Podcast: Stabilization Following Vehicular Trauma Prior to Tertiary Referral with Dr. Blutinger

Alex Blutinger, VMD, DACVECC, Veterinary Emergency Group, White Plains, New York, Greenwich, Connecticut

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In this episode, host Alyssa Watson, DVM, is joined by Alex Blutinger, VMD, DACVECC, to talk about his recent Clinician’s Brief article, “Stabilization Following Vehicular Trauma Prior to Tertiary Referral.” Dr. Blutinger gives a thorough review of the approach to trauma cases—emphasizing management of hemorrhages—and the steps we can take to stabilize these patients. He also shares a helpful mnemonic to keep in mind because the last thing you need when dealing with these stressful cases is wondering what to do next (or first)!


Episode Transcript

This podcast recording represents the opinions of Dr. Watson and Dr. Blutinger. Content, including the transcript, is presented for discussion purposes and should not be taken as medical advice. No guarantee is given regarding the accuracy of any statements or opinions made on the podcast. The transcript—which was prepared with the assistance of artificial intelligence—is provided as a service to our audience.

Dr. Alyssa [00:00:10] Hi, everyone! I'm happy to welcome you back to another installment of Clinician's Brief: The Podcast, where we bring you the conversations behind all of our Clinician's Brief content. I'm the host of the show Dr. Alyssa Watson, and in today's episode, I am joined by Dr. Alex Blutinger. Dr. Blutinger is a criticalist and also the medical director at Veterinary Emergency Group in White Plains, New York and also Greenwood, Connecticut. In today's conversation, we are going to be looking at some of the crucial steps for us general practitioners that we need to take when we're presented with a patient that has suffered vehicular trauma, and we need to stabilize this patient in order to be able to transfer it, maybe to another facility. So I invite you all to kind of sit back and listen in as we talk about all of these complexities of emergency care and hopefully gain some really good insights from Dr. Blutinger because this is his wheelhouse. How are you doing today, doc?

Dr. Blutinger [00:01:08] I'm great. I'm very happy to be here. Thank you.

Dr. Alyssa [00:01:10] Good, good. We are so happy to be here. Before we jump into this, I would love it if you could just introduce yourself to the audience and tell us a little bit about your background.

Dr. Blutinger [00:01:20] Sure. So as Dr. Watson mentioned, my name is Alex Blutinger. I am a critical care specialist. I did my training at the Animal Medical Center in New York. A very high volume trauma center, level one trauma center. So I was exposed to, lots of interesting trauma cases. And that's where I ultimately developed my passion for working in critical care and particularly with trauma. Subsequent to my residency, I spent time at Blue Pearl in Manhattan working in the city. And a few years ago, I moved out to the hospital in Westchester, Veterinary Emergency Group, where I work with an amazing team, super high volume setting, see lots of trauma there and across the the area as well. When I'm in Greenwich, we see lots of trauma, as well. So I've been fortunate that I've been able to stay in an area that is just wrought with lots and lots of cases, and it's sparked my interest in this particular topic.

Dr. Alyssa [00:02:24] Yeah. That's wonderful. Well, it's something certainly that, you know, we all need to know about, and I've got a lot of questions for you today. You know, I mentioned in the intro that we're really going to be talking about vehicular trauma because that is really the most common, you know, presentation when we have blunt force trauma. But what other, you know, incidents or accidents can cause blunt force trauma?

Dr. Blutinger [00:02:52] So, like you said, blunt force trauma by far is most commonly seen with vehicular accidents. We can see it particularly in city and more urban settings. We will see high-rise syndrome, which is another form of blunt force trauma, more of what we call a decelerating trauma, where sort of a moving object comes or moving animal comes into contact with a stagnant object. And then, you know, the unfortunate and oftentimes, you know, difficult part of our job is seeing blunt force trauma in the form of animal abuse, as well, that happens to be a significant minority of cases. But we do see that, but blunt force trauma, I would say, in those three categories, tends to be the most common way that we see it presenting.

Dr. Alyssa [00:03:42] Yeah, I definitely have seen a couple patients over the years that have fallen, you know, from a second story window or something like that, you know, and they can present similarly. So with these presentations, how do they differ from, you know, I mean, another kind of trauma that I see all the time is something like, you know, a dogfight or dogfight wounds. So how does blunt force trauma kind of differ from those other types of trauma presentation?

Dr. Blutinger [00:04:08] Yeah. So those kinds of presenting patients, particularly dog bite wounds or impalements, we would consider those more of the penetrating trauma category. They can present similarly in the sense that our approach to those patients tends to be quite similar, the systematic approach so we don't miss the critical injuries that might cause, you know, significant morbidity and mortality in those patients. But generally speaking, when we have penetrating trauma, such as bite wounds, those tend to be injuries that are more obvious to us. We see very quickly where the injury is. And the biggest risk for those patients tends to be bleeding. And it's because of the fact that we're, we know that we're breaking through tissue. And so the bleeding aspect tends to be more, more clear and more obvious and sort of our primary focus from the beginning. With blunt trauma, the challenge with that particular category is that we don't always know what's going on under the surface. And so bleeding is, of course, a big concern, but there's lots of other injuries that we need to be made aware of. And lots of other considerations that we need to take into account when we're stabilizing them.

Dr. Alyssa [00:05:23] I found it interesting in your article, you talked about the fact that, you know, studies have shown in humans that trauma-related death usually occurs fairly quickly within 48 hours of being in the hospital. Do we have any idea if this you know, if this correlates with animals? Do we believe that time frame is similar?

Dr. Blutinger [00:05:44] I think that we extrapolate a lot from human medicine. Unfortunately, and maybe fortunately, we... I say unfortunately, because we don't have the data, but fortunately it allows us to sort of pave our own path. We like to think that the data that exists in people can be translated to an extent in veterinary medicine. The cause for death within 48 hours tends to be related to life-threatening hemorrhage from trauma to the brain or neurologic, significant or severe neurologic dysfunction that progresses either from TBI or cervical spine injury, things like that. So we do believe that there's probably significant truth to the fact that in the first 48 hours, those injuries patients will either succumb to or they'll be stabilized from, and we'll be able to kind of get them out of that initial window. That's typically referred to as the golden hour is what a lot of people reference as is this historic dogma that if, you know, we can stabilize patients within that first hour, they have the best chance of survival. We say our but that timeline is sort of arbitrary. We know that the sooner these patients can get care and be resuscitated, the better off they'll be. And so it's used to be just as a reference to work quickly and get them to a facility as quickly as possible to give them the best chance at recovery.

Dr. Alyssa [00:07:10] And one of the ways that we can do that is just like you said, with a systematic approach. And, so you used a mnemonic and I love mnemonics. So we have a pneumonic that X A B C D. So you talk about this, can you walk it to walk us through it? You know, let the audience know go through each component and how that helps us when we're prioritizing these life-threatening complications.

Dr. Blutinger [00:07:36] Yeah, absolutely. So I guess I'll start by saying that this mnemonic has evolved a little bit over time. I think many listeners, myself included, earlier in my career, I was always taught ABCD, and X became sort of the, the addition to the front of that mnemonic to emphasize the importance of, if you see bleeding, stop it right away. And that sort of coincides with C, which is circulation. And we'll kind of go through them systematically. But the other thing I'll say is, you know, in people, they're, they often have the luxury and trauma centers of having multiple people, physicians, nurses around a patient, and this systematic approach is sort of done all at once. You know, it's not as they go through one letter at a time, one body system at a time. They have multiple people addressing every system at the same time. And yeah, that's really what's called the parallel approach. But we have a sort of a vertical approach, or we have one doctor typically, or maybe two if we're lucky, that can, you know, get to the patient. It has to work through it systematically in order of most life-threatening to least life-threatening. And so that's where this mnemonic, I think becomes most helpful for us as practitioners, especially if we're a solo practitioner and this patient walks in or comes into our, our, our facility. So X is the first letter of the mnemonic which stands for exsanguination. And basically what this means is if you see an active bleed, stop the bleed. There's lots of ways you can do this. Externally, you can apply pressure. You can apply pressure bandages. Manual pressure. You can put a tourniquet on the patient if it's on the extremity. You can get creative, and if there's a hole somewhere in the body wall bleeding or, you know, somewhere in the extremities, you can place a Foley catheter in, blow up the Foley and just use that to apply pressure. Really, there's there's no limitations here. You might have to get creative, but the point is that because bleeding is one of the leading causes of death, we have to stop it if we can see it. So that's where X comes into play A and B I sort of put together airway and breathing. Basically, for airway, we're just making sure that the patient has a patent airway. If a patient has oral facial trauma, trauma to the cervical region, the larynx, if they don't have the ability to, to, to pass air, obviously that's something that needs to be addressed very quickly. And that can typically be visualized. As a patient comes into the facility and is being evaluated. And then B is just a close relative to A, which is breathing. And that's basically an evaluation of pulmonary function. So is the patient oxygenating and is the patient ventilating, you know, quick and simple tests to look at that. Besides visually assessing the patient to see sort of how their body posture is what they look like as they're breathing. Getting a pulse ox, listening to the lungs and their airway. And if you're able to obtain a blood gas to look at a CO2 to see if that patient is ventilating, that's also an added benefit. I know, lots of facilities don't carry blood gas machines. It's not a necessity. But pulse ox can give you a lot of information on, on status of the patient's lungs as well. So that's going through XABC. And then D, which is the last of the mnemonic is disability. And that really stands for neurologic status. It's oftentimes very difficult to do a full neurologic exam on a patient. Many of the listeners may be familiar with the modified Glasglow Coma Score, which was derived from the Glasglow Coma Score in people, and that's a way to evaluate for brain stem function, neurologically intact function, which can be prognostic in patients over time. So it's nice to have that information, but it's sometimes difficult to score a patient when they're coming in needing pain meds, getting a, you know, really significant evaluation. And lots of things are going on. Catheters are being placed. So for me, I think, what's the most important about that part of the exam is evaluating their pupils, because you can very quickly tell if the patient has brain injury or trauma to the brain if their pupils are different sizes, not reactive to light. And that can oftentimes help you localize the, the injury in the brain. And then, patients mentation, so their mental status, are they aware of what's going on around them can be very helpful to also evaluate whether there's any sort of brain trauma that might have taken place. And then lastly, just getting a general sense of can they move their limbs. Are they able to feel their limbs? Can they move them if you pinch them, if you pull them gently, of course. But those things can give you a pretty rough idea of where your patient stands neurologically before you give pain meds, maybe sedate them, do more things to them.

Dr. Alyssa [00:12:40] So let's go back and talk a little bit about, you know, each of these things in more detail. We'll start with, you know, controlling hemorrhage. So you know that the Foley catheter idea is fantastic. You know, like you said, anything that you can do to stop bleeding. What are, you know, just kind of to review for us... How do we recognize, you know, that real significant bleeding, like when we have bleeding of arterial origin versus just, you know, venous bleeding or capillary bleeding, bleeding that we know we need to get on, get a clamp on, do something right away?

Dr. Blutinger [00:13:17] So I realize I missed C in this discussion.

Dr. Alyssa [00:13:21] Oh!

Dr. Blutinger [00:13:22] Which is circulation. But let me refer back to that because that's going to answer the question, I think.

Dr. Alyssa [00:13:29] Yeah!

Dr. Blutinger [00:13:31] So C and X are related, but C is the circulatory system. Right? And I think a really important consideration here is if we're trying to evaluate for bleeding that may not be so obvious. Because we may not see it and it may be internal. That's where evaluating your circulation is going to be crucial. And that can be measured through various perfusion parameters. Right. So we classically think of our patients as having six perfusion parameters that we can measure quite easily when they come in. It's temperature. It's pulses. It's pulse rate. It's body mental status. If they're perfusing their brain, then they're going to have, be conscious, aware, bright and alert. If not, they might be more dull. And it's pulse quality. And so these are the six things that we typically think about when we're looking at perfusion parameters. And so your patient that comes in if they come in tachycardic, if they come in with weak pulses, if they come in and they're mentally dull, or obtunded, then those all might be indications that this patient's in shock coming in the hospital and in trauma, a patient that comes in shock should be presumed to be bleeding somewhere until proven otherwise. That is sort of the understood, rationale behind why is my patient in shock and they're bleeding until proven otherwise. So as a as a clinician, your job is to figure out where are they bleeding from. And that's not always the easiest thing to do if you can't see with your naked eye. So typically I would rely on those perfusion parameters on my exam to kind of get a general assessment if I have to kind of look a little bit deeper as to why, why this patient's in shock and where they're bleeding from.

Dr. Alyssa [00:15:13] Okay. And then do you utilize techniques like belly wraps and things like that? Do you find that those are really useful if we do have, you know, suspect intrabdominal hemorrhage?

Dr. Blutinger [00:15:26] So I've done that a few times. I would say that I have mixed feelings about placing a belly wrap. I don't think there's great evidence behind doing that. Certainly, if the patient has no evidence of traumatic brain injury and just evidence of bleeding within the abdomen, I think it's a reasonable thing to do. Generally, the the consensus is to keep the wrap on for 12 to 24 hours and kind of track red blood cell count, PCV total solids, track volume in the abdomen, those kinds of things. But if there's any evidence of traumatic brain injury, you don't want to place a belly wrap on. Because what that can do is that can increase your intrabdominal pressure, which can then redirect that pressure to the brain, by reducing venous outflow from the brain, all that pressure kind of gets pushed upstream towards the vena cava, and then that can actually exacerbate that. So you just want to be careful about what patients you're, you're using that with.

Dr. Alyssa [00:16:25] Absolutely cautious in your patient selection. That's a really good tip. Thank you. Can we talk a little bit about oxygen? Because it seems it's funny, it seems like, oh, yeah, we'll just give them oxygen. But sometimes that's harder than, like then it seems like it should be, you know, especially if they're anxious. They're shying away. They don't want a mask over their face. They're painful. So, can you give a little advice to us about what are the the easiest, less least stressful ways to deliver oxygen to these patients? Because lots of times I don't want to stick them in an oxygen cage either. They need we need to be doing other things with them.

Dr. Blutinger [00:17:04] Absolutely. So I agree, and you made a great point, which is the last thing you want to do is stress these patients out. Especially if they're already in shock and their catecholamine drive is through the roof just trying to keep them compensating. So this can be a challenge. I find that the simplest and the least stressful way to apply oxygen is to just do it with flow by. I usually will set my oxygen gauge at 2 to 3 liters per minute. Just that's sort of my, my go to. I feel like it's not, it's not uncomfortable for patients. It's not too high of a rate where it's blowing air in their face. And if I find that they're resistant to it, then I'll either move the hose away, or maybe I'll be more inclined to give them pain meds sooner. Or try and sedate them a little bit if they're too agitated. The other thing about oxygen supplementation and agitation, which has come up several times with trauma cases that I've seen is trying to kind of figure out why they're agitated. And it can be pain, it can be the stress of the environment. Lots of reasons in trauma where patients can be, uncomfortable and, and agitated and in that new environment. But it also could be because they are they can't breathe. And so they might be flailing because they can't ventilate, they can't oxygenate. And so one of the sort of common presenting problems with blunt trauma, blunt force trauma is pneumothorax. And it might be the patient is just stressed and is trying to move because they they just can't get comfortable from lack of ability to ventilate. And so if you're seeing that and you're watching the patient breathe and you feel that that could be a contributor, that might be an opportunity to tap the chest. And that's daunting for lots of people. And it should be when you're putting a needle into the thorax and you get poke a lung, and you could cause more trauma. But the reality is that most of these patients are going to die from the pneumothorax before they'll die from a poke to the chest, even if they didn't need that. And so for me, if I have a patient come in coming into the hospital, that looks like it's having a hard time breathing, and I believe that there could be a pneumothorax and I don't have x rays yet. Because I'm not going to prioritize x rays in a sick patient at that point. In that moment, I'll actually just shave a small window, up sort of the dorsal aspect of the chest between the seventh and ninth rib space. Do a quick a quick scrub. And I'll actually just put a 22 gauge needle in just to see if I get air out. And if I don't and I poke a lung, it's probably okay. You're probably not going to cause any harm. But if you do happen to get air out, you probably do save that patient's life. So I think it's a really important consideration. If they're, if they're agitated, but if they're not and they're just resistant to the flow, then I will give them pain meds a little bit quicker, and try and just sort of get the hose away from their face as far as possible. Just to make sure that I'm not making them more stressed out.

Dr. Alyssa [00:20:11] And then what parameters do we need to be looking at? I mean, you had mentioned, the, the perfusion as well as as monitoring maybe SpO2, CO2 if you have it but we don't always have that. How frequently should we be monitoring this? How do we use that to guide our therapy? And most importantly, what are the endpoints I'm looking at to know that it's okay to transfer this patient? Because, you know, for me, I don't have like an ambulatory service. If I'm transferring this patient, it's gotta take a 30 minute car ride, you know, over to our local tertiary facility.

Dr. Blutinger [00:20:47] Yeah, that's a that's tough. You know, I think every patient's going to be a little bit different. And maybe our risk tolerance will be different based on how quickly we feel they need to be in a definitive tertiary care facility or a definitive care center. In terms of parameters for me, my goals are making sure that their heart rate's a little bit more under control. So if they come in with an elevated heart rate, hopefully we all have EKGs that we can be monitoring patient's heart rates and lots of reasons patients come in tachycardic, but the most common ones would be shock and pain, and stress. And typically fluids and pain meds solve all those problems, at least for for a little while. And that might give you a window to be able to transport. When we think about shock, of course, we think about blood pressure as well. Blood pressure's a topic in and of itself when it comes to trauma cases. You know, I think we all would love to have patients transferred when we're comfortable where their blood pressure is at. And then trauma, the, the concept of permissive hypertension or hypertensive resuscitation has become a really interesting area of research. And, you know, the evidence in animals, it comes from animal models that people are using for their own patients. But the concept is that if we can keep the blood pressure at sort of a subnormal level, but just enough to perfuse our critical organs, our brain, our heart, and our kidneys, then, hopefully we can stop, stop or slow down bleeding. We can help preserve clots that are formed and give these patients a better chance at stabilizing. The challenge with this approach is that it requires targeting blood pressures of anywhere from a map of 65 to 80, and that's a very hard thing to accomplish if we're really just trying to aim for that blood pressure. The other challenge with this approach is that you can't have them at that blood pressure for an indefinite amount of time because over time, then the organs will start to suffer and they'll go into organ failure and have, you know, more catastrophic issues. So I would say that while we do aim for that for about a, you know, 60 minute window, if we can accomplish that pressure, transporting a patient that has a pressure above a map of 65 or 70 or a systolic above a 90 or 100 would be a very reasonable time to transport. If they're oxygen dependent and pulse oxygenation is showing that they are persistently hypoxemia and there's no way to transport them with oxygen, that's a challenging position to be in. And again, understanding why the patient's hypoxemia might be important because if it's because they have contusions, we know that that we're not going to fix that before transportation. But if it's because they have a pneumothorax, we may be able to tap them before we send them and then have a better chance that they'll make it to the facility without complications.

Dr. Alyssa [00:23:50] Might give us just a little window that we need to get them there.

Dr. Blutinger [00:23:53] Exactly.

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Dr. Alyssa [00:24:25] So let's talk a little bit about fluid resuscitation because this is another thing that I find over my 20 years in practice has changed significantly, you know, when they talk about shock boluses of fluids and how we handle, you know, giving fluids now. So can you talk to us a little bit about low volume fluid resuscitation when we're using crystalloid fluids?

Dr. Blutinger [00:24:47] Absolutely. So the concept of low volume resuscitation is exactly how it sounds, which is trying to administer low volumes of isotonic crystalloids to our patients. The reason behind this concept are that, you know, we when our patients come in in shock, as you know, I mentioned earlier, it's presumed to be hemorrhagic shock until proven otherwise. And so logically, if our patients are losing blood, then we have to replace the components of what they're losing. And that means that we have to replace the red blood cells, their plasma and their platelets. Right. Unfortunately, platelet transfusions in veterinary medicine still are not really flushed out. We don't have great options for that, even though platelets do exist as a transfusion product. But plasma and packed red blood cells are, more abundant. And if you have the luxury of having whole blood, then that's that's amazing. That's even more valuable. But most of us don't have that. And the challenge with whole blood is that platelets are only viable for a very short window of time. So you kind of have to have donors on standby ready to go to really get the maximal benefits of whole blood. So when we consider the fact that we need to give these patients what they're losing, you know, in our in our practice, we don't have blood and plasma at the ready to go. You know, in human medicine a patient comes in with massive trauma. They can get blood products moving very, very quickly. Right. We have the challenges of communicating with the owners, having conversations about finances, having conversations about quality of life, about realistic expectations, prognosis, all these things. And that might delay our ability to give these products. And so to start, it's very reasonable and appropriate to start with asanguinous fluids being crystalloids. And, so when we talk about low volume, because we know that we're going to initially stabilize these patients with isotonic crystalloids starting with a low volume of something like LRS, p-lyte, and anything that's at your disposal that can just restore circulatory volume is going to be effective at the get go. And low volume, meaning ten mil per kg, 15 mil per kg to start just to kind of help get blood pressure up, improve heart rate, get perfusion parameters slightly improved. But the idea is that this is a temporary measure. While we try and evaluate whether this patient is going to receive blood product because ultimately that's what they're probably going to need if our initial low volume resuscitation is ineffective at stabilizing them. And the reason that we have evolved as a medical community to use low volume resuscitation in the form of crystalloids is because we know that if we give too high volumes of fluids that don't carry oxygen, like red blood cells don't carry clotting factors like plasma, all we're doing is diluting out those valuable precious cells that we need to clot to carry oxygen, or blowing off clots that have been formed by the body by increasing the blood pressure with these fluids. And so the intention behind it is really to help the body preserve what it has and what's trying to do to stop the bleeding until we can get the blood products into that patient.

Dr. Alyssa [00:28:08] And then when we need those products, you know, what are what are your parameters just like you said, you know, how do we know if our crystalloids have not done the job and we need to move on to something else?

Dr. Blutinger [00:28:23] So typically, I would say it's based on our parameters that we're monitoring. So heart rate, blood pressure, mentation status, temperature, perfusion parameters, as well as blood work parameters. So if we have the ability to measure things like PCV lactate, those are two of two of the big ones, I would say that can help guide whether or not our our resuscitation efforts are successful. And the patient isn't continuously bleeding, but if not, heart rate and blood pressure can be very effective ways of monitoring our our effectiveness of resuscitation. And so typically, for me, my starting point is a small volume of isotonic crystalloids, so I would typically start with a ten mil per kg bolus for a dog, 5 or 10 mills per kg for a cat. And that might be variable depending on the patient, but still a low volume isotonic. I'll then move to a hypertonic settling bolus. And hypertonic saline is a very effective way of using low volume resuscitation. And that fluid type in particular has lots of other benefits that have been studied in models, including increased cardiac output in animal models where they've sort of replicated hemorrhagic shock, it's shown that it might reduce the need for transfusions, it might improve outcome. It's great if you think your patient has traumatic brain injury because it also serves as an asthma asthma therapy for these patients. So lots of value there. So I typically reach for that second. And then if I feel like the patient either isn't stabilized or my parameters are showing that there's progression in dropping of the PCV, lactate still is either static or going up, then I'll immediately move to blood products as my next option if that's available for me. And that's something that, you know, the owners are comfortable with.

Dr. Alyssa [00:30:15] Yeah. One thing I've always I've never had to do in it or I've, you know, never done it in, in my 20 years. But I always keep it in my mind is that like autotransfusion, you know, especially if you have something like, you know, intraabdominal hemorrhage or, or, you know, hemorrhage that you can tap very easily, hemorrhage outside the lungs, you know. And so, it's something that I like I said, it's always been in the back of my mind, but I don't even know exactly what I would need to do that. Do you just take the blood out and and put it in a big 60 ML syringe and pump it in IV?

Dr. Blutinger [00:30:52] It's actually that simple. Yes. I think I feel and so that's the sometimes I've forgotten tool that we have in our toolbox to, to use especially for facilities that don't have blood products stored. I'll never forget a case I had last year at the Veterinary Emergency Group. It was a hit by car. It was a 50 kg lab, giant lab, that came in and was in severe hemorrhagic shock, bleeding into its abdomen, and it was such a big we have the luxury of blood products, but the dog was so big that we couldn't give it enough blood to actually make a dent in what it needed. And I remember the dog had a heart rate of 200. Its blood pressure was 40. It started to become opisthotonic like this dog was was dying before our eyes, and we decided that we were going to autotransfuse this dog. As we were pumping in plasma that we did have on, you know, fortunately store that we were giving this dog, and we basically put a giant 20 gauge catheter in this dog's abdomen, and we pulled out 60 cc syringes one at a time, and one person was pulling it out. The other person was we were handing it off to the other person who was pushing it through the peripheral line. We just had a filter on the end of it just to catch any, you know, clots or anything else. And as we're pumping the and we're literally just pulling, pushing, pulling, pushing, syringe after syringe, and we watch this dog's heart rate in front of our eyes go from 200 down to 100 after about a liter of of blood that we pushed back into this dog, and it was actively bleeding. But in the meantime, we were able to push plasma into this dog, which I think might have helped the dog clot whatever the bleed was coming from. And ultimately we saved this dog's life. But the only reason was because we were able to autotransfuse this dog because we did not have enough blood in the hospital to be able to replace what this dog was losing. So it can be a real life, life saving technique, and you avoid all of the possible complications of giving blood products that are from donors. And so that's the added benefit of doing it.

Dr. Alyssa [00:33:00] Don't have to have the cross matching or anything. You can just skip all of that.

Dr. Blutinger [00:33:05] Exactly.

Dr. Alyssa [00:33:06] Well, I mean. I certainly don't wish to see a whole bunch of trauma patients, but it would be something that I feel like would be cool to do someday. So I'm still going to keep it in my back pocket.

Dr. Blutinger [00:33:16] Definitely.

Dr. Alyssa [00:33:18] You already talked a little bit about permissive hypertension, you know, and talking about that target, that blood pressure target, and that we really can't keep those animals you know, in that range for more than an hour or so. But could you talk a little bit as to why that approach is not recommended in patients that you do suspect have traumatic brain injury?

Dr. Blutinger [00:33:41] Yeah. So traumatic brain injury changes the equation a little bit. And, you're sort of faced with a complicated situation if you have a patient that has traumatic brain injury and let's say, for example, intraabdominal hemorrhage, right. Because you want to apply the principles of low volume resuscitation and hemostatic resuscitation with patients that are bleeding, but you also want to make sure that you're not ignoring these organs that need critical perfusion. Right. And the brain happens to be one of them. So for permissive hypotension, we are still allowing the brain to perfuse, but when the brain sustains a traumatic injury, it loses its ability to autoregulate and to perfuse the way that it should be perfusing, even under critically ill circumstances. And what we know from human medicine is that hypotension is sort of an independent risk factor for severe morbidity and mortality in patients. And it's because perfusion to the brain is so essential for recovery that we can't sacrifice that if we know that it's present. And so if you're trying to figure out the lesser of two evils in that, in that situation, it seems that the lesser of two evils is to get the blood pressure up to preserve the brain and perhaps be more aggressive in controlling hemorrhage knowing that you may not be able to accomplish that permissive hypotensive target that you're going for.

Dr. Alyssa [00:35:18] Another concept that I had learned about recently was this kind of lethal triad when patients are in hemorrhagic shock, and it has to do you know with this circle and and, not only hypotension, but hypothermia was a really big component of that and the hemodilution. And that can actually exacerbate these coagulopathy in these patients. Which, you know, anytime I'm in surgery, I'm always, you know, I want to make sure I have my patient on a warmer and everything like that, but I hadn't really occurred to me that it was such a big deal in trauma patients. Can you talk a little bit about that?

Dr. Blutinger [00:35:53] Sure. So, yeah, the triad of death has been or the lethal triad. So morbid. People call it different things. But I think the takeaway from from that concept is that all three of those together really are are the most is the most dangerous presentation for any trauma patient. Individually, they carry less weight. Certainly we don't want our patients to be cold because that's typically an indication of poor perfusion and then therefore bleeding. But the the issue that we face in trauma, and this is where a lot of the concepts that we've talked about have come from, such as low volume resuscitation, reaching for blood products quickly, the issue is that much of what we do actually exacerbates these problems, and not intentionally, but just by the nature of these interventions. So, for example, a patient comes in after being hit by a car. They're typically brought in, put on a metal table, which is cold, and they're probably already under perfused. So they're cold to begin with. Then we start pumping them full of fluids that are not warm, typically, and those are going to make them cold as well. And in the process of being cold, our giving them a fluid that's going to actually dilute out more red blood cells potentially make bleeding worse, which is going to make them hypothermic, more hypothermic. And now it's going to exacerbate coagulopathy by causing dilutional coagulopathy. And by doing that, then they're going to become more acidotic as their lactate goes up, their bicarb starts to go down. And so these things sort of perpetuate one another. And when we see them in synchrony all together, that tends to be a recipe for disaster. And that's been seen sort of over time. Individually, like I said, probably not the end of the world. But keeping in mind that if one starts, that means that the others could start to follow. And so being mindful of it is, I think, the most important thing that we don't get all three happening at the same time.

Dr. Alyssa [00:37:59] Can we talk a little bit about like antifibrinolytic agents? It's hard work for me to say. I just I find that there's a lot more emphasis on some of these medications than there was, you know, early on in my career. And so, can we talk about kind of the two main ones out there and what the differences between them are?

Dr. Blutinger [00:38:23] Sure. So the two main ones that exist out there are aminocaproic acid and tranexamic acid. They both work the same way. And in simplistically what they do is they basically stabilize a blood clot. So we have a blood clot that forms in, in health. And when that happens eventually the mechanisms that break down the clot are activated over time, and the cycle sort of goes around and around where clots are formed, they're broken down. And so that part of the the cycle where clot breakdown occurs, which is via plasminogen, these antifibrinolytic will sort of inhibit that process. So they're not clotting factors. They don't help build clots. They just kind of help assist the body to stabilize the clots that the body has already formed. They are they have the same mechanism, tranexamic acid is 7 to 10 times more potent than aminocaproic acid. And the reason why it tends to be more, I would say reached for in at least human medicine, is because of the literature surrounding it. If for anyone who's interested and wants to go down the rabbit hole, the crash to trial is this trial that made tranexamic acid, what it is today. And as used readily as it is today, and it was a massive study involving over 16,000 patients, military application of bleeding trauma patients. And they found that patients that received tranexamic acid had a survival benefit of over 1.5%. So that was what sort of prompted people to start looking at TXA as part of the cocktail of resuscitating trauma patients. And so it's used readily now in trauma facilities in people. But in, in human, in veterinary medicine, we've sort of, like many things, extrapolated that information. I mean, there are papers that have that have looked at antifibrinolytics in greyhounds post-surgery. They have looked at it in trauma as well, in dogs and cats. And it's hard to know whether there's really a benefit in trauma, at least. Some, some studies have shown that in some case studies and smaller studies have shown that maybe it does help with, with bleeding, but generally, it's they're use because there is evidence that it might work and it doesn't tend to do harm as far as we know. So it's it's something that is sort of hedging on, on an additional way of, of promoting hemostasis. In addition to all the other mechanisms we talked about.

Dr. Alyssa [00:40:58] Okay. Yeah, that's another area, just like you said, the greyhounds insight hounds that can have that delayed post-operative bleeding is another area that I've seen it, you know, being discussed and used for. So I was just wondering if it was something that at this point, you know, criticalists, like yourself, suggest a general practitioner like me keeps on the shelf.

Dr. Blutinger [00:41:20] Yeah. I mean, I think that it's again, we don't know if it really makes a difference. I don't think anyone would say that. It's just magic drug where if you give it, they stop bleeding. In in combination to everything else we do, it might do something. The other challenge with the drug is that we don't have ways of readily measuring fibrinolysis in in the clotting cascade, and you can only really do that with TEG and ROTEM, which are viscoelastic methods of measuring clotting. And we only have traditional PT PTT measurements, and that's not evaluating for the fibrinolytic of clot formation and breakdown. And that would be the breakdown phase. So we don't have ways of guiding the therapy. But they are relatively inexpensive. I think aminocaproic acid is probably a less expensive version. And the nice thing about it is that you can give it orally as well. At least for the aminocaproic acid, you can give the injectable form orally. So I think it's it's a nice tool to have on the shelf and available if it's not going to break the bank. But I don't think it's an essential medication to have for for trauma patients.

Dr. Alyssa [00:42:32] That's very helpful. Thank you. All right, let's end up our discussion with pain control. Because this obviously is something that we always want to be cognizant of. Making sure that that our patients are not in pain. A lot of times these guys are so critically ill that they don't they may not need sedation in order to do some of these initial stabilization things. Tap the chest or, you know, put in IVs, certainly, and start fluids, but they really do need analgesia. So which drugs are you reaching for? What do you consider the safest? And are there certain classes that you, you know, really feel strongly that we should avoid?

Dr. Blutinger [00:43:12] My my go to is typically a pure mu opioid. I like them because they are reversible. They're effective. They tend to be relatively cardiovascularly sparing. And I will put an asterisks on that because any drug that you give to a critically ill patient can kill them. So even the ones that we suspect, you know, that we know, don't have the same systemic effects, cardiovascular effects, respiratory suppressing effects, they can still make a critically ill patient worse. So I do like opioids. I think fentanyl is a great option because it's short-acting. You can bolus it. Again, you can reverse it, and you can just sort of see what kind of response the patient has to it before you commit them to a longer-acting opioid like methadone. But I think methadone is also a great option. And that tends to be a little bit, you know, longer acting it lasts for a 4 to 6 hours. So my, my go to are pure mu opioids for pain control. That tends to also help with the blood pressure situation. So catecholamines are what drive our blood pressure up as we're stressed or painful for our patients. And so by giving opioids, you can actually sort of help the catecholamine surge calm down a little bit. And that might help bring their blood pressure down, which might, again, help with your permissive hypotensive targets that you might be going for. If I'm looking for more than just an opioid because I feel like my patient either needs a procedure like, you know, quick wound repair or needs a chest tap and the opioids aren't doing it for me, then my next option would be to reach for something like ketamine. And I like ketamine because it doesn't have the cardiovascular-suppressing effects that medications like propofol might have, dexdomitor might have. They're all great drugs, they just in the setting of critical illness, I'd be worried about altering those parameters that I'm monitoring so closely and really trying to keep stabilized. So I think ketamine is a great option as well. And then certainly if they're hospitalized, they need a wound repair, they have pelvic fractures, things like that, then I might add lidocaine to the mix as another pain adjunctive pain control.

Dr. Alyssa [00:45:28] So do any of those analgesic choices change if you suspect head trauma? You know, we had said with some of these other things that head trauma can change our approach when stabilizing these patients.

Dr. Blutinger [00:45:42] Generally, no. They're there. Again, my my goal in head trauma is to maximize perfusion and and maximize oxygen delivery. Right. So I'm choosing drugs that hopefully will not alter blood pressure in a way where it'll know the patient will become hypotensive. But I also don't want to increase pressure in the brain. I know there's there's been a lot of debate historically about drugs like ketamine potentially increasing intracranial pressure because one of the actions of ketamine is that it can increase sympathetic tone. And, sympathetic tone can drive blood pressure up, and too high blood pressure might increase pressure in the brain. So that that, that theory has been reevaluated over and over, and it's been disproven that ketamine is not a safe drug for that, that it's not a safe drug for intracranial hypertension. In reality, it can be used safely. So the doses that we're using for pain control are typically lower than anesthetic doses, where you might see more of an effect on, on blood pressure in the brain. But for traumatic brain injury, I'm still reaching for opioids first. I'm still comfortable using ketamine, lidocaine. I'm still going to stay away from drugs like dexdomitor. If I get to a point where I have to intubate a patient, and, I need, you know, more, more control and need them to have additional medications on board, I probably will reach for propofol next. Just titrate it to a sort of a low as effective dose as possible.

Dr. Alyssa [00:47:19] Okay. Thank you. Well, that was all of my questions about stabilizing these patients. This was a fantastic conversation. At the end of our episodes, we actually have a couple more questions. It's a little game. These are these are would you rather questions. And it's just for fun. And I was wondering if you'd like to play with us.

Dr. Blutinger [00:47:42] I'd love to play. Let's do it!

Dr. Alyssa [00:47:43] Awesome. Excellent. Okay, so would you rather. And you. Okay, there's a couple conditions on this one. You have to do it. You can't have your awesome licensed nurses do it. And. And you can't cheat and do like an intraosseous catheter. Would you rather place an IV in a tiny dehydrated kitten or an obese basset hound?

Dr. Blutinger [00:48:04] An obese basset hound.

Dr. Alyssa [00:48:06] You go for the basset hound.

Dr. Blutinger [00:48:07] I'd go for the basset hound.

Dr. Alyssa [00:48:11] If you had to set up an emergency clinic on a remote island and you could only bring one, would you bring an x ray machine or would you bring an ultrasound machine?

Dr. Blutinger [00:48:20] I would bring an ultrasound machine.

Dr. Alyssa [00:48:22] Take ultrasound. Okay. If they could both rate you on Yelp, would you rather get a review from your last feline patient or your last canine patient?

Dr. Blutinger [00:48:34] My last canine patient.

Dr. Alyssa [00:48:36] I feel like cats are a little bit more judgy.

Dr. Blutinger [00:48:39] They are. Yeah, they are definitely more judgy. And I will be honest and admit this. I have a fear of cats. So I think my, like, maybe subconsciously, I feel like I just connect more with dogs because of that. So I think the dogs would agree with that.

Dr. Alyssa [00:48:56] Yeah, well, I mean, it's good to have a healthy fear of cats. Cats can mess you up.

Dr. Blutinger [00:49:01] Yeah, I'm lucky enough, knock on wood, that I've not been messed up by cat yet, so yeah.

Dr. Alyssa [00:49:06] Me too, thank goodness.

Dr. Blutinger [00:49:08] Yeah.

Dr. Alyssa [00:49:09] All right, final question. If you had a werewolf come in with trauma and you had to give blood products, would you choose human blood or would you choose wolf blood?

Dr. Blutinger [00:49:22] Oh my God. That's a really tough question. I'm not really well-versed in werewolves, but I would probably choose human blood.

Dr. Alyssa [00:49:33] Okay. Human blood? I think so, too, because I think because they're they're human more of the time. Right? Like they were werewolves only, like one night a month or something?

Dr. Blutinger [00:49:42] Exactly. That was my thinking too.

Dr. Alyssa [00:49:44] I feel like I feel like the human blood would be. Yeah, more a larger percentage of their bloodstream.

Dr. Blutinger [00:49:50] Yeah. I don't know how I would how I would try and get that from a human hospital, like what I would say to them, but I would. My brother's a human emergency doctor, so maybe I would ask him and.

Dr. Alyssa [00:50:00] Oh, my gosh, you're kidding.

Dr. Blutinger [00:50:01] Yeah.

Dr. Alyssa [00:50:02] My brother is an emergency human physician too. Yes, absolutely. Here in Vegas. So he was eight years older than I am. So he was graduating medical school, right when I got out of high school, and my dad said if he had one more kid, he could have had a dentist.

Dr. Blutinger [00:50:18] Oh, my gosh. Yeah. Well, it's it's one of the reasons why I love this topic so much because my brother and I, we debate and we compare stories and patients. And so it's it's nice to have a perspective on the other side of the, the the line.

Dr. Alyssa [00:50:35] Yeah. Yeah, it really is. And they have a really difficult job. So I know I look up to my brother so much and I'm glad that he's there seeing those things. I'm sure you feel the same way about yours.

Dr. Blutinger [00:50:45] Absolutely. Absolutely.

Dr. Alyssa [00:50:47] What a wonderful coincidence. This has been just a great conversation. Thank you again so much for joining us. Thank you to everybody at home. I hope you enjoyed it as much as I did. And we'll catch you next time on the podcast.

Dr. Blutinger [00:51:00] Thanks so much.



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