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< Back Free Fluid in the Abdomen A 62-year-old male presents following a motor vehicle collision in which he was an unrestrained driver. He was intubated in the trauma bay for decreased mental status. A focused assessment with sonography for trauma (FAST) was performed, which did not reveal intra-abdominal fluid. Computed tomography (CT) of the head demonstrated minimal intra-cranial injury. CT of the abdomen and pelvis (see below) revealed decreased blood supply to the left kidney, small irregularity of the splenic contour, and a moderate amount of free fluid in the abdomen and pelvis. Hounsfield units are consistent with simple fluid. CT of the abdomen and pelvis https://video.wixstatic.com/video/3b6ff6_b03419943e9941d281c3d8f0b800e37f/480p/mp4/file.mp4 What is the differential diagnosis for the free fluid in the abdomen? Free fluid due to trauma can be urine, enteric contents (bowel injury with spillage of succus) or blood. It is possible to have fluid present prior to the trauma, such as ascites from chronic liver disease. In this case, the free fluid in the abdomen had characteristics of “simple fluid,” based on Hounsfield units, suggesting that the fluid was not blood. In females, free fluid in the pelvis can be normal (physiologic fluid). However, free fluid is NOT normal in a male, and it's concerning for hollow viscus injury. What are the possible causes of decreased blood flow to the kidney? The renal artery can be injured in blunt trauma. Blunt injury can disrupt the layers of the artery wall, leading to thrombosis and decreased blood flow beyond the injury. He was admitted to the intensive care unit. A foley catheter was placed and demonstrated pink-tinged urine [NOT frank gross blood/ clots]. What are the possible causes of blood-tinged urine? Bloody urine indicates a traumatic injury to the genitourinary tract, anywhere from the kidneys down to the urethra. A CT cystogram was performed, which did not reveal any extravasation of contrast from the bladder. CT Cystogram https://video.wixstatic.com/video/3b6ff6_119074429b224cc98677d4f101fef666/480p/mp4/file.mp4 Next steps? Based on an unreliable physical exam and a normal CT cystogram, it is necessary to rule out bowel injury. The patient was hemodynamically stable and had normal laboratory values. He remained with a decreased mental status, and therefore serial abdominal exams were not a viable management plan. The patient was taken to the operating room and underwent diagnostic laparoscopy. His small bowel, colon, and mesentery were examined in there entirety and found to be completely normal. There was a small amount of clear thin fluid in the pelvis, but there was no evidence of bile staining or bleeding. After completing the evaluation of the gastrointestinal tract, we repositioned the patient in Trendelenburg. The pelvis was inspected, and it was quickly apparent that the patient in fact had a large defect in the dome of the bladder. We elected to proceed with a low midline laparotomy. The bladder was easily mobilized, and the extent of the defect was defined. The edges were grasped, and the defect was closed in two layers with absorbable suture. Postoperatively, we reviewed the preoperative CT cystogram. In retrospect, there was a suggestion of bladder irregularity. We reviewed the CT cystogram with the radiologist and there was no evidence of contrast extravasation. However, the bladder does not appear to have been completely distended with contrast. It is very atypical that a large bladder wall defect was not associated with contrast extravasation, and this highlights the importance and ensuring complete filling of the bladder with contrast. Evaluation and Management of Bladder Injuries Bladder injuries can occur from blunt or penetrating trauma. For example, bladder injuries can occur when blunt force is exerted on a full bladder or in the setting of a pelvis fracture. Diagnosis Gross hematuria is seen in most patients with bladder injuries. Cystography, either using plain x-ray or CT, is the diagnostic test of choice. Management The management of bladder injuries is based on location. Intra-peritoneal injuries require operative management. This is done in two or three layers with absorbable suture. A decompressive foley catheter is left following repair. Extra-peritoneal injuries can typically be managed non-operatively with a foley catheter for 10-14 days. Exceptions include large bony segments protruding into the bladder wall, associated rectal or vaginal injuries, bladder neck injuries, or an associated pelvic fracture undergoing operative intervention to prevent hardware contamination. Current guidelines recommend a cystogram before foley removal, except for the most uncomplicated injuries. Yeung LL et al. Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2019;86(2):326-336. Previous Next

< Back Common Conditions Trauma and ICU Patient education: Preventing infection in people with impaired spleen function (Beyond the Basics) For patients who have had their spleen removed (typically related to trauma) Patient education: Pulmonary embolism (Beyond the Basics) Also known as a blood clot in the lung or PE. Disclaimer from UpToDate (included at the end of every patient handout) [This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2022 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.] Previous Next

< Back Vent Mgmt #3: Pressures Inspiratory Pressures Pressure Controlled Ventilation (PCV) End-inspiratory pressure= alveolar pressure. The pressure is essentially constant during PCV- high flow at the beginning to get to target pressure, then flow tapers until it ends (no airflow at end inspiration). Can't measure resistance because flow rate is dynamic. Volume Controlled Ventilation (VCV) Peak inspiratory pressure (PIP)- maximal pressure with inspiration. Sum of plateau pressure and pressure required to overcome airway resistance. Keep <40 cm H2O, SCCM recommends below 30 for ARDS. Abnormalities: elevated PIP indicates high resistance (secretions, bronchospasm, biting tube). Plateau pressure= alveolar pressure. Mean pressure during end-inspiratory pause, basically when there is no air movement. Not affected by resistance. Goal ≤30 cm H2O. Abnormalities: elevated plateau pressure indicates poor compliance. Driving pressure= plateau - PEEP. Goal ≤15 cm H2O (>15 is associated with ↑mortality). PEEP can either improve or worsen driving pressure. If the set PEEP promotes recruitment→ ↓driving pressure. If the set PEEP creates overdistension of the alveoli→ ↑driving pressure. End Expiratory Pressure Positive end expiratory pressure (PEEP)- lowest pressure that avoids alveolar collapse, which occurs when intrapleural pressure is higher than intra-alveolar pressure. This is indicated by the lower bend on the pressure/ volume curve, known as the lower inflection point. Mean Airway Pressure Mean airway pressure (MAP)- average pressure the lungs are exposed to during the breathing cycle. One of the two parameters that determine oxygenation. - How to increase MAP: ↑PEEP. If using IRV, ↑inspiratory time (Thigh) and ↑inspiratory pressure (Phigh). Parameters that Impact Airway Pressures Resistance- change in pressure relative to flow (PIP - plateau/ peak inspiratory flow). Relationship between PIP and plateau is directly related to airway resistance. ↑PIP and [PIP - plateau >5 cmH2O]= ↑resistance (bronchospasm, ETT obstruction/ kink). ↑PIP and ↑plateau [PIP - plateau <5 cmH2O]= ↓compliance (PTX, ARDS, pneumonia, edema, auto-PEEP). Compliance- change in volume per change in pressure. Normal- 50-100 mL/ cm H2O Previous Next

5 Critical Care References ICU Rounds A-F Bundle .pdf Download PDF • 33KB Pharmacology Med Doses .pdf Download PDF • 56KB Neurologic RASS .pdf Download PDF • 281KB CAM-ICU .pdf Download PDF • 127KB CPOT .pdf Download PDF • 76KB EtOH Withdrawal .pdf Download PDF • 1.02MB Cardiac Arrhythmias .pdf Download PDF • 1.55MB Pulmonary Cuff Leak .pdf Download PDF • 15KB Fluids, Electrolytes and Nutrition Fluids .pdf Download PDF • 29KB Na and pH .pdf Download PDF • 53KB Endocrine and Nutrition Types of Insulin .pdf Download PDF • 85KB TPN .pdf Download PDF • 221KB Steroids .pdf Download PDF • 36KB Hematology Anticoag .pdf Download PDF • 44KB Anticoag Reversal .pdf Download PDF • 334KB Organ Donation Hormone Therapy .pdf Download PDF • 13KB

< Back Definitions Common Abbreviations ACS- Acute care surgery. Field of surgery that encompasses trauma, emergency general surgery and surgical critical care. APP- advanced practice provider. Includes physician assistants (PA) and nurse practitioners (NP). ICU- intensive care unit. Higher-acuity (sicker) patients requiring closer monitoring (continuous evaluation of vital signs), more invasive or more frequent interventions (mechanical ventilation, multiple cardiac medication infusions). CRNA- certified registered nurse anesthetist. CRRT- continuous renal replacement therapy. EGS- Emergency General Surgery. GCS- Glasgow Coma Scale. IV- intravenous. MCC- motorcycle crash/ collision. MVC- motor vehicle crash/ collision. SCC- surgical critical care. Common Personnel - Attending physician- most senior physician caring for a patient. - Bedside nurse- the nurse who provides the direct patient care, including assessing a patient's current clinical status, providing medications, interact with other teams that see the patient such as physical therapy or the wound care team, placing urinary catheters and monitoring urine output, communicating with the patient's physician team, providing patient education. - Chief Resident- resident in their final year of residency training. - Fellow- a physician that has completed preliminary training and undertakes advanced training in a subspecialty. Typically follows residency graduation, although Surgical Critical Care can be completed prior to graduating from surgical residency. - Intern- a physician in their first year of residency training following medical school graduation. Common Procedures - Arterial line placement- similar to an IV, this is a skinny catheter, but instead of being in a vein, it’s placed in an artery. This allows continuous monitoring of blood pressure and allows repeat labs, specifically arterial blood gas to assess respiratory status. - Bronchoscopy- use of a small camera (think of a really skinny colonoscope) to examine the airways of the lungs, take a specimen for culture or remove an obstruction. - Central line placement- placement of a large catheter into a large vein in the neck, under the clavicle (collarbone), or in the groin. The purpose is similar to an IV (intravenous) line, which is commonly placed to provide medication, fluids, or draw blood. A central line is larger- more drips can be connected to it, it can be kept in place longer than a peripheral IV, and it can allow delivery of special medications. - Intubation- placement of a plastic breathing tube (endotracheal tube) through a patients mouth, into their trachea (airway). Patients receive sedation medication and paralytic medication (medication to prevent muscle movement. This is commonly used for patients who are unconscious or are having breathing difficulties. It is also commonly used while patients are undergoing surgery - Laparotomy- vertical incision on the abdomen to allow examination of the organs in the abdomen. Also known as an “exploratory laparotomy” or “ex lap”. - Ostomy creation- in the unplanned setting, patients who undergo emergent surgery for trauma or bowel ischemia/ perforation, a segment of the bowel might be removed, reconnected or repaired. These patients are at a higher risk for their bowel connection or repair to fall apart (known as an anastomotic leak). To prevent this, sometimes it is safer to divert the stool toward an opening in the skin to allow stool to pass outside into a bag, instead of moving into the intestine that was repaired/ reconnected. - Ostomy reversal- reconnection of the bowel after a patient has recovery from emergency surgery. The bowel is reconnected (so the patient will now pass stool normally) and the skin opening is closed. - Percutaneous endoscopic gastrostomy tube (PEG)- creation of a connection directly through the anterior abdominal wall into the stomach to allow feeding without requiring a tube in the patient’s nose. - Thoracotomy- incision on the chest to allow access to the organs in the chest (heart, lungs, esophagus). - Tracheostomy- creation of a connection directly from the front of the neck to the trachea (airway). A short curved tube is placed in the open, and the endotracheal tube (breathing tube) is removed from the mouth. Common definitions - Rounds- the process of evaluating and examining patients currently in the hospital. Previous Next

< Back Ultrasound: Misc Abdomen Assess for intra-abdominal fluid to rule-out an intra-abdominal source of hypotension. Examine the gallbladder- gallstones, wall thickening (>3 mm) and pericholecystic fluid are consistent with cholecystitis Examine the kidneys and bladder- overt hydronephrosis concerning for mechanical obstruction. Distended bladder despite foley suggests obstructed foley. Vascular Presence of DVT- patent veins are fully collapsible with light ultrasound compression- pressure has to be lower than the pressure needed to collapse the artery. Vascular access for arterial and central line placement. Previous Next

< Back Guts on the Floor and Exposed Spine Patient #1 A 32-year-old male was involved in a head-on motor vehicle collision. He was ejected and pinned between two vehicles. He was brought in by EMS and on arrival to the trauma bay, he was covered with a sheet. When he was transferred to the gurney, it was clear that there was something unusual. He was eviscerated with a large wound in his right lower abdomen just above his inguinal ligament, and his intestines were entangled in his clothing. Patient #2 A patient was brought in by EMS following a motorcycle accident with a report of "exposed spine". Primary survey unremarkable, hemodynamically stable. FAST revealed fluid in the abdomen. A secondary survey revealed multiple extremity abrasions. When the patient was log rolled, he was noted to have a full-thickness degloving injury of the soft tissue and partial avulsion of the back musculature with exposed spinous processes. What are the management priorities? Prioritize primary and secondary survey, treat life-threatening injuries first. Secure airway. Evaluate for concomitant injuries, including thoracoabdominal injuries, requiring emergent surgical intervention. The challenge of Distracting injuries Remember- very painful or frightening injuries may distract from pressing clinical priorities. Regardless of how horrifying or novel an injury is, the goal of rapid evaluation and management of trauma patients is to identify and treat the most life-threatening injuries first. Remember to evaluate the airway, breathing, and circulation, and don't be concerned with the exposed intestine until you have ensured the patient doesn't have a pending loss of airway, tension pneumothorax, cardiac tamponade, etc. Control active arterial hemorrhage. Don't let the patient die from an unsecured airway while you are frantically attending to grass and flecks of wood and rock covering the exposed back muscle overlying the spine. Previous Next

< Back Thoracoabdominal Wound A 32-year-old male is brought to the ER after sustaining a gunshot wound to the right thoraco-abdomen. He is hemodynamically stable. What are the initial steps of evaluation and management? Imaging? Secondary survey to rule out other wounds. FAST exam. CXR. What injuries must be considered with these wounds and imaging patterns? Chest (heart, lungs, etc.), abdomen (solid organs or hollow viscus), and diaphragm. He underwent exploratory laparotomy. He was found to have a right diaphragm defect, which was repaired primarily. There was a transhepatic GSW and hepatorrhaphy was performed with chromic suture. A blast injury to the anterior gastro-esophageal junction was buttressed with an anterior Dor fundoplication. Management of Thoracoabdominal Wounds The thoraco-abdomen is between the nipples and the costal margin. Organs in the chest and abdomen can be injured, and the diaphragm is also at risk. Liver Trauma Management depends on how it is diagnosed and the patient's hemodynamic stability and physical exam. Diagnosed pre-operatively on CT scan + no concern for the need for operative intervention for concurrent injury→ non-operative management if the patient is hemodynamically stable without peritonitis. Embolization should be considered in adults with active arterial extravasation on CT. Operative intervention is indicated for hemodynamic instability, ongoing transfusion requirement, and/ or change in the abdominal exam. Diagnosed intra-operatively→ management depends on the severity and presence of bleeding, presence of concomitant injuries. Hemorrhage control is the immediate concern. Manual pressure and packing (sandwich lap pads above and below) first. If this is ineffective, use the Pringle maneuver (hepatic inflow control)→ if bleeding stops, it was either hepatic artery or portal venous in origin. If bleeding continues, hepatic vein or IVC are likely injured. Minimal bleeding can be controlled with cautery, hemostatic agents, omental packing, or argon beam coagulation. Moderate bleeding from a laceration from often be controlled with suture hepatorrhaphy. More significant bleeding may require non-anatomic resection or vessel ligation. Topical hemostatic agents Absorbable hemostatics Oxidized regenerated cellulose- Surgicel, Surgicel Fibrillar (sheet), Surgicel NuKnit Polysaccharide- Arista Porcine collagen (gelatin matrix)- sponge, film, or powder. Brands- Gelfoam, Gelfilm, Surgifoam. Bovine collagen (microfibrillar)- sponge, sheet, powder. Brands- Avitene, Ultrafoam. Sealants with thrombin or fibrin Thrombin, reconstituted (Recothrom) Thrombin + collagen + chondroitin sulfate (Hemoblast) Thrombin + bovine gelatin (Floseal) Thrombin + porcine gelatin (Surgiflo) Thrombin + fibrinogen + aprotinin + plasminogen (Tisseel) Thrombin + fibrinogen + albumin (Evicel) QuikClot- kaolin HemCon- chitosan If there is a trans-hepatic wound, tamponade can be created by threading a red rubber catheter through a Penrose drain, placing this into the wound, and then filling the Penrose with saline. Stabina S, Kaminskis A, Pupelis G. Start of Polytrauma Management in University Hospital: First Experience with Liver Trauma. Acta Chirurgica Latviensis. 2014;14(1):20-25. Previous Next

< Back Dogs #2 Supplies- Adventures This is not professional/ medical advice. These are all based on my personal experience. I’m not a paid sponsor for any of these items. I have included reviews where appropriate. Travel Dog goggles Amazon Link Dog backpack K9 Sport Sack Plus 2 Forward Facing Dog Carrier Chewy Link Car crate- Gunner Dog Crate, Medium Gunner Link Dog sling carrier Amazon Link Car seat Amazon Link Notes: I initially used the car seat, but as she grew up, she became increasingly unlikely to lay down and would spend her time standing, typically bracing her back legs against the back of the seat. I felt relatively comfortable when she was laying down, but when she switched to mainly standing, I decided that it was too unsafe and I chose to switch to a car crate. I have been very happy with the Gunner crate. It's an expensive product but absolutely worth the cost in my opinion. I used the dog sling carrier during puppy socialization before my pup was fully vaccinated. Apparel and Winter Gear Outward Hound Granby Splash Dog Life Jacket, Life Vest, Orange, Medium Amazon Link Fleece Jacket, Gold Paw Series GoldPaw Link Winter Jacket, Plaid Amazon Link Winter Jacket, RuffWear Powder Hound Dog Jacket RuffWear Link Winter boots- Youly, The Adventurer, All-Weather boots PetCo Link Summer boots Amazon Link Paw Wax- Musher's Secret Amazon Link Post-spay body suit, BellyGuard surgery recovery suit Amazon Link Notes: Winter boots were an in-person purchase at PetCo, when we had a surprise snow storm and Amazon delivery wasn’t available. They fit really well, although the velcro isn’t very hearty- I’ve had to repair them by hand. Leashes, Collars and Tethers Leash, biothane Amazon Link Collar, neoprene and nylon Amazon Link Collar, nylon, waterproof (doesn’t bleed color onto fur) Amazon Link Identification tag, silent, slide on collar Amazon Link Medium-length nylon leash, 15 ft- Hi Kiss Dog/Puppy Obedience Amazon Link Chew-Proof Tether, 6 foot Amazon Link Chew-Proof Tether, 50 foot Amazon Link Back-clip harness for car rides Amazon Link Notes: Bovie loves chewing leashes, and we went through several nylon leashes before I wised up and purchased chew-proof varieties, specifically for tethering in the house. For example, when she was a puppy, we trained her to stay on her place during mealtime, and she was tethered as a reminder. When we are outside eating or working, she has a 50 foot tether so she doesn’t take off down the hill or into a neighbors yard. I don’t keep her tethered for extended periods of time and she’s never unattended while tethered. Previous Next

< Back GERD What is GERD? Gastroesophageal Reflux Disease (GERD), more commonly known as heartburn, is caused by acid from the stomach moving into the esophagus, which causes a burning pain in the middle of the chest. Anatomy After swallowing, food moves down the esophagus and into the stomach. The lower esophageal sphincter (LES), which is at the connection between the esophagus and stomach, prevents stomach contents from moving back into the esophagus. The lower esophageal sphincter is located below the diaphragm, where pressure from the abdominal organs helps keep the sphincter closed. There are different causes of GERD, but the lower esophageal sphincter is key to preventing reflux. See below for more details about why GERD occurs. Source: UpToDate Images: Gastroesophageal Reflux (GERD) Causes of GERD Decreased pressure of the lower esophageal sphincter- if the lower esophageal sphincter is too loose/ relaxed, stomach contents move more easily into the esophagus. This can be a pre-existing condition but it can also be caused or worsened by lifestyle habits. For example, tobacco and certain foods such as alcohol, chocolate, caffeine, carbonation, mint, citrus/ tomato-based foods, spicy/ fried/ fatty foods, can also decrease the pressure of the sphincter. Eating too much/ too fast→ overfilling the stomach leads to increased pressure, causing stomach contents to be pushed into the esophagus Laying flat- when you are standing or sitting upright gravity helps avoid reflux by keeping food in the stomach, but when laying flat, stomach contents can move into the esophagus more easily. This is why symptoms are often more severe at night or first thing in the morning. Hiatal hernia - when the lower esophageal sphincter is able to move into the chest, it no longer has the external pressure normally present when it’s in it’s correct position, and it more easily allows stomach contents to move into the esophagus. See link for image. Obesity or pregnancy- increased pressure on the abdomen from excess weight can put pressure on the stomach and allows stomach contents to move into the esophagus for easily. GERD: Symptoms and Causes [Mayo Clinic: Patient Care & Health Information] Diagnosis Symptoms are often adequate to diagnosis GERD. A swallow study can provide further information. This study is performed in radiology, and involves drinking contrast material and having x-ray images taken to evaluate the esophagus and stomach while you swallow. This study can diagnose esophageal problems, such as poor muscle function leading to swallowing difficulty. In addition, a hiatal hernia can be identified. John Hopkins Medicine: Barium Swallow An esophagogastroduodenoscopy (EGD), also known as an upper endoscopy (see link) can be used to assess the inner lining of the esophagus, stomach and the first part of the small intestine (duodenum). There are many things that can be identified on an EGD, but specifically related to GERD, damage to the lining of the esophagus and the presence of a hiatal hernia can be identified with an EGD. Patient education: Upper endoscopy (Beyond the Basics) [UpToDate] Upper Endoscopy [Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)] Additional testing can be performed based on symptoms, results of initial testing and response to treatment. Esophageal manometry- a study to evaluate the muscle function of the esophagus ( pH test- a study to evaluate how much acid the esophagus is exposed to, which is one measure of the severity of GERD. GERD: Diagnosis and Treatment [Mayo Clinic: Patient Care & Health Information] Treatment Lifestyle Modifications [ Patient Handout: Anti-Reflux Diet and Lifestyle Modifications ] Eat slowly, avoid eating large meals and stop eating before you feel full. Avoiding alcohol, chocolate, caffeine, carbonation, mint, citrus/ tomato-based foods, spicy/ fried/ fatty foods. Avoid lying down for at least 2-3 hours after meals. Don't snack after dinner/ before bed. Elevating the head of the bed by 6-8 inches. This is NOT done by placing multiple pillows under your head- multiple pillows would actually increase pressure in the abdomen (like doing a sit-up or crunch). For more information, see this guide from the Kingsley clinic. Lose weight. Stop smoking. Avoid tight-fitting clothing. Medication Over the counter antacids Prescription medication Surgery Depending on how well medication and lifestyle modifications improve your GERD symptoms, and depending on the results of your other studies, such as your swallow study, esophageal manometry and pH testing, surgery may be an option for GERD. UpToDate Patient Education Patient Education: Gastroesophageal reflux disease in adults (Beyond the Basics) Previous Next

< Back Gunshot Wound to the Leg A 26-year-old male soldier sustained a gunshot wound to the right medial thigh. He had a compressive dressing that was placed prehospital. He arrived at the hospital and underwent a rapid primary and secondary survey. Initial X-ray Evaluation? Radiologic imaging. Evaluation for extremity vascular injury. He had active bleeding from the wounds. After plain films and initial stabilization, the patient underwent operative exploration of the vascular structures of his right lower extremity. His right femoral artery was intact. His right femoral vein was transected and there was a long segment of destroyed vein, which was treated with ligation. He underwent right lower extremity fasciotomy. This was followed by femur fixation with the placement of an external fixator. Intraoperative Image Postoperative Image Management of Combined Arterial and Orthopedic Injury EAST Guidelines In this scenario, the priority is restoring distal arterial blood flow to minimize ischemia time. If there is an associated unstable fracture, blood flow can be re-established with a temporary intravascular shunt, followed by rigid fixation of the bony injury. If the arterial injury is definitively repaired, it can become disrupted with the manipulation required for rigid fixation. If the associated fracture is stable, the arterial injury can be repaired before addressing the fracture. Previous Next

Confessions of an ICU Physician with a terrible memory Accessing the Right Information < Back Confessions of an ICU Physician with a terrible memory Training in medicine starts with textbook learning. But the art of caring for patients can’t be learned in a textbook. Higher-order thinking is essential to understand the interaction between multiple conflicting disease processes, identify nuisances of atypical presentations and find solutions for clinical conundrums. As the field of medicine grows exponentially, the volume of information is too much for one person to keep track of. I find that understanding clinical concepts is much easier than rote memorization of pharmaceutical brand names with their associated generic name, recalling the dose of a paralytic, or identifying the ideal antibiotic for a multi-drug resistant bacteria. After several years of learning and studying mechanical ventilation and how it interacts with and affects a patient's respiratory physiology, I now understand the principles of how to optimize oxygenation and ventilation. As an ICU physician, I can't re-read the basic textbook of mechanical ventilation every time I care for a patient with respiratory failure. I must be able to make decisions relatively quickly and must be able to explain my rationale to residents and bedside nurses while we are working to manage a patient with severe lung disease. But I can pause to look up the recommended dosing of a medication for a patient on dialysis or identify the best anti-microbial for a particular bacteria or fungi. What do I do about important information that I need immediate access to but that doesn't reside in the forefront of my mind? Smartphones, with access to websites and applications , have revolutionized our ability to bring evidence-based medicine to the bedside. Clinical practice guidelines can be accessed on society websites. Deployed Medicine is a resource that provides access to Tactical Combat Casualty Care and Joint Trauma System Clinical Practice Guidelines. There are apps for a wide number of clinical programs that were initially web-based, such as UpToDate. In addition to the resources that are openly available to the public, I have created a database of personal high-yield references. Medication dose ranges, CPGs for our trauma center, AAST Injury Scales, sedation/ pain scores, TEG parameters, and a wide variety of other information that I refer to on a relatively routine basis are now in the palm of my hand. I use the Trello app. I created a dedicated workspace with a group of lists (titles such as trauma, medication, ICU, etc) which each contain multiple individual cards (titles such as A-F bundle, CAM-ICU/ RASS/ CPOT, TEG). I'm not saying you have to use this. But I highly recommend finding a tool that works for you. TL;DR • Take the time to understand processes and concepts- learn one physiology concept from each pt • Have an external tool for storing “rote memorization” facts that you can readily access Previous Next