00-8:20 AM
Basic endovascular skills for trauma course: Bridging the gap between endovascular techniques and the
acute care surgeon Megan Brenner, MD, MS, RPVI, Melanie Hoehn, MD, Jason Pasley, DO, Joseph
Dubose, MD, Deborah Stein, MD, MPH, and Thomas Scalea, MD, JOT 2014; 77(2) 287-291
A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and
resuscitation Megan L. Brenner, MD, Laura J. Moore, MD, Joseph J. DuBose, MD, George H. Tyson, MD,
Michelle K. McNutt, MD, Rondel P. Albarado, MD, John B. Holcomb, MD, Thomas M. Scalea, MD, and Todd
E. Rasmussen, MD; JOT 2013; 75(3) 506-511
A novel fluoroscopy-free, resuscitative endovascular aortic balloon occlusion system in a model of
hemorrhagic shock Daniel J. Scott, MD, Jonathan L. Eliason, MD, Carole Villamaria, MD, Jonathan J.
Morrison, MRCS, Robert Houston, IV, MD, Jerry R. Spencer, BS, and Todd E. Rasmussen, MD EAST 2013
Poster Paper
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an Adjunct for Hemorrhagic Shock
Adam Stannard, MRCS, Jonathan L. Eliason, MD, and Todd E. Rasmussen, MD JOT 2011; 71 (6) 18691872
The inflammatory sequelae of aortic balloon occlusion in hemorrhagic shock Jonathan J. Morrison, MRCS,
James D. Ross, PhD, Nickolay P. Markov, MD, Daniel J. Scott, MD, Jerry R. Spencer, BS, and Todd E.
Rasmussen, MD journal of surgical research 191 (2014) 423-431
Endovascular Skills for Trauma and Resuscitative Surgery (ESTARS) course: Curriculum development,
content validation, and program assessment Carole Y. Villamaria, MD, Jonathan L. Eliason, MD, Lena M.
Napolitano, MD, R. Brent Stansfield, PhD, Jerry R. Spencer, BS, and Todd E. Rasmussen, MD, AAST 2013
plenary paper
Bibilography
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The Problem with Actually Tattooing DNR across Your Chest Alexander K. Smith, MD MS MPH1,2
and Bernard Lo, MD3,4 J Gen Intern Med 27(10):1238–9
DNR Tattoos: A Cautionary Tale Lori Cooper, MD and Paul Aronowitz, MDJ Gen Intern Med
27(10):1383
OVERWHELMING TPA RELEASE, NOT PAI-1 DEGRADATION, IS RESPONSIBLE FOR
HYPERFIBRINOLYSIS IN MASSIVELY TRANSFUSED TRAUMA PATIENTS Michael P. Chapman MD,
Ernest E. Moore* MD, Eduardo Gonzalez MD, Hunter B. Moore MD, Theresa L. Chin MD, Arsen
Ghasabyan MPH, CCRC, Fabia Gamboni Ph.D., Sanchayita Mitra MS, Anirban Banerjee Ph.D., Angela
Sauaia MD,Ph.D., Christopher C. Silliman MD,Ph.D., Denver Health Medical Center AAST 2014
National Conference Plenary Papers Session: XA: Papers 17-25 Paper 19: 2:40-3:00 PM