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.