E72 Clay Cothren On Pelvic Packing And Blunt Cerebrovascular Injuries (BCVI)

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Chad Ball  00:12

Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We’ve had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been broad in range, whether clinical, social or political, our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.

Clay Cothren Burlew  01:12

Dr. Clay Cothren Burlew is a trauma surgeon in Denver, Colorado. She is world-renowned for her work on pelvic packing as well blunt cerebrovascular injuries, among many other things. We caught up with her to find out how she manages to do so much and have such a productive career, and specifically to talk to us about pelvic packing and blunt cerebrovascular injury.

Chad Ball  01:34

Well, for all of our listeners, it’s an absolute pleasure to have Dr. Clay Cothren on the podcast today. Dr. Cothren is a remarkable human being both in terms of work life as well as personal life. And I hope we get to explore some of those things in the next next few minutes. Dr. Cothren, welcome. Thank you for being on the podcast. And for some of the listeners in across Canada in particular who may not know you as well as we do, can you tell us about where you grew up and what your training pathway was?

Clay Cothren Burlew  02:02

Absolutely. And thank you so much, Chad, for having me. It’s really an honor, as as you know, this is one of my first forays into the podcast realm. So so yes, I hopefully this will, this will translate well. So, um, I grew up in Texas, I grew up in San Antonio, I went to the east coast for college, returned back to Dallas for medical school, and then did my training and fellowship here in Denver, and then have been on faculty here in Denver for almost 20 years. So that’s what it is, in a nutshell is a little bit of my training pathway.

Chad Ball  02:35

Wow, time flies, eh.

Clay Cothren Burlew  02:38

It does. It does, thankfully, and sometimes not. So thankfully.

Chad Ball  02:41

Yeah, exactly. You know, a lot of us not, not just me have admired your career and your contributions, not only to clinical medicine, but to the research side of it as well. I was wondering if you could tell our listeners, what sort of prompted you to be so prolific and so thoughtful in terms of research on the one side, and really continuing medical education on the other.

Clay Cothren Burlew  03:02

You know, I think, you know, when I have been fortunate to give talks, and particularly to talk to medical students and residents, one of the things I always try to, to emphasize is that you as a single individual can really make an impact upon the care of the, for me, the injured patient or for any patients. And I think that the ability in surgical research to pose a question and to develop a hypothesis and, you know, rigorously tested into actually answer that question. And to really alter how we manage patients for the better, is really one of, I think, the most incredible things that we can do as surgeons, as educators and as scientists. And I think that’s really what has driven me once you know, once you have the bug and you figure out that you can really answer questions that you don’t know how to take care of something that that just begets, you know, more injury, so it always seems to answer one question, and then you get three others.

Chad Ball  04:03

Yeah, that’s, that’s well stated. It’s, it’s, it seems like there’s no no end to the voyage anytime soon. There’s no doubt

Clay Cothren Burlew  04:09

So true. So true.

Chad Ball  04:10

Yeah, you know, your productivity, obviously, as we call it, dance around here, but I’ll just state it is, is really, really impressive. And it’s something we all try and emulate. You are a busy mom, you have a busy family, you have an incredibly busy practice with a lot of demands. And then there’s the academic side of it. And of course, your administrative side. I’m curious, how do you how do you balance that and how do you remain so impressively productive, just overall? What are some of your tricks?

Clay Cothren Burlew  04:37

Well, I think you know, one of the things that I encourage younger surgeons, both both men and women, and maybe particularly for women, the first thing that I do is I throw the word balance out the window. Because I think that that trying to quote unquote “attain balance” means that you’re trying to accomplish something. And the minute you have imbalance means that you failed at something. And so for me, I really have tried to have focus. And really, it’s a matter of where is my focus at the current moment. And some days, I have more focus on my academic and political life and other days, I have more focus on my family and my home life. I think, you know, any busy working mom learns how to delegate well, we learned that you try to outsource everything humanly possible. You know, I joke with my husband, that we’re stimulating the economy, because we have a cleaning service, a dog walker, a yard person. We have a spectacular nanny, we have so many people that help us, allow us to do our jobs very effectively. And then to really focus on our family. And so I think having that infrastructure of help enables me to be really good at my job, and hopefully really good as, as a family member, as a wife, and as a mom. And so I think those sort of mental adjustments have been really important to me. And then I think that the other key to success in being, you know, sort of, by the, by the historic measures of productivity, whether it’s book chapters, or articles published, or presentations given is it you have to be really interested in what you’re doing. And I have been fortunate to fall into a couple of different areas that really have piqued my interest. I’m fascinated in how we manage patients in those particular areas, whether it’s open abdomen management, or pelvic fracture management, or atherectomy or PCBIs. So I have a couple of arenas that really have have interested me. And then, you know, once you have that, that interest, it’s really easy to keep, to keep, you know, foraging and, and trying to figure out new and better ways to take care of patients. So hopefully, that that it’s a, it’s a, you know, a compendium of thoughts, but hopefully that helps delineate a little bit of the juggle.

Chad Ball  06:57

Yeah, you know, as usually that that’s, that’s so well said. I’m so happy to hear you talk about the term balance in that way. Because I, you know, on this podcast, and in real life around the hospital here with our trainees, I often challenged the use of that word, both locally as well as greater society. And I think words like the that you’ve used, like passion, in particular, are probably more important for a lot of us than than the traditional notion of balance. You know, since you brought it up and in particular, I think it would be helpful for maybe some of our community general surgical crew across, you know, a very large geographically dispersed population and country here to maybe delve into a little bit about pelvic fractures and management of that, in general. It’s, it’s, of course, fine when you know, super trauma surgeons like yourself are hopefully maybe at the foothills hospital here, when we have all the toys and the hybrid ORs, and in all these different things, but what would you recommend for the, the really critically ill patient that maybe can’t have an immediate transfer out from a more rural location in terms of management of that pelvic fractures? How do you frame that and, and maybe beyond that, you could describe or at least frame the concept of preperitoneal packing in particular?

Clay Cothren Burlew  08:21

Yeah, so obviously, I’ve been interested in pelvic fracture management and, and our group have been some of the early people to push the idea of pelvic packing for trauma. And I think for those that are in the rural setting, or in, you know, in an in an area in which you may not have angiography, probably packing is a perfect way to address pelvic fracture related hemorrhage. So when I, when I talk about pelvic trauma as a whole, I remind people that the vast majority of patients that have pelvic trauma, don’t need an intervention. They don’t need angiography even or they don’t need pelvic packing. And so it’s really a very small proportion about maybe at most 10% of all pelvic fracture patients that need an intervention for bleeding. And so when you really call down those numbers, and then look at those patients, we use our intervention point for pelvic fracture related bleeding and whether you choose to do pelvic packing, which is what I would advocate, others still do angiography. Our intervention point is the same for both of those groups. And so for us, if patients were made even amicably unstable, despite getting two units of blood, those are the patients that have ongoing bleeding that need an intervention. So it’s not based upon their CAT scan finding it’s not based upon that blush on your 64 slice CT scan. That probably doesn’t mean much. It’s really based on the patient’s physiology. And so even if you are in an area where you can’t, you know, take a patient angiography, you can take them for pelvic packing. And so using those simple techniques of binding, you know whether you use pelvic sheeting or use a binder in order to stabilize the bony pelvis, prevent ongoing shifting of the bony elements, you do massive resuscitation with one to one ratios of doing hemostatic resuscitation. And then in those patients that don’t stabilize, those are the patients that really go on for pelvic packing. And that can be done anywhere. And we’ve even, you know, we get a fair number of transfers here. We’ve talked surgeons through the procedure and outside facilities that that really, you know, are level three trauma centers that don’t have the resources of a level one center. So I think pelvic packing is absolutely something that should be in the armamentarium of any surgeon.

Chad Ball  10:46

I couldn’t agree with you more. And you know, we’ve seen it used as well, in some pretty remote locations by some pretty, you know, inexperienced surgeons is the wrong term because of course, they’re very experienced, but maybe not super high volume trauma exposures at any point in their training or their or their practice. I was wondering if you could maybe just very briefly walk us through those steps in terms of preperitoneal packing. And of course, to the for the listeners we’ll we’ll link your your, your papers and the Denver papers on on this as well. But just to get us started, give us give us a sense of what’s involved.

Clay Cothren Burlew  11:21

Yeah, absolutely. And it, you know, that the several years ago, two or three years ago, I was asked to give a video session, actually at EAST. And so you can actually look Journal of trauma has a link to that video session in case you want to see sort of real time what it looks like. I think the key, the key thing to remember is that pelvic packing is asking you to do exactly what you’ve been told your whole career not to do, which is to go and touch the pelvic hematoma, right? We’re always told, don’t unroot the pelvic hematoma don’t jump in there. And now I’m telling you go jump right in there. I think the important thing to keep in mind as you as you talk about pelvic packing is number one, if you have an orthopod, who can put an external fixator on I think that is a critical component to stabilize the bony pelvis, so that you really have a stable framework into which you place your pads. If not, then it’s perfectly fine to keep your pelvic sheet on. Its going to be down on your greater trochanters. And you’ll be able to get to the suprapubic space without an issue. But my first vote would be to try to have your orthopods to put an external fixator on. Barring  that, I would still go ahead and with pelvic packing. What you simply do, you make about a 6 to 8 centimeter incision, you start it with symphysis and and proceed cephalad. You just sharply go down and then use a Bovie to go down through the sub Q and the fascia. As soon as you go through that, that puts your fascia, you pop into that preperitoneal, but it’s also really this pair of vessels in space. So if you think of the bladder as a simple midline structure, it’s an inverted U around the bladder. And it actually extends from the backside of the symphysis down into that sort of para-vesicle space all the way down posteriorly. So if you think of it as an inverted U around the bladder, that’s what it helps you visualize what that space is to look like. Moreover, the pelvic hematoma from the pelvic pressure actually dissects that entire space. So once you sort of place your hand in there and push down on the bladder, typically, that’s when the pelvic hematoma will start to egress out of that space. I put my hand around the bladder, pull the bladder to one side with unpacking the right hemi-pelvis. I put my left hand in, I’m standing on the patient’s left side, I put my left hand in, hold the bladder over to my side. And then I use a ring forcep for my first lap pad, put it all the way down posteriorly, and you pack in another two pads up around the side of the bladder, and then you repeat the entire thing on the opposite side. So usually you get five to seven laparotomy pads in, but usually it’s about six pads with three on each side. And then I simply run the fascia close with a running PDF suture and then put some skin staples in. It really is not challenging. And I think that’s been the hardest thing in the last, you know, 15 years in talking about this technique. It’s not that hard to do. I think it is scary for individuals because we’ve been told not to go into that space or to under the hematoma. But as long as you keep it in that confined suprapubic incision, you’re not egressing that pelvic hematoma in the abdomen. When you do a transabdominal exploration of the pelvic hematoma, I think you get into trouble. So if you stay in that preperitoneal space, pack it off, then those patients will stabilize for you. And it’s not that hard.

Chad Ball  14:51

Yeah, that’s a brilliant description. I totally agree. And your last point, I think it just emphasize it again is really salient that this is a different procedure from diving into a large pelvic hematoma that’s contained from the top five laparotomy. And they should be separate and distinct.

Clay Cothren Burlew  15:09

Absolutely. And keeping those incisions separate is really critical. If you allow those incisions if you have to do a laparotomy say you have to pack the liver or you need to do a splenectomy, you need to do that through a super umbilical separate incision. And, and your pelvic packing incision is is way down low right next to your pubic symphysis. Occasionally, you know, a patient comes in, you’re hemodynamically unstable, we do a FAST exam, and it’s positive. So we lift them up to the operating room, we do the splenectomy, we pack the liver, we take out the bowel, whatever needs to be done. And then you look down and they still have this big pelvic hematoma. If the patient’s unstable, then they also need pelvic packing. If they’re stable, they may not need an intervention for that pelvic hematoma. But if they’re unstable in the OR, you see that pelvic hematoma, the key then is to come back out of the abdomen and do a separate incision for pelvic packing. I totally agree.

Chad Ball  16:03

Well, one of the other things that I’ve seen you answer on a number of your talks around the world is is the the efficacy of packing more specifically with regard to anatomy. And I’ve seen people ask you the question, they sort of framed it by saying it makes a sort of intuitive sense that you can pack venous hemorrhage through this preperitoneal space. But can you really pack arterial hemorrhage as well? Which of course is the driver for a lot of our persistently hypotensive bad that pelvic fractures. What are your thoughts on that?

Clay Cothren Burlew  16:36

You absolutely can. So that’s the simple answer. So yes, the whole reason we adopted pelvic packing was because 85% of bleeding is due to venous and bony elements. So we thought why not go address that preponderance of bleeding sources, but there still is about 10 to 15% of bleeding sources, it’s arterial. The great thing about pelvic packing is once you pack that pelvis that I mean, I would say upwards of 95% of patients stabilize. And even if they end up needing to go for angiography and into embolization, which are now almost two decades of experience about 9  to 13% of patients have ongoing bleeding during the ICU, and they go and they actually have a identified arterial bleed that needs an embolization. The nice thing is by packing the patient and actually temporize them, you can take them to the ICU, you can resuscitate them, you can correct their coagulopathy, you can address obviously, if they have other injuries, if you need to scan them, if you need monitors. You can do lots of other things. But you’ll temporize that pelvic fracture bleeding. And it enables you to figure out which are the 10 to 10 to 13% of patients that need to take the trip for angiography or need that invasive additional step because the vast majority 90% of patients don’t need to have embolization.

Chad Ball  18:00

Yeah, absolutely. I want to shift gears here just just a little bit and ask you about potential interactions with REBOA, which, of course, you know, is is a it’s been a hot topic now for a number of years, and probably very overstated in general, I think, probably more more sizzle than steak. But you know, having said that, where does  REBOA fit into your algorithm for persistently hypotensive pelvic fracture patients or does it at all?

Clay Cothren Burlew  18:28

Yeah, so I agree with you. REBOA has been, has been quite the topic of conversation for several years now. I was very skeptical, I have to admit skeptical of REBOA at first came out, I’ll just admit my bias. And for me, I really have I don’t use it for everybody. But I feel that there are definitely patients that are now walking around out there. that would not be out walking around without that REBOA in addition to their their pelvic packing. So for me, the way that we’ve incorporated into our algorithm is we initiated it. And we actually presented our data to WSU this past September. We initiated it back in 2015, if I recall correctly, 2016. And we did in a very careful, stepwise manner. We incorporated that if a patient had a persistent systolic pressure less than 80, that those patients will be considered but for REBOA by the individual practitioner. And as we all recognize, there are patients that have a single systolic of 75 and then they bounce back up to 90 and back to 82. And then back up to 100. Those maybe aren’t the patients that need REBOA. But the patients for me that needs a REBOA is a patient who has a solid a 55 and they are not budging from 55-60 they’re peri-arrest. It’s amazing if you put that catheter in the sheath and then the catheter in, and I will I only put it in zone 3. I feel that’s the safest thing for me to do. It’s amazing that their blood pressure pops back up to 90 to 100. It stabilizes them, it gets them upstairs, we pack them get the balloon down and get the sheath out. So from for me literally from start to finish from the moment they hit the ED and we can go through the entire process REBOA downstairs upstairs pelvic packing, sheath out. And it’s about an hour total from start to finish. So, so to sort of sum up for me, the REBOA, I tend to use it if they have persistent systolic less than 80, and probably less than 70, despite getting massive transfusion. And it’s really a bridge to get them to the operating room for pelvic packing.

Chad Ball  20:46

Yeah, that’s, that’s absolutely a beautiful way to frame it. And to use it if you have those skill sets. There’s no doubt. I want to switch gears once again here to a final clinical topic with you. Yeah, and that’s touch on BCVI or blunt cerebrovascular injuries for listeners that that don’t deal with on a daily basis. And obviously, very much like pelvic fracture fractures, you and the Denver group have become extremely well known and sort of industry leaders, so to speak with this topic. So I’m curious in particular, you know, if you could define a BCVI for our listeners, number one. Number two, tell us about who your screen screening in 2020 in particular, number two?

Clay Cothren Burlew  21:29

Yeah, great question. So, you know, BCVIs have been recognized, well, really probably recognized since the 90s, I would say. And we’ve become much more adept at identifying them and and treating them I think, in the last probably 10 to 15 years. We have a standard classification system. Grade one and two injuries are the sections with relative narrowing of the artery. Grade three is a two way aneurism, grade four is an occlusion and rarely you get a transaction with a grade five, and three, but the vast majority are graded one through four. And the reason that we grade them is not only so that we have an easy taxonomy, a way to talk about it, but that in general, the risk of stroke is related to the grade of injury. And so I think as we are determining who should be treated, and how quickly, particularly in relation to other injuries, the the risk of stroke, I think goes into that conversation so that you can risk benefit, the risk of bleeding related to treatment, which is some type of antithrombotic, either antiplatelet, or systemic heparin versus the risk of stroke related to that, how many in how many injured vessels you had and what rate of injury those are? As far as how do we figure out the patient has an injury, who do we screen we still obviously have a Denver screening criteria we’ve, we’ve published that we most recently updated it a couple of years ago. And it’s called the expanded Denver criteria. And I think that the key, you know, the expanded Denver criteria has a big laundry list of different specific injuries. But I think in addition to that, you really have to think about the mechanism of injury. And so one of the top line of the of the expanded criteria says that it’s injury mechanism. The reason that we like to use those two things in combination is that you can have a very low injury mechanism, you know, it’s far from standing, we’ve seen this, particularly several groups have published in the geriatric population of late that fall from see and use is a significant mechanism. But those patients also have one of those identified injury patterns that are associated with BCVI. So so for us, it’s a combination, both of the mechanism and of the specific associated injuries that go along with it.

Chad Ball  23:55

That’s that’s beautifully stated as as usual on it. I think really the the the expanded Denver criteria that you talked about that will link to the podcast really have become the, again, the industry standard and throughout the world. And so we we no doubt thank you for that. How does the synchronous or the concurrent, you know, moderate to severe traumatic brain injury impact our ability to treat these patients and what are some of the innovative things that you guys are doing, whether it’s monitoring or critical care or treatment, to try and help look after some of these really, really tough scenarios?

Clay Cothren Burlew  24:30

I think you have absolutely hit on the crux of one of the hardest clinical conundrums. I think many of us treat the CDI, patients say with a solid organ injury or even with a pelvic fracture, I’m much more likely to put a patient who has pelvic packing in place I have just halted pelvic fracture related bleeding, I’ll put them on a heparin drip for you know, they have a grade three to grade four BCVI because I’m so worried about stroking that patient. Same probably true for solid organs, I’m much more likely to start with patients on a low-dose heparin drip. A TBI is a much more difficult question and answer and I don’t think any of us really have a great set of guidelines. You know, if you look at the literature to date, most institutions don’t start some type of treatment until at least 48 hours and sometimes 72 hours after identification of the injury and a stable head CT. So so when you look at the literature in TBI patients with associated CDI, you really have to look at the timing of initiation of the of the treatment. You can start treatment, but it the timing really, I think, is critical and a discussion with your neurosurgery colleagues is part of that. For us, you know, I think our neurosurgeons get tired of us asking every single day for for permission to start a heparin drip. And so one of our goals actually in the, in the coming years to describe our current experience as far as which, which TBIs are more likely to bleed, which ones are higher risk, which ones are we willing to start, you know, heparin drip on sooner. And hopefully, that’ll help delineate some of these these care questions because I agree that it’s it’s just you’re the the misstep is can be tragic if you start that anticoagulation too soon.

Chad Ball  26:25

Well, that that kind of nuanced contribution to the the, you know, the injury community would be unbelievable. So I, I hope, I hope thats successful. I guess, thank you very much. On behalf of all of us for, you know, 30,000 foot and even more granular than that masterclass on on pelvic fractures and blunt cerebrovascular injuries. I can can’t thank you enough. I want to ask two questions in closing, and bring us back out if that’s okay. The first is that you are relatively active on social media platforms. And I’m, I’m curious how you frame that as a as an academic surgeon, how you use it, how you maybe think it shouldn’t be used briefly, and how it’s been helpful for you in particular? And the last question that that I’d love you to comment on, and we ask a lot of our guests is that if you were to go back to being a trainee, or maybe starting out your career, what piece of advice would you give yourself at that time?

Clay Cothren Burlew  27:28

Oh, two, two. Okay, I’m gonna start with the easy question. Um, yeah, you’re kind in saying that I’m on active on Twitter, which which accounts for I could be more active, maybe that’s the best way to put it. So I actually, I oh, you know, Lilly Lau, several years ago, when I was president of the southwest and surgical convinced me that I needed to get onto Twitter, because it was, it was a terrific way to connect with other surgical colleagues. And, and it’s funny, she actually took the picture that still is on my profile, she took me in the lobby of the of the hotel at that meeting. And I leave it up because it reminds me of the instigating point that I had actually gone to Twitter. And, and I think that that, you know, I’ve tried to follow a little bit in Lilly’s footsteps or Ronnie Stewart or my current partner, Jamie Coleman. I think that for me Twitter is, is I stick only to me, occasionally someone posts a funny, you know, COVID-related saving that I have to think is hysterical. But I really stick to scientific items in there, whether it’s to promote something within a Swiss organization that I’m a member of. The WST has something happening or is that something surgical. And then I also think that it’s a great way to to have conversations about clinical conundrums. And to me, it’s fascinating to see so many different perspectives about the way that we manage the injured patient. And so I think being active on Twitter, for me, I am almost more of an active observer, because it provides me with such an insight into how people manage patients differently across the country in the world. And I think that has been really eye opening. You know, I think we all recognize that we are a product of where we train and who our partners are, and what the latest meeting is that we went to and so I think it’s a terrific way to get new and different ideas out there. And so it’s it’s kind of fun to see different people sparring about how we should be doing things. So, so that’s, that’s my take on Twitter. And I have I have to say, that’s the only social media of which I ascribe intimately to. As far as your oh, what would I what would I tell my my younger self? Oh, that is that is so interesting. Maybe interesting is not the right word. Because you know, on any given day, I think that I am my younger self and not my older self. So, um, I think that probably, you know, so many people are are being asked, as residents, where do you see yourself in 10 to 15 years, I would say that I didn’t have a great plan, which maybe doesn’t sound particularly inspiring. But I do think it’s important that in some ways, not having a master plan helps open up opportunity. And so, for me, I think it, it really was, allow yourself to see the opportunity, allow yourself to become interested in things that you want to do and pursue those. And that you don’t always have to adopt the things that your mentor wants you to do or the interest that someone else wants. And so I think, you know, rather than projecting where you might be in 10, or 20 or 30 years, I think taking advantage of the daily opportunity and seeing the possibility in that, I think it’s really important.

Ameer Farooq  31:08

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So feel free to email us at podcast.cjs@gmail.com or connect with us on Twitter @CanJSurg. Thanks again.