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.
