Tag Archives: MTP

Trauma Reflections – December 2018

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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.

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Trauma Reflections – October 2018

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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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