Hot Trends in Trauma: TXA,

Ketamine, and Tactical

Medicine

Kari F Jerge, MD

Assistant Professor of Surgery

Trauma, Critical Care, and Acute Care Surgery

Overview

• Disclosure

• TXA

• Ketamine

• Tactical Medicine

• Summary

• Questions

10/17/2018 2

Disclosure

• No financial disclosures

• Intellectual disclosures

– TCCC instructor

– Trained by military surgeons

– Tactical Medical Director for SWAT team in AZ

– We stand on the shoulders of giants

– I might ramble, feel free to throw something at me

The Problem Defined

10/17/2018 4

Key Issues

• Scene Safety

• Triage

• Hemorrhage control

• Medical management of hemorrhagic shock

• Pain control

10/17/2018 5

Coagulopathy of Trauma

• Triad of Death– COLD

– COAGULPATHIC

– ACIDOTIC

• Cold = enzymes in clotting cascade will not function

• Acidosis = result of hypovolemia/hemorrhagic shock = enzymes in clotting cascade will not function

• = BLOOD IS TOO THIN10/17/2018 6

Coagulopathy of Trauma

• Present on admission in ~ 25% of trauma patients

• 5-fold increase in mortality

• Particularly severe in TBI patients

• Two aspects of coagulopathy…

– First is activated by hypoperfusion

– Second is iatrogenic

10/17/2018 7

Traumatic Coagulopathy

10/17/2018 8

Acute Traumatic Coagulopathy

• Hypocoagulable State

– Component of this that occurs at time of trauma = very hard to reverse/treat = carries poor prognosis

– Component that is associated with resuscitation

• Consume all coagulation factors

• Dilute out coagulation factors

• Cold and acidosis make coagulation factors malfunction, impair thrombin production

• Hyperfibrinolysis

– Protein C activation = hyperfibrinolysis = clot breakdown

– Patient breaking down whatever clot they are able to form

– Associated with HIGH MORTALITY 70-100%

– This is where TXA comes in

10/17/2018 9

Treatment Options

• Don’t let patients get cold!

– By any means necessary

– Remove cold or soaked clothing

– Emergency blankets

– Warm fluids

– Warm ambo

– Warm blankets

– Heating packs around head/neck, groin, axilla

• Replace red stuff with red stuff

• Don’t let patients bleed out

– Pandora’s box- Once its started, no perfect way to fix

problem

– TQ, wound packing, TXA, diesel fuel10/17/2018 10

What is TXA?

• Anti-fibrinolytic

• Stops body from breaking down clot

• Generic medication

• Costs ~ 100 bucks

• WHO list of essential medicines

• IV and po route

• Uses:

– Trauma

– Heavy menstrual bleeding (OTC in UK)

– Postpartum hemorrhage

– Orthopedic and cardiac surgery

10/17/2018 11

TXA Administration

• 1g IV over 10 min, second gram runs over 8 hours

• Contraindications:– Allergy

– H/o seizures

– Thromboembolism (arterial or venous)

– Renal impairment

• Side effects:– HA

– Diarrhea, abd pain

– Fatigue

– DVT10/17/2018 12

What Do We Know?

• TXA Administration

– 1.5% reduction in 28 day all cause mortality in bleeding

trauma patients

– Reduction in all-cause mortality from 16 to 14.5%

• NNT 67

– Reduction in risk of death caused by bleeding from 5.7%

to 4.9%

• NNT 121

– Benefit seen in the patients in severe shock

10/17/2018 13

What Do We Know?

• Giving < 1 hour greatest reduction in deaths from

bleeding

• Giving 1-3 hours after injury still decreased risk of

death from bleeding

• Giving > 3 hours after injury = INCR RISK OF

DEATH

• No impact on TBI outcomes

• Not associated with increased risk of VTE10/17/2018 14

What Don’t We Know?

• Mechanism by which TXA decreases mortality?

– Fibrinolysis evaluation and coagulation testing weren’t

done in CRASH-2

• Should fibrinolysis testing be performed prior to

giving TXA?

• Optimal timing and dose?

• Other anti-fibrinolytics possible?

10/17/2018 15

CRASH 2

• CRASH 2 2010

– Large, randomized, double blind, placebo-controlled

multicenter trial

– 274 hospitals, 40 countries

– 20,211 patients with or at risk for severe bleeding

– TXA vs placebo

– Outcomes = 9% reduction in RR of all cause mortality

– 1.5% ARR

– NNT 67 trauma patient to prevent one from dying

– Benefit greatest within 3 hours and within the

sickest group of patients

10/17/2018 16

Cliff Notes TXA

• Given within 3 hours of severe traumatic injury

• Patients with or risk for hemorrhagic shock

• Improves mortality, coagulation profile, rates of

MOF

• Standard of care in military combat medicine

• Logistics

– Rural trauma

– Flight paramedics

– Trauma transfers

10/17/2018 21

Who needs TXA?

10/17/2018 22

10/17/2018 23

10/17/2018 24

TXA Further Resources

• Major Hemorrhage and Trauma Induced

Coagulopathy

– https://www.youtube.com/watch?v=7F0qamkiPN8

• Brohi on TXA in Trauma: The Denier’s Handbook

– https://emcrit.org/racc/more-on-txa/

10/17/2018 25

The Problem Defined

10/17/2018 26

Key Issues

• Scene Safety

• Triage

• Hemorrhage control

• Medical management of hemorrhagic shock

• Pain control

10/17/2018 27

Pain Secondary to Trauma

• Nature of the Problem

– Patients typically hypovolemic

– Frequently in hemorrhagic shock

– Pain control required for:

• Severe poly-trauma

• Splinting

• Tourniquets

• Transport

10/17/2018 28

Options for Pain Management

• Non-Narcotic– Aspirin

• Anti-Platelet

– Tylenol

• PO, PR

• IV Tylenol great pain relief, but restricted ($$)

– NSAIDS

• Meloxicam

– PO, Cox2 inhibitor > Cox1

• Toradol

– Inhibits platelet function, renal insufficiency

• PO, PR less than ideal

• No great options here for civilian prehospital

• Not to mention…10/17/2018 29

Tell this guy he can’t have

narcotics…

10/17/2018 30

Options for Pain Management

• Narcotics– Morphine

• Histamine Release- itching, flushing, capillary dilation, bronchiolar constriction

• HYPOTENSION

• Weak narcotic

– Dilaudid• Potent narcotic

• Half life of 2 hours

• Can cause hypotension

– Fentanyl• Potent narcotic

• Fast on, fast off

• Least hemodynamically active narcotic

• No lasting relief

• We don’t have fentanyl lollipops yet

• All cause respiratory depression, some degree of hypotension, CNS depression, airway compromise10/17/2018 31

Ketamine

• Ketamine Hydrochloride

• Derivative of PCP– Psychedelic type high

• Site of Action:– Multiple sites= opioid, muscarinic, nicotinic Ach receptors

– NMDA receptor antagonist

• Low Dose– Potent analgesic

– Mild sedation

• High dose– Dissociative anesthesia

– Moderate to deep sedation

10/17/2018 32

Ketamine

• Routes:

– PO, PR, IN, IM, IV, IO

• Effects:

– Sympathomimetic

• Tachycardia, HTN

– Pupil dilation, nystagmus

– Bronchodilation

– Increased salivary and tracheobronchial secretions

• Give with anticholinergic if need be

10/17/2018 33

Dose

• Analgesia

– 0.1 to 0.5 mg/kg IV

– 0.4 to 1 mg/kg IM

• Procedural Sedation

– 1 to 2 mg/kg IV

– 4 to 5 mg/kg IM

• RSI

– 1.5 mg/kg IV

• Repeat dose every 20-30 min prn

• How Do You Know?...

10/17/2018 34

10/17/2018 35

Ketamine Use in Trauma

10/17/2018 36

Practical Tips

• Hypersalivation

– Anticholinergic

– Have suction handy

• Airway maintained, but you may need to suction, NPA,

jaw thrust

• Warn family that patient may look “catatonic”

– Eyes open, nystagmus, minimal responsiveness

• Not ideal if you need patient perfectly still for

procedure

• Great for agitated, violent, combative patients

• Excellent for RSI, pain management, sedation, single

agent anesthesia for rural/remote/austere medicine

10/17/2018 37

Practical Tips

• Bad Trip/Side Effects

– Bad dreams

– Hallucinations

– Sensory dissociation

– Near death experience

– Feeling of “being paralyzed”

• Emergence Reaction

– Dose related

– 12% of patients will experience

– Give small bump of benzo

– Ie Versed 2 mg IV x 1

10/17/2018 38

Safety

10/17/2018 39

Contraindications

• Absolute– Age < 3 months

• Relative– Schizophrenia

– Unstable angina/significant CAD

– Head Trauma

• Increased oxygen consumption

• But, cerebral vasodilation

• Minimal (probably not relevant) increase ICP

– Ocular Trauma

• Prior concern for increasing IOP

• Now questioned

10/17/2018 40

That Being Said…

• Use common sense

– Avoid in patients who are:

• Extremes of age

• Schizophrenic

• Already severely tachycardic or HTN, known unstable

angina or unstable CAD

– If give too high of a dose:

• Give oxygen

• Chin lift, jaw thrust

• NPA

• Suction as needed

• = Support airway until ketamine wears off

10/17/2018 43

Ketamine Data

• Upchurch CP et al. Comparison of etomidate

and ketamine for induction during rapid

sequence intubation of adult trauma

patients. Ann Emerg Med 2017; 69: 24-

33. PMID: 27993308

10/17/2018 44

10/17/2018 45

Future Directions

• Data/SOP for Ketamine uses:

– Excited Delirium

– Acute pain control

– Chronic pain

– Chronic depression

– PTSD

10/17/2018 48

The Problem Defined

10/17/2018 49

Key Issues

• Scene Safety

• Triage

• Hemorrhage control

• Medical management of hemorrhagic shock

• Pain control

10/17/2018 50

Why should we talk about tactical

medicine?

• Terminology

• Recent civilian man-made mass-casualties

• Rise of active shooter

• Trends in law enforcement

• Gap in POI care

• End Result

10/17/2018 51

Terminology

• Man-Made Mass-Casualty– Not accident, not natural disaster

• Active Threat Scenario– Fails to include medical response needed

• Active Shooter– Limited scope

– Tactical term that media has twisted and misconstrued

– LE “owns” this scenario

– FBI data flawed by changing definition mid-study

• Complex Coordinated Attack– Mumbai, Paris

– Multiple weapons, multiple targets

– Synchronized attack

– Variety of weapons

– *First responders as targets*

10/17/2018 53

Recent Events

• 1993 Waco TX (Fire)

• 1995 Oklahoma City Bombing

• 2002 Beltway Snipers

• 2009 Fort Hood Shooting

• 2013 Boston Marathon Bombing

• 2015 Charleston SC Church Shooting

• 2015 Paris Bataclan Massacre (*CCA*)

• 2015 San Bernadino (Handgun, rifle, pipe bombs)

• 2016 Orlando Pulse Nightclub Shooting

• 2016 Dallas Police Shooting

• 2016 Nice France (vehicle and gunfire)

• 2017 Las Vegas Massacre

• 2017 Sutherland Springs Church

• 2017 Egypt Mosque Attack (bomb, rifle)

10/17/2018 54

What do these have in common?

• Active threat

• Multiple weapons used

– Explosive Devices

– Fire

– Rifle and handgun

– Nice and London vehicles

• Attackers wearing ballistic protection

• Combat style weapons inflicting combat style

injuries in wartime numbers

• Increasing visibility in public consciousness

10/17/2018 55

Rise of the Active Shooter

Trends in Law Enforcement

10/17/2018 58

Gap in POI Care Pulse AAR

End Result

• These events are increasing in frequency (we

think) and visibility

• These are civilian “combat” scenarios

• There is a gap between POI and definitive

medical care

• We need to be prepared to respond appropriately

to active threat scenarios and combat wounding

patterns in a timely fashion! = we need to

incorporate combat medical principles into

civilian America

10/17/2018 60

Paradigm Shift

10/17/2018 61

Paradigm Shift

• Abundance of resources

• Safe setting

• Vs

• Austere environment

• Logistical constraints

• Unsafe scene

• But why can’t we apply ATLS protocol?

10/17/2018 62

Civilian Treatment Priorities

• ABCDE

– PHTLS

– ATLS

– ACLS

• BUT I just told you that < 15% die from Airway

10/17/2018 65

Paradigm Shift

• #1 Priority is preventing further casualties

NEUTRALIZE THREAT

• #2 Priority is hemorrhage control

• Treatment modalities have to be portable,

compact, high-speed and low-drag

• In this specific context, FORGET ATLS!

10/17/2018 67

Now that your paradigm has

shifted…

• New medical response paradigm

• New order of treatment priorities

• Generate force multipliers

10/17/2018 70

Hartford Consensus II

Massive Hemorrhage

10/17/2018 73

Massive Hemorrhage

• Truncal

– Aggressive prehospital use of TXA

– Evacuate

• Junctional Hemorrhage

– Not TQ amenable

– Junctional Tourniquet

• SAM, AAJT, Croc (ALL HAVE LIMITATIONS)

• Water bottle or can of chew and ace bandage

– Wound packing

• Quick Clot/Combat Gauze

• Celox

• Cool training videos

10/17/2018 74

Massive Hemorrhage

• Extremity Hemorrhage– Direct pressure is a resource distribution issue

– TQ

• Extensive military data

• 1 limb lost in over ~4,500 TQ deployments (not result of TQ)

• CATT or SOFTT (lots of junk on market)

• Lessons learned from Boston

• 2 inch width

• ”Go high or die”

• Take out all slack first, tighten windlass, secure velcro and windlass

• Give pain meds!

• First one fails, second TQ higher

10/17/2018 76

CoTCCC Approved TQ

10/17/2018 77

Tourniquets

• Anything else on market is JUNK with ZERO

VALID DATA

10/17/2018 78

Airway Management

Airway Management

• Sit patient up, tripod position

• NPA

• +/- King

• Surgical Cricothyroidotomy

10/17/2018 80

Respiratory Management

Respiratory Management

• 4-5th intercostal space, anterior axillary line

• Needle Decompression or Digital Thoracostomy

• Sucking chest wounds get occlusive dressing

– Gorilla Tape or AED pads

– If respiratory distress progresses, burp dressing

10/17/2018 82

Circulation Management

• Conscious casualties take P.O. fluids

• Unconscious casualties in shock get:

– Intraosseous access > IV access

– Minimal crystalloid

– Single 500 mL bolus of Hextend

– Freeze Dried Plasma

– Fresh Whole Blood

– MTP (“yellow red yellow red”)

• Resuscitate to PALPABLE RADIAL PULSE

• Why?

– IVF are heavy and take up space in limited environment

– Bleeding red stuff, give them back red stuff

– BP cuff not available

10/17/2018 83

Hypothermia Management

10/17/2018 84

Head Injury Management

• Support BP and oxygenation

• Elevate head

• DISARM CONFUSED CASUALTY

10/17/2018 85

Now that your paradigm has

shifted…

• New medical response paradigm

• New order of treatment priorities

• Generate force multipliers

10/17/2018 86

Generate Force Multipliers

• Law Enforcement Tactical Medical Training

– TECC

– LEFR TCCC

– 1-4 hours of training for non-medical LE

• Civilian Prehospital Hemorrhage Control

– BCON

– Stop the Bleed

10/17/2018 87

10/17/2018 88

Civilian BCON

10/17/2018 89

10/17/2018 90

Most of you are eligible to teach

BCON

10/17/2018 91

Get Trained

• Civilian

– BCON

• Fire/EMS

– Included in PHTLS curriculum

– We are happy to provide in-service training

– ALERRT conference

• Law Enforcement

– LEFR TCCC (curriculum under revision)

– Bcon

– 1-4 hour tactical medical course

• Rescue Task Force/MCI response

– TECC vs TCCC course (2 days, 16 hours)

– ALERRT train the trainer course

10/17/2018 92

Summary

• Disclosure

• TXA

• Ketamine

• Tactical Medicine

• Questions

10/17/2018 94

Summary

10/17/2018 96

10/17/2018 98

Summary

• Why should we talk about tactical medicine?

– Terminology

– Recent civilian man-made mass-casualties

– Rise of active shooter

– Trends in law enforcement

– Gap in POI care

– End Result

• Paradigm shift

– Unsafe scene

– Logistical constraints

– Major cause of preventable death

10/17/2018 99

Summary

• Treatment Priorities

– THREAT vs MARCH

– Focus on threat neutralization and massive hemorrhage

• Generate Force Multipliers

– Stop the Bleed

• Further Training

10/17/2018 100

Further Resources

• Gear

– https://www.narescue.com/

– http://www.tacmedsolutions.com/

– https://www.chinookmed.com/

• Training/Videos/Information

– https://www.dhs.gov/stopthebleed

– https://www.bleedingcontrol.org/

– https://www.naemt.org/education/naemt-tccc

– http://www.naemt.org/education/tecc

– http://www.celoxmedical.com/na/resourcestraining-and-

education/

– You Tube and NAR have solid training videos

10/17/2018 101

10/17/2018 103

Questions?

10/17/2018 104