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
