Trauma Reflections – October 2018

Thanks to Dr. Andrew Lohoar and Sue Benjamin for leading the discussions this month

 


Major points of interest:

 

A)  Intubated patients should not need restraints..

Post intubation sedation and analgesia can be challenging. Key is to avoid starting medications that could potentially drop blood pressure at very high infusion rates, but we need sedation and analgesia promptly.

Consider bolus of sedatives and analgesics prior to initiating infusions and prn boluses afterwards. Inadequate analgesia is often the cause of continued agitation.

 

B)   But what about this guy with the BP of low / really low?

Consider “vitamin K” – ketamine – can augment BP in patients who are not catecholamine depleted.

 

C)  Trauma patients you know will require consultants

When services are known to be required for patients prior to arrival (intubated, critical ortho injuries, penetrating trauma, transfers etc.) call a level A activation – consultants should meet patient with you. Give the consultants notice when patient is 15 minutes out.

Required consultants need to attend to critically injured in a timely fashion. Escalate to department head or chief of staff if there is unreasonable delay.

View the SJRHEM Trauma Page for list of definitions including Trauma Team, Activation Levels etc

 

E) Managing the pediatric airway – adrenalizing for all involved

Pediatric trauma is the pinnacle of a HALF (high acuity, low frequency) event. Team approach is key. Get out the Broselow tape.

Bradycardia with intubation attempts is not infrequent in youngest patients. Consider atropine as pre-med if  < 1 year of age or < 5 years of age and using succinylcholine.

 

F) MTP

Do not forget platelets and plasma if onto 4th unit of PRBCs – 4:1:1 ratio.

 

G)  Where is this patient being admitted?

Not to the hospitalist service, that is where!

Patients with significant injuries, but not needing immediate surgical intervention, should be admitted/observed in ICE x 24 hrs. Department head and/or chief of staff are available to assist if needed.

 

H)  Chest tube types and sizes

Pigtail catheters for traumatic pneumothorax are effective, less painful and are gaining favour as an alternative to traditional chest tubes. As for sizes, there is likely little benefit for 36F over 32 F catheters – probably time to retire these monsters from the chest tube cart.

I)     Why do bedside U/S if patient about to go to CT?

Chest scan might prompt chest tube placement prior to CT if pneumothorax is identified. Although identifying blood in the abdomen prior to CT may not change your management – it may prompt an earlier call to general surgery.

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Trauma Reflections – August 2018

Thanks to Dr. Andrew Lohoar and Sue Benjamin for leading the discussions this month

 


 

Major points of interest:

 

A) Blood is important stuff…so keep track of it.

Recent ATLS guidelines are suggesting switching to blood for resuscitation after one litre crystalloid bolus, not two. We will be using blood more often and it is important to keep track of amount ordered and infused. Give clear orders, document, and send any unused units back to transfusion medicine.

 

B) Analgesia/anti-emetics prior to leaving for diagnostic imaging

Moving on/off DI tables can increase pain or provoke nausea in some patients.

 

C) Who put that thing there?

If you decide to put something into your patient, such as a chest tube or ET tube, then write a procedure note, including details of placement confirmation.

 

D) Trauma patients you know will require consultants

When services are known to be required for patients prior to arrival (intubated, critical ortho injuries, penetrating trauma, transfers etc.) call a level A activation – consultants should meet patient with you. Give the consultants notice when patient is 15 minutes out.

In pediatric traumas that cannot be managed locally use the NB Trauma TCP to coordinate transfers to IWK.

 

E) Yo-yoing to DI for yet another film

“Pan-scanning” a younger patient can be a difficult decision, but if there is a high energy MOI and indication for spine imaging, CT scan is the superior imaging choice.

 

F) Pregnancy tests for everybody

Do not forget this in ‘older’ pediatric age group.

 

G) “Moving all limbs”..

..is NOT an acceptable documentation of exam findings in a patient with suspected neurologic injury. Thorough exam to detect any deficits is needed for neurologic baseline and for comparison later. Dermatome level of sensory dysfunction, key muscle group strength (0-5 scale) and anal sphincter tone should all be recorded, with time of exam.

 

H) Severe traumatic brain injury

Remember the CRASH 3 study – adult with TBI < 3hrs from time of injury.

 

I) Motorcycle + cocaine + EtOH + no helmet…

Equals an agitated head injured patient very difficult to sedate after intubation. Consider fentanyl infusion in addition to sedation infusion.

 

 

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Trauma Reflections – June 2018

Thanks to Dr. Andrew Lohoar and Sue Benjamin for leading the discussions this month

 


 

Major points of interest:

 

A)  Should that be bubbling like that?

Chest tube placement is a critical procedure in managing trauma patients – successful placement can be challenging, complications are common. Post-procedural imaging and check of chest drain system should determine adequate positioning/effectiveness. Check for fluctuation (tidaling) of fluid level in water seal chamber.

 

B)   Nice intubation…but why is his BP now70?

Post intubation sedation and analgesia infusions are superior to push dosing, but should be titrated up slowly to effect. Avoid starting medications that could potentially drop blood pressure at very high infusion rates – yo-yoing BP is not good for damaged neurons.

See attached NB consensus statement for suggested medications and dosages.

FINAL Consensus statement – RSI+ – July 2018

C)  Crystalloid choice in burns

(Warmed) Ringer’s lactate is the preferred crystalloid for initial management of burns patients. And probably all trauma patients for that matter.

 

D)  TTA log sheets – numbers are only slightly better

Ensure qualifying traumas have activations, and TTA log sheets are filled out. Don’t forget transfers should have activations as well.

When services are known to be required for transfer patients (intubated, critical ortho injuries etc.) call a level A activation – consultants should meet patient with you.

Remember, ED length of stay < 4hours is significantly higher with trauma activations (60% vs. 30%), so it is to our advantage to identify these patients immediately on arrival.

 

E) Propofol infusions in pediatric population

This in still a no-no in patients < 18 yo. Single doses for procedure is fine, but for maintaining sedation choose something else.

 

F)  “Moving all limbs”..

..is NOT an acceptable documentation of exam findings in a patient with suspected neurologic injury. Thorough exam to detect any deficits is needed for neurologic baseline and for comparison later. Dermatome level of sensory dysfunction, key muscle group strength (0-5 scale) and anal sphincter tone should all be recorded, with time of exam.

 

G)  We don’t talk anymore..

There should be TTL to TTL handover at shift change if the trauma patient still resides in our ED. Even if consultants are involved.

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