Transcript Slide 1

Trauma Institutional Education Program
(Trauma IEP)
2012 Q1-2
Target Audience:
Physicians and nurses
involved in the care of Trauma Service patients.
Written by: J. Forrest Calland, M.D.
Second Reviewer: J. Young, MD
Date Written: October 2012
For questions regarding content, contact J. Forrest Calland, M.D., [email protected].
© 2010 by the UVa Health System
Trauma Program IEP - 2012 Q1-2
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Agenda
Quiz Responses:
2012 Quarter 1-2 Institutional
Education Program Quiz
Responses
Trauma Bay Topics
•ED X-rays –
What, Where, When and How
•Upgrading Alert Level
•Blunt trauma arrests
•ED Scopes
•King Airways
General Topics
•Changes to Guideline Updating Process
•Outside Imaging &
Internal Interpretations
•Expectations for pre-rounding
•Superficial Venous Thrombosis
•Propofol
•Cardiotomy
•EARLY, Aggressive Treatment of Hypothermia
•Simultaneous Procedures
•ED Thoracotomy
ICU Topics:
•ICU LIP Hand-of of care &
Order Set Clean-up
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Objectives
Upon completion of this module,
the participant will be able to communicate
the most current guidelines for optimal care
of the injured patient at the
University of Virginia.
A grade of 80% on the Posttest is required to
successfully complete the CBL.
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What is important to have available prior
to and during an
Alpha or Beta alerted patient?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
If you do not have
maintenance
medications ready after
intubation then you will
find yourself in an
unsafe situation when
you get in the elevator
/ CT / angio. Consider
having a fentanyl gtt &
propofol infusion AND a
long-acting
neuromuscular agent
with you at all times.
DO NOT USE IV PUSH
PROPOFOL or BENZO
gtts if they can be
avoided.
Financial
Forms
Credentials
Medications
Coffee
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Immediately following trauma alert
imaging completion, what disposition
steps need to occur?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Contact trauma
faculty
The key
neglected /
inconsistent step
in this algorithm
is the surgery
chief calling the
bed center – this
must happen
IMMEDIATELY
upon
discernment of
unit / acuity
disposition.
Provide
admission
details to EM
resident
Call bed center
if an ICU
admission
All of the
above
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Patients with sustained hypotension
and unclear etiology need:
a quiet
environment
90%
80%
70%
60%
50%
40%
30%
20%
10%
We have underutilized
DPL in recent years and
have, as a result of this,
occasionally missed
hemoperitoneum as a
cause of early / recurrent
hypotension Do not
hesitate to use DPL to
triage the abdomen if you
are AT ALL uncertain
about the FAST results.
0%
additional
imaging
EARLY
diagnostic
peritoneal
lavage or OR
a medicine
consult
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IV push propofol should NEVER be used in
the care of the multi-trauma patient due to
the high risk (>20%) for:
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Just don’t do it!
The hypotension that
PUSH propofol
induces causes a lot
of confusion as to
whether these
patients are bleeding
and increases the
mortality of comatose
head injured patients
by up to 50% !!
GI bleed
hypotension
migraines
scabies
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Injured patients with suspected aortic
stenosis pulsus parvus et tardus,
systolic murmur, syncope)
need to be seen by cardiology when:
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Critical Aortic
STENOSIS is a
major determinant
of adverse
outcomes in our
elderly patients –
ESPECIALLY when it
is undiagnosed /
inadequately
worked up prior to
surgical
procedures.
Trauma Program IEP - 2012 Q1-2
asymptomatic
symptomatic
All of the
above
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It looks like
60% of you
found this
helpful.
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Remember,
educational
content only
makes it to this
IEP module if a
knowledge gap
was implicated
in a serious
adverse event
or DEATH by
our Trauma PI
program.
We will strive to
make these
modules more
interesting and
informative in
the future!!
The
information in
this module
advanced my
understanding
of the topics.
Strongly Agree
Agree
Neutral
Disagree
Strongly
Disagree
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(Forrest)
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ICU LIP Hand off of care &
Order Set Clean-up
• There is now a system-wide EPIC dot-phrase that must be
completed before any patient transfers out to acute care from
the ICU service (.tricutransfer)
― You will be asked to document that you cleaned up the orders and
to whom you gave verbal report to on the acute-care service.
― The ICU nurse shall check the EPIC chart to make certain there is
a recent transfer note before transporting the patient.
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Changes to Guideline Updating Process
• Beginning in July 2012, mid-year changes to trauma
guidelines will only be noted in the electronic version of the
Trauma Handbook. A document listing changes will reside on
the Trauma Intranet site.
• Email communication will go to PI Liaisons, notifying them of
such updates. The hard copies will be replaced once per year
before the resident change-over.
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ED X-rays – What, Where, When and How
• In general, patients requiring ICU-level care should not be
transported to plain film radiology except when ABSOLUTELY
necessary to advance care.
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Outside films and Timely reads:
Preliminary Reads by 06:00 for Finals by 10:00
•
For acutely injured patients, the Department of Radiology provides internal
interpretations of outside imaging when:
1) An order exists
2) The images are in PACS
That is all that is required!!
•
Obtaining timely final reads:
― For patients coming to our hospital after hours, in general, there must be
preliminary reads available in EPIC within hours of arrival if you expect to
see final reads by 10 AM.
•
Call the reading room EARLY (by 0730) to notify them of spine films that have
not yet been read for patients that are still presumptively immobilized / in spine
precautions.
•
No pain, tenderness, distracting injury, or deficit = clinically clear with prelim
reads.
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Expectations for pre-rounding
• ICU Pre-rounds MUST NEVER be performed solely by looking
at a computer!
― The greatest potential of EPIC, at times, seems to be its
capacity to perpetuate lies carried forward from previous
days / encounters.
• BELIEVE NOTHING YOU FIND THERE!
• VERIFY it YOURSELF!
• SIGN-OUT IN THE ROOM, NOT OUTSIDE!
• VERIFY FINDINGS!
• Don’t be the reason why rounds are stopped to update
the notes.
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Superficial Venous Thrombosis
• Saphenous vein thrombosis is not DVT!!
― (it is SUPERFICIAL venous thrombosis.)
• That said, recheck in a couple of days to make sure it has not
advanced INTO the sapheno-femoral junction.
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Upgrading Alert Level
When a patient deteriorates during a BETA or GAMMA alert and
subsequently meets Alpha trauma alert criteria (e.g., for
hypotension) the alert level should be upgraded to ALPHA so as
to prepare the entire system for potential need for expedient
operative care and intervention.
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King Airways
• The Alpha Alert criteria is being modified to include patients
with King Airways.
• Replace immediately if pt. hypoxic / airway unprotected
otherwise wait until pt. is in OR, IR or ICU. Alternatively
intubation could occur in such upon completion of diagnostic
imaging
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ED Scope Availability
• One Glidescope is available with stylet & various blades
• Two Bronchoscopes are available
― In the Difficult airway cart with separate light source,
suction and injection port. The key for the cart is kept in
the Pyxis by the ED charge RN desk. It is an approximate
4.0 scope.
― In the Express Care Pyxis with suction and separate light
source. The ~2.8 scope itself is located in the bottom
drawer of Pyxis under “Nasal scope”.
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Beta Alert for Out-of-Hospital
Pulseless Blunt Arrest
• Out-of-hospital blunt arrest (never had vitals on UVA grounds)
is a BETA level alert.
• Blunt arrest that occurs on the grounds of the hospital helipad
to trauma bay, is considered IN-HOSPITAL / WITNESSED
arrest and should perhaps be treated with thoracotomy.
• Assess A-B-C’s, assure proper placement of ETT, and then
proceed with left thoracotomy / RIGHT chest tube
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ED Thoracotomy
Resuscitative thoracotomy if:
• Witnessed blunt arrest
― Must have had a palpable pulse or peripheral SaO2 on
UVA grounds !!!!
• Recent penetrating arrest
• May hold/withdraw thoracotomy if PEA, wide complex rhythm
and HR < 40.
• Aggressive blood resuscitation, chest decompression, ACLS is
indicated for blunt agonal scenarios.
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Propofol…
• Must NEVER be administered IV PUSH during acute resuscitation
due to the high rate of hypotension associated with this practice
(>25%) which often CLOUDS the clinical picture.
• Should not be administered to those with metabolic or lactic
acidosis due to increased risk for propofol infusion syndrome.
• Should NEVER be administered at rates > 85 mcg / kg / min for
ICU sedation.
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Cardiotomy
When making decisions regarding whether to go “on-pump” in
patients with cardiac wounds, the main determinants in decisionmaking are whether the heart can be adequately immobilized
and repaired while beating AND whether there are injuries to the
coronaries.
That said, some (but not all) require the help of a perfusionist to
adequately repair.
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EARLY, Aggressive
Treatment of Hypothermia
• Each year, 1-2 injured patients in our trauma center die solely
due to the fact that their hypothermia (<36 degrees C) is not
adequately appreciated or treated in the trauma bay, and
more importantly, in the OR with subspecialists!
• Keep an eye on the temperature of freshly injured patients,
and in those who are not moribund, treat their hypothermia
FIRST before elective and urgent operative care.
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Simultaneous Procedures
• Yes, it is possible (and desirable) to surgically intervene in two
body cavities at once. We need to be very aggressive in
triaging which body cavity the bleeding is coming from, AND
operatively treating mass lesions in the head. For the most
severely injured, this is their only shot at survival!
• Drape the head AND the entire torso!
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Exit
You have completed the information portion of this module.
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For questions regarding content, contact J. Forrest Calland, M.D., [email protected].
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