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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Trauma Reflections – April 2018

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

 


 

Major points of interest:

 

A) Managing airway in severely head injured patient

Intubate GCS < 5 prior to CT scan or after? Good discussion ensued. The bottom line – with a well-placed i-gel LMA and spontaneous respirations with O2 sats of 99%, obtaining CT to rule out potentially correctable brain injury is the priority. Intubation on return to ED from DI should be done using appropriate techniques and medications to minimize surge in ICP – SEE THIS PODCAST

 

B) He is on Riveroxaban? That’s just great..

Trauma patient on NOAC/DOAC can be a challenge. Only medication with true reversal agent is dabigatran (Praxbind 5G IV). Consider Octaplex until true reversal agents for the Xa inhibitors become available. Remember TXA!

 

C) Trauma transfers from other centers

Expectation is trauma activation for all major trauma transfers, even if “direct” for a consultant.

 

D) Post intubation analgesia and sedation – “Is he hungry?”

No he isn’t! – biting the ET tube means it is time to crank up the meds. Infusions are superior to push dosing. Analgesia is often given in inadequate doses or not at all. Also consider the need for larger doses of opioids in patients on methadone.

 

E) Disposition from Emergency Department

NB Trauma Program Policy 2.4-010, which has long been approved by LMAC – commit this to memory!

“The TTL, in consultation with other inpatient services, shall determine the most appropriate service and level of care for admission, transfer or discharge.”

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Trauma Reflections – December 2017

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

 


 

Major points of interest:

 

A) Burns – Get out your crayons……

Accurate documentation of total body surface involved is key to determination of appropriate initial fluid resuscitation. Parkland formula = 4ml Ringer’s lactate x %BSA x kg – 1⁄2 in first 8 hours. Only count 2nd and 3rd degree burns. Lund and Browder documentation sheets. Urinary output will influence adjustment of fluid rates, so careful documentation of ins/outs is important.

B) Trauma in Maine – Get me out of here!

Canadian citizens injured in the U.S. often are transferred to NB for further investigation and management. TCP does NOT coordinate these transfers. Expectation is that the TTL will communicate with the sending physician and/or receiving consultant and manage as we would any other transfer from another facility.

C) Trauma transfers from other centers

Expectation is trauma activation for all major trauma transfers, even if “direct” for a consultant.

D) Crash 3- We are recruiting….

We are recruiting to the CRASH 3 study. Please familiarize yourself with eligibility criteria – adult, TBI < 3 hours isolated TBI.

E) Pre-alert of consultants – “Call me back when he gets there…”

In cases where immediate need for surgical consultation is clear, TTL should “pre-alert” consultants with ETA. Simultaneous arrival of consultant and patient is the goal.

F) Trauma activation package

Folder box on counter in room #19 has trauma activation packages – one stop shopping for all documents needed. Please fill out ‘MD Trauma Activation Log’ for every activation.
“SJRH ED Trauma Process Checklist” is in package and is a very useful prompt. Call it overhead. Put on a sticker.

G) Documentation

Documentation is important. Consider verbalizing full physical exam during secondary survey for documentation RN to chart on page 3 of trauma notes. MD can sign these notes. This will free up space on ED chart for “higher level” documentation such as list of injuries and treatments.

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Trauma Reflections – October 2017

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

 


 

Major points of interest:

 

A) Tranexamic acid administration

It should be given to patients “who have, or are at risk for, significant hemorrhage”.
It has to be given within 3 hours of injury to be of benefit.

Loading dose of 1 gram over 10 minutes and start the infusion as well – 1 gram over the next 8 hours. .

B) Trauma in elderly – Old people are very breakable.

This is a high-risk population with increased morbidity/mortality from all injuries, even simple falls. Consider liberal use of “pan scan” to delineate extent of injuries. Given decreased physiologic reserve, anticipate this group may decompensate and will benefit from observation in intensive care setting.

 

C) Crush injuries

Patients with crush injuries are at risk for rhabdomyolysis and acute renal failure. Baseline CK is recommended as part of routine trauma panel. Ensure aggressive resuscitation in this group, with ongoing monitoring of urine output (100ml/hr.).

 

D) Time in Department – Have you noticed our department is really busy?

Keeping time spent in ED to a minimum is in the best interest of the trauma patient and decreases pressure on our departmental resources. This goal can be met by expediting imaging studies – holding patients for CT should not be regular practice. Goal should be time to CT < 1 hour.

Notify consultants as early as possible. “Pre-alert” consultants that will likely be required to attend to patients based on information from dispatch/ANB.

 

E) Pelvic fractures

Think pelvic fracture with motorcycle MVCs. This diagnosis should be considered during primary survey and resuscitation, using pelvic x-ray as adjunct. Like a tension pneumothorax, diagnosing an open book pelvic fracture with CT is considered bad form. When in doubt, apply pelvic binder and remove when pelvis has been cleared.

 

F) Limb threatening injuries

Open fractures and limb injuries with evidence of vascular compromise need prompt recognition and management. Antibiotics should be administered immediately after diagnosing an open fracture.
In cases where limb threatening injuries are being transferred to SJRH ED for orthopedics/vascular consultants, TTL should “pre-alert” consultants when ETA is established.

 

G) Pediatric trauma

Children with isolated head traumas may be transferred to SJRH ED for direct consultation with pediatrics. TTL should be aware/involved with assessing these patients on arrival in ED to determine if there has been deterioration en route.

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Trauma Reflections – August 2017

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

 


 

Major points of interest:

 

A) Tranexamic acid administration

It should be given to patients “who have, or are at risk for, significant hemorrhage”. It has to be given within 3 hours of injury to be of benefit.
Free fluid on POCUS? Discussing trauma transfer from peripheral facility? “Trauma bloods” have been ordered? – Think TXA.

Isolated head injury patients may be candidates for CRASH 3 study.

“I don’t ask myself if I should give it, I ask myself why I shouldn’t give it!” – Dr Jay Mekwan, airway guru and trauma enthusiast

B) Injured patients self-presenting to department

Trauma patients that “walk-in” to department may have significant injuries. Be vigilant with this group, especially if a significant MOI is described.

C) Disposition

Patients with significant injuries, but not needing immediate surgical intervention, should be admitted/observed in ICU x 24 hrs. TTLs have a duty/right in policy to effect appropriate disposition setting. Department head and/or chief of staff are available to assist if needed.

D) Time to CT

Results of CT scan are often critical to determining next steps in treatment. CT should be ordered early. If more than one patient is waiting for CT, prioritize and communicate with staff as to which patient should go first.

 

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Trauma Reflections – June 2017

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

 


 

Major points of interest:

 

A) Activation improves resource accessibility

Trauma Team Activation is intended to give increased ability to request consultant services, diagnostic imaging, lab, access to inpatient beds, on the TTLs authority.

Be aware that by policy, we should have disposition resolved by 4 hours.

Issues with process can be documented on the TTA form. Every case is reviewed.

 

B) Time dependent injuries transferred to our ED

These cases should have enough lead time that the required surgical services can be on site on arrival. Please call consultants in advance with an ETA for patients.

C) Important not to miss steps in primary and secondary surveys, including eFAST

Occult injuries can be picked up more quickly with attention to detail.

 

D) EtOH can mask major injuries

Enough said.

 

E) Tranexamic acid administration

Ensure given within 3 hours for appropriate “potential” blood loss. (also see CRASH3 trial)

 

F) Pan Scan CTs/ C spine CT

Will pick up occult injuries which are otherwise potentially missed. Have a low threshold.

 

G) Trauma transfers for DI

These cases should come through ED for reassessment and not go direct to scanner.

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