Handover from EMS to Trauma Team: an analysis

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Rib Fractures and Serratus Anterior Plane Block

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Tube Thoracostomy

Saint John EM Rounds – February 2021

Dr Crispin Russell

Thoracic Surgeon, Dalhousie University, Saint John

 

 


 

Trauma Rounds Summary:  January 19 2021 “Chest Tube Management in Trauma – Insights from a Thoracic Surgeon”

Summary – Dr. Andrew Lohoar

Major take home points:

 

  • Most common complication with insertion is advancing tube too far.

  • Consider placing tube if pneumothorax is > 10%, lower threshold if transporting patient from peripheral hospital.

  • Use 28 French tube for most cases

  • Direction you puncture chest wall is generally direction chest tube will follow

  • Bigger skin incision may make procedure easier

  • “Corkscrewing” or twisting chest tube while placing it, helps ‘feel’ where it is in the chest cavity (avoids advancing too far)

  • Post-chest tube insertion CXR is critical to identify placement issues

  • Use large volume of local anesthetic (20+ cc) – try to infiltrate parietal pleura

  • Consider infiltrating prior to setting up your tray, allowing more time for anesthesia

  • Consider holding Kelly clamp with one hand when puncturing pleural, to protect from pushing tip to far into chest. Spread clamp parallel to ribs

  • 0 Silk is still preferred for securing chest tube

  • Consider tying an ‘air knot’ 1 cm above skin when securing tube, allows easier adjustment later

  • Secure chest tube connections with longitudinal taping – stronger and can see joint

  • U/S can be used to assist with placement

  • Always assess for chest tube functioning post-procedure

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EM Reflections December 2020 – Pelvic Trauma

Big thanks to Dr. Joanna Middleton for leading discussions this month.

All cases are theoretical, but highlight important discussion points.

Authored and Edited by Dr. Mandy Peach

Case

A 46 yo male is transported to the ED via EMS after sustaining multiple injuries in a motorcycle accident. He was helmeted and driving on a community street, he estimates at 70km/hr, when he hit a patch of water and hydroplaned off the road into a ditch. He was not ambulatory on scene and a bystander called EMS. On arrival in the trauma bay his vitals are: BP 100/62 HR 115 Sat 100% on NRB, T 37.2

You begin your primary survey. His airway is patent and he is speaking full sentences. He complains primarily of chest pain with breathing and pain in his hips and legs. His helmet was removed on scene by EMS and is in good condition. He was collared as a precaution. He has obvious bruising over the anterior chest, you suspect from hitting the handlebars, but normal chest rise bilaterally with breathing. He has decreased air entry bilaterally to the bases, PoCUS reveals normal lung slide. You move on to circulation. There is no sign of arterial bleeding. FAST exam shows negative RUQ and LUQ views, however it is indeterminate as the patient was placed in a pelvic binder on scene and you can’t visualize the pelvic views.

Do you remove the pelvic binder to access for pelvic injuries?

No – pelvic ring injuries can result in massive venous hemorrhage. This patient is hypotensive and tachycardic, given the mechanism a pelvic injury is quite likely – therefore removing the binder could stop any tamponade of vessels, leading to move blood loss and an unstable patient.

If a patient is externally hemorrhaging from a source thought to be under the binder than the binder can be transiently removed to control the bleeding1 .

You decide to leave the binder in place and get portable XRs as you work through your trauma survey. XR’s confirm a pelvic ring fracture – you suspect open book that has been ‘closed’ with the binder.

This patient has a pelvic injury, other than hemorrhage what other injuries/complications is this patient at risk of 2,7,8?

Intraabdominal: 16%
Rectal injury – considered open fracture
High risk of infection/sepsis if missed

Urologic injury: <5%
More common in men (10X more likely)
Consider in anterior pelvic fractures

Gynecologic injury (if patient were female): 2-4%
Vaginal injury – considered open fracture

Neurological: 10-15%
Sacral plexus injury
The worsening instability of fracture = higher neurological risk
Cauda equina

Thoracic aortic rupture: 1.4% in pelvic fracture compared to 0.3% in blunt trauma without pelvic fracture

Imagine this patient was dropped off at the door by his friends who lifted him in, instead of being assessed by EMS – what injuries on visual exam would be concerning for pelvic injury3?

Perineal/scrotal bruising or hematomas

Blood at the urinary meatus or vaginal introitus or rectum

Malrotation of the lower limbs

Is a DRE warranted in this patient? In every trauma patient 4?

Rectal exam changes the management in 1.2% of trauma cases.

3 situations where a rectal exam is warranted

Spinal cord injury to access for sacral sparing

Pelvic fracture to determine if fracture is open

Penetrating abdominal trauma to assess for gross blood.

*Consider vaginal exam if consider genital injury as well.

What would be a contraindication to foley insertion?

Concern for genitourinary injury5
– Blood at the urethral meatus
– Penile/scrotal ecchymosis
– Gross hematuria or
– Patient unable to urinate

If possible, insert foley before application of pelvic binder if no contraindications. But in the field foley insertion does not delay the application of a pelvic binder.

If you were concerned about pelvic injury do you want to confirm with XR before placing a binder4?

No – if any concern for pelvic injury bind immediately.
Consider foregoing the pelvic exam and just place the binder on spec if mechanism of injury is concerning for pelvic injury.

If I do examine the pelvis – what is the best approach 4?

Do not place outward pressure or assess for vertical instability
Do not rock the pelvis.
Apply an inward pressure of the iliac wings once to assess for any movement.

Movement felt? Hold that inward pressure and immediately apply a pelvic binder.

How do you place a binder6?
This video reviews both the use of a commercial binder and using a bedsheet if you’re in a ‘bind’.

Remember that the binder goes over the greater trochanters (even though it is called a ‘pelvic’ binder). You can also internally rotate the legs and tape them together at the ankles to decreased anatomic bleed space4

 

Now imagine you are working a peripheral ED and the patient can’t be transported immediately due to mass casualty event at the nearest trauma center. The patient has been stabilized and will likely be in your department for hours.

Other than vitals, monitoring of symptoms and PoCUS assessment, what else should be part of your reassessment for a patient in a pelvic binder?

“Circumferential compression provided by pelvic binders should be released every 12 hours to check skin integrity and provide wound care as required1

The patient had pulmonary contusions and other superficial injuries on exam in additional to an unstable pelvic fracture. He went on to have a successful OR and recovery.

 

References & further reading:

  1. NB Trauma Program (2015). Consensus statement: Pelvic Binders. https://nbtrauma.ca/wp-content/uploads/2018/02/Consensus-Statement-Pelvic-Binders-December-2015.pdf
  2. Thomas (2016). Crackcast Ep 055: Pelvic Trauma. CanadiaEM https://canadiem.org/crackcast-e055-pelvic-trauma/
  3. Nickson (2020). Pelvic Trauma. Life in the fast lane. https://litfl.com/pelvic-trauma/
  4. Helman, A. Bosman, K. Hicks, C. Petrosoniak, A. Trauma – The First and Last 15 Minutes Part 2. Emergency Medicine Cases. January, 2019. https://emergencymedicinecases.com/trauma-first-last-15-minutes-part-2. Accessed Jan 12 2021.
  5. Lipp (2016). Genitourinary Trauma. https://canadiem.org/crackcast-e047-genitourinary-trauma/
  6. How to Apply a Pelvic Binder. CoreEM https://www.youtube.com/watch?v=tWLBZKeWEkg&ab_channel=CoreEM
  7. Fiechtl (2020). Pelvic trauma: Initial evaluation and management. Uptodate. Retrieved Jan 12, 2020.
  8. Li, P., Zhou, D., Fu, B. et al. Management and outcome of pelvic fracture associated with vaginal injuries: a retrospective study of 25 cases. BMC Musculoskelet Disord 20, 466 (2019). https://doi.org/10.1186/s12891-019-2839-y

Pelvic image from: Govaert, Geertje & Siriwardhane, Mehan & Hatzifotis, Michael & Malisano, Lawrence & Schuetz, Michael. (2012). Prevention of pelvic sepsis in major open pelviperineal injury. Injury. 43. 533-6. 10.1016/j.injury.2011.12.002.

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Wound Management in the ED: Absorbing the Literature – Case Study

 

A review of the principles of emergency wound management including detailed guide to suture material.

 

Medical Student Clinical Pearl – June 2020

Robert Hanlon

@roberthanlon12

Year: 4
DMNB Class of 2021

Reviewed and Edited by Dr. David Lewis

All case histories are illustrative and not based on any individual


 

Case Report

You are a third year clinical clerk asked to go see a patient and assess their injuries. A 28 year old female, who is sitting upright in bed and texting her friends, came into the Emergency department via ambulance with a laceration over her right forearm and wrist. EMT vital signs are as follows: BP 128/84, HR 106, RR 18, Temp 37.2, O2 Sats 99% on RA, GCS 15, and Blood glucose 6.4 mmol/L. She weighs 60 kg. The paramedics had wrapped her arm with gauze, which has a blood tinged color to it.

Crying Boy Laying Down With Injured Leg. Selective Focus On Shin.. Stock Photo, Picture And Royalty Free Image. Image 81697370.

What is your approach?


 

Emergency Wound Management

 

A – Ask yourself: is the patient stable or unstable?

  • Based on this patient’s vital signs and the fact that they seem calm and comfortable in bed, they are stable. The tachycardia noted in the vitals is likely due to pain/stress at the time collection and when taken again in the ED her heart rate is 78 and regular.
  • A critical wound (hemorrhage or arterial bleeding) will likely need immediate attention and the patient may be presenting with vital signs that suggest more instability (low BP, high HR, high RR, High Temp, low O2 Sats).
  • If the patient is stable and not exsanguinating, then a brief history and physical should be performed. 1,2 Obtain a brief history:

Arterial bleeding

 

 

B – Obtain a brief history:

Mechanism and timing of injury: The patient was carrying towels down the stairs to her pool, tripped and fell down 5 steps, landing on her right side and breaking through a glass panel on her deck. This occurred 45 minutes ago.

Potential for concurrent injuries based on mechanism: The patient denies any loss of consciousness or head trauma. Denies any pain besides the laceration and does not feel like she has broken any bones.

Functional status prior to injury: She had full range of movement and full sensation in her right arm, wrist, and hand prior to the injury.

Medical History: Patient denies any allergies, diabetes, renal disease, cardiac and vascular diseases, and no bleeding disorder. She is a healthy non-smoker, and her only medication is an OCP.

Tetanus Status: She is up-to-date with her immunizations and her last tetanus shot was 2 years ago.

 

C- Perform a Physical Exam:

Patient is a well-looking 28 year old female with no signs of distress. She is alert and oriented to person, place, and time. She has a bandage on her right forearm that has dried blood on it. She denies any numbness or tingling in her hand. There is no obvious deformity of the arm.

Remove bandage and assess wound: Patient has a 6 cm rounded laceration with the wound extending from the mid-wrist on the volar side to Lister’s tubercle on the dorsal side. It looks like you can see some tendons and muscle at the wound base, but they do not look injured. There is no sign of glass or other foreign bodies, no dead tissue, and the wound bed appears bloody. It has a slow stream of blood running out of it. The surround skin is pink and appears undamaged.

Assess for neurovascular compromise 3,4  : The wrist anatomy is complex and it is important to consider the underlying anatomy when deciding on how to test for injury. Also compare to the patients “normal” other side.

Test for motor function: patient is able to fully extend, flex, and deviate the wrist to both ulnar and radial sides. She is able to flex, extend, abduct, and adduct her thumb, and has no trouble with opposition. She has flexion at the PIP and DIP joints from D2 to D5. She is able to fully extend her fingers and perform abduction as well. Her strength is 5/5 for these movements as well.

Test for sensation: Patient has sensation to light-touch and pin-prick over her thenar eminence, distal aspect and dorsal aspect (proximal to PIP) of D2, D3, and radial half of D3 (testing for intact median nerve). As well as sensation over the radial aspect of the dorsal hand (Radial Nerve). With this injury you should not expect the ulnar nerve to be damaged, but you’re a studious clerk and testing reveals intact sensation.

Test for vascular compromise: You do not notice any pulsatile aspect to the bleeding, her skin is pink, warm, and has <3 seconds of capillary refill. You palpate strong radial pulses and are reassured that she has not injured this artery.

 

With this examination you are reassured that she has not injured any underlying structures (tendons, nerves, muscles, and vasculature). You tell the patient that despite a large cut, she is lucky that no serious damage was done.

 

D- Obtain Pain Control: Either local or regional anesthesia.

Luckily, you just finished your plastic surgery rotation and had plenty of experience drawing up local anesthetic. You also learned how to inject a wound while trying to minimize the patients pain. You were told to ALWAYS USE EPI and ALWAYS USE BICARB in your anesthetic solution.5 You draw up one 10 ml solutions (or 100mg) of Lidocaine 1% with epinephrine 1:100,000 buffered with 1 ml bicarbonate (1:10 ratio of bicarb to lidocaine). Maximum dose being 7mg/kg or 420 mg for this patient. You’re wondering if you might need more and realize that you could be getting close to the patient maximum dose; however, you remembered you could always dilute your solutions to double the amount of syringes and still have effective analgesia.5,6 You use a smaller gauge needle (27 or 30 gauge) as this helps to reduce the pain experienced by the patient.5 You let the patient sit for a while so the analgesia will be effective.

ED Rounds – EM and Hand Surgery – Dr Don Lalonde

Regional anesthesia of the hand

 

E – Irrigation and Cleansing:

You irrigation the wound with copious amounts of tap water (or saline). Again, you notice no foreign bodies or signs of infection. You position the patient lying down in bed and cleanse the skin around the wound with chlorhexidine swabs to prep the surface for wound closure.1,3,7,8

Note: Debridement of jagged, dead, or highly contaminated tissue may be necessary in order to promote wound healing and provide an optimal surface for closure and cosmetic effect.3

 

F- Wound Closure with Sutures:

When you were gathering your supplies you realized there were many options for sutures, so you decided to ask your attending. They recommended a non-absorbable either 4-0 or 5-0 Nylon suture and to use a simple interrupted technique. You closed the wound and the edges approximated well. You, your patient, attending are all happy with the result. The patient is discharged with follow-up for suture removal in 7 days.

Wound Closure Resources

 

Useful Patient Information Reference from the ACS

 


 

Suture Types: To absorb or not to absorb?

 

Typical emergency department suture choice is a monofilament non-absorbable suture, this is due to ease of handling, knot security (does not easily break), and emergency texts report a lower rate of infections.1,2,3 There is also the need for suture removal, which requires follow-up and a second look at how the wound is healing. Absorbable sutures are usually harder to handle and tying knots can be tricky due to ease of breaking, especially with smaller sized sutures. Much of the emergency texts cite an increase in rates of infection with absorbable sutures as a reason not to choose them. However, evidence suggests that there is no significant difference in rates of infections or clinical outcome.9-12 Literature does point towards higher rates of tissue reactivity (inflammation associated with placing of suture) with absorbable sutures.12 Really selection of sutures comes down to wound factors (location and tension requirements), patient factors (need for follow-up, compliance, etc.), as well as physician preference. See tables for types and recommended use.

 


 

References:

  1. Busse, Brittany, and SpringerLink. Wound Management in Urgent Care. 1st Ed. 2016.. ed. Cham: Springer International : Imprint: Springer, 2016. Web.
  2. Cydulka, Rita K. Tintinalli’s Emergency Medicine Manual. 8th ed. New York: McGraw-Hill Education, 2018. Print.
  3. Reichman, Eric F. Reichman’s Emergency Medicine Procedures. McGraw Hill Professional, 2018.
  4. Janis, Jeffrey E. Essentials of plastic surgery. CRC Press, 2014.
  5. Strazar, A. Robert, Peter G. Leynes, and Donald H. Lalonde. “Minimizing the Pain of Local Anesthesia Injection.” Plastic and Reconstructive Surgery3 (2013): 675-84. Web.
  6. Lalonde, Donald H. ““Hole-in-One” Local Anesthesia for Wide-Awake Carpal Tunnel Surgery.”Plastic and Reconstructive Surgery 5 (2010): 1642-644. Web.
  7. Deboard, Ryan H, Dawn F Rondeau, Christopher S Kang, Alfredo Sabbaj, and John G Mcmanus. “Principles of Basic Wound Evaluation and Management in the Emergency Department.”Emergency Medicine Clinics of North America 1 (2007): 23-39. Web.
  8. Forsch, Randall T. “Essentials of Skin Laceration Repair.” American Family Physician8 (2008): 945-51. Web.
  9. Kharwadkar, N., S. Naique, and P.J.A Molitor. “Prospective Randomized Trial Comparing Absorbable and Non-absorbable Sutures in Open Carpal Tunnel Release.” Journal of Hand Surgery1 (2005): 92-95. Web.
  10. Xu, Utku, Bin, Xu, Utku, Bo, Wang, Utku, Liwei, Chen, Utku, Chunqiu, Yilmaz, Utku, Tonguç, Zheng, Utku, Wenyan, and He, Utku, Bin. “Absorbable Versus Nonabsorbable Sutures for Skin Closure: A Meta-analysis of Randomized Controlled Trials.” Annals of Plastic Surgery5 (2016): 598-606. Web.
  11. Sheik-Ali, Sharaf, and Wilfried Guets. “Absorbable vs Non Absorbable Sutures for Wound Closure. Systematic Review of Systematic Reviews.” IDEAS Working Paper Series from RePEc(2018): IDEAS Working Paper Series from RePEc, 2018. Web.
  12. deLemos, D. (2018). Closure of minor skin wounds with sutures. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Retrieved July 3rd, 2020. Source
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ADULT Rapid Sequence Intubation and Post-Intubation Analgesia and Sedation for Major Trauma Patients – NB Trauma

Consensus Statement:

ADULT Rapid Sequence Intubation and Post-Intubation

Analgesia and Sedation for Major Trauma Patients

NB Trauma Program – July 2018

Background:

  • Major trauma patients frequently require advanced airway control.
  • Endotracheal intubation is the preferred advanced airway intervention in major trauma patients.
  • Intubated trauma patients also need significant post-intubation pharmacological support.
  • Specifically, these patients require analgesia and sedation. This is particularly true when transfer to another facility is required, during which ICU level support is not available unless transfer occurs via Air Ambulance.
  • In New Brunswick, there is significant variation in the approach to both advanced airway control and post-intubation analgesia and sedation practices for major trauma patients.
  • Physicians in smaller centres in particular have asked for standardized, evidence-based guidance for both Rapid Sequence Intubation (RSI) and post-intubation pharmacological support in preparation for (and during) ground-based interfacility transfer.
  • Rapid Sequence Intubation (RSI) is a method to achieve airway control that involves rapid administration of sedative and paralytic agents, followed by endotracheal intubation.
  • The purpose of RSI is to affect a state of unconsciousness and neuromuscular blockade, allowing for increased first pass success of endotracheal intubation.
  • Post-intubation analgesia and sedation is a method of controlling pain, agitation and medically induced amnesia for major trauma patients.

 

Consensus Statements:

 

  • A provincially standardized, evidence-based guideline for Rapid Sequence Intubation should be available in all NB Trauma Centres (Appendix A).
  • Similarly, a provincially standardized, evidence-based guideline for Post-Intubation Analgesia and Sedation should be available in the Emergency Department of all NB Trauma Centres (Appendix B).
  • In addition to standardized, evidence-based guidelines, a provincially standardized equipment layout is recommended to optimize the preparation for RSI (Appendix C).
  • Ambulance New Brunswick should ensure consistency with the provincially standardized guidelines for RSI and Post-Intubation Sedation and Analgesia in procedures for Ambulance New Brunswick’s Air Medical Crew.
  • RSI should not be considered or applied for trauma patients who are in cardiac arrest or who are apneic.
  • RSI should not be considered in patients with a predicted difficult airway.
  • RSI should be considered for all trauma patients meeting the following:
    • GCS < 8, quickly deteriorating GCS or loss of airway protection
    • Facial trauma with poor airway control
    • Burns with suspected inhalation injury
    • Respiratory failure
    • Hypoxia
    • Persistent or uncompensated shock (reduction of respiratory efforts)
    • Agitation with possible injury to self or others
    • Potential for eventual respiratory compromise
    • Possible respiratory and/or neurological deterioration during prolonged transport
    • Transport in a confined space with limited resources
  • In addition to the above, RSI Guidelines should include
    • Assessment of the possibility of a difficult intubation
    • Troubleshooting
    • Immediate reference to post-intubation analgesia and sedation
  • In addition to standardized, evidence-based guidelines, a provincially standardized pre-induction checklist is recommended to optimize the preparation for RSI (Appendix D)

 


 

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EM Reflections – May 2019

Thanks to Dr Paul Page for leading the discussions this month

Edited by Dr David Lewis 


 

Discussion Topics

  1. Measles – Refresher
  2. Posterior Stroke – Beware of Mimics
  3. Missed Fracture – Distracting Injuries

 

Measles – Refresher

Measles has for many years been an infrequent diagnosis in our population. However falling herd immunity is resulting in cases presenting to Canadian ED’s.

Measles signs and symptoms appear around 10 to 14 days after exposure to the virus.

  • Fever
  • Dry cough
  • Runny nose
  • Sore throat
  • Conjunctivitis

 

Measles causes a red, blotchy (erythematous maculopapular) rash that usually appears first on the face and behind the ears, then spreads downward to the chest and back and finally to the feet. Koplick’s spots can appear 1-2 days before the rash. The rash appearance can be variable, discrete maculopapular or merging erythematous.

 

Visit emDocs.net for this great refresher on EMin5 – Measles

EM in 5: Measles


 

Posterior Stroke – Beware of Mimics

Stroke Mimics

  • Acute peripheral vestibular dysfunction (Don’t forget the HINTS exam)
  • Basilar migraine
  • Intracranial hemorrhage
  • SAH
  • Brain Tumour
  • Toxic or metabolic disturbances
  • Neuroinflammatory or chronic infectious disorders

Note that it is possible to be influenced by past experience with mimics, resulting in falsely diagnosing a mimic in the presence of a stroke.

Stroke Chameleons

Stroke chameleons are disorders that look like other disorders but are actually stroke syndromes

  • Bilateral thalamic ischaemia is such a disorder and may cause reduced consciousness level or a global amnesic syndrome
  • Bilateral occipital stroke may present as confusion or delirium
  • Infarcts limited to the medial vermis in medial posterior inferior cerebellar artery (PICA) territory usually cause a vertiginous syndrome that resembles peripheral vestibulopathy

A very useful BMJ review article on Posterior Stroke can be accessed here.

Be cautious of migraine diagnosis with history that is different to typical migraine presentation. Multiple visits should raise concerns. Importance of thorough neuro exam to find possible deficits that would raise suspicion for more serious pathology. In posterior stroke, special attention should be given to examining the visual fields.

 

Imaging in Stroke and TIA

See Rounds Presentation by Dr. Dylan Blacquiere (Neurologist)

Imaging Recommendations. Dr Jake Swan (Radiologist)

After meeting with Dr. Blacquiere and the ER Department regarding stroke management and SAH management, I’m recommending the following based on new literature and evolving management in “high risk” patients.

1) High risk TIA patients, such as those who had a profound motor / speech deficit that is resolving should have a CTA carotid / COW as well as their standard CT head.

2) SAH patients should have CT done prior to LP due to false positive LP rates.  If there is any question about vascular malformation / aneurysm, follow with a CTA. The CTA isn’t necessary for every headache patient, etc, just those with a positive bleed on the unenhanced CT.

 

The evidence is summarised in this recent paper – Imaging Recommendations for Acute Stroke and Transient Ischemic Attack Patients: A Joint Statement by the American Society of Neuroradiology, the American College of Radiology and the Society of NeuroInterventional Surgery


 

Missed Fracture – Distracting Injuries

Standard ATLS teaching, but this error still occurs……

Ensure a complete secondary survey is completed in all patients presenting with history of trauma.

Read the StatPearl Article and then do the MCQ test here

 

Trauma! Initial Assessment and Management

 

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EM Reflections – October 2018

Thanks to Dr. Paul Page for leading the discussions this month

Edited by Dr David Lewis 

 


 

Top tips from this month’s rounds:

 

Trauma – Secondary Survey

DNAR Considerations 

ED Neonatal Equipment

 


Trauma – Secondary Survey

The secondary survey is performed once the primary survey and resuscitation has been completed.

The secondary survey does not begin until the primary survey (ABCDEs) is completed, resuscitative efforts are underway, and the normalization of vital functions has been demonstrated. When additional personnel are available, part of the secondary survey may be conducted while the other personnel attend to the primary survey. In this setting the conduction of the secondary survey should not interfere with the primary survey, which takes first priority. ATLS 9e

This means that on occasions trauma patients may be transferred to the OR or ICU before the secondary survey has been completed. The secondary survey is a thorough head to toe examination including where indicated adjunct investigations e.g limb radiographs. This assessment must be carefully performed and documented. It should not be rushed.

If there is not enough time to complete a thorough secondary survey (e.g patient transferred to OR during primary survey) then this should be communicated to the surgeon or other responsible physician (e.g ICU) and the documentation should reflect this.

We would recommend that all trauma patients admitted to the ICU undergo a repeat secondary survey assessment as part of the standard admission process. In some systems this is referred to as a Tertiary survey.

This systematic review reports a reduction missed injury rate when a tertiary survey is used as part of a trauma system.

Trauma.org article on tertiary survey


DNAR Considerations 

The CMPA provides excellent guidance for clinicians considering Do Not Attempt Resuscitation orders. CMPA Website

CMPA – Key Concepts for End of Life Issues

  • The best interests of the patient are paramount.

  • The capable patient has the right to consent to or refuse medical treatment, including life-sustaining treatment.

  • Thoughtful and timely advance care planning, discussion, and documentation of a patient’s wishes and healthcare goals can help avoid misunderstandings.

  • Physicians should be familiar with any relevant laws and regulatory authority (College) policies concerning end-of-life care, and the withholding or withdrawing of life-sustaining treatment, and medical assistance in dying.

  • When considering placing a do-not-resuscitate order in the medical record, or acting upon a do-not-resuscitate order, consent from the patient or substitute decision-maker is advisable. It may also be helpful and appropriate to consult with physician colleagues and the patient’s family to determine support for the order.

  • Decisions about withholding or withdrawing life-sustaining treatment that is considered futile or not medically indicated should be discussed with the patient, or the substitute decision-maker on behalf of an incapable patient. When consensus is not achieved despite discussions with the substitute decision-maker, the family, and others such as ethics consultants, patient advocates, and spiritual advisors, it may be necessary to make an application to the court (or an administrative body) or seek intervention from the local public guardian’s office.

  • Physicians considering a request for medical assistance in dying should be familiar with the eligibility criteria set out in the Criminal Codewith applicable provincial legislation, and with applicable regulatory authority (College) guidelines.

  • Physicians should be familiar with the role of advance directives (including living wills).

  • End-of-life decisions should be carefully documented in the patient’s medical record.

Horizon Health, NB uses these accepted Canadian DNAR definitions:

 


 

ED Neonatal Equipment

Perinatal Services BC, Canada have published an excellent document – Standards for Neonatal Resuscitation

It includes this Appendix for suggested Radiant Warmer Equipment checklist:

 

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EM Reflections – December 2017

Thanks to Dr Joanna Middleton for leading the discussion this month and providing these tips and references.

Edited by Dr David Lewis 

 

Top tips from this month’s rounds:

Incomprehensible Patient – Delirium or Aphasia?

Pediatric Trauma

CME QUIZ

 

Take Home Points

  • Sudden onset language impairment should be assumed to be aphasia until proven otherwise
  • Aphasia is most commonly caused by CVA and usually has associated lateralising motor signs (but not always)
  • Aphasic patients will be able to perform non-verbal tasks normally
  • If in doubt involve telestroke / neurology early
  • Global aphasia can have a catastrophic outcome on quality of life. In selected patients, early thrombolysis can significantly improve prognosis.
  • The injuries sustained by children in chest trauma are frequently different from adults
  • Signs of shock in pediatric trauma can be subtle
  • Use evidence based guidelines e.g PECARN when considering CT for abdominal trauma
  • Elevated Tropinin or abnormal ECG suggest blunt cardiac injury

 


Incomprehensible Patient – Delirium or Aphasia?

Both can present with disorders of speech and language, however it is important to rapidly distinguish aphasia due to it’s association with stroke and the benefits of early thrombolysis.

Delirium, also known as acute confusional state, is an organically caused decline from a previously baseline level of mental function. It often has a fluctuating course, attentional deficits, and disorganization of behaviour including speech and language.

Aphasia is an impairment of language, affecting the production or comprehension of speech and the ability to read or write. Aphasia is always due to injury to the brain, most commonly from a stroke, but also trauma, tumour or infection.

 

The first tip here is to figure out how to describe the features of a patient’s language. How is the patient’s language produced and understood?

Are the words clearly enunciated (favoring aphasia) or slurred (favoring delirium)?

Is the patient’s speech grammatically correct (delirium) or lacking in appropriate syntax (aphasia)?

Is the patient’s prosody—or pattern of speech—fluent (delirium) or irregular (aphasia)?

Can the patient understand spoken language (delirium) or is there a major difficulty with following simple verbal/written commands (aphasia)?

Naming and repetition should also be assessed as part of any neurologic examination, but impairment in these modalities is not as useful in distinguishing delirium from aphasia.

The motor evaluation of inattention in a delirious patient involves testing for asterixis, either with arms and wrists fully extended or having the patient squeeze the fingers of the examiner (the “milk maid’s sign”). A delirious patient will struggle with these tasks, the extended hands may flap or the fingers may intermittently lose their grip. The aphasic patient, in contrast, may not have trouble with this.

Speak of the devil: Aphasia vs. delirium

 

Global Aphasia

  • Severe impairment of production, comprehension and repetition of language
  • Usually large CVA of left MCA
  • Usually associated with extensive perisylvian injury affecting both Broca’s and Wernicke’s areas
  • Usually accompanied by right hemiparesis and often a right visual field deficit (in right handed pt)
  • Patients with global aphasia can be shown to perform normally on nonverbal tasks such as picture matching, demonstrating they are not suffering from confusion or dementia

 

Stroke Thrombolysis – Indications and Contraindications Reminder

Patient Selection for Thrombolytic Therapy in AIS:

Inclusion criteria: Patients  >18 years of age with symptoms of AIS and a measurable neurological deficit with time of onset <4.5 h.

Exclusion criteria:

A. History

  • History of intracranial hemorrhage
  • Stroke, serious head injury or spinal trauma in the preceding 3 months
  • Recent major surgery, such as cardiac, thoracic, abdominal, or orthopedic in previous 14 days
  • Arterial puncture at a non-compressible site in the previous 7 days
  • Any other condition that could increase the risk of hemorrhage after rt-PA administration

B. Clinical

  • Symptoms suggestive of subarachnoid hemorrhage
  • Stroke symptoms due to another non-ischemic acute neurological condition such as seizure with post-ictal Todd’s paralysis or focal neurological signs due to severe hypo- or hyperglycemia
  • Hypertension refractory to antihypertensives such that target blood pressure <185/110 cannot be achieved
  • Suspected endocarditis

C. Laboratory

  • Blood glucose concentration below 2.7 mmol/L or above 22.2 mmol/L
  • Elevated activated partial-thromboplastin time (aPTT)
  • International Normalized Ratio (INR) greater than 1.7
  • Platelet count <100 x 109/L
  • Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated insensitive global coagulation tests (aPTT for dabigatran, INR for rivaroxaban) or a quantitative test of drug activity (Hemoclot® for dabigatran, specific anti-factor Xa activity assays for rivaroxaban, apixaban and edoxaban). In this situation, endovascular treatment (thrombectomy) should be considered if patient eligible.

D. CT or MRI Findings

  • Any hemorrhage on brain CT or MRI
  • CT showing early signs of extensive infarction (hypodensity more 1/3 of cerebral hemisphere), or a score of less than 5 on the Alberta Stroke Program Early CT Score [ASPECTS], or MRI showing an infarct volume greater than 150 cc on diffusion-weighted imaging.

Relative contraindications for rt-PA therapy in AIS include the following:

  • Recent myocardial infarction with suspected pericarditis
  • Rapidly improving stroke symptoms
  • Pregnancy or post-partum period
  • Recent GI or urinary tract hemorrhage (within 21 days)

From Thrombosis Canada

Take Home Points

  • Sudden onset language impairment should be assumed to be aphasia until proven otherwise
  • Aphasia is most commonly caused by CVA and usually has associated lateralising motor signs (but not always)
  • Aphasic patients will be able to perform non-verbal tasks normally
  • If in doubt involve telestroke / neurology early
  • Global aphasia can have a catastrophic outcome on quality of life. In selected patients, early thrombolysis can significantly improve prognosis.

 


Pediatric Trauma

Some specific issues particular to pediatric trauma are highlighted:

Pediatric Chest Trauma

Children have compliant chests and thus sustain musculoskeletal thoracic injuries far less frequently (5% of traumas). However, due to this elasticity, the most common injury is a pulmonary contusion.

PITFALLS

Don’t expect traditional adult injury findings: Absence of chest tenderness, crepitus and flail chests does not preclude injury.

Bendy ribs – injury to internal organs with little external evidence

Lung contusions ~50% of chest trauma

Force transmitted to lung parenchyma – lung lacerations much less common <2%

 

Pediatric Abdominal Trauma

Beware: 20-30% of pediatric trauma patients with a “normal” abdominal exam will have significant abdominal injuries on imaging.

Any polytrauma patient with hemodynamic instability should be considered to have a serious abdominal injury until proven otherwise. Tachycardia primary reflex for kids in response to hypovolemia and it may be the only sign of shock.

HIGH RISK – Indications for CT

• History that suggests severe intra-abdominal injury e.g abrupt acceleration/deceleration, pedestrian vs vehicle, handlebar injury, fall from horse etc

• Concerning physical – tenderness, peritoneal signs, seatbelt sign or other bruising

• AST >200 or ALT >125

• Decreasing Hb or Hct

• Gross hematuria

• Positive FAST

PECARN 

The Pediatric Emergency Care Applied Research Network (PECARN) network derived a clinical prediction rule to identify children (median age, 11 years) with acute blunt torso trauma at very low risk for having intra-abdominal injuries (IAIs) that require acute intervention.

The prediction rule consisted of (in descending order of importance)

  • no evidence of abdominal wall trauma or seat belt sign
  • Glasgow Coma Scale score greater than 13
  • no abdominal tenderness
  • no evidence of thoracic wall trauma
  • no complaints of abdominal pain
  • no decreased breath sounds
  • no vomiting

The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15).

Holmes JF et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med 2013 Feb 4; [e-pub ahead of print]. (http://dx.doi.org/10.1016/j.annemergmed.2012.11.009)

 

Blunt Cardiac Injury

Largest pediatric case series of BCI – 184 patients – 95% had simple cardiac contusions. https://www.ncbi.nlm.nih.gov/pubmed/8577001

The clinical presentation of blunt cardiac injury varies. Mild injuries may present without objective findings, while some patients may have minor dysrhythmias.

A normal ECG and troponin I during the first 8 hours of hospital stay rules out blunt cardiac injury, and the negative predictive value of combining these 2 simple tests was 100%. https://www.ncbi.nlm.nih.gov/pubmed/12544898

 

Click image to link to full article

 

Traumatic Tricuspid Injuries

Location, location, location

RV posterior to sternum – blunt force elevates pressures resulting in rupture of chordae, papillary muscle injury or tear of leaflet

Most frequent associated injury:  pulmonary contusion

“The presence of a transient right bundle branch block in the setting of myocardial contusion is a described, but under-recognized occurrence.”

“Although an rsr’ in the right precordial leads may be normal in children, it’s combination with an abnormal frontal axis (“bifasicular block”) is always abnormal and suggest injury to the RV”

 

Episode 95 Pediatric Trauma

Take Home Points

  • The injuries sustained by children in chest trauma are frequently different from adults
  • Signs of shock in pediatric trauma can be subtle
  • Use evidence based guidelines e.g PECARN when considering CT for abdominal trauma
  • Elevated Tropinin or abnormal ECG suggest blunt cardiac injury

 


CME QUIZ

EM Reflections - Dec 17 - CME Quiz

EM Reflections – Dec 17 – CME Quiz

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NB Trauma – ATLS Course – April 21-23, 2017 – last few places remaining…!

The Advanced Trauma Life Support® (ATLS®) program can teach you a systematic, concise approach to the care of a trauma patient. ATLS was developed by the American College of Surgeons (ACS) Committee on Trauma (COT) and was first introduced in the US and abroad in 1980.  Its courses provide you with a safe and reliable method for immediate management of injured patients.  The course teaches you how to assess a patient’s condition, resuscitate and stabilize him or her, and determine if his or her needs exceed a facility’s capacity. Inter hospital transfer and assurance of optimal patient care during transfer is also covered.  An ATLS course provides an easy method to remember for evaluation and treatment of a trauma victim.

 

 

The NB Trauma Program invites physicians to register for this 2 ½ day course that provides physicians with a measurable, comprehensive and reproducible system of trauma assessment and critical interventions for the patient with multiple injuries.

 

Enrollment is limited and registration is first-come, first-served basis, upon receipt of full payment. A one-day Refresher course is also being offered (on Sunday) and starts at 8:00am.  These courses will be conducted in English.

 

Location:       Saint John Regional Hospital

 

Dates:

April 21, 2017              4:00pm – 9:30pm

April 22, 2017              8:00am – 6:30pm

April 23, 2017              8:00am – 3:30pm

 

Questions?    Please contact Lisa at (506) 648-5056 or Lisa.Miller-Snow@HorizonNB.ca

 


 

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Application Form:

 

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