hot trends in trauma: txa, ketamine, and tactical medicine · • abcde – phtls – atls – acls...
TRANSCRIPT
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Hot Trends in Trauma: TXA,
Ketamine, and Tactical
Medicine
Kari F Jerge, MD
Assistant Professor of Surgery
Trauma, Critical Care, and Acute Care Surgery
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Overview
• Disclosure
• TXA
• Ketamine
• Tactical Medicine
• Summary
• Questions
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Disclosure
• No financial disclosures
• Intellectual disclosures
– TCCC instructor
– Trained by military surgeons
– Tactical Medical Director for SWAT team in AZ
– We stand on the shoulders of giants
– I might ramble, feel free to throw something at me
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The Problem Defined
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Key Issues
• Scene Safety
• Triage
• Hemorrhage control
• Medical management of hemorrhagic shock
• Pain control
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Coagulopathy of Trauma
• Triad of Death– COLD
– COAGULPATHIC
– ACIDOTIC
• Cold = enzymes in clotting cascade will not function
• Acidosis = result of hypovolemia/hemorrhagic shock = enzymes in clotting cascade will not function
• = BLOOD IS TOO THIN10/17/2018 6
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Coagulopathy of Trauma
• Present on admission in ~ 25% of trauma patients
• 5-fold increase in mortality
• Particularly severe in TBI patients
• Two aspects of coagulopathy…
– First is activated by hypoperfusion
– Second is iatrogenic
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Traumatic Coagulopathy
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Acute Traumatic Coagulopathy
• Hypocoagulable State
– Component of this that occurs at time of trauma = very hard to reverse/treat = carries poor prognosis
– Component that is associated with resuscitation
• Consume all coagulation factors
• Dilute out coagulation factors
• Cold and acidosis make coagulation factors malfunction, impair thrombin production
• Hyperfibrinolysis
– Protein C activation = hyperfibrinolysis = clot breakdown
– Patient breaking down whatever clot they are able to form
– Associated with HIGH MORTALITY 70-100%
– This is where TXA comes in
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Treatment Options
• Don’t let patients get cold!
– By any means necessary
– Remove cold or soaked clothing
– Emergency blankets
– Warm fluids
– Warm ambo
– Warm blankets
– Heating packs around head/neck, groin, axilla
• Replace red stuff with red stuff
• Don’t let patients bleed out
– Pandora’s box- Once its started, no perfect way to fix
problem
– TQ, wound packing, TXA, diesel fuel10/17/2018 10
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What is TXA?
• Anti-fibrinolytic
• Stops body from breaking down clot
• Generic medication
• Costs ~ 100 bucks
• WHO list of essential medicines
• IV and po route
• Uses:
– Trauma
– Heavy menstrual bleeding (OTC in UK)
– Postpartum hemorrhage
– Orthopedic and cardiac surgery
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TXA Administration
• 1g IV over 10 min, second gram runs over 8 hours
• Contraindications:– Allergy
– H/o seizures
– Thromboembolism (arterial or venous)
– Renal impairment
• Side effects:– HA
– Diarrhea, abd pain
– Fatigue
– DVT10/17/2018 12
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What Do We Know?
• TXA Administration
– 1.5% reduction in 28 day all cause mortality in bleeding
trauma patients
– Reduction in all-cause mortality from 16 to 14.5%
• NNT 67
– Reduction in risk of death caused by bleeding from 5.7%
to 4.9%
• NNT 121
– Benefit seen in the patients in severe shock
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What Do We Know?
• Giving < 1 hour greatest reduction in deaths from
bleeding
• Giving 1-3 hours after injury still decreased risk of
death from bleeding
• Giving > 3 hours after injury = INCR RISK OF
DEATH
• No impact on TBI outcomes
• Not associated with increased risk of VTE10/17/2018 14
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What Don’t We Know?
• Mechanism by which TXA decreases mortality?
– Fibrinolysis evaluation and coagulation testing weren’t
done in CRASH-2
• Should fibrinolysis testing be performed prior to
giving TXA?
• Optimal timing and dose?
• Other anti-fibrinolytics possible?
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CRASH 2
• CRASH 2 2010
– Large, randomized, double blind, placebo-controlled
multicenter trial
– 274 hospitals, 40 countries
– 20,211 patients with or at risk for severe bleeding
– TXA vs placebo
– Outcomes = 9% reduction in RR of all cause mortality
– 1.5% ARR
– NNT 67 trauma patient to prevent one from dying
– Benefit greatest within 3 hours and within the
sickest group of patients
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Cliff Notes TXA
• Given within 3 hours of severe traumatic injury
• Patients with or risk for hemorrhagic shock
• Improves mortality, coagulation profile, rates of
MOF
• Standard of care in military combat medicine
• Logistics
– Rural trauma
– Flight paramedics
– Trauma transfers
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Who needs TXA?
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TXA Further Resources
• Major Hemorrhage and Trauma Induced
Coagulopathy
– https://www.youtube.com/watch?v=7F0qamkiPN8
• Brohi on TXA in Trauma: The Denier’s Handbook
– https://emcrit.org/racc/more-on-txa/
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The Problem Defined
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Key Issues
• Scene Safety
• Triage
• Hemorrhage control
• Medical management of hemorrhagic shock
• Pain control
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Pain Secondary to Trauma
• Nature of the Problem
– Patients typically hypovolemic
– Frequently in hemorrhagic shock
– Pain control required for:
• Severe poly-trauma
• Splinting
• Tourniquets
• Transport
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Options for Pain Management
• Non-Narcotic– Aspirin
• Anti-Platelet
– Tylenol
• PO, PR
• IV Tylenol great pain relief, but restricted ($$)
– NSAIDS
• Meloxicam
– PO, Cox2 inhibitor > Cox1
• Toradol
– Inhibits platelet function, renal insufficiency
• PO, PR less than ideal
• No great options here for civilian prehospital
• Not to mention…10/17/2018 29
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Tell this guy he can’t have
narcotics…
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Options for Pain Management
• Narcotics– Morphine
• Histamine Release- itching, flushing, capillary dilation, bronchiolar constriction
• HYPOTENSION
• Weak narcotic
– Dilaudid• Potent narcotic
• Half life of 2 hours
• Can cause hypotension
– Fentanyl• Potent narcotic
• Fast on, fast off
• Least hemodynamically active narcotic
• No lasting relief
• We don’t have fentanyl lollipops yet
• All cause respiratory depression, some degree of hypotension, CNS depression, airway compromise10/17/2018 31
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Ketamine
• Ketamine Hydrochloride
• Derivative of PCP– Psychedelic type high
• Site of Action:– Multiple sites= opioid, muscarinic, nicotinic Ach receptors
– NMDA receptor antagonist
• Low Dose– Potent analgesic
– Mild sedation
• High dose– Dissociative anesthesia
– Moderate to deep sedation
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Ketamine
• Routes:
– PO, PR, IN, IM, IV, IO
• Effects:
– Sympathomimetic
• Tachycardia, HTN
– Pupil dilation, nystagmus
– Bronchodilation
– Increased salivary and tracheobronchial secretions
• Give with anticholinergic if need be
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Dose
• Analgesia
– 0.1 to 0.5 mg/kg IV
– 0.4 to 1 mg/kg IM
• Procedural Sedation
– 1 to 2 mg/kg IV
– 4 to 5 mg/kg IM
• RSI
– 1.5 mg/kg IV
• Repeat dose every 20-30 min prn
• How Do You Know?...
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Ketamine Use in Trauma
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Practical Tips
• Hypersalivation
– Anticholinergic
– Have suction handy
• Airway maintained, but you may need to suction, NPA,
jaw thrust
• Warn family that patient may look “catatonic”
– Eyes open, nystagmus, minimal responsiveness
• Not ideal if you need patient perfectly still for
procedure
• Great for agitated, violent, combative patients
• Excellent for RSI, pain management, sedation, single
agent anesthesia for rural/remote/austere medicine
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Practical Tips
• Bad Trip/Side Effects
– Bad dreams
– Hallucinations
– Sensory dissociation
– Near death experience
– Feeling of “being paralyzed”
• Emergence Reaction
– Dose related
– 12% of patients will experience
– Give small bump of benzo
– Ie Versed 2 mg IV x 1
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Safety
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Contraindications
• Absolute– Age < 3 months
• Relative– Schizophrenia
– Unstable angina/significant CAD
– Head Trauma
• Increased oxygen consumption
• But, cerebral vasodilation
• Minimal (probably not relevant) increase ICP
– Ocular Trauma
• Prior concern for increasing IOP
• Now questioned
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That Being Said…
• Use common sense
– Avoid in patients who are:
• Extremes of age
• Schizophrenic
• Already severely tachycardic or HTN, known unstable
angina or unstable CAD
– If give too high of a dose:
• Give oxygen
• Chin lift, jaw thrust
• NPA
• Suction as needed
• = Support airway until ketamine wears off
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Ketamine Data
• Upchurch CP et al. Comparison of etomidate
and ketamine for induction during rapid
sequence intubation of adult trauma
patients. Ann Emerg Med 2017; 69: 24-
33. PMID: 27993308
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Future Directions
• Data/SOP for Ketamine uses:
– Excited Delirium
– Acute pain control
– Chronic pain
– Chronic depression
– PTSD
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The Problem Defined
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Key Issues
• Scene Safety
• Triage
• Hemorrhage control
• Medical management of hemorrhagic shock
• Pain control
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Why should we talk about tactical
medicine?
• Terminology
• Recent civilian man-made mass-casualties
• Rise of active shooter
• Trends in law enforcement
• Gap in POI care
• End Result
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Terminology
• Man-Made Mass-Casualty– Not accident, not natural disaster
• Active Threat Scenario– Fails to include medical response needed
• Active Shooter– Limited scope
– Tactical term that media has twisted and misconstrued
– LE “owns” this scenario
– FBI data flawed by changing definition mid-study
• Complex Coordinated Attack– Mumbai, Paris
– Multiple weapons, multiple targets
– Synchronized attack
– Variety of weapons
– *First responders as targets*
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Recent Events
• 1993 Waco TX (Fire)
• 1995 Oklahoma City Bombing
• 2002 Beltway Snipers
• 2009 Fort Hood Shooting
• 2013 Boston Marathon Bombing
• 2015 Charleston SC Church Shooting
• 2015 Paris Bataclan Massacre (*CCA*)
• 2015 San Bernadino (Handgun, rifle, pipe bombs)
• 2016 Orlando Pulse Nightclub Shooting
• 2016 Dallas Police Shooting
• 2016 Nice France (vehicle and gunfire)
• 2017 Las Vegas Massacre
• 2017 Sutherland Springs Church
• 2017 Egypt Mosque Attack (bomb, rifle)
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What do these have in common?
• Active threat
• Multiple weapons used
– Explosive Devices
– Fire
– Rifle and handgun
– Nice and London vehicles
• Attackers wearing ballistic protection
• Combat style weapons inflicting combat style
injuries in wartime numbers
• Increasing visibility in public consciousness
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Rise of the Active Shooter
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Trends in Law Enforcement
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Gap in POI Care Pulse AAR
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End Result
• These events are increasing in frequency (we
think) and visibility
• These are civilian “combat” scenarios
• There is a gap between POI and definitive
medical care
• We need to be prepared to respond appropriately
to active threat scenarios and combat wounding
patterns in a timely fashion! = we need to
incorporate combat medical principles into
civilian America
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Paradigm Shift
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Paradigm Shift
• Abundance of resources
• Safe setting
• Vs
• Austere environment
• Logistical constraints
• Unsafe scene
• But why can’t we apply ATLS protocol?
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Civilian Treatment Priorities
• ABCDE
– PHTLS
– ATLS
– ACLS
• BUT I just told you that < 15% die from Airway
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Paradigm Shift
• #1 Priority is preventing further casualties
NEUTRALIZE THREAT
• #2 Priority is hemorrhage control
• Treatment modalities have to be portable,
compact, high-speed and low-drag
• In this specific context, FORGET ATLS!
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Now that your paradigm has
shifted…
• New medical response paradigm
• New order of treatment priorities
• Generate force multipliers
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Hartford Consensus II
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Massive Hemorrhage
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Massive Hemorrhage
• Truncal
– Aggressive prehospital use of TXA
– Evacuate
• Junctional Hemorrhage
– Not TQ amenable
– Junctional Tourniquet
• SAM, AAJT, Croc (ALL HAVE LIMITATIONS)
• Water bottle or can of chew and ace bandage
– Wound packing
• Quick Clot/Combat Gauze
• Celox
• Cool training videos
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Massive Hemorrhage
• Extremity Hemorrhage– Direct pressure is a resource distribution issue
– TQ
• Extensive military data
• 1 limb lost in over ~4,500 TQ deployments (not result of TQ)
• CATT or SOFTT (lots of junk on market)
• Lessons learned from Boston
• 2 inch width
• ”Go high or die”
• Take out all slack first, tighten windlass, secure velcro and windlass
• Give pain meds!
• First one fails, second TQ higher
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CoTCCC Approved TQ
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Tourniquets
• Anything else on market is JUNK with ZERO
VALID DATA
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Airway Management
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Airway Management
• Sit patient up, tripod position
• NPA
• +/- King
• Surgical Cricothyroidotomy
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Respiratory Management
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Respiratory Management
• 4-5th intercostal space, anterior axillary line
• Needle Decompression or Digital Thoracostomy
• Sucking chest wounds get occlusive dressing
– Gorilla Tape or AED pads
– If respiratory distress progresses, burp dressing
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Circulation Management
• Conscious casualties take P.O. fluids
• Unconscious casualties in shock get:
– Intraosseous access > IV access
– Minimal crystalloid
– Single 500 mL bolus of Hextend
– Freeze Dried Plasma
– Fresh Whole Blood
– MTP (“yellow red yellow red”)
• Resuscitate to PALPABLE RADIAL PULSE
• Why?
– IVF are heavy and take up space in limited environment
– Bleeding red stuff, give them back red stuff
– BP cuff not available
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Hypothermia Management
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Head Injury Management
• Support BP and oxygenation
• Elevate head
• DISARM CONFUSED CASUALTY
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Now that your paradigm has
shifted…
• New medical response paradigm
• New order of treatment priorities
• Generate force multipliers
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Generate Force Multipliers
• Law Enforcement Tactical Medical Training
– TECC
– LEFR TCCC
– 1-4 hours of training for non-medical LE
• Civilian Prehospital Hemorrhage Control
– BCON
– Stop the Bleed
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Civilian BCON
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Most of you are eligible to teach
BCON
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Get Trained
• Civilian
– BCON
• Fire/EMS
– Included in PHTLS curriculum
– We are happy to provide in-service training
– ALERRT conference
• Law Enforcement
– LEFR TCCC (curriculum under revision)
– Bcon
– 1-4 hour tactical medical course
• Rescue Task Force/MCI response
– TECC vs TCCC course (2 days, 16 hours)
– ALERRT train the trainer course
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Summary
• Disclosure
• TXA
• Ketamine
• Tactical Medicine
• Questions
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Summary
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Summary
• Why should we talk about tactical medicine?
– Terminology
– Recent civilian man-made mass-casualties
– Rise of active shooter
– Trends in law enforcement
– Gap in POI care
– End Result
• Paradigm shift
– Unsafe scene
– Logistical constraints
– Major cause of preventable death
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Summary
• Treatment Priorities
– THREAT vs MARCH
– Focus on threat neutralization and massive hemorrhage
• Generate Force Multipliers
– Stop the Bleed
• Further Training
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Further Resources
• Gear
– https://www.narescue.com/
– http://www.tacmedsolutions.com/
– https://www.chinookmed.com/
• Training/Videos/Information
– https://www.dhs.gov/stopthebleed
– https://www.bleedingcontrol.org/
– https://www.naemt.org/education/naemt-tccc
– http://www.naemt.org/education/tecc
– http://www.celoxmedical.com/na/resourcestraining-and-
education/
– You Tube and NAR have solid training videos
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Questions?
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