Trauma

Repeat Head CT – Diane

Trauma surgeons discussed this morning and agreed:

  • If at neuro baseline or GCS 15 (ie NO CHANGE or alteration of mental status)
  • Family is reliable to monitor for neuro changes
  • Initial head CT is negative
  • INR is within normal therapeutic range OR lower,

Then patients may be considered for discharge to home without follow-up CT.

 

Massive Transfusion/ Trauma Resuscitation – Zack/Diane

  • Normal Saline – only if no radial pulse or not mentating
  • Place A-line in R femoral artery AND send ABG for base deficit
  • Transfuse 1:1:1 FFP/pRBCs/Platelets
    • Platelets come in 6 pack therefore 6 FFP/6 pRBCs/1 Platelet
    • Thawed FFP in trauma room
  • Titrate MAP to 80 on head injury/Titrate to MAP of 65 on everyone else

 

Which pelvic fractures should be considered for trauma evaluation/consultation?  – Diane

Anterior pubic bone or pubic rami fractures:  These types of fractures can be associated with bleeds.  Trauma will be available to see any patient with anterior pelvic fracture patterns although we may not always admit (some of these are stable, most are weight bearing and non-operative).  The ED should screen the patients who fall with anterior pelvic fracture patterns (pubic rami, pubic bone) for evidence of HD lability and bleeding, obtain a non-contrast CT scan to ensure there is no hematoma.  If patient is unstable, trauma activation and intervention to be determined by trauma.   IF no hematoma/no bleed, patient may be admitted as per usual for disposition, ambulation etc.   Other helpful tests are UA to rule out blood in urine, or follow-up Hg at 4-6 hours.

Insufficiency fractures should never need trauma (unless other injuries exist).    If the patient has an insufficiency fracture of the intertrochanteric femur/femur neck, then trauma does not see those patients- their injuries are osteopenic in nature and have traditionally been managed safely by ORS and medicine.

Posterior fracture patterns should always have trauma consult.  If the patient has posterior injury patterns to the sacrum/iliac/ischium, then trauma should be called by the ED to assess the type of fracture.  There is fairly robust nerve and blood supply in that area.

 

 

MTP and Emergency release are two different terms with different meanings.

MTP activation gets you a prepared cooler with type specific PRBCs and FFP (and a platelet) in a ratio for coagulopathy prevention in massive transfusion. (takes about 10 minutes to release blood)

Emergency release gets you universal donor blood/FFP from the blood bank directly and is available immediately. 

 

The Trauma Room stocks 4 O NEG (women of childbearing age) and 8 O POS (men/women over 50) and 4 universal donor FFP ready to go.  They are labeled and in O- (pink) bins and O+ (blue) bins.

The blood products in the trauma room are for trauma patients, not for ER patients, but with either the MTP or Emergency Release (above) should have transfusion needs covered for ER patients.

The labels are:
BLOOD O NEG, FEMALE 0-50 (PINK)  4 Units
BLOOD O POS, MALE, FEMALE 50+ (BLUE)  8 Units

For a trauma that has MTP need:
You will activate MTP by phone.  You will begin/finish the ED available units above.  You will simultaneously send the HCP to the blood bank.  At 10 minutes into transfusion (which is about the length of time it would take you to go thru the ED units), the following are possible: 1) cooler for MTP is ready and will arrive at the trauma bay.  2) The cooler for MTP is not ready and you need emergency release of blood and FFP.  3) The cooler for MTP is not ready and you can wait until it is ready.

The trauma surgeon is to make the FINAL decision on whether the stored emergency blood bank blood/FFP is needed and will instruct the HCP to bring the emergency release OR to wait on the cooler.

MTP and emergency release are NOT the same.

MTP is the cooler with the predetermined ratio products and is typed, which is why it takes 10 min plus.

Emergency release means “I need the blood right this second because my patient is bleeding out” and will get you an additional 8 PRBC and 4 FFP of universal donor.

Blood bank is asking, and I agree, for the estimated age (if possible) and the male/female designation.  This piece of info will further help them conserve the O-.  The O- is the most valuable and scarce and they want to maintain as much as they can for Mary Birch.  They can release O+ to you for emergency release if they know your patient is male or female >50.

Each and every time you activate AND use an MTP, please alert Dr Wintz so that she can huddle with the bank and we can improve the process.  If you also want to huddle, you are invited.  Huddles are 24-48 hours from time of MTP so that the timeline and data from the MTP can be collected.

 

***We should emphasize the importance of the runner. The runner must go to the blood bank immediately and be prepared to go back and forth at a rate that blood is prepared/needed. Take the stairs! Not the elevator!

***Turn the MTP off when no longer needed so that we don’t thaw more FFP than needed.