Emerge in EM

E13: Trauma talks with Zaf Qasim

• Mohamed Hagahmed

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In this episode of EMERGE, I had the pleasure of speaking with Zaf Qassim, an associate professor of emergency medicine, about critical interventions in trauma care. We discussed the TRAUMOX2 trial, which questions the reflexive use of high-flow oxygen in trauma patients and suggests that a restrictive oxygen strategy can reduce atelectasis without increasing other complications. We then contrasted delayed sequence intubation (DSI) with rapid sequence intubation (RSI) in trauma patients, highlighting how DSI can significantly reduce peri-intubation hypoxia. Lastly, we explored a study comparing non-invasive blood pressure monitoring to arterial BP monitoring in critically ill patients, emphasizing the inaccuracies of non-invasive methods, especially in severe cases, and the value of using arterial lines. The episode aims to encourage clinicians to reexamine traditional practices and adopt evidence-based approaches for better patient outcomes.

Links to papers discussed in this episode:

https://jamanetwork.com/journals/jama/fullarticle/2827980

https://pubmed.ncbi.nlm.nih.gov/37058727/

https://pubmed.ncbi.nlm.nih.gov/39192296/

M0:

Hello everyone and welcome to another episode of EMERGE. This time I have someone from the city of Brotherly love. Zaf Qassim! How are you my man?

Zaf:

Great. Great. Mohamed, thanks so much for the invitation to be here. I really appreciate it. How's life in the other side of Pennsylvania?

M0:

well. And by that you mean the better side of Pennsylvania.

Zaf:

Oh,

M0:

Yeah,

Zaf:

fighting words.

M0:

the Steeler season started.

Zaf:

Can we'll send you, we'll send our Cheesesteaks over with the eagles.

M0:

I love that Zaf. Can you introduce yourself to the audience and tell us a more about who you are and where you're from?

Zaf:

Yeah, sure. I am working here in Philadelphia. I am a associate professor of emergency medicine critical care and EMS here at the University of Pennsylvania. And I'm lucky to have a job that lets me work really from pre-hospital all the way to critical care in various shapes and forms. Happy to be here.

M0:

I'm really excited to discuss these three common interventions that we perform in trauma patients. And I know that might sound basic, but I wanna make sure that we question our practice so we can aim for improvement and aim for perfection because this is our job. We work in high stake environments, right, Zaf?

Zaf:

Yeah, totally. It's certainly these three trials that we're gonna talk about, I think will really kind let us reflect on some of the practice that we're doing already.

M0:

Absolutely, and we start from the basics. As always, we give oxygen. Oxygen is important in our trauma patients. We have to provide that high flow oxygen in every trauma patient as per the ATLS guidelines, is that right, Zaff?

Zaf:

That's how it's always been, right? That we don't think twice we've been told. Okay. I remember in all the ATLS scenarios, guys, 15 liters of oxygen, non-rebreather mask check, and then you can move on to the next thing. But there's this trial now that's come out, it's called TRAUMOX2, and maybe that will challenge some of that reflex oxygen application that we've been doing.

M0:

And it seems like an easy thing to do. Just cognitive unloading, put everybody on high flow oxygen via a non-rebreather mask and just move on with your life. But like you said, this TRAUMOX2 trial really jumped at me by questioning that practice. And this is a multicenter RCT trial that included more than 1500 trauma patients from European nations in Denmark, the Netherlands, and Switzerland. And they randomized these patients early. Can you discuss the randomization process, Zaf?

Zaf:

Yeah as you said, the several countries that were involved almost 1500 patients and their randomization was either to a restrictive strategy, which meant that they would give oxygen to target SATs of 94%. And if they were achieving that on their own, then no additional oxygen. Versus a more liberal approach where they applied kind of 12 to 15 liters permitted of oxygen or kind of achieving a FiO2 of 0.6 to 1. And measured that over the first eight hours after injury. And so that could have started in the pre-hospital phase, and it could have started in the emergency department phase depending on where the trial enrollment occurred.

M0:

And that eight hour window is interesting to me, right? Because it seems to me like a short number, but we'll discuss this later. So they looked at composite outcome of death or major respiratory complications. These respiratory complications include, respiratory arrest, apnea, needing intubations or some advanced airway interventions. And they looked at these complications at 30 days and the difference there was none right. No differences.

Zaf:

Really no difference.

M0:

And I think about like in, it was almost identical when I looked at the data. It was like 16% in both groups with no mortality, different and no reduction in pneumonia or other lung complications like ARDS.

Zaf:

When they l looked at this particular outcome, certainly they saw no difference. The only one area that they did find a difference though was that there was a slightly lower atelectasis rate in the restrictive group. They measured about 27% versus 35%, but otherwise, no real kind of divergence in any of the other factors. We know, a lot of these patients can become atelectatic, especially if they have a chest wall injury or they have abdominal injury that could cause some splinting. And so it's equally important later on, especially in the hospital, to think about methods to prevent that, whether that's positioning or through incentive spirometry and things like that.

M0:

Yeah, that's an important point, right? Because it's something that we always have to keep an eye for pneumonia and such infections that we need to prevent. And like you said, that atelectasis was lower in the restrictive group, meaning the oxygen saturation up to 94%, so that was 27% versus. Almost a third, like more than a third, 35% in the more liberal oxygen. Yeah. So in terms of like strength of this paper, I really liked the RCT component, the large institutional inclusion from multiple nations, multiple European nations, and multiple big trauma centers. What do you think about any other strength about this paper, Zaf?

Zaf:

Yeah, it's hard to do a good RCT in the pre-hospital setting, so kudos to the authors for being able to pull that off. And they also had a real kind of separation in terms of the pO2 difference. It was pretty dramatic between the two groups.

M0:

I agree with you. I'll tell you, I think one practical thing in this paper, they looked at SpO2. I know in subset of patients, sometimes we have to actually. Identify and make sure that SpO2 number is actually accurate by measuring the PaO2, so the arterial oxygen concentration in the blood by getting, something invasive like an A line or something like that. I tell you to me, I change nothing with this data. I would tell you with oxygen therapy, I never put almost anybody on oxygen. If their oxygen saturation level up to 93, 94%, sometimes even 96, I just let'em be. I don't know your style of practice in Philadelphia.

Zaf:

Yeah, I think, our practice has been adapted from a multitude of the trials that were done on liberal versus restrictive oxygen strategies in, in critically ill patients. And we've seen the challenges of of that in terms of the free radical injury that high oxygen levels can provide. And so we realized, I think overall we've set our. SATs targets a little bit lower for these patients and trauma patients should be no different. But I think that also brings in some of the limitations on this paper that they only looked at that eight hours and that eight hours is a period that could be spent entirely in the emergency department. As you and I well know with the boarding and all that. But what happens beyond those eight hours in the first 24, 48 hours say these patients are admitted to the ICU and stuff. So that's something you really have to factor into your practice. But I think overall, this kind of feeds into some of the culture change we've already seen in terms of targeting a lower oxygen saturation and not unnecessarily giving oxygen, which is really a drug just like any other drug.

M0:

That's an important point to consider that oxygen is a drug. Indeed, and in any trauma patient we have to focus on the immediate life threats, right? Bleeding, hemorrhage bleeding control, providing things like TXA blood products. And then if they're oxygenating fine, we don't need to proceed with some advanced measures, which this study indeed validates. Is there anything else you want to change about your practice with this study? I don't. I really, I feel like just something that we need to be more aware of and that's why I brought it up. Anything else you wanna add, Zaf?

Zaf:

Yeah, I think the only other thing to remember is also that we need to be wary of patients with, brain injury. Clearly we don't want those patients to be hypoxic. So really focusing on the oxygen level in that instance is important. We've seen worsening mortality with those patients. So really we, when we say restrictive oxygen strategy, we don't mean that absolutely no oxygen for these patients. It's really we need to, think about the patient their selves, see what their pathology is, and then apply oxygen accordingly as needed. Even if it's at a low rate, just to maintain that target saturation.

M0:

Very important point, Zaf. Let's jump to the more anxiety inducing topic, which is the agitated trauma patient. I tell you, whenever I hear that call from EMS or whenever we show up on a scene and the passenger in the crashed vehicle just screaming and so agitated, we can't really sedate them. And I can see them like almost about to vomit and blood everywhere. That scares me. That situation really scares me because I am ready to anticipate a disastrous airway.

Zaf:

Yeah, totally. It's not infrequent. In fact, I can remember the last one just within the last week we had similar patient, and it does give you pause because you have to balance the need to manage the agitation, protect the airway, but also prevent. Peri intubation and post intubation complications, which we know are significantly higher in our critically ill patients and trauma patients are in that group. So how do we address and balance those approaches to improve safety and prevent complications in these patients? And I think that's really what this next paper is gonna talk about a little bit more.

M0:

And this paper specifically addressed the issue of DSI versus RSI in the sick trauma patient who comes into the ED. Either obtunded or agitated and you know that airway situation is gonna be bad. So this was a single center randomized controlled trial comparing delayed sequence intubation versus RSI. So let me ask you,Zaf, real quick. So I know most of our listeners know the difference between DSI and RSI, but in your practice, is this what you do normally? Mostly DSI or do you have a preference or does it depend on the situation for you?

Zaf:

Yeah. First of all, let's break this down a little bit, right? So what do we talk about when we're talking about. Rapid sequence intubation. And so I like how the British kinda look at this a little bit better because they focus on what's really happening, which is rapid sequence induction and intubation. And so they, the RSI for them is really focused on the administration of the induction and paralytic agent, which is what RSI is, where you're successively and rapidly administering the sedative and the paralytic. Not necessarily rushing the intubation procedure itself, which you can separate out. And so you have to think in your mind that let's separate these two. Parts of the intubation process. So I think, for years we've gone through this RSI approach where we're needing to do, or feeling like we need to do these airways pretty quickly, when actually, we probably set us, set ourselves up for a little bit for failure if we a adopt that more rapid approach without kind of thinking things through, especially in our agitated patient. My approach has always been to focus on kind of methods that we can pre-oxygenate and improve things to prevent post intubation hypotension, post intubation hypoxia. Hopefully get a line in, get a. Get the oxygen on non-rebreather mask or maybe even n IV as some recent trials have shown. And really think about the drugs and dosages and things before proceeding to intubation. Now with the agitated patient, that becomes difficult, right? There's flailing around. You might not even get an IV in properly. Everybody's looking at you saying, can you do something about this? And so it's almost pushing you. improve or cut some corners to try and get the patient down. When really using this DSI approach, you can actually make life a whole lot better for your patient as well as yourself and your team by thinking of this as a, another kind of procedural sedation type of approach using your sedative agent. And to achieve a little bit of calm, maybe half the dose he would give for induction. some time to do all those things, to improve the oxygenation, improve the hemodynamics, get another IV in, and then prepare yourself appropriately with your first plan, your backup plan so that you don't have any problems either anatomically or physiologically before proceeding with the rest of the induction and intubation. So I think you know more and more. This DSI term has come into our practice over the last 10, 15 years, but the adoption has been a little bit slow, but actually makes a lot of sense. Especially for the types of patients that we're dealing with, either in the field or in the emergency department who might be agitated or for other reasons, needs some preparation before we subject them to positive pressure ventilation.

M0:

You brought up that interesting point, which that delayed sequence approach makes you. More ready to anticipate a tough airway, right? You have all the equipment available. Ideally, you have all the people you needed. You are ready for your backup plan if that first approach does not work. So it gives you just more what I call cognitive room to work with.

Zaf:

Yeah, and I think that's a really important point, Mohamed, because when we're rushing this, then even an easy airway becomes a difficult airway sometimes because we are so stressed out ourselves, our adrenaline is pumping, as you said earlier, and we might not so we might subconsciously do an unexpected error that makes the intubation more difficult than it than it actually is. And giving yourself that time with this DSI approach can be really beneficial to yourself as the intubator.

M0:

And in this paper specifically. In a single center in India and sounds like a very busy trauma center in India. They randomized the groups into DSI and RSI and the RSI approach. You and I know, and most of all listeners know, so you have, you give an induction agent in this case was ketamine, followed by a paralytic. In this case, succinylcholine. I tend to prefer rocuronium, but I'm not gonna go to that, in that battle of roc and succs in trauma patients. And honestly, in all the studies been that looked at this, there was no difference. But maybe Zaf, you have a different opinion about succs versus roc and trauma patients.

Zaf:

Ultimately, I think, succs and rock are both good drugs. You just need to know the indications and contraindications, especially with succs. In our, in our. Trauma center, we see a lot of neurologically injured patients. And using succs is useful for our neurosurgical consultants who really have to depend on the physical exam in part to make their decision to operate or not. And having a patient who's examinable quickly after the intubation is really useful for them. And sure, you can use like something like sugammadex for reversal of rock if you need to. But it give, it means that you're administering another drug. With its own potential for complications delay potentially in care, and also an added cost to the patient in the hospital for that. So for me, I, I think as long as you know when to use what either drug is fine and I think it's important as a, as an expert intubator to be able to be familiar with at least kind of two different paralytics to use in different scenarios.

M0:

So in this paper, they use Get me. As 1.5 milligram per kilo as an induction agent and followed by the succinylcholine, 1.5 milligram per kilo. And then they looked at the other group, that delayed sequence approach group. So they gave aliquots of ketamine as at 0.5. Milligram per kilo and just weighted it out as a patient is being preoxygenated with high flow oxygen or maybe supraglottic airway or non breather mask. And again, the DSI group also was intubated with succinylcholine. And the results for me is,Zaf, striking, right? Complete different pictures in both groups. The DSI group had about 8% rate of complications, specifically when it comes to peri-intubation, hypoxia versus 35% in the RSI group. And that's a huge striking difference. Now, be mindful these sick cohort patients were intubated by trainees, anesthesia, trainees in their, I think second year of residency. So it makes you question the applicability in our settings.

Zaf:

Yeah, no, I think it's a real kind of game changer difference here because we really wanna avoid that hypoxic problem, especially as we talked about earlier in our head, injured patients where every desaturation episode, we know can worsen outcomes and whether it's the a more novice intubator or a more expert intubator. I think this still carries with it a significant kind of potential for practice change because again, going through that logistical kind of step of being able to optimize pre oxygenation, I think that's not gonna harm any of our patients. It'll only help it. So I think this is really one to look for and see if it can be applied to your practice.

M0:

I'm gonna digress here a little bit because in this paper they use direct laryngoscopy. Okay. I'll tell you, in my experience, I use a lot of vl, so a lot of video laryngoscopy in all of my patients. And this has been my practice now for years. And once in a while, I'll tell you, maybe in really rare instances in the pre-hospital setting where I had to use direct laryngoscopy with, bougie assisted intubation. And that was a very soiled airway that I had to really, I couldn't, I was having trouble with suctioning that much of blood. And I was helping the unit on a scene and I actually felt a little bit uncomfortable because. My level of comfort was with vl and we had VL in a pre-hospital setting, but I just couldn't see anything. So I'll tell you as we become more comfortable with VL sometimes, and that may be in rare situations, we also need to be comfortable in direct endoscopy. In this case, all of these patients were intubated with dl. And what also was interesting to me that. The rates of upper airway complication. This in this study was minimal. Not like the patient that you and I see. I think mostly were torso injuries, limb injuries, but nothing from the neck up.

Zaf:

Yeah, I agree with you. I've moved to primarily VL for my practice having grown up with dl. And if you go back to DL from time to time, it's it does you have to think twice a little bit about the approach and the view that you end up getting because you're so used to that nice kind of camera, being able to give you a beautiful view. Of the airway. But, and we talked about this a lot during the evolution of VL into practice that you lose your DL skills and sometimes DL is useful and I agree with you. Sometimes it is, and, but the reality is I don't think, you can negate the benefits of using VL primarily. And we've seen several papers now from neonates up to adults that show that intubation success is better with vls. So you do enough DL to keep up your skills? I think it's difficult with the number of intubations you do, especially if you're working with trainees where they're likely to do the procedure primarily, and you're watching. But it's a challenge. And, I think if you have the opportunity sometimes to just do a DL in a relatively straightforward intubation, maybe you should use that just to keep your skills up. But ultimately do what you are most facile with. This group, I don't think had access much to VL at all. And so used DL primarily. actually, if you look at their first pass success rates, it's in an emergency situation. It's approaching some of the numbers that you might see, say from the NEAR registry and things here in the United States. For critically ill patients, our first pass success rate is certainly lower than 90% in a lot of cases. And and so their numbers with this DSI approach really approached what we are with VL here.

M0:

And that was almost like, what? Like almost 97%, 98%, almost a perfection, which validates that approach because they were ready for everything, for all the complications,

Zaf:

yeah, exactly. Yeah.

M0:

Helps with oxygenation as we said. One, one important point that I just had to bring up, and I know this is not related to this paper, is the importance of initiating sedation as you intubate, right? Just make sure you have that as well. Ready and'cause we tend to have the tendency to forget about post intubation sedation. Once we get a tube, we get busy and do other things and lines and blood and all these things. So I always keep it in the back of my mind as an important point to always think about sedation and actually order these medication already, like fentanyl or propofol or whatever that is. Ketamine, even for analgesia. But I think I really like the ketamine approach because Ketamine provides, as it's not only an anesthetic, so a dissociative anesthetic, but also. It has analgesic properties and also a more hemodynamically stable properties in the sick cohort of patients. Is this usually your approach,Zaf, or do you have any other like tips or tricks?

Zaf:

Yeah, I can't it's a big bugbear of mine for, when my residents or anybody's intubating that if they haven't thought about and asked for post intubation, sedation. And really in the in the hospital environment, the nurses really have to have the drip ready to go rather than fumbling with it when when while you're doing the intubation. And there was a recent paper that actually looked at this, that between emergency departments and ICUs, there might be up to 12 minutes between the kind of the intubation and the start of sedation. Certainly as you prefer roc, that's a time period where the patient may well be aware that they're paralyzed. And that's certainly something that we wanna avoid. In the field you might think about, having a little bit extra ketamine drawn up for after. You got the tube in just until you get, say, a drip setup or, you get pushed doses of fentanyl or something versed(midazolam) while you're transporting the patient. But in the hospital, really there should be no excuse, but to have that drip ready to go for the post intubation sedation as soon as the tube secure just to prevent that awareness. So really important point.

M0:

I do remember one of my attending used to say, paralysis with awareness is the worst punishment you can give to your patients. And we always have to be compassionate that way to think about that and hopefully, evading this painful process of being paralyzed and also while being aware. So yes, sedation's an important point. The last paper is something that I had to bring up because you and I, we use non-invasive blood pressure monitoring very frequently, right? Very frequently in our trauma and non-trauma patients, pre-hospital and hospital. And I'll tell you. Once I hit that cycle button on the monitor, I forget about it. Like I just okay, we're done. And most often I do get a wrong number, especially in that sick patient. So I had to bring this study up because this is a paper that is looking at non-invasive BP monitoring versus arterial BP monitoring in the pre-hospital critical care and guess where this paper took place? Zaf, in your neck of the woods.

Zaf:

Uk. So yeah, this is a really interesting paper, and I feel you. It's you know when you get that sick patient and you're waiting, or either you get the dashes or it cycles again, that means that patient. it has a crappy blood pressure and the numbers that will eventually come up are likely to be wrong. So this group really took that to heart and I think really something that's of interest of mine is like invasive blood pressure monitoring, doing that in the pre-hospital setting. So they actually did a pretty good job in terms of looking retrospectively. But nevertheless, they looked at about 2300 paired BP measurements from 221 critically ill or injured patients. Oftentimes getting this invasive monitoring en route to their hospital. And really interesting kinda key finding that non-invasive blood pressure really was way off. Especially the more sick your patient was. And in fact, even the opposite and say you have a hypertensive crisis. Your non-invasive blood pressure really wasn't correlating well with the invasive blood pressure that they found.

M0:

And also another point to bring up is. That the critical care team in this case and the Queensland

Zaf:

Now there's the Kingsland now.

M0:

now is a kingsland, is comprised of a EMS physician. That was an EMS trained physician and a critical care paramedic. That was the team. So only the two of them. And the physician initiated the a line en route to the hospital so that I feel like this is mad skills, bro. I'm like, come on mad. I think it takes me maybe. Half an hour, including set up and getting the line from upstairs.'cause we find we cannot find the pump and the nurse is now busy. So I have nobody to help me with flushing and I can't do the flush, I can't do the flushing by myself, but sometimes I can't. And it's just like a disaster. So they did it in the back of a helicopter, right? Sometimes on the scene, and that was quick. Like within minutes they got an airline in radial! femoral! Let's go. The point of this paper is just to tell you and show you. It's a huge discrepancy between invasive and just to make you think, okay, if I see that number doesn't make sense, does it correlate with the patient in front of me? And I think that's what I'm trying to at least make sure that our audience get out of this paper. I'm not just telling you to go and scream to you medical directors and scream to your assistant directors. I need an a line training stat. No, that's not the point.

Zaf:

Yeah, and it's it calls back to the systems level approach that a lot of these agencies have. And really they when you look at how they train, they really hone down on the technical skills of being able to do ultrasound guided arterial access. Which really, when you do enough reps of it, you can get down tight. And ultimately, I think some of these agencies in the UK have moved to having the paramedic as well, being trained in being able to get the line in. Because a lot of times the paramedic will be with that service for a lot longer than the rotating doctors, and so they they can continue to maintain those skills, but it calls to the interchangeability of the roles of, even though it's a physician paramedic, there's still some skills that are equally able to be done by either in the team, which is really good. But as you say, yeah, not every service will be able to do that. And I think the key kind of physiologic finding here was that with their non-invasive patients, they found that it tended to overestimate the systolic and the MAP in hypotension and in severe hypertension. It was the opposite. It tended to underestimate. So if you're not able to do a lines in your service. But you have a patient who looks really sick, like they might be bleeding out, or they might have stroked out maybe from an intracranial bleed, and you're getting non-invasive measurements on this. You can surmise that, in those situations, the non-invasive cuff will either under or overestimate your blood pressure, and so you can manage these patients accordingly based on that information.

M0:

I remember one myth that vibration during transport in the back of the helicopter or in the back of the ambulance, always gave me an erroneous number, right? But that does not seem to be the case in this study.

Zaf:

Yeah, I mean they had a aeromedical platform that they were using this in, and the the amount of vibration, I guess just didn't didn't really affect things. And, they had a ton of readings that they were able to kinda look at. So got pretty recently accurate kinda readings in that. So I think that's that's really cool and it pulls to the strength of the paper that this was a real world prehospital critical care service that was providing this information to us for sick patients, whether they were trauma or critically unwell. And they had some clear kind of clinically relevant thresholds for what was acceptable in terms of agreeing between the pair pairings and what was not.

M0:

You mentioned one weakness of this study, it being a retrospective paper. But, and also it's from a single HEMS service, and they used fairly generous thresholds for agreement, right? It was less than 20 millimeter mercury for systolic blood pressure and diastolic blood pressure, and less than 10 millimeter mercury for a map. And also I would tell you these individuals are like well-trained, and I think you and I like talked about this before, is that we should aim for excellence, that we should aim for excellence. We should be able to generate a system that is capable of these kind of high skillset that we can use in a pre-hospital setting, in a critical care transport setting that can help our patient and if that's an a-line, Sure. In our HEMS center here, sometimes we have the ability to initiate an a-line if needed, if we feel like it's needed for that patient. And usually it's done in the facility itself, in the referring facility. Before we go in a helicopter.

Zaf:

It's easy to look at this paper and, a lot of the papers that come out of the European, UK kind of models of prehospital care that include physician paramedic teams or physician nurse teams and say we can't do that over here in the States. Our models are different, but there's a hundred different type of approaches that. Different agencies have taken to pre-hospital care and I think you need to look at that and see, what? can we do to do the best for our patients? And this is how we've made some evolutions, right? I remember the time when CPAP was never a thing in pre-hospital care, and now it's been brought into a lot of practice. And you can say the same thing with pre-hospital transfusions now that, people thought it would never happen and now people are doing it because they feel it's the right thing to do. And so certainly I think critical care transport teams that have critical care paramedics a lot of them are already using ultrasound. They might be placing ultrasound guided IVs. And so going on to place an arterial line shouldn't be a big stretch for them. And even some paramedic agencies might be able to fit that into their practice. But I think one of the things also to think about as a system is also that remember to make sure you've done all your basics first. And this is something that can be done as part of the care en route, while you're making your trajectory to the hospital. And but think about those places that have maybe 30, 40 minutes of transport time. And certainly having blood pressure readings would be really useful for that team to guide their therapy while they're getting to the hospital.

M0:

The main point of this paper is that don't trust that number, right? If you suspect that your patient is volume depleted, hypotensive shock is worsening, look for those physical examination findings, right? Look for the depressed or decreased mental state. If they have a Foley look for the urine output. If your transport time is long if you have the ability to check a lactate What's happening, lactate is not just a marker for sepsis, right? Lactate is a marker for badness, maybe tissue hypoperfusion. So always rely on the global picture, before you just make sure that number in front of you, is accurate. And to be honest with you, Zaf, when I read this, I was like, a lines are a-lines. It didn't matter whether you placed them arterially, femorally, but I was shocked here. There was a difference between an arterial and a femoral line.

Zaf:

Yeah, it is. And if you think about it anatomically and physiologically, it makes sense. How do we look at our shock patient, have they lost their peripheral pulses? Are the central pulses present or not? As we get more into shock, the body will tend to shut down peripherally to move blood centrally. And so it makes sense that, your radial a-line in a shocked patient won't provide as reliable or reading as your. More central arterial line, which is in the femoral. And if you can think of doing that putting it in the femoral artery to be able to get your readings, that's ideal. and I think that also brings a logistical issue. In some airframes you might be able to access the groin in flight, and some you might not. And so it's it can certainly change your approach there. You might wanna do it before you load them, but if you can and you're able to put in a lines, then think about getting that central arterial line in the femoral.

M0:

So I'm gonna try my best to summarize the important points. For the first trial, oxygen does matter, but not as much as you think. So more is not always better. Target the mid nineties for SpO2 in stable patients. Avoid unnecessary hyperoxia, so avoid too much oxygen and titrate to clinical situation. Airway: DSI, love DSI can dramatically reduce peri-intubation, hypoxia in your agitated and sick trauma patient. If you've got ketamine, give it. Consider it just as a better way of controlling the situation and just sending that woo saw in the room. Everybody's calm, including yourself, and you have a clear mindset about what to do next in case that airway went bad. Last but not least, blood pressure. Yes. Don't always trust the monitor and always think about the proper size of the cuff. Always gets to me Zaf, when the cuff is not applicable to that patient. It can mislead you right at the extremes in shock or severe hypertension, that number definitely mislead you. A lines obviously give you a better and true picture, but it might not be possible in a lot of systems. So make sure you continue to reexamine and evaluate your patient and always look at the clinical picture before you trust a number on a monitor. Did I cover everything?

Zaf:

I think that's a great summary and I think you know what really wraps all of these papers together is that we're using a precision. Patient guided approach as opposed to a random algorithmic approach to these patients like we've been taught with P-H-T-L-S or ATLS. And it's takes us away from this is how we've always done things, to really thinking about how can we tailor the things the patient based on the situation. And I think that's for the clinician mind is really important to. Be able to be empowered to do that based on evidence from these trials.

M0:

Thank you so much for your time and recording this with me. And I appreciate you

Zaf:

Yeah. No, thanks.

M0:

enlightening us and again, to our audience, send us your questions. I hope you can share this podcast and enjoy the papers and the discussions. Thank you so much for tuning in.

Zaf:

Thanks a lot, Mohamed. Appreciate being here.