#10 – Part 2 Combat Trauma Anesthesia – Dustin Degman, MSN, CRNA

Part 2: Combat Trauma Anesthesia with Dustin Degman, MSN, CRNA.  Dustin discusses the specifics of Damage Control Resuscitation that he utilized as the sole anesthesia provider at Forward Operating Base (FOB) Orgun-E in Afghanistan.

Dustin Degman, MSN, CRNA is an Associate Professor of Anesthesia at Western Carolina University works with AllCare Clinical Associates in Asheville, North Carolina as a CRNA.  He served Active Duty with the United States Air Force from 1998-2002 as a critical care nurse.  In 2010, he joined the Army Reserves as a CRNA.  Dustin was deployed in November 2012 to Forward Operating Base (FOB) Orgun-E in Paktika Province, Afghanistan where he was the sole anesthesia provider on a forward surgical team which provided damage control resuscitation to injured soldiers.  He has a special interest in trauma anesthesia and has served on trauma call teams in civilian centers as well as in his military service.  Many thanks to Dustin and the brave men and women who have served and serve in and with the United States Armed Services!

Combat Trauma Anesthesia

Part 1:  Key differences and challenges facing CRNAs serving in Forward Surgical Teams (FSTs) and managing combat trauma patients

Part 2:  Damage Control Resuscitation principles and particulars

Part 3:  Getting involved as a military CRNA and support our troops

 

Topics Discussed:

  • What constitutes the “front lines.”  You’ve got to hear Degman humbly give credit to those who, in his opinion, really served on the front lines (first two minutes of the show…).
  • Assessment priorities for CRNAs including physical exams “from the neck up” (i.e. ruptured tympanic membranes may indicate proximity to explosions)
  • Induction sequence & airway management
  • Use of tourniquets
  • Techniques to support clot formation
    • fluid, blood product, pharmacological and hemodynamic management
  • Surgical goals of damage control resuscitation

 

Highlights:

  • Blood product management
    • 1:1 transfusion protocol was frequently used for hemorrhagic shock patients.  Dustin did not have platelets available so one fresh frozen plasma (FFP) unit was given with every packed red blood cell (PRBC) unit.
    • Very limited crystalloid replacement
    • Walking Donor Protocol – use of direct, typed whole blood administration from uninjured soldiers to hemorrhagic shock patients.  Benefits:  the blood’s got all the products (red cells, plasma, platelets, cry0, factor 7) and it’s warm.
    • Colloid resuscitation end points:
      • 80-90 systolic blood pressure
      • goal for INR less than 1.5
      • base excess greater that -4
      • hemoglobin & pH monitoring
      • surgical hemostasis
  • Pharmacological management
    • Induction drugs
    • Overview of antibiotics
    • Use of ketamine with head trauma patients*
    • transexamic acid (TXA) and Factor 7 commonly administered
  • Vascular access
    • Goal was bilateral 16g peripheral IVs
    • Central lines uncommon but were typically used with 3% sodium chloride, especially once the patient was bundled or “burrito wrapped” for the flights out of the FOB to more definitive care.
    • Arterial lines were commonly placed
  • Tourniquet use
    • very common
    • hemostatic agents/products (e.g. chitosan) were not commonly used
  • Resuscitation end points
    • Dustin discusses a case from his civilian trauma experience that was similar to one he experienced in Afghanistan in which ultrasound was used to evaluate cardiac wall motion (specifically, the lack there of) in a hemorrhagic shock patient in order to make the decision to not attempt surgical resuscitation.
  • Team work and communication
    • Immediate After Action Reviews where the OR team discussed 3 things the team did well and 3 things that could be improved on.  These AARs happened immediately after every case.

 

*Ketamine use in head trauma.  Dustin discusses the use of ketamine in neuro-trauma patients under his care.  Reference is made to recent literature showing the acceptable use of ketamine in neuro-trauma as it does not increase intracranial pressure.  The following article citation is a meta-analysis of randomized control trials published in December of 2014 in the Journal of Anesthesia showing that “ketamine does not increase ICP compared with opioids. Ketamine provides good maintenance of hemodynamic status. Clinical application of ketamine should not be discouraged on the basis of ICP-related concerns.”

Wang, X., Ding, X., Tong, Y., Zong, J., Zhao, X., Ren, H., & Li, Q. (2014). Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. Journal Of Anesthesia28(6), 821-827. doi:10.1007/s00540-014-1845-3

 

First to Cut – Trauma Lessons Learned in the Combat Zone, Second Edition.  (2012)  U.S. Army Institute of Surgical Research.  Fort Sam Huston, Texas.

Access the full-text pdf version of First to Cut here: http://www.usaisr.amedd.army.mil/assets/pdfs/First2Cut.pdf

 

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