< 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

About Doc on the Run About Doc on the Run Active Duty Army Acute Care Surgeon. Nomad. Runner. Music aficionado. Culinary amateur. Intermediate-level technology nerd. Christian. Inquisitive life-long learner. My primary passion is surgery, and my life has been dedicated to becoming a trauma surgeon. After graduating high school at 17, I attended the University of Missouri, Kansas City, a six-year medical school. I was commissioned in the Army and completed 6 years of General Surgery residency in Augusta, Georgia. Board-certified in General Surgery. For 3 years, I was a staff General Surgeon in North Carolina and deployed to Iraq, Kuwait, Jordan, and Africa. Board-certified in Surgical Critical Care and completed a two-year AAST Acute Care Surgery fellowship in North Carolina. I spent two years in San Antonio, Texas, and then 1 year in South Korea, where I finished out my career on Active Duty. Photo courtesy of JW, 2013

< 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

< Back Ultrasound: Just The Basics Ultrasound is a non-invasive, repeatable, portable, reproducible diagnostic tool. It can be used virtually anywhere that patient care is being performed, including pre-hospital, the ER, OR, ICU, and non-ICU inpatient wards. Ultrasound skills vary between providers. I am a strong advocate of utilizing the ultrasound, and you will become more comfortable as you increase your utilization of the US. The credentialing process for ACS surgeons is not well-established, and we do not have the same expertise as radiologists. SCCM guidelines currently support ICU providers' utilization of US for certain scenarios. However, ICU providers are not as reliable in certain diagnoses, such as biliary pathology. Basics of Ultrasound: How Does it Work? Crystal excited by electrical pulses (piezoelectric effect)→ mechanical oscillations→ sound waves emitted. Sound waves are reflected at interfaces of different acoustic densities. Higher acoustic density→ increased intensity of reflected sound and decreased transmission of remaining sound waves. If the interface is between objects of vastly different acoustic density→ complete sound wave reflects and total acoustic shadowing occurs (dark behind the object); examples include bone, stones, and air. Probe selection Linear array- parallel sound waves→ rectangular images. Near-field resolution, high frequencies 5-7.5 MHz)- good for thyroid and soft tissue. Artifact on curved surfaces. Not good for intra-thoracic or upper abdominal organs. Sector/ phased array- fan-like image (narrow nearest transducer and widening with deeper penetration). Frequency 2-3 MHz. Poor for near-field resolution. Used for cardiac imaging. Curved (convex) array- abdominal sonography. 3.5-3.75 MHz. Deeper tissue penetration. *Probe marker correlates with the dot on the screen to establish orientation. Artifacts Reverberation echoes-several strongly reflecting boundaries→ reflection of sound waves back and forth→ echoes (several parallel lines close to the transducer). A-lines when scanning the lung- hyperechoic arcs parallel to the pleural line. These are seen at intervals that are the same as the interval from the skin to the pleural line. Absence of A lines= change in attenuation coefficient of the lung (edema, consolidation). B-lines when scanning the lung (comet-tail artifact)- vertical hyperechoic lines, caused by fluid-filled intra-lobular or interlobular septa touching the visceral pleural surface. Distal acoustic enhancement- sound waves travel through homogenous fluid (low reflection)→ less sound wave attenuation, so they are more amplified compared to adjacent sound waves (because the structures they passed through reflected some of the waves). *Brightness (increased echogenicity) behind fluid-filled structures such as the bladder or gallbladder. Mirror image- diaphragm and visceral pleura→ intrahepatic structures can be seen on the pulmonary side of the diaphragm. Acoustic shadowing- interface between tissue and bone or tissue and air→ scattered beam→ inability to image deeper structures. Knobology Identify the probe Identify the selected study type (cardiac, FAST, soft tissue, etc) Gain- increases the strength of sound/ brightness of the visualized area Depth-gain compensation- selective enhancement of echoes received at different depths→ moving depth up or down increases or decreased the field of view. Time-gain compensation- adjust the strength of the beam to areas that would normally have attenuated beams. M-mode- display and measure movement of structures over time along a single lione (axis of the beam). Good for heart or valve motion (echo), hemodynamic status (respiratory change in IVC diameter) and lung sliding or diaphragm movement. Doppler- changes in frequency cause by reflections off a moving target (usually blood). References Frankel HL et al. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part I: General Ultrasonography. Crit Care Med. 2015 Nov;43(11):2479-502. Levitov A et al. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part II: Cardiac Ultrasonography. Crit Care Med. 2016 Jun;44(6):1206-27. Labovitz AJ et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010 Dec;23(12):1225-30. Borloz MP et al. Emergency department focused bedside echocardiography in massive pulmonary embolism. J Emerg Med. 2011 Dec;41(6):658-60. Bakhru RN, Schweickert WD. Intensive care ultrasound: I. Physics, equipment, and image quality. Ann Am Thorac Soc. 2013 Oct;10(5):540-8. Silverberg MJ et al. Intensive care ultrasound: II. Central vascular access and venous diagnostic ultrasound. Ann Am Thorac Soc. 2013 Oct;10(5):549-56. Doerschug KC et al. Intensive care ultrasound: III. Lung and pleural ultrasound for the intensivist. Ann Am Thorac Soc. 2013 Dec;10(6):708-12. Boniface KS et al. Intensive care ultrasound: IV. Abdominal ultrasound in critical care. Ann Am Thorac Soc. 2013 Dec;10(6):713-24. Repessé X et al. Intensive care ultrasound: V. Goal-directed echocardiography. Ann Am Thorac Soc. 2014 Jan;11(1):122-8. De Backer D et al. Intensive care ultrasound: VI. Fluid responsiveness and shock assessment. Ann Am Thorac Soc. 2014 Jan;11(1):129-36 Labovitz AJ et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010 Dec;23(12):1225-30. Borloz MP et al. Emergency department focused bedside echocardiography in massive pulmonary embolism. J Emerg Med. 2011 Dec;41(6):658-60 . Emergency Ultrasound Tutorials American College of Emergency Physicians: Ultrasound Lectures Previous Next

Things I don't want to do (or do again) Anti-Bucket List Things I don't want to do (or do again) Experiences I don't care to repeat, but glad I did them once Tough Mudder Eaten alligator and shark Things others want to do that I have no desire to do Skydiving Scuba diving Attend the Masters Previous Next

< Back Intracranial Hypertension A 32-year-old male was an unhelmeted motorcyclist who was struck by a car and throw 20 feet. He had decreased alertness on the scene and was urgently transported to the hospital. On arrival to the ED, his GCS was 7 (E2V2M3). He was hemodynamically normal and secondary survey was only remarkable for diffuse road rash and a large scalp laceration. He was intubated for concern for inadequate airway protection. Chest x-ray revealed multiple left sided rib fractures, FAST was positive in the right upper quadrant and the pelvis x-ray was unremarkable. He was taken to the CT scanner for head, c-spine, chest, abdomen and pelvis imaging. He was transported to the trauma ICU as his images were reviewed. Head CT Case courtesy of Derek Smith. From the case rID: 169704. Imaging revealed a large right sided subdural hematoma. He has left lower rib fractures and a grade 3 splenic injury. Neurosurgery evaluated him upon arrival to the ICU. How is intracranial pressure monitored? The preferred method for ICP monitoring is with an external ventricular drain. This allows the dual function of monitoring ICP as well as allowing to treatment of elevated ICP via drainage of cerebrospinal fluid (CSF). What is a normal value for ICP? Normal ICP is <20 mmHg and treatment is recommended for sustained ICP >22 mmHg. Neurosurgery places an external ventricular drain. His opening pressure was 32, and his ICP ranges from 25-32 over the next few hours. He was in reverse Trendelenburg, and he was adequately sedated. His repeat head CT was unchanged. He had CSF drainage via his EVD. He was given 2 boluses of hypertonic saline. His ICPs improved, and were sustained at 18-20 mmHg. He develops hypotension, with systolic pressures in the 80s. What are some of the possible etiologies for hypotension, and how would you evaluate/ treat the various etiologies? Bleeding from his spleen→ urgent splenectomy. Hypotension is detrimental to TBI. Side effects from sedation medication→ decrease dosages or switch therapeutic agents, implement other treatment strategies Evaluation and Management of Traumatic Brain Injury The goal of the initial management of TBI is the prevention of secondary brain injury. Avoid hypotension and hypoxemia Target normal pulse oximetry, normal PaCO2 (35-45 mmHg) and PaO2 (≥100 mmHg), normal blood pressure (SBP ≥100), normal electrolytes, normal temperature, platelets >75K, hemoglobin >7 g/dL.[1] Treat pain and provide sedation as appropriate. Optimize patient positioning to promote cerebral venous drainage- elevate the head of the bed and ensure the cervical collar or endotracheal tube support is not too tight. Monro-Kellie Doctrine[2] Inside the bony skull, there is brain tissue, blood and cerebrospinal fluid. Increase in any one of these (tumor, hemorrhage, edema) requires a compensatory decrease in one of the other substances in order to maintain normal intracranial pressure (ICP). ICP rises when compensatory mechanisms fail. Elevated ICP leads to decreased cerebral perfusion pressure (CPP). CPP is the difference between mean arterial pressure and intracranial pressure, and serves as an additional measure of adequacy of cerebral perfusion [CPP= MAP – ICP]. This is similar to the concept of abdominal compartment syndrome- when intraabdominal pressure increases above a threshold, there is decreased organ perfusion. Initially, the brain is able to autoregulate and maintain cerebral blood flow (CBF) across a narrow range of CPP, but this compensation is also limited, and CBF decreases as CPP falls. The general target for CPP is ≥60 mmHg, but note that this may vary if cerebral blood flow autoregulation is impaired. Monitoring intracranial pressure (ICP) is not independently associated with improved outcomes. It does not replace serial neurologic exams. Clinical decision making based on the neurologic exam, the ICP, CT imaging and any other relevant information is the key to improving outcomes. There are several patient scenarios that should prompt consideration of ICP monitoring.[1,3] GCS ≤8 + structural brain injury on head CT GCS >8 + structural brain injury on head CT + high risk for progression (large/ multiple contusions, coagulopathy Severe TBI with a normal CT scan + at least 2 of the following- age >40 years, unilateral or bilateral motor posturing, or SBP <90 mm Hg. Progression of brain injury on repeat CT imaging Patients who require urgent surgery for extracranial injuries Clinical deterioration There is a tiered approach to treating elevated ICP.[1] At each tier, patients should continue to have close neurologic exams as well as interval repeat CT imaging of the head to rule-out the progression of hemorrhage. Tier 1- ensure optimization of analgesia and sedation, elevate head of bed, intermittent drainage of CSF. Tier 2- hyperosmolar therapy- mannitol or hypertonic saline. Consider advanced monitoring, including assessment of cerebral autoregulation and other markers of cerebral oxygenation. If utilizing advanced monitoring, consider hyperventilation to PaCO2 30-35 as long as cerebral oxygenation is maintained. Paralysis with neuromuscular blockade. Tier 3- decompressive craniectomy is a potential salvage therapy- may be associated with decreased mortality, but no improvement in neurologic outcomes.[4,5] Continuous infusion of neuromuscular blockade if there is a response to the test dose in Tier 2. Consider Barbiturate coma. Hypothermia and hyperventilation are no longer routinely recommended. Hyperventilation therapy can be used as a bridge to additional interventions. A study of hypothermia in severe TBI has shown no improvement in early neurologic outcome.[6] References ACS Committee on Trauma. American College of Surgeons Trauma Quality Improvement Program. Best Practices in the Management of Traumatic Brain Injury. 2015 Jan. Wells AJ et al. The management of traumatic brain injury. Surgery (Oxford). 2021;39(8):470-478. Carney N et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15. Cooper DJ et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med. 2011 Apr 21;364(16):1493-502. Cooper JD et al. Effect of Early Sustained Prophylactic Hypothermia on Neurologic Outcomes Among Patients With Severe Traumatic Brain Injury: The POLAR Randomized Clinical Trial. JAMA. 2018;320(21):2211-2220 Sahuquillo J, Dennis JA. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst Rev. 2019 Dec 31;12(12):CD003983 Previous Next

< 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 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 ACS Fellowship Is Acute Care Surgery the right specialty for you? If you are considering a career in Acute Care Surgery, it's important to explore the profession thoroughly before making any decisions. While there are numerous resources available to help you make an informed decision, one of the most valuable resources is speaking with surgeons who currently practice in this field. Experiences can vary widely at different hospitals, so don’t rely on just one opinion. Acute Care Surgery is a challenging specialty that will test you in ways you may never have imagined. It requires a high level of expertise in multiple clinical disciplines. As a surgical critical care fellow, you will face many challenges, such as long working hours, unpredictable workloads managing a mixture of high acuity critically-ill and injured patients, high patient mortality rates, and frequent exposure to severely injured patients. These challenges are not unique to Acute Care Surgery, but they are particularly profound in this field. One of the most significant challenges of this specialty is the emotional toll that it can take on practitioners. Managing patients in the ICU requires a high degree of empathy and compassion, and you will be required to deliver bad news to families and help them navigate difficult decision-making processes. It can be incredibly challenging to witness the suffering of patients and their loved ones, and it's essential to have a good support system in place to help you manage the emotional demands of the job. Despite these challenges, many surgeons find Acute Care Surgery to be an incredibly rewarding profession. Through their work, they have the opportunity to make a significant impact on the lives of their patients and their families. They develop strong relationships with patients and their loved ones, and they have the opportunity to witness the resilience of the human spirit in the face of adversity. If you are considering a career in Acute Care Surgery, it's essential to be well-prepared for the challenges that you will face. Seek out opportunities to speak with surgeons who practice in this field and learn from their experiences. Develop a strong support system that can help you manage the emotional demands of the job, and focus on developing the critical skills that are required to be successful in this challenging and rewarding specialty. With the right preparation and mindset, you can make a significant difference in the lives of your patients and their families as an Acute Care Surgeon. How do I become an Acute Care Surgery fellow? While there are many one-year surgical critical care and two-year trauma/surgical critical care fellowships available, it's important to note that as of 5 October 2020, there were only 28 AAST-approved Acute Care Surgery Fellowships. The application process for these fellowships is centralized through SAFAS . This means that you will need to enter standard personal information, test scores, and personal statements. Additionally, you will need to obtain several letters of recommendation. After you submit your application, programs will contact you if they are interested in offering you an interview. When applying for these fellowships, it's important to cast a wide net and not limit yourself to just a few programs. This may seem daunting if you are applying during your final year of residency, and you are likely already very busy with patient care, managing your team, preparing for board examinations and completing the documentation required for residency completion. Before the COVID pandemic, fellowship interviews were in-person. This was expensive and time-consuming. Virtual interviews may ease this burden, but it’s still a time-consuming process. While you may have a short list of your top choices, I would encourage you to consider a broader range of options. Some programs have online resources that can provide valuable information about the program's strengths and focus areas. When selecting programs, consider your own priorities. Are you looking for a strong critical care focus or a high volume of operative trauma cases? Do you have specific research goals? Fellowship is a short and intense period of focused training to allow you to develop the clinical knowledge and procedural skillset to thrive in this field, so be prepared to commit yourself fully to this opportunity. It's important to note that no program will be a perfect fit for everyone. However, if you approach the application process with an open mind and invest time in your search, you can find a fellowship that sets you on a path towards a fulfilling career in acute care surgery. Helpful Websites AAST ACS Fellowship Applicants . Website with more detailed information about what an Acute Care Surgery Fellowship entails. Approved Acute Care Surgery Fellowships . American Board of Surgery . National organization for board certification in General Surgery, as well as subspecialties including Vascular Surgery, Pediatric Surgery, Surgical Critical Care, Hand Surgery, Surgical Oncology, and Hospice and Palliative Medicine. This is one example of the experience of an ACS fellow at a Level 1 trauma center with a well-organized fellowship program and a well-developed research team. Please refer to " How to get involved " for more information. Clinical Work 12 months of critical care based rotations 8 months of trauma/ surgical critical care (TICU/ SICU) 1 month of cardiac surgical critical care 1 month of medical critical care (MICU) 1 month of Emergency Department Ultrasound training 2 weeks with Nephrology 2 weeks of Research 12 months of surgical rotations 6 months of trauma 3 months of emergency general surgery (EGS) 1 month of transplant surgery 1 month of vascular surgery 1 month of cardiothoracic surgery Research and Publications Two IRB approved research protocols. Lead author on 4 submitted manuscripts. 2 peer-reviewed publications (one as first author). Accepted literature review. Published personal essay. Sub-Investigator on Chest Tube Insertion Trial Author of a book chapter on thoracic trauma management in the ICU Presentations Presented basic science research at AAST Conference Presented process improvement project at department level research symposium Presented a personal essay presented at the EAST conference Nine formal department level lectures. Multiple ICU team lectures. Educational Opportunities Attended operative rib fixation training course Attended training course on IVC filter placement Attended two AAST conferences and one EAST conference Attended critical care/ trauma outcomes committee meetings and trauma morbidity and mortality conferences Attended quality improvement symposium Involvement with local and state trauma advisory committee meetings Previous Next

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< Back Vent Mgmt #2: Modes Mandatory Breaths Volume control (volume limited)- set TV and flow, pressure and inspiratory time are the dependent variables. Pressure control (pressure limited)- set inspiratory pressure and inspiratory time, volume and flow are the dependent variables. What is the downside of VC and PC? You can only control one parameter, and the dependent variable varies based on the patient's lung mechanics. For a patient on VC, if their lungs become less compliant, delivering the same tidal volume will generate higher pressure, increasing the risk of barotrauma. For a patient on PC, if their lungs become less compliant, the target pressure will be reached at a lower volume, so there is a risk of decreased ventilation (↑PaCO2). Pressure-regulated volume control (PRVC) is a hybrid mode that attempts to overcome this limitation. The target volume is delivered at the lowest possible inspiratory pressure by assessing the delivered tidal volume at the inspiratory pressure during each breath. What about inverse ratio (IR, IRV-PC) ? Increasing the inspiratory time relative to expiratory time increases mean airway pressure. This can be accomplished with pressure-controlled modes, where inspiratory time can be prolonged (normal ratio 1:2, IRV is when inspiratory time is greater than expiratory time). As discussed, MAP affects the surface available for oxygen exchange. This is why IR can be used to optimize oxygenation. Mandatory and Spontaneous Breaths Synchronized intermittent mandatory ventilation (SIMV)- a variation on VC or PC. The machine delivers mandatory breaths, but the patient can also control spontaneous breaths in between the mandatory breaths. Spontaneous Breaths Pressure support- spontaneous mode, the patient initiates breath, the ventilator provides support to overcome the resistance of breathing through the endotracheal tube, flow is adjusted to maintain the inspiratory pressure. The support is terminated when the flow decreases to <25% of peak flow. The patient controls duration and volume. *This is also a setting that can be adjusted in SIMV for assisting spontaneous breaths between ventilator breaths. Airway Pressure Release Ventilation (APRV)- invasive form of ventilation with BiPAP. The patient breaths spontaneously, alternating between a sustained time (time-high) at a set pressure (pressure-high) with a very brief release (time-low) of pressure (pressure low) to allow expiration. The goal is to maintain a higher MAP to optimize oxygenation. 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