The Use of Point-of-Care Ultrasonography in Trauma Anesthesia

Point-of-Care Ultrasound-History, Current and Evolving Clinical Concepts in Emergency Medicine

Point-of-care ultrasound (PoCUS) has become an indispensable standard in emergency medicine. Emergency medicine ultrasound (EMUS) is the application of bedside PoCUS by the attending emergency physician to assist in the diagnosis and management of many time-sensitive health emergencies. In many ways, using PoCUS is not only the mere application of technology, but also a fusion of already existing examiner skills and technology in the context of a patient encounter. EMUS practice can be defined using distinct anatomy-based applications. The type of applications and their complexity usually depend on local needs and resources, and practice patterns can vary significantly among regions, countries, or even continents. A different approach suggests defining EMUS in categories such as resuscitative, diagnostic, procedural guidance, symptom- or sign-based, and therapeutic. Because EMUS is practiced in a constantly evolving emergency medical setting where no two patient encounters are identical, the concept of EMUS should also be practiced in a fluid, constantly adapting manner driven by the physician treating the patient. Many recent advances in ultrasound technology have received little or no attention from the EMUS community, and several important technical advances and research findings have not been translated into routine clinical practice. The authors believe that four main areas have great potential for the future growth and development of EMUS and are worth integrating: 1. In recent years, many articles have been published on novel ultrasound applications. Only a small percentage has found its way into routine use. We will discuss two important examples: trauma ultrasound that goes beyond e-FAST and EMUS lung ultrasound for suspected pulmonary embolism. 2. The more ultrasound equipment becomes financially affordable; the more ultrasound should be incorporated into the physical examination. This merging and possibly even replacement of aspects of the classical physical exam by technology will likely outperform the isolated use of stethoscope, percussion, and auscultation. 3. The knowledge of pathophysiological processes in acute illness and ultrasound findings should be merged in clinical practice. The translation of this knowledge into practical concepts will allow us to better manage many presentations, such as hypotension or the dyspnea of unclear etiology. 4. Technical innovations such as elastography; CEUS; highly sensitive color Doppler such as M-flow, vector flow, or other novel technology; artificial intelligence; cloud-based POCUS functions; and augmented reality devices such as smart glasses should become standard in emergencies over time.

Five Decades of Trauma Anesthesiology

We present a brief history of the scientific and educational development of trauma anesthesiology. Key milestones from the past 50 years are noted, as well as the current standing of the subspecialty and prospects for the future.

Utilization and Efficacy of Resuscitation Endpoints in Trauma and Burn Patients: A Review Article

Shock is a sequelae in trauma and burn patients that substantially increases the risk for morbidity and mortality. The use of resuscitation endpoints allows for improved management of these patients, with the potential to prevent further morbidity/mortality. We conducted a review of the current literature on the efficacy of hemodynamic, metabolic, and regional resuscitation endpoints for use in trauma and burn patients. Hemodynamic endpoints included mean arterial pressure (MAP), heart rate (HR), urinary output (UO), compensatory reserve index (CRI), intrathoracic blood volume, and stroke volume variation (SVV). Metabolic endpoints measure cellular responses to decreased oxygen delivery and include serum lactic acid (LA), base deficit (BD), bicarbonate, anion gap, apparent strong ion difference, and serum pH. Mean arterial pressure, HR, UO, and LA are the most established markers of trauma and burn resuscitation. The evidence suggests LA is a superior metabolic endpoint marker. Newer resuscitation endpoint technologies such as point-of-care ultrasound (PoCUS), thromboelastography (TEG), and rotational thromboelastometry (ROTEM) may improve patient outcomes; however, additional research is needed to establish the efficacy in trauma and burn patients. The endpoints discussed have situational strengths and weaknesses and no single universal resuscitation endpoint has yet emerged. This review may increase knowledge and aid in guideline development. We recommend clinicians continue to integrate multiple endpoints with emphasis on MAP, HR, UO, LA, and BD. Future investigation should aim to standardize endpoints for each clinical presentation. The search for universal and novel resuscitation parameters in trauma and burns should also continue.

The Damage Control Resuscitation and Surgical Team: The New French Paradigm for Management of Combat Casualties

INTRODUCTION

The aim of this work was to introduce the new French forward resuscitation and surgical unit. It's also to discuss the choices and waivers granted to fit the tactical context of modern conflicts and the current epidemiology of combat casualties.

MATERIALS AND METHODS

A multidisciplinary task force of 11 people proceeded to the conception and the creation of a new military resuscitation and surgical unit. The preliminary work included a scoping review of the combat casualties' epidemiology in modern conflicts and an analysis of the recent French medical-surgical treatment facilities lessons learned. In April 2019, a technical-operational evaluation was conducted to confirm all the technical, ergonomic, and organizational choices made during the design phase.

RESULTS

The multidisciplinary task force resulted in the creation of the Damage Control Resuscitation and Surgical Team (DCRST). The DCRST focused on the resuscitation strategy, including transfusion of blood products, and the life-saving surgical procedures to be performed as close as possible to the point of injury. It was designed for the resuscitation of two patients: the life-saving surgery of two patients and the very short-term intensive care (<12 hours) of four patients at the same time. The DCRST provided sufficient autonomy to provide take care of four T1 and four T2 or T3 casualties per day for 48 hours. It was armed with 23 soldiers. The technical equipment represented 5,300 kg and 27 m3. All the technical medical equipment could be stored in two 20-foot containers.

CONCLUSION

The DCRST represents a new paradigm in medical support of French military operations. It offers the advantage of two combat casualties' surgical management at the same time, as close as possible to the combat zone. It responds to a 2-fold epidemiological and logistical challenge.