Trauma Reflections April 2021

Posted on April 22, 2021 by Mandy Peach

Big thank you to our guest Dr Zlatko Pozeg and Sue Benjamin for her efforts in putting these reviews together.

Major points of interest:

A) Approach to airway management in peri-arrest patients

Shocked patients should have no more than 1/2 dose of induction agents during RSI.

Ketamine and etomidate are medications least likely to negatively affect hemodynamic status.

B) “The IV line is blown” – Now what?

Establishing vascular status quickly is a critically important step in the resuscitation of trauma patients – have a plan B (and C).

If a large bore peripheral IV catheter placement cannot be achieved, intraosseous access is likely the quickest alternative.

Also consider using ultrasound to identify other peripheral venous sites, direct cannulation of external jugular vein or saphenous vein at ankle or establish central venous access.

C) Reversible causes of traumatic cardiac arrest – Fix what you can fix, quickly

D) When was the last time I did an intubation in a trauma patient?

Probably a long time ago.

This underscores the importance of simulation for these high acuity low frequency events.

E) That patient is here for CT, just send them..

In this series of trauma patients transferred to the SJRH that were NOT evaluated by ED MD or RN on arrival, majority were admitted and ½ went to ICE. These are high risk patients that should be evaluated for stability prior to sending for imaging.

F) There are very few indications for ECMO in trauma in the ED

Consider in drowning and severe hypothermia.

G)ED Thoracotomy

See following podcast from EMCrit: https://emcrit.org/emcrit/procedure-of-thoracotomy/

Trauma Reflections – October 2020

Posted on October 26, 2020 by Mandy Peach

Big thanks to Sue Benjamin for her efforts in putting these reviews together!

Major points of interest:

A) Kudos – Trauma Codes for qualifying cases has improved!

May – September 2020, for cases qualifying for trauma team activation, the rate of calling ‘Trauma Codes’ has improved to 84%. RN trauma note is 93% for the activations.

Many of the missed activations are transfers from peripheral sites

Please review the attached updated simplified activation criteria – notable changes are:

1/ Removal of minor head injuries without signs or symptoms on anticoagulants under “D”

2/ Addition of pulseless extremity under “C”

B) Chest Tubes in trauma – 5 year review

Chest tubes are placed infrequently (~ 1 per month) in our departments.

Review of post procedure x-rays (thanks J ‘Mek1’) showed there was less than optimal tube positioning 60% of the time.

Tube position and function must be critically reviewed post procedure.

Chest tube discussion/demonstration with Dr Russell will take place at next Trauma case review (January 2021)

C) Oh, that patient is just here for Plastics..

‘Distracting’ injuries are called that for a reason. It is hard to look past deformed limbs, but always perform a head to toe assessment (including FAST) to identify associated injuries to others systems.

Trauma transfers should be re-assessed by ED physician at receiving hospital, to also determine if there are any other concerning injuries that have been missed.

Trauma cases being transferred to consultants, outside of NB trauma line, should be identified by charge MD when taking report.

D) “Penetrating neck trauma is en route”

Those words will wake you up in a hurry.

Keys to management are early notification (pre-arrival) of consultants (ENT +/- vascular) and clear airway plans that include a ‘double set’ up for potential need for surgical airway.

E) What kind of monster would order a ‘Panscan’ on a child?

One that can weigh the risks (missed injuries) vs. benefits (minimizing radiation exposure).

Panscans in pediatric patients should never be ordered routinely, but should be considered in cases with high risk for clinically significant multi-system injuries (head, spine, thorax, abdomen).

F) Blunt traumatic cardiac arrest

This population has a grave prognosis.

Airway management, continuous chest compressions, rapid fluid/blood resuscitation and consideration for procedural interventions (thoracostomies, pericardiocentesis) are usual steps in care.

Epinephrine has no role unless medical cause for arrest is suspected.

A more in-depth review will be topic of upcoming SJRH ED rounds.

G) What did this guy have for supper?

Pizza and beer, and lots of it.

Ducanto catheters – large bore suction catheters – are available on all airway carts in the top drawer. They are much more efficient at decontaminating airways soiled with semi-solid material when compared to Yankauer.

H) Updated Trauma checklist:

“SJRH ED Trauma Process Checklist” is in trauma note package in room 19 and is a very useful prompt (see below). K/ T- L spine Traumatic Spine Injury Guidelines also below.

Download (PDF, 98KB)

Trauma Reflections – June 2020

Posted on June 19, 2020 by David Lewis

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

Major points of interest:

A) How are we doing with calling Trauma Codes for qualifying cases?

In the past year, for cases qualifying for trauma team activation, the rate of calling ‘Trauma Codes’ has fallen to 66%.

If a Trauma Code was called, RN trauma note use increased to 85% and time to disposition to an ICE setting was significantly decreased.

Please review the attached updated simplified activation criteria – notable changes are:

Removal of minor head injuries without signs or symptoms on anticoagulants under “D”
Addition of pulseless extremity under “C”

B) ECMO in trauma

MVC victim survived after being submerged x 20 minutes – CPR (with LUCAS) and then managed further with ECMO.

Key to successful outcome will be EARLY recognition of cases that may benefit and early alert/consultation with CV surgery.

Best evidence for ECMO is for re-warming severe hypothermic patients.

C) Significant MOI + spine pain = CT

Obtaining spine x-rays in cases with moderate probability of bony injury inevitably leads to another trip down the long hallway to visit our diagnostic imaging colleagues (and delay to definitive diagnosis).

If your patient needs a CT, order a CT.

See attached consensus guideline.

D) Pelvic binders are not used to ‘treat’ the pelvic fracture

They are used to treat any hemodynamic instability caused by the fracture. If a patient is stable or has a pelvic fracture that is not likely causing significant bleeding, the binder can likely be loosened or removed.

A pelvic binder can exacerbate some fractures, such as lateral compression fractures. Orthopedics should be assisting with this decision.

E) That intubated transfer patient just waved at me!

There is a reason trauma transfers should be assessed on arrival.

Consultants are expected to attend to these patients ASAP, but timely review by emergency MD is expected to assess/treat priorities (ventilatory status, analgesia need, sedation etc.)

F) The patient is on warfarin…how quaint!

Do you remember when anticoagulants could be reversed? In the event you do meet a trauma patient on warfarin, early correct dosing of vitamin K and PCC may be crucial.

Review of such charts in past 2 years has our dosing all over the map.

Easy dosing regime is:

Vitamin K – 10mg IV and PCC – 2000IU if INR unknown,

If INR known: PCC – 3000IU if INR > 5, PCC – 2000IU if INR 3-5, PCC – 1000 if INR < 3.

G) Trauma checklist:

“SJRH ED Trauma Process Checklist” is in trauma note package in room 19 and is a very useful prompt (see below).

H/ High MOI Knee injuries are at risk for deterioration in department

Vascular status may change, compartment syndrome may develop.

Consider repeating physical exams, early orthopedic consultation and low threshold for CT with vascular studies.

I/ Where is this guy bleeding?

Maybe he isn’t. Failure to respond to resuscitation suggests continued hemorrhage or non-hemorrhagic cause for shock. With neurogenic shock, loss of sympathetic tone may cause hypotension without tachycardia or vasoconstriction.

Consideration should be made to start vasopressors in patients with spinal cord injury with persistent hypotension after attempted resuscitation and no evidence of hemorrhagic shock. Aim for a SBP of 90-100. Avoid overzealous fluid administration.

J/ NB Trauma Traumatic Brain Injury Consensus statement – May 2020

See attached

Download (PDF, 1.32MB)

Trauma Reflections – December 2019

Posted on December 12, 2019 by David Lewis

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

Major points of interest:

A) How are we doing with calling Trauma Codes for qualifying cases?

In the past year, for cases qualifying for trauma team activation, Trauma Codes were called 80% of time.

If a Trauma Code was called, trauma note use increased to 90% and time to disposition to an ICE setting was significantly decreased.

Please review the attached updated SIMPLIFIED activation criteria.

B) End of year AWARDS – the “Crashys”

‘Crashy’ for the Busiest TTL of the Year with 17 cases …

P “I don’t see weak and dizzy patients” P

‘Crashy’ for the Most Trauma Intubations of the Year with 7 …

C “If he’s not move’n, I’m a tube’n” A

‘Crashy’ for the Most Trauma Chest Tubes of the Year with 3 …

T “Fetch me my scalpel” W

Congratulations to all (Sorry, there is no monetary gift associated with these awards!)

C) Head injury, combative and on methadone – this should be easy..

Not really. 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. Under-dosing analgesic is often the reason adequate sedation is a struggle. Bolus, then increase infusion. Repeat.

D) End-tidal CO2 is an important vital sign

Especially in intubated patients.

E) Pediatric head injury transfer for imaging

Reassessing these patients on arrival, prior to CT, may influence management.

If there has been worsening in clinical condition, neurosurgery can be pre-alerted.

If there has been complete resolution of symptoms, CT scan may be deemed unnecessary.

F) “Clearing C-spine” can’t be done remotely..

CT C-spine is not 100% sensitive for ruling out injury. If radiologist reports there is no significant abnormality seen, it is a CLINICIAN”S responsibility to examine the neck before removing c-collar. If there is discrepancy (elevated pain, tenderness or neurologic symptoms/signs) or inability to cooperate with exam, leave the collar in place.

Make it known c-spine has not been cleared.

G) Pelvic binders are not used to ‘treat’ the pelvic fracture

A pelvic binder can exacerbate some fractures, such as lateral compression fractures. Orthopedics should be assisting with this decision.

H) ‘Shock’ dosing of sedatives

Hypotension is not good for damaged neurons.

Shocked patients should have 1/2 dose of induction agents during RSI.

RSI Drugs

ADULT Rapid Sequence Intubation and Post-Intubation Analgesia and Sedation for Major Trauma Patients – NB Trauma

Trauma Reflections – February 2019

Posted on May 28, 2019 by David Lewis

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

Another highly informative and brilliantly written summary by Dr. Lohoar:

Major points of interest:

A) Are we still calling ‘Trauma Codes’ in post TTL era?

Yes. Call away. Activation rates for cases that qualify continue to hover around 80%. Patient care is always improved with a coordinated team approach – triggered by calling a trauma code overhead. Activation criteria are as follows:

B) Should RN Trauma notes continue to be used?

Yes. Folder box on counter in room #19 has trauma activation packages – one stop shopping for all documents needed. “SJRH ED Trauma Process Checklist” is in package and is a very useful prompt (see below). Put on a sticker, get into character.

C) Are you feeling lucky?

Symptomatic head injured patients seen in peripheral centers, with concern enough for an emergent CT head request should come by ambulance not car.

D) What did this guy eat for supper?

Pizza and beer, and lots of it.

Ducanto suction catheters are available on all airway carts. They are much more efficient at decontaminating airways soiled with semi-solid material when compared to Yankauer suction catheters

E) Boom, ET tube is in – high five – I am going for coffee..

Not so fast Slick, there is more work to be done.

1/ Check for ET tube placement, check for cuff leaks

2/ 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. Reassess frequently. Inadequate analgesia is often the cause of continued agitation. See attached guidelines from NB trauma – page 5 in particular

3/ NG or OG tubes should be placed and position checked as well

F) Transfers “just for imaging”

Calls from other facilities for imaging should be screened for potential trauma patients. Care is often substandard if we are not aware of these patients, and they are being managed remotely by MDs in other facilities (playing phone tag with a radiologist).

Trauma Reflections – December 2018

Posted on January 8, 2019 by David Lewis

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

Major points of interest:

A) TXA – “When did this MVA actually happen?”

Only 75% of cases receiving TXA are receiving it within 3 hours of injury. And only ½ of theses cases are having the drip started.

CRASH study found patients receiving TXA after 3 hours do not benefit.

B) Bleeding on warfarin

If emergent reversal of anti-coagulation from warfarin is needed, vitamin K (5-10mg) should be given IV (not PO), along with PCC.

C) Trauma transfers from outside of our region in the post TTL era..

Consultants accepting transfers from other regions through NB trauma line may request that patient stop in ED first for evaluation/imaging prior to transfer to floor or ICE.

The consultant should make every effort to evaluate their patient on arrival to ED

Expectation is that TCP and/or consultant clearly delineate their plan with ED charge MD.

E) Matthew 4:1:1 “Man shall not live by [RBCs] alone”

I might not have gotten that one quite right, but the MTP policy follows a 4:1:1 rule – after 4th unit of PRBCs, give a unit of platelets and FFP.

F) This guy is bleeding all over my triage room!

Patients occasionally “self-present” to triage with significant injuries or a history of a high energy MOI. The most efficient way to mobilize resources is to have the triage RN call a “Trauma CODE”.

G) Analgesia in pediatric population

Pain management in pediatric population is often challenging. If IV access is delayed consider alternative routes – intranasal fentanyl 1.5 ug/kg using MAD (mucosal atomizing device).

H) May the hoses R.I.P.

Chest tube sizes 36 F and 345F are now no longer being stocked on chest tube cart.

I) Post-intubation sedation

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.

Trauma Reflections – October 2018

Posted on October 30, 2018 by David Lewis

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..

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 4^th 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.

Trauma Reflections – August 2018

Posted on August 15, 2018 by David Lewis

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.

Trauma Reflections – June 2018

Posted on June 15, 2018 by David Lewis

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”..

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.

Trauma Reflections – April 2018

Posted on April 15, 2018 by David Lewis

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.”

Trauma Reflections – December 2017

Posted on December 30, 2017 by David Lewis

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.

Trauma Reflections – October 2017

Posted on October 15, 2017 by David Lewis

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.