Emerge in EM

E7: Prehospital trauma care

• Mohamed Hagahmed, MD

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In this episode of EMERGE, I am joined by Dr. Frank Guyette, an emergency physician and EMS expert from the University of Pittsburgh and the medical director of STAT Medevac. Dr. Guyette offers insights into pre-hospital trauma care, discussing critical topics such as the trauma triad and diamond of death, the complexities of hypocalcemia in trauma patients, and evolving practices in fluid management. He also delves into the latest research and protocols, including the controversial use of TXA and the challenges of resuscitating trauma patients with advanced techniques. Looking towards the future, Dr. Guyette explores the promising role of artificial intelligence and cutting-edge medical devices like REBOA in advancing trauma care. This episode is packed with vital information for EMS providers, medical professionals, and anyone interested in the latest trends in emergency care.

Dr. Mohamed Hagahmed:

Welcome everybody to EMERGE, and I'm really excited to announce today's guest in my podcast Dr. Frank Guyette. Can you tell us a little bit more about you?

Dr. Frank Guyette:

Sure. My name is Frank Guyette. I'm an emergency physician and EMS physician at the University of Pittsburgh. I'm also the medical director of STAT Medevac, which is the UPMC's critical care transport network.

Dr. Mohamed Hagahmed:

Frank, I really enjoyed your talk today about pre hospital trauma care. I was, very familiar with the trauma triad of death which is, remind me, acidosis, coagulopathy, and hypothermia. But you brought up the idea of the diamond of death in trauma care. Can you tell us more about that?

Dr. Frank Guyette:

Sure. So one of the concerns would be hypocalcemia, and this is common in our patients. About half of all trauma patients that come to the trauma bay have hypocalcemia. But that becomes even a higher percentage among those who require resuscitative care, particularly if they've been given pre hospital blood products. And the reason being is that those blood products are stored in citrate to prevent coagulation of the blood product. The citrate will remove the calcium from the blood, making them further hypocalcemic. And the concern is that we need that calcium in order to allow for smooth muscle contraction to help with hemorrhage control for cardiac contraction to help mitigate shock and also for the coagulation pathways themselves.

Dr. Mohamed Hagahmed:

So is a practice to give an amp of calcium to anyone who's getting blood or is there like a certain protocol?

Dr. Frank Guyette:

That's a great question and it's an it's one that we don't have a definitive answer yet. So I think many Services that are already deploying blood have thought about this and do give an amp of calcium But the practice is fairly variable in the EMS community in some places. They'll give an amp of calcium with Two units of blood in some places they'll give an amp of calcium with each unit administered. I don't know of too many places giving it empirically, but that has been the subject of a recent study. So the CAVALIER trial through the LITES Network is studying pre hospital calcium empirically, meaning even before you give blood products in trauma patients, but the results won't be available for a few more years.

Dr. Mohamed Hagahmed:

And what is the current practice now in STAT MEDEVAC when it comes to giving calcium?

Dr. Frank Guyette:

So our standing orders now are to give an amp of calcium for every two units of product. And this does get a little bit tricky depending on the product that you're carrying. Packed red blood cells do contain citrate, but less than liquid plasma or thawed plasma. And less than whole blood. If you're giving whole blood, or you're giving plasma products, they're much more likely to be citrated or have higher concentrations of citrate. While two giving an amp of calcium for every two or four units of PAC cells might be acceptable, for a unit of whole blood, you might need to give an amp of calcium for every unit. Yeah.

Dr. Mohamed Hagahmed:

We're Talking to a lot of people here that don't have access to blood in their systems. And I know there's been the discussion or debate about giving IV fluid to trauma patients. What is your thought process when it comes to giving fluid to trauma patients? Everybody gets a full liter and an 18 G in the AC? Yeah,

Dr. Frank Guyette:

and I think we're finally evolving past that, right? And I think you're absolutely right. When you and I were providing care as EMTs and paramedics. Back in the day, that's what we were taught, right? Two large bore IVs, blast the fluid in, if you didn't have two liters in, you were doing something wrong, right? And I think what we have to do is really have a plan for judicious use of fluid. If the patient has signs of shock, then we should give fluid. And maybe in smaller aliquots, instead of giving a liter at a time, maybe it's 250 or 500, just enough to see those signs of shock start to go away, right? So if we can get that blood pressure up a little bit, if the patient's mental status improves a little bit, then maybe we hold off on additional fluid. And the reason being is that there have been studies published demonstrating that the amount of fluid you receive correlates with your your mortality and morbidity. And some of that is biased by indication, right? Because people who are in shock are going to get more fluid. But we know that the fluid is making people more coagulopathic and worsening their outcomes. Exactly because of that diamond to death that you just described, right? Because, what temperature is the fluid? It's room temperature. So we're making the patient hypothermic, right? We're diluting out those coagulation factors, so we're worsening the coagulopathy. If it happens to be normal saline it creates a hyperchloremic acidosis. So you're making the acidosis worse, right? That's the concern. If fluid is the only resuscitative product that you have, we have to give it, but we should give the minimum amount necessary. And in most cases, for a patient in hemorrhagic shock, the answer is blood, if you have it.

Dr. Mohamed Hagahmed:

So blood, ideally fluid to maintain just hemodynamics stable enough to get them out of there. And I know a lot of my EMS colleagues love magnesium and TXA, right? Everybody gets magnesium who has shortness of breath and everybody gets TXA if they have bleeding somewhere. Yeah. Is this like the current practice when it comes to trauma care and giving TXA to patients and what is. What is the current evidence when it comes to giving TXA in terms of mortality and outcome?

Dr. Frank Guyette:

Yeah, that's a great point. If we go back to the classic trial, the CRASH222 trial, the mortality, the reduction in mortality was about 6 percent with TXA. And from that standpoint, we should give it right. It's inexpensive. It's safe. If you give it within three hours after the traumatic injury, the risk of harm is very small. And it's really not costly. So It makes sense to give it, but the benefit, the effect size of that reduction in mortality is really small, right? Would, I think what you have to do is you have to think about what is the order of operations of your trauma resuscitation, and if you have, if you're, it depends on what you're using. If you're using MARCH or TCCC, whatever your algorithm is, if you're talking about say a MARCH algorithm, You have to control that massive hemorrhage first, right? You have to get your tourniquets on, your pelvic binder, plug the holes and save the souls as they say, right? But but once you've done that, Then, you can go, keep going down that algorithm, and if you've already addressed that patient's shock with some fluid, if you have it, or blood, if you have it, then TXA is a good answer and it is something that we should give, but because the effect size is small, it's probably something that I would prioritize further down the line. If you're in an urban system with really short transport times, maybe it's not as important because you're going to a, in those urban systems, you're going to a trauma center, where they're likely to give it. Whereas if you're in a rural community, longer transport times, it may be more important for you to give it in the field.

Dr. Mohamed Hagahmed:

Is there harm with giving TXA?

Dr. Frank Guyette:

Only if you give it after three hours from time of injury. And the reason being is that TXA is a really interesting drug. What it does is it stabilizes clot, right? So it, the clot is held together for a little bit longer. And that's probably what's affecting the reduction in in bleeding and subsequently mortality. But there is a risk of venous thromboembolism, right? So DVTs, PEs, that type of thing. That risk seems to be really low immediately after injury, but increases over time. And in about three hours, that risk starts to go up. There is good evidence both from CRASH222 and subsequent trials that after three hours, the risk is higher for mortality. We assume that it's because of that risk of VTE, although it's hard to say cause obviously patients in the CRASH2 trial and subsequently the matters trial, which was a military TXA trial, they had really bad vascular injuries. Many of them did. They would naturally be at greater risk for venous thromboembolism anyway. So it's, it is hard to parse that out.

Dr. Mohamed Hagahmed:

If we can go over a quick scenario. Someone got shot in the chest. GSW, unconscious. They still have some kind of blood pressure. They have a pulse. EMS shows up. They're bleeding everywhere. What would be like the top priorities for EMS when they show up to the scene?

Dr. Frank Guyette:

That's a great point. So first, massive hemorrhage control, right? Pack that wound, that gunshot wound to the chest, put a chest seal on it. The next thing I would do is airway, right? And with airway that doesn't necessarily mean intubating, right? In fact, that could be dangerous in that patient, right? If they're, that patient's shocked and you intubate them while they're hypotensive or they're hypoxic, that could lead to worsening outcomes. The better strategy would be to just manage the airway with BLS intervention, so maybe open the airway, maybe use an adjunct if you have the additional manpower, start providing support with a bag valve mask if the patient's not conscious. But I wouldn't go to intubate until I've addressed the shock state moving from there also as part of the MARCH algorithm, I would go to respiration next. And I'd want to make sure that I have that chest seal so I'm not re accumulating air into the chest. I'd want to make sure that I've needle decompressed in that case because I'd be concerned about a pneumothorax. There's some debate on when to needle decompress. Just because you have a penetrating chest wound doesn't necessarily mean that you have tension physiology, right? And the needle is really there to help you address tension physiology. And by needle I also mean any Thoracostomy, right? So it'd be that finger thoracostomy or tube thoracostomy, depending on the scope of practice of your provider. But I would think about doing that early. But knowing that you may have to go back and reassess that and redo it later. After you get past respiration then circulation. So that's where our fluid or our blood is gonna come in and then then you're going to look at your hypothermia, hypotension, that type of thing. And I think at that point if you want to go back and reassess all those things, right? So if, am I still bleeding through the wound, right? Should I be using a hemostatic agent? Is there some other method of hemorrhage control that I can impact? Do I need to if the patient's not being, Bag valve mass ventilated adequately. Do I need to put in a more definitive airway? And we don't know what the answer to that is either. The PACT trial is ongoing now. That's comparing strategies of endotracheal tube first versus strategies of supraglottic first. So I think again probably in about another year we'll have a little bit more definitive evidence as to what the right answer is in that situation. And then, I want to make sure That I've adequately addressed that hemorrhage, that I'm reassessing the patient, and that extrication plan because we, we want to get that patient off the scene, get them to definitive care.

Dr. Mohamed Hagahmed:

I really want to discuss a controversial topic, and this is a situation that I remember getting exposed to when I was a resident, and that's the case of a cardiac arrest after GSW to chest. And everything was addressed, airway, supraglottic airway hemostatic control of the bleeding. But then the question that came up was chest compressions in that setting. So CPR because it is a cardiac arrest. So initially the patient was peri arrest and then became a full blown arrest and now we're like discussed, okay, but he has a hole in the chest. So what do we do with that? when it comes to compressions?

Dr. Frank Guyette:

That's a great question. And Mohamed I'm going to have to say I don't know the answer. And I think there are times when you have a definitive answer, right? And I think if the patient was a medical arrest, that was traumatized, right? So you're driving along, you have a big MI, you arrest, and then you wreck the car, CPR all the way, right? Like that, I 100 percent agree with that. If it's a situation where you have hemorrhage control. Let's say the patient exsanguinated from their dialysis fistula and now we have a tourniquet on it. We have hemorrhage control. You can circulate that blood just fine, so CPR definitely. But man, the situation that you outlined where the patient has an uncontrolled hemorrhage, thoracic hemorrhage, that our medics are just not going to be able to fix. Are we doing harm by doing CPR? And I just don't know the answer to that. I think you have to take it back to what is my transport time? What are my termination resuscitation protocols for trauma in this particular situation, right? And also can I affect the reversible causes of arrest. So if we think that this patient who has a transthoracic gunshot wound is dead because of a tension pneumothorax and we correct that, then that's one thing, right? But if they're just exsanguinated I don't think we can fix that in the field. But it's going to be really hard for our medics to know that. So I think we as physicians have to make policies and protocols that are going to give the patient Some chance, right? So I think if it's a short transport time, it's reasonable to continue CPR until you get to the hospital but I think that those other things, the hemorrhage control, the resuscitation, the needle decompression, those things have to be prioritized over the CPR because the CPR won't matter if you don't fix those other issues. But very difficult situation.

Dr. Mohamed Hagahmed:

It is, and I think, with that specific situation, unfortunately and sadly it happens frequently, is that, we now have to make a decision. Like you said, the decision is hemostatic control of bleeding and then if they need, compression, you do it per the ACLS protocol. However, what I'm struggling with is if there's a hole in the heart, how is that going to affect? And I think the paradigm is shifting slowly towards maybe not do anything, just control the bleeding finger or needle thoracostomy and then transport without compressions. But again, we need to see more data in order to come up with a definitive.

Dr. Frank Guyette:

And this is something that for which we're never going to have an RCT, right? So it's going to be, it's going to have to be observational data. And I think the question gets even more nuanced, right? Because, Do you have mechanical CPR, right? Does that make it worse? I have no idea, right? And then and again, I think if we're in an urban environment, where you're, 8 10 minutes from the trauma center, pump and blow, let's go, right? And if you're in a rural community where it might be 30 40 minutes to a facility I don't think you have any options.

Dr. Mohamed Hagahmed:

One question that I had is about the needle thoracostomy. And the optimal location, which is something we can debate forever, right? But even just the indication of needle decompression in a trauma patient. And this is the misconception that I've heard by other clinicians on the street. They've been telling me that if the patient is oxygenating and ventilating with a BVM or supraglottic airway, and they're sat'ing 100%,

Dr. Frank Guyette:

Yeah.

Dr. Mohamed Hagahmed:

But there is signs of chest wall trauma. Do I still decompress that?

Dr. Frank Guyette:

I probably wouldn't. So I think if you can adequately ventilate and oxygenate the patient and the patient's hemodynamically normal, then I don't think there's any benefit in needle decompressing that patient. If the patient has signs of shock, so if they're becoming more hypotensive, they're becoming more tachycardic, shock index is going up then I don't know what I'm treating. But that is one reversible cause of that shock that I can address and I have to tell you, Mohamed I think when I was training and even when I was an early attending and you were training I think I was very reticent to order the needle right and obviously Depending on your protocols, most medics can do it without an order. But, I was very reticent to say, oh yeah, needle that patient, unless there was evidence of tension physiology. So either we had, they were really hard to bag, they were, hypoxic, tachycardic, hypotensive, tracheal deviation, something of that nature. Then it's a no brainer, right? Needle the chest. I think that the reason I was reticent to do that is because I've, I think our practice at the time was, if you got needled, you immediately got a chest tube. And maybe that patient didn't need the chest tube. So if their physiology was normal, am I causing them to have another procedure that they don't need? We recently published trial sorry, a study, it was observational 2022, where we looked at patients who got emergent chest tubes in the trauma bay, and we looked to see if they had a needle decompression. And it turned out that less than half of them had a pre hospital needle decompression, even though it was within the scope of practice of the medics who cared for the patient, and that patient got an emergent chest tube in the ED. What is the reason for that? So I think it's, I think it's because they didn't recognize that the patient was at risk for for a pneumothorax, a clinically significant pneumothorax. I think some of it is also that there are probably pneumothoraces where they're large enough that they need a chest tube, but maybe they didn't need it when the medic assessed the patient. And things change, particularly if we're giving positive pressure ventilation, because you're probably increasing the size of that chest tube. Pneumothorax and transport with positive pressure ventilation. I think now my threshold's a little lower, knowing that we probably don't do it enough. And also because, and you've seen this too, we need to decompress somebody. If we're wrong, they're not going to put chest tube in, right? If the, if they have a small pneumothorax, we're just going to watch it. I think the consequence of not doing it is lower. And and I think the rationale for doing it. Maybe it's a little bit clearer, so I'm a little bit more aggressive about doing needle decompressions. I think if you're going to escalate beyond that, like if you're going to start, if your service is doing finger thoracostomies, or if you're doing real tube thoracostomies, then I think you you have to take into account, is, does this patient really need this procedure right now. Because not only do you not want to unnecessarily do the procedure, but you also don't want to distract from the real cause of that patient's shock. Yeah. So I think it requires a little bit of nuance, but I think, we have maybe swung the pendulum to not doing enough of them.

Dr. Mohamed Hagahmed:

And just briefly to talk about location. Always Mid sternal. Third intercostal space, right? That's what you do?

Dr. Frank Guyette:

It's, yeah, exactly. So we see them all over the place. What, the way we train folks in our shop is to either to go second intercostal space, midclavicular line, or fourth intercostal interlateral line and interaxillary. And there's data on both. So I think, the second intercostal space was very popular with, in, in our region for a long time. There was some military data that came out showing that particularly in, you know, young men with, robust pec muscles and whatnot that, that the needles wouldn't penetrate. I think things have changed a little bit in terms of we have that the, many of those studies were done just using a 12 or 14 gauge angiocatheter. With dedicated Needlethoracostomy needles they're longer, usually the three and a half inch ones. Many of them have some type of either a transducer or have some type of visual cue that you're getting a rush of air back. So you know that they're in properly, and I think that's helped us a little bit. We do teach both ways And I think it may also depend on the patient, right? If it's a, if it's a frail little old lady, it may not make sense to do the second intercostal space.

Dr. Mohamed Hagahmed:

And while we're still on the topic of pneumothoraces and a critically ill shock trauma patient, is there any role for pre hospital ultrasound and looking for these? reversible causes of, Oh my goodness. That's a great

Dr. Frank Guyette:

question. And absolutely. And I think doing an EFAST protocol where you're looking for pneumothoraces, you're looking for intra abdominal blood those can help guide your therapy. So clearly if you don't see lung sliding, then your threshold to needle decompress that patient might be higher, right? If you have an advanced provider who can do a pericardiocentesis and, that the patient has a big pericardial effusion particularly in a trauma situation, that could be life saving, right? But, I think the limitation is, How do you train your medics to do that? And can they act on the information as well, right? So can they do the procedures that matter? And it, and I think it all comes back to that that order of operations, right? Short transport times probably not worth it, right? If you have longer transport times, if you if you have a cadre of providers that are going to do enough ultrasound where you can provide the training where they do enough ultrasound to be proficient, then it's a great tool, right? They can assess volume status. They can get a lot of information just like we would in the emergency department. And there's and I truly believe you could train any paramedic to do it. But the question is, will they have enough reps? to be good at it? Will they have the scope of practice to act on it? And can I maintain the competency, right? And even in my critical care service, I really struggle with that because trying to train 170 people to be proficient is challenging, right? In a smaller service or even better if you have the opportunity in your service to have super users. Be it a supervisor or an advanced patient care tech, who can be trained to do that. With a smaller cadre of people in your service who are doing it, then it's more likely, it's going to be easier to train them, and it's more likely that they're going to get the experience to maintain that skill.

Dr. Mohamed Hagahmed:

Do we have enough evidence today that would support the use of ultrasound and pre hospital care in trauma patients? Obviously. Yes

Dr. Frank Guyette:

and no. So I think the answer is yes. I think that there are definitely interventions where we know pre hospital ultrasound would be beneficial and and be that assessments for shock or assessments for pneumothorax or assessments for pulmonary edema. We in controlled environments where we've trained people and we're observing them, we've demonstrated these things in the literature to be beneficial for patients. I think the challenge is, is for you as a medical director is how do you deploy this in your system, right? And and which and you can't teach everybody all the skills, right? Like you can't have master ultrasonographers, You can't have every medic being a master ultrasonographer. I think you can do it a couple of ways. Either you can have the super users, like we discussed, or you can pick a target that you think is really impactful, right? So let's say, respiratory distress, right? That's a high value target, right? It's, depending on your system, it could be 20 or 30 percent of your calls, right? And with an ultrasound, with pretty minimal training, it you can determine, you can train somebody to identify a pneumothorax, you can train somebody to identify B lines and fluid overload and that will change their care and potentially impact outcomes for the better. And if you limit it to that then you, maybe it's easier to train and maintain those skills because, you're only doing a handful of exams. I think if you try to do too much You know, I'm going to teach cardiac, and I'm going to teach the RUSH protocol, and I'm going to teach the blue protocol. Then I think most medics would get overwhelmed, and they're not going to use it enough to be really skilled.

Dr. Mohamed Hagahmed:

I fully agree. I think just doing the same protocol over and over again to promote competency in that skill, that way you can see how your service or your agency is doing when it comes to reviewing those cases. Yeah. Before advancing that technology to other patient population, like trauma patients.

Dr. Frank Guyette:

And if you look how we train physicians you don't need to have an indication to do the ultrasound for training, right? As many as half of the ultrasounds that we do in the ED, are essentially for practice, right? So I think in the right system, you could set the same thing up. If you have a non emergent call, the patient doesn't have any concerns with it. The medic can. You're having some belly pain, here, let me take a look at your gallbladder, right? Or, I'm going to do this exam, and I'm just going to make sure there's no fluid in your belly. And and I think by doing them on the non emergent cases, where you're not, it's not necessarily going to help you make the critical decision, but it's going to give you the practice to do the skill that may be one way to advance it. But I think it's got to be a really conscious choice, and I think it also You also have to weigh it against all your other priorities, right? If you're going to teach six hours of ultrasound, does that mean you're not going to teach like PALS that, you know, and because not, we don't all have unlimited resources or time.

Dr. Mohamed Hagahmed:

Now, if we go back to the same patient, Got fluid since that service doesn't have blood, so they got about 500 CC of saline bleeding is controlled. Airway is established with that SGA. And they also got a right sided needle thoracosomy. Now, they're about 35 minutes to the hospital to a level 1 trauma center. And the patient is now becoming more hypotensive. And somebody mentioned, Hey, we have push dose epinephrine. Can we do that in trauma patients? Vasopressor agents, obviously in most agents they have epinephrine, what about other vasopressors as well?

Dr. Frank Guyette:

Yeah. So I think that's, I think that's an interesting question. And I think you have to ask yourself, why do I think the patient's decompensating? And I think this is really challenging because this is where we really have to educate and empower medics to make these decisions. I think it's, it would be super challenging to have the mother may I this and call medical control. I think what they have to do is if we think the patient is still bleeding then is my hemorrhage control effective do I need to give another fluid bolus, right? Because you're going to fix a volume problem by giving volume. If they think the patient is now having tension physiology because the pneumothorax is reaccumulated and they need to re needle the chest. Think if the patient. I think I'd be really reticent to push the push-dose epinephrine in that case and any other pressure for that matter if they have norepinephrine or whatnot. Because my concern would be that if I get the heart rate up and the blood pressure up, they're just going to bleed faster. They're going to, you're going to push more blood out the holes. I think there are times when the patient is peri arrest and near circulatory collapse where that's probably your best option is to use push-dose epinephrine. But I think I'd be wanting to reassess. All of my March algorithm and make sure that I'm addressing all those other things before I reached for the PDE.

Dr. Mohamed Hagahmed:

And, there have been recent talks about vasopressin and its role in trauma patients. Yeah. I know vasopressin is one of your favorite agents, is that right? It's true.

Dr. Frank Guyette:

And it's, and the, there's, Unfortunately, there's only been one study so far that's used vasopressin in trauma patients. It was an in hospital trial, and it was a phase 2 study, so it was a safety and efficacy study. It wasn't powered to show an improvement in survival, but what it did show is that patients who got vasopressin while they were being resuscitated from hemorrhagic shock had lower blood, total blood requirements. It's intriguing enough that there is a randomized control trial that has started to look at vasopressin in the hospital. So these are patients who are already receiving blood products, already going to the OR for hemorrhage control. And in the OR and in the ICU, can we reduce our use of blood, again, precious resource, limited, we want to save it for the folks that don't have other options with vasopressin. Would I use it in the field for that purpose? No. Because I just don't think we're there yet. I don't think we have enough data. I think the one field patient where I think it might be useful, and you and I have talked about this in the past, is that patient who is an interfacility transporter, who's got profound acidemia. And, we know our catechol pressors just don't bind the receptors that well. Particularly when the pH is below 7. 1. So if, you already have, if you've already volume resuscitated the patient's already gotten blood, the, maybe you've done, maybe they've done some damage control surgery at a outside facility, the patient's now on some norepi and you're escalating doses and the pH is low, then, vasopressin is a great adjunct. But it's probably let me rephrase that, it's not the first drug I would reach for.

Dr. Mohamed Hagahmed:

The first drug would be obviously blood or Right. IV fluid or fluid you

Dr. Frank Guyette:

don't have. And then if I couldn't resuscitate the patient with blood or fluid then maybe norepi first. But yeah I think in the near future there may be a role for vasopressin.

Dr. Mohamed Hagahmed:

And what is your goal of the titration of the vasopressor? Is that to a certain number, like a map of 65, a systolic of 90 in a trauma patient? And is there any evidence to.

Dr. Frank Guyette:

And one that there's a lot of controversy about, right? So I think in the absence of other data, right? I think treat it like any other critically ill patient. So like a mean arterial pressure 65. A lot of people will use like a systolic of 90 as a correlate and I say that because obviously our medics, particularly with the advanced monitors they have, they can get mean arterial pressures, but maybe if the patient's in extremis or bad trauma, maybe all you have is a palped blood pressure. So I always like to give that caveat to give somebody a systolic target as well, because if you're palping, that's all you've got. But I think There, I think as a general rule, like a systolic 90 map of 65 is probably where we were a safe area to target. But I would say that, there, there are certainly evidence from the military that using permissive hypotension in trauma patients may be reasonable. But I think you have to think about that in the context. These were primarily young, healthy individuals. Involved in combat, right? They can probably tolerate that little bit of hypotension. Granny, with their essential hypertension and everything else, they're not going to tolerate that hypotension. And maybe, the, maybe that patient even needs to be a little higher. And if you look at Maddox's work, maybe a systolic of 100 or even 110 for an elderly patient. I think it's a really, it's one hard to write protocol. Because it's a really nuanced question and I think you can give a general answer that's safe for most people at, MAP 65 or Systolic 90, but I, I think maybe I'd be, if it was that young, healthy patient, I'd be willing to tolerate a little lower, and if it's that elderly patient with a lot of comorbidities, I'm going to want a little bit higher.

Dr. Mohamed Hagahmed:

Yeah, that is very interesting and like you said, it's a very nuanced as well approach to each individual patient. Now when it comes to endovascular devices and I have to mention the name is REBOA. It's basically the new sexy toy on the street, right? It's what are your thoughts on that? And

Dr. Frank Guyette:

yeah, so I think it's an

Dr. Mohamed Hagahmed:

impact mortality and mobility in trauma patients.

Dr. Frank Guyette:

So I think. The best analogy I can make is intracerebral catheters for stroke before 2015, right? Like really cool tool, right? Makes sense, should work, but like maybe the technology is just not there yet. Like we, we haven't found the right tool, the right indication the current generation of the device is a little bit smaller, it's a little bit easier to put in. There are newer generations that may be coming in the near future that either have balloons that can be intermittently inflated or only partially inflated to allow some trickle flow beyond the balloon. I'm aware of some folks that are working on AI algorithms that will inflate and deflate the balloons based on the mean arterial pressure because there's a transducer in the balloon that will measure the pressure on either side of the balloon. So I think the technology will evolve to the point where it will become more useful, but it's still a large bore intra arterial catheter, right? And again, that doesn't mean that a medic can't put it in. Certainly could if they were trained, but like you have to, again, it's one of those things where is the juice worth the squeeze to train them to do something like that? And the limitations with the current generation are, if it's, zone three roboa, your crushed pelvis, you have 30 minutes to get to an operating room. If it's a, a Zone 1, where you're, basically shutting down the whole splenic circulation, you only have 15 minutes to get to the OR. Even in an inter facility transport, where you're going from say, a Level 3 trauma center to a Level 1, to get an operative intervention, that's a really short window, right? It's going to be really hard to get the person from balloon up To the operating room in those time windows. So I think we need the technology to mature a little bit. We need to learn which patients are, best suited for this device. But I think I would say I would sit on the sidelines for now. If that would make sense.

Dr. Mohamed Hagahmed:

Not a completely no for now, but sit on a sideline.

Dr. Frank Guyette:

Yeah. Yeah.

Dr. Mohamed Hagahmed:

And that's a nice segue to the future of trauma care. And I think. There's a lot of exciting things happening in trauma care in the near future, but what are some of the things that our audience will be anticipating to see in the future of trauma care.

Dr. Frank Guyette:

Awesome. And I, so I'll start off with the toys. So obviously like the the endovascular balloons, certainly that's one thing. Another are, there are now foams, which can be introduced through an incision, like we used to do for DPLs, where you can inject a foam into the belly. It will immediately harden. And it'll give hemorrhage control. And again, right now, that foam has to go to the OR and be removed within 30 minutes. So there are some pretty significant limitations similar to the endovascular balloons. But those types of things those mechanical solutions, I think will improve over time. I think the other things that we'll see are the introduction of artificial intelligence into these things, into Our systems of triage, so we already have teams working on that, where monitor data or even wearable data can be used to risk stratify people and even potentially indicate which life saving interventions, so intubation, blood administration, needle decompression, are indicated with a really high degree of fidelity. It's a decision support tool. It's not replacing the medic, and I think that's something we have to be really careful about. These systems are really designed to help the medic to offload cognitively some of the work. And, definitely true in a mass casualty situation where you have to make lots of these decisions all at once. But I think we will definitely benefit from artificial intelligence being able to help us with some of that decision making via triage or who to do what. Certain interventions on the other thing, the other place where AI I think will be really useful is in terms of medical logistics. You're a 9 1 1 operator and you get a call for a car off the side of a road in a rural community AI can analyze that 9 1 1 call and it might be able to help you decide, is this a BLS call, is this an ALS call, Do I need a rescue tech? Whatever it might be, right? And those things will happen by the machine much faster than they'll happen via even a skilled 911 dispatcher. The other possibility too is that those same tools might even be able to identify the need for certain interventions. Like the, does that patient need blood? And, while we may not be able to field blood everywhere, maybe we have like our friends at STRAC in, in San Antonio, they have blood on certain units, so they can dispatch a blood unit to the patient. Or if we're gonna be if we're gonna be really forward thinking there's a group in Rwanda called Zipline that sends blood all over the country with drones. So there's lots of really cool things that are very close to being fielded. So I think it's a really exciting time for our specialty.

Dr. Mohamed Hagahmed:

Man, that's a really packed information of all the goodness that Dr. Guyette provided today. And I really want Something that our listeners can get out of this episode. So what are some of the important pearls as of 2025 in the current state of trauma care? What are some of the tools that our audiences can use and take with back to their services?

Dr. Frank Guyette:

So I think the first one is, think about that order of operations. And I think, the TCCC, MARCH algorithm. CAB, whatever you're using is really a tool to help you identify what are those things I need to do first, right? And that should be part of your training. Make sure that your medics are controlling the hemorrhage, resuscitating the patient before they're doing things like intubating. And again, not because I don't want them to intubate, because I want them to intubate in conditions that are safe for the patient, right? The next thing I would say is that blood is as best we can tell, and I want to caveat this, that the evidence for pre hospital blood products right now is limited to plasma. We have evidence that we can extrapolate from the hospital that would suggest that whole blood may be better, but that's limited. So we'll, there are pre hospital trials of whole blood ongoing right now. And so I think we'll have better data in the very near future. There are freeze dried products are on the cusp my understanding is that they may be FDA approved this year for use in the United States. And for those of you who don't know, the freeze dried plasma is lyophilized, it's stored and then reconstituted with a little bit of saline. And it's got a two year shelf life and will, probably be on the order expense wise of a blood product, but even a rural unit that might only see a couple of bad traumas a year could carry that and have a blood product essentially to resuscitate a patient with. I think that'll be a real game changer because it'll help us to deal with some of the inequality about how we distribute blood now, it'll help us deal with some of the scarcity it'll reduce the bar in terms of the storage and the, and everything else associated with the blood product. So I think that'll be a real game changer but ultimately, if you have to resuscitate a patient from hemorrhagic shock, you should give them blood. If you don't have blood, then you should give them fluid. But only the least amount that you need to in order to correct whatever physiologic abnormality they have, be it hypotension or tachycardia or whatever.

Dr. Mohamed Hagahmed:

So basic things are not so basic in trauma care. So control the bleed secure that airway with BLS maneuvers. Make sure that they're hemodynamically somewhat stable initially with IV fluid. And if you have blood, please use it. And of course level one trauma center. As soon as possible. And I really appreciate this conversation. I feel like we unpacked so many things that I hope that it was useful to you. And I hope you get something out of this conversation. And just as to be continued, this is just only a teaser of what to come for EMERGE with Dr. Guyette, because I'm sure I'm going to bring you back for more conversations about this and other topics in prehospital care. Thank you for tuning in. Stay motivated, stay compassionate, and please take care of yourselves.