Top Ten Topics
Panel Discussion
Top Ten Topics
1. Appropriateness of helicopter
transport
Top Ten Topics
2. Surgeons won’t come in to
see trauma patients in rural
hospitals (?EMTALA
considerations)
Top Ten Topics
3. Massive transfusion protocols
– transfusion ratio
FFP : RBC Ratio / 6 Hr – Civilian Experience
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
1:1 1:2 1:3 1:4 ≥1:5
PredictedProbabi...
J Trauma Acute Care Surg. 2012;72: 106–111
Objective : To characterize changes in resuscitation which
have occurred over t...
J Trauma Acute Care Surg. 2012;72:106–111.
FFP : RBC Transfusion Ratios over Time
J Trauma Acute Care Surg. 2012;72:106–111.
Sub-MT = 7 – 10 RBC
PLT : RBC Ratios for Sub-MT
Patients Across Time Periods
FF...
Top Ten Topics
4. Volume resuscitation in
trauma: penetrating vs blunt
Top Ten Topics
5. Blunt neck trauma – who
needs a workup and what
should it be?
OHSU Neurotrauma
Research Group
UW/HMC Neurotrauma
Research Group
Clearing the C Spine
The rule on our wall in the ED is:
...
Clinical Decision Rules
• Canadian Spine Rules
• Nexus Low Risk Criteria
• Both meant to select patients who
don’t need C-...
Canadian C-spine Rules
No
Algorithm_CSpine Evaluation_FINAL_11-20-2012
Clinical Decision Rules
Reproduced from Stiell I. et al. “The Canadian C-s...
Nexus Exclusionary Rules
OHSU Neurotrauma
Research Group
UW/HMC Neurotrauma
Research Group
Spine is CLEARED
1 - Remove cervical collar
2 - Mobilize...
OHSU Neurotrauma
Research Group
UW/HMC Neurotrauma
Research Group
TRAUMA PATIENT
With ALTERED LEVEL of CONSCIOUSNESS
Traum...
Missing C Spine Injuries
• 1985-1991
• 740 c-spine injuries in San Diego Trauma Centers
• 34 delayed or missed diagnosis (...
OHSU Neurotrauma
Research Group
UW/HMC Neurotrauma
Research Group
Spine Clearance Form
Purpose
• Clarify understanding of ...
Suspected Cervical Spine Injury
· Apply C-collar
· Assess using Clinical Decision
Rules if able to communicate and
age 3 o...
Suspected Cervical Spine Injury
· Apply C-collar
· Assess using Clinical Decision
Rules Criteria.
Collar Off
Cleared C-Spi...
Suspected Cervical Spine Inj.
· Apply C-collar
Algorithm_CSpine Evaluation_FINAL_11-20-2012
Cervical Spine Injury Algorith...
Spine “A” Clearance: Evaluation Complete
Spine “B” Clearance: Injury Present or Probably
Spine “C” Clearance: C-Spine Cleared Clinically or Radiographically
BCVI: Mechanism of Injury
• 3 Fundamental
Mechanisms:
– direct blow to the neck
– laceration by adjacent
fractures of
sphe...
BCVI: Mechanism of Injury
Hyperextension with contralateral
rotation causing a stretch injury
BCVI: Stroke Rate
I 3% 6%
II 14% 38%
III 26% 27%
IV 50% 28%
V 100% 100%
VAIsCAIs
Injury
Grade
Biffl et al., Annals
2002
BCVI: Denver Series
15,767 Admissions
727 Angiograms
screening
244 BCVI
diagnosis
21 symptomatic pts
Gender 68% men
Age 35...
BCVI: Denver Series
48 no therapy
10 strokes (21%)
244 asymptomatic BCVI pts
187 antithrombotics
• Heparin – 117
• Antipla...
Seattle BCVI High Risk
Imaging Indication Definite
BCVI
Number of
patients
%
Midface fracture 4 20 20.0%
Mandible fracture...
Harborview BCVI High Risk
Screening
l Midface fracture (Lefort II or III)
l Skull base fracture
l C-spinse transverse fora...
Top Ten Topics
6. Pelvic fracture management
32 y.o. : injury to you: x? hours
Relevant Imaging
Pelvic Fractures & Mortality
Source of mortality:
Head
Injury
31%
Bleeding
39%
MOF
30%
Scalea et al. J Trauma
2003
Pelvic Fracture Bleeding
mechanical stabilization
resuscitation
Close down the pelvic volume.
Mechanical Stabilization
• Pros: Quick. Easy.
• Goals: Splint bone, tissue.
Decrease, stabilize pelvic volume.
“pelvic she...
Trauma Ultrasound
• FAST: Focused Abdominal Sonography in Trauma
– portable, rapid, repeatable
– noninvasive
– no contrain...
PITFALL
If persistent or
recurrent hypotension,
remember FAST isn’t
100% accurate!
(as much as 30% false negative)
Diagnostic Peritoneal Aspirate
• Catheter placed at umbilicus
• “Positive” aspirate = 10cc of blood,
enteric contents
Gross Hemoperitoneum by CT, US, or DPA
OR?
Angio?
Pelvis Fx + HD Unstable
resuscitation mechanical stabilization embolization
Importance of management protocols:
20% decrease in mortality
Biffl et...
• Described in Europe
– rapid transport to OR
– external bony fixation
– packing of retroperitoneum
Pelvic Packing
Pohlema...
Pelvic fixation first:
– C-clamp application
– External fixator
Pelvic Packing
Modified European technique:
– 6-8 cm suprapubic incision
– divide midline fascia
Pelvic Packing
Smith et al. J Trauma 200...
KEY POINT
Incision should be away from a laparotomy
incision – keep the spaces separate!
You will encounter the hematoma!
Pelvic Packing
Packing the pelvis:
– 3 lap pads on either side of bladder
– 1st one is all the way down to presacral space
Pelvic Packing
Typically 6 packs for adults, 4 for children
Pelvic Packing
Suprapubic catheters
Pelvic Packing
Close fascia
and skin
Pelvic Packing
• 5½ years – 1245 pelvic fx patients
• Pelvic fx classification:
APC III (17) LC II (12) LC III (11)
APC II...
Packing: Hemorrhage Control
• Time to OR: 66 ± 7 minutes
• RBCs: 4 ± 0.4 units in ED
• Pre-SICU vs. subsequent 24˚
10 ± 0....
Packing and Concurrent Procedures
• 87% of pts underwent 3 ± 0.3 procedures
– External fixation of long bone fractures = 4...
Angiography After Packing
• 10 (13%) patients underwent AE
• Time to angio = 10 hours
(range 1-38 hours)
pelvic
packs
• Fx...
Who Needs Angiography?
• Can’t predict by:
age, ISS, presenting SBP, presenting base
deficit, ED blood tx, or fracture pat...
Operation
Top Ten Topics
7. Termination of resuscitation;
when to stop (adults vs kids)
Top Ten Topics
8. When to return to sports and
play in minor TBI
(football, soccer, basketball, is
there a difference?)
Top Ten Topics
9 . Current indications for an ED
thoracotomy
Patient
in Extremis
–
Undergoing
CPR
Penetrating
Trauma
EDT
ECG: Any
Rhythm?
Yes
CPR < 5 min
Blunt
Trauma
Dead
No
Yes
Yes
...
Top Ten Topics
10. What is the minimum
workup needed in the
multiply injured patient who
needs to be transferred to a
high...
Top Ten Topics
• 1. Appropriateness of helicopter transport
• 2. Surgeons won’t come in to see trauma patients
• 3. Massiv...
Day 2 | CME- Trauma Symposium | Master trauma panel perspective
Day 2 | CME- Trauma Symposium | Master trauma panel perspective
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Day 2 | CME- Trauma Symposium | Master trauma panel perspective

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Master trauma panel perspective

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Day 2 | CME- Trauma Symposium | Master trauma panel perspective

  1. 1. Top Ten Topics Panel Discussion
  2. 2. Top Ten Topics 1. Appropriateness of helicopter transport
  3. 3. Top Ten Topics 2. Surgeons won’t come in to see trauma patients in rural hospitals (?EMTALA considerations)
  4. 4. Top Ten Topics 3. Massive transfusion protocols – transfusion ratio
  5. 5. FFP : RBC Ratio / 6 Hr – Civilian Experience 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1:1 1:2 1:3 1:4 ≥1:5 PredictedProbability FFP:RBC at 6 hrs Upper Quartile Trendline Lower Quartile AAST / J Trauma 2008
  6. 6. J Trauma Acute Care Surg. 2012;72: 106–111 Objective : To characterize changes in resuscitation which have occurred over time in a cohort of severely injured patients requiring MT. Glue Grant: Blunt BD <6
  7. 7. J Trauma Acute Care Surg. 2012;72:106–111. FFP : RBC Transfusion Ratios over Time
  8. 8. J Trauma Acute Care Surg. 2012;72:106–111. Sub-MT = 7 – 10 RBC PLT : RBC Ratios for Sub-MT Patients Across Time Periods FFP and PLT Transfusion in First 6, 12, 24 Hr Post-injury
  9. 9. Top Ten Topics 4. Volume resuscitation in trauma: penetrating vs blunt
  10. 10. Top Ten Topics 5. Blunt neck trauma – who needs a workup and what should it be?
  11. 11. OHSU Neurotrauma Research Group UW/HMC Neurotrauma Research Group Clearing the C Spine The rule on our wall in the ED is: INDICATIONS FOR SCREENING CT OF THE CERVICAL SPINE In patients receiving initial HMC CT head: Screening cervical spine CT used in those patients considered to be at "high-risk (pre-test probability of > 5%) Includes: 1. High speed collisions (MVC > 35 mph combined impact.) 2. Crash with death at the scene 3. Patients with an acute myelopathy or radiculopathy 4. Falls > 10 feet. 5. Patients with known or strongly suspected pelvic or multiple extremity fractures. 6. Patients with significant closed head injury (intra-cranial blood.) Since we use the same inclusion criteria, all you need to include is something like "Initial spine imaging according to HMC ED protocols.” • I think radiology would all be happy with that
  12. 12. Clinical Decision Rules • Canadian Spine Rules • Nexus Low Risk Criteria • Both meant to select patients who don’t need C-spine imaging in the Emergency Department
  13. 13. Canadian C-spine Rules
  14. 14. No Algorithm_CSpine Evaluation_FINAL_11-20-2012 Clinical Decision Rules Reproduced from Stiell I. et al. “The Canadian C-spine Rule versus the NEXUS Low Risk Criteria in patients with trauma” NEJM 2003;349:2510-8 Table 1. The NEXUS Low-Risk Criteria. * *Criteria are from Hoffman and colleagues. 26 † Midline posterior bony cervical-spine tenderness is present if the patient reports pain on palpation of the posterior midline neck from the nuchal ridge to the prominence of the first thoracic vertebra, or the patient evinces pain with direct palpation of any cervical spinous process. ‡ Patients should be considered intoxicated if they have either of the following: A recent history provided by the patient or an observer of intoxication or intoxicating ingestion, or evidence of intoxication on physical examination such as an odor of alcohol, slurred speech, ataxia, dysmetria, or other cerebellar findings, or any behavior consistent with intoxication. Patients may also be considered to be intoxicated if tests of bodily secretions are positive for alcohol or drugs that affect the level of alertness. § An altered level of alertness can include and of the following: a Glasgow Coma Scale score of 14 or less; disorientation to person , place, time, or events; an inability to remember three objects at five minutes; a delayed or inappropriate response to external stimuli; or other findings. ¶ A focal neurologic deficit is any focal neurologic finding on motor or sensory examination. ║ No precise definition of a painful distracting injury is possible. This category includes any condition thought by the clinician to be producing pain sufficient to distract the patient from a second (neck) injury. Such injuries may include, but are not limited to, any long bone fracture; a visceral injury requiring surgical consultation; a large laceration, degloving injury or crush injury; large burns; or any other injury causing acute functional impairment. Physicians may also classify any injury as distracting if it is thought to have the potential to impair the patient’s ability to appreciate other injuries. Cervical-spine radiography is indicated for patients with trauma unless they meet all of the following criteria; No posterior midline cervical-spine tenderness, † No evidence of intoxication, ‡ A normal level of alertness, § No focal neurological deficit, ¶ and No painful distracting injuries. ║ Figure 1. The Canadian C-Spine Rule Any high-risk factor that mandates radiography? Age > 65 or dangerous mechanism or paraesthesias in extremities Able to rotate neck actively? 45 o left and right For patients with trauma who are alert (as indicated by a score of 15 on the Glasgow Coma Scale) and in stable condition and in whom cervical-spine injury is a concern, the determination of the risk factors guides the use of cervical-spine radiography. A dangerous mechanism is considered to a fall from an elevation of >= 3 ft. or 5 stairs; an axial load to the head (e.g. diving); a motor vehicle collision at high speed (>100 km/hr.) or rollover or ejection; a collision involving a motorized recreations vehicle; or a bicycle collision. A simple rear-end motor vehicle collision excludes being pushed into oncoming traffic, being hit by a bus or large truck, a rollover, and being hit by a high speed vehicle Any low-risk factor that allows safe assessment of range of motion ? Simple rear end MVC or sitting position in the emergency department or ambulatory at any time or delayed (not immediate) onset of neck pain or absence of midline cervical-spine tenderness Radiography No Radiography No Yes Unable Yes Yes
  15. 15. Nexus Exclusionary Rules
  16. 16. OHSU Neurotrauma Research Group UW/HMC Neurotrauma Research Group Spine is CLEARED 1 - Remove cervical collar 2 - Mobilize as tolerated Trauma admission: FULL SPINE precautions FULL SPINE PRECAUTIONS. Consult Spine Service PARTIAL SPINE precautions ALERT TRAUMA PATIENT Primary service examines patient Spine is TREATED 1 - Maintain cervical collar 2 - Review supine films again for possible missed injury 3 - F/U in spine clinic in 2-3 wks for flex-ex images Supine Imaging Studies Is there a fracture, ligamentous injury, or neurologic deficit? Neck pain or tenderness? Yes Yes N o N o
  17. 17. OHSU Neurotrauma Research Group UW/HMC Neurotrauma Research Group TRAUMA PATIENT With ALTERED LEVEL of CONSCIOUSNESS Trauma admission: FULL SPINE precautions C Spine CT Is there a fracture or ligamentous injury documented by final radiology report? FULL SPINE PRECAUTIONS. Consult Spine Service Is a gross motor exam possible? (No neuromuscular blockade, extreme sedation/analgesia, or hypotension) Primary service examines patient Does pt have neurologic exam suspicious for SCI? PARTIAL SPINE PRECAUTIONS. Maintain cervical collar pending motor exam Spine is CLEARED 1 - Remove cervical collar 2 - Mobilize as tolerated Yes N o FULL SPINE PRECAUTIONS. Consult Spine Service e.g. Motor asymmetry not attributable to other causes Old CVA New brain injury Initial spine imaging according to HMC ED protocols N o No Yes Yes
  18. 18. Missing C Spine Injuries • 1985-1991 • 740 c-spine injuries in San Diego Trauma Centers • 34 delayed or missed diagnosis (4.6%) • 10 of 34 (29%) with permanent sequelae of missed injury • Delayed diagnosis could have been avoided in 31 of 34 patients by appropriate use of a standard three- view C-spine series. Jim et al later go on to tell us: • Ah, yes, but don’t do flex-extension views to clear the spine • Too rare (0.02%) and some danger of quadriplegia (J Trauma 2001)
  19. 19. OHSU Neurotrauma Research Group UW/HMC Neurotrauma Research Group Spine Clearance Form Purpose • Clarify understanding of relationship between status of diagnosis and clearance of spine
  20. 20. Suspected Cervical Spine Injury · Apply C-collar · Assess using Clinical Decision Rules if able to communicate and age 3 or older. Collar Off Cleared C-Spine Clinical Decision Rules Clear Algorithm_CSpine Evaluation_FINAL_11-20-2012 Cervical Spine Injury Algorithm Pediatric (age 0-10) If Head CT is obtained, tailored CT will be extended to include skull base through C2 and Xrays of the rest of the C-spine should be performed Imaging Clinically Clear by Palpation and Range of Motion? YES NO Clinical Decision Rules NOT Clear, or under 3 or unable to communicate Imaging Normal, and no neurologic abnormality Imaging Abnormal, or persistent neurologic abnormality Maintain full spine precautions, consult Spine service Collar off Cleared C-spine If head CT is not obtained, spine Xrays should be used as a first line imaging tool with follow up CT cervical spine if necessary
  21. 21. Suspected Cervical Spine Injury · Apply C-collar · Assess using Clinical Decision Rules Criteria. Collar Off Cleared C-Spine Clinical Decision Rules Clear Cervical Spine Injury Algorithm Adult (age 11-64) CT of C-Spine NO Clinically Clear by Palpation and Range of Motion? YES Clinical Decision Rules NOT Clear Meets Criteria for Xrays? ** YES Normal C-Spine Xrays Abnormal, Inadequate or Can’t clear Clinically after normal film. CT suggests acute injury, or persistent neurologic abnormality CT with no acute injury and Patient obtunded / intubated Refer to Inpatient C Spine clearance protocol Full spine precautions Spine Consult in ED ** X rays if all of the following: · No head CT is required. · No h/o DJD or C-spine hardware. · Able to cooperate. · No known TLS spine injury. · Does Not meet HMC High Risk Criteria. HMC High Risk Criteria Presence of any of the following criteria indicates a patient at high risk (>5%) for C- Spine injury and should warrant imaging with CT. 1. High energy mechanism (high speed > 35 mph MVC or MCC, MVC with death at scene, fall from > 10ft.) 2. High risk clinical parameter (significant head injury, unconscious in ED, focal neurologic symptoms referable to cervical spine, pelvic or multiple extremity fractures. CT Normal or non- acute findings, unable to clear clinically Use Clinical Judgment to clear pt., or if concerned, consider leaving collar on and evaluate as INPATIENT (Spine consult, +/- MRI) or OUTPATIENT (flex/ex Xrays in 7-10 days CT with no acute injury, and no neurologic abnormality Collar Off Cleared C-Spine Algorithm_CSpine Evaluation_FINAL_11-20-2012 NO
  22. 22. Suspected Cervical Spine Inj. · Apply C-collar Algorithm_CSpine Evaluation_FINAL_11-20-2012 Cervical Spine Injury Algorithm Adult (age 65 and up) CT with no acute injury, and no neurologic abnormality CT with no acute injury or non-acute findings, unable to clear clinically CT with no acute injury and Patient obtunded / intubated Collar Off Cleared C-Spine Use Clinical Judgment to clear pt., or if concerned, consider leaving collar on and evaluate as INPATIENT (Spine consult, +/- MRI) or OUTPATIENT (flex/ex Xrays in 7-10 days Full spine precautions Spine Consult in ED CT of Cervical Spine is the recommended imaging test of choice for the elderly CT suggests acute injury, or persistent neurologic abnormality Refer to Inpatient C Spine clearance protocol
  23. 23. Spine “A” Clearance: Evaluation Complete
  24. 24. Spine “B” Clearance: Injury Present or Probably
  25. 25. Spine “C” Clearance: C-Spine Cleared Clinically or Radiographically
  26. 26. BCVI: Mechanism of Injury • 3 Fundamental Mechanisms: – direct blow to the neck – laceration by adjacent fractures of sphenoid/petrous bones – hyperextension with contralateral rotation Seat belt sign? Drawing from Curr Prob Surg Crissey et al., Surgery 1974 Biffl et al., Curr Probl Surg 1999
  27. 27. BCVI: Mechanism of Injury Hyperextension with contralateral rotation causing a stretch injury
  28. 28. BCVI: Stroke Rate I 3% 6% II 14% 38% III 26% 27% IV 50% 28% V 100% 100% VAIsCAIs Injury Grade Biffl et al., Annals 2002
  29. 29. BCVI: Denver Series 15,767 Admissions 727 Angiograms screening 244 BCVI diagnosis 21 symptomatic pts Gender 68% men Age 35 ± 3.7 years ISS 28 ± 3.8 1.5% + rate
  30. 30. BCVI: Denver Series 48 no therapy 10 strokes (21%) 244 asymptomatic BCVI pts 187 antithrombotics • Heparin – 117 • Antiplatelet – 59 • LMWH – 11 1 stroke (0.5%) Cothren et al., Am J Surg 2005 In press.
  31. 31. Seattle BCVI High Risk Imaging Indication Definite BCVI Number of patients % Midface fracture 4 20 20.0% Mandible fracture 2 24 8.3% Skull base fx 16 79 20.3% Cspine trans. for. Fx 15 66 22.7% C1,C2,C3 fx 2 11 18.2% Seatbelt sign 0 26 0.0% Hanging/strang. 1 21 4.8% Clinical stroke 1 6 16.7% Infarct 0 1 0.0% Other/Unknown 8 53 15.1% Total 49 307 16.0%
  32. 32. Harborview BCVI High Risk Screening l Midface fracture (Lefort II or III) l Skull base fracture l C-spinse transverse foramen fracture l C1, C2, or C3 fracture l High energy or bilateral mandible fracture l Unexplained stroke/neuroexam l Hanging or strangulation
  33. 33. Top Ten Topics 6. Pelvic fracture management
  34. 34. 32 y.o. : injury to you: x? hours
  35. 35. Relevant Imaging
  36. 36. Pelvic Fractures & Mortality Source of mortality: Head Injury 31% Bleeding 39% MOF 30% Scalea et al. J Trauma 2003
  37. 37. Pelvic Fracture Bleeding mechanical stabilization resuscitation Close down the pelvic volume.
  38. 38. Mechanical Stabilization • Pros: Quick. Easy. • Goals: Splint bone, tissue. Decrease, stabilize pelvic volume. “pelvic sheeting” pelvic binder C-clamp
  39. 39. Trauma Ultrasound • FAST: Focused Abdominal Sonography in Trauma – portable, rapid, repeatable – noninvasive – no contraindications – 3 views of abdomen SPLEEN KIDNEY RUQ LUQ pelvis
  40. 40. PITFALL If persistent or recurrent hypotension, remember FAST isn’t 100% accurate! (as much as 30% false negative)
  41. 41. Diagnostic Peritoneal Aspirate • Catheter placed at umbilicus • “Positive” aspirate = 10cc of blood, enteric contents
  42. 42. Gross Hemoperitoneum by CT, US, or DPA OR? Angio? Pelvis Fx + HD Unstable
  43. 43. resuscitation mechanical stabilization embolization Importance of management protocols: 20% decrease in mortality Biffl et al. Ann Surg 2001 Current management: USA Pelvis Fx + HD Unstable
  44. 44. • Described in Europe – rapid transport to OR – external bony fixation – packing of retroperitoneum Pelvic Packing Pohlemann et al. OTA Ann Mtg 2000 • Rationale: – addresses venous/bony bleeding – additional procedures as indicated
  45. 45. Pelvic fixation first: – C-clamp application – External fixator Pelvic Packing
  46. 46. Modified European technique: – 6-8 cm suprapubic incision – divide midline fascia Pelvic Packing Smith et al. J Trauma 2005 Cothren et al. J Trauma 2007
  47. 47. KEY POINT Incision should be away from a laparotomy incision – keep the spaces separate!
  48. 48. You will encounter the hematoma! Pelvic Packing
  49. 49. Packing the pelvis: – 3 lap pads on either side of bladder – 1st one is all the way down to presacral space Pelvic Packing
  50. 50. Typically 6 packs for adults, 4 for children Pelvic Packing
  51. 51. Suprapubic catheters Pelvic Packing Close fascia and skin
  52. 52. Pelvic Packing • 5½ years – 1245 pelvic fx patients • Pelvic fx classification: APC III (17) LC II (12) LC III (11) APC II (11) LC I (10) APC I (4) vertical shear (10) • 75 patients underwent PPP/EF 75% men Age = 42 ± 2 yrs ISS = 52 ± 2 • ED vitals: SBP 76 ± 2 HR 119 ± 2 BD 12 ± 1
  53. 53. Packing: Hemorrhage Control • Time to OR: 66 ± 7 minutes • RBCs: 4 ± 0.4 units in ED • Pre-SICU vs. subsequent 24˚ 10 ± 0.8 units vs. 4 ± 0.5 units • FFP:RBC ratio was 1:2
  54. 54. Packing and Concurrent Procedures • 87% of pts underwent 3 ± 0.3 procedures – External fixation of long bone fractures = 44 – I&D wounds/fasciotomy = 43 – Laparotomy = 34 – Urologic procedures = 15 – Extremity vascular = 4 – Neurosurgical/spine = 4 – Thoracotomy = 2
  55. 55. Angiography After Packing • 10 (13%) patients underwent AE • Time to angio = 10 hours (range 1-38 hours) pelvic packs • Fx classification: LC I (3) LC II (2) APC III (2) APC II (1) LC III (1) VS (1)
  56. 56. Who Needs Angiography? • Can’t predict by: age, ISS, presenting SBP, presenting base deficit, ED blood tx, or fracture pattern • Patients with AE after packing: lower HR (105  8 vs 121  3) more RBC pre-SICU (15  3 vs 9  1) more FFP pre-SICU (9  2 vs 4  1) more RBC in subseq 24˚ (7  2 vs 3  1) more FFP in subseq 24˚ (6  2 vs 2  0.4)
  57. 57. Operation
  58. 58. Top Ten Topics 7. Termination of resuscitation; when to stop (adults vs kids)
  59. 59. Top Ten Topics 8. When to return to sports and play in minor TBI (football, soccer, basketball, is there a difference?)
  60. 60. Top Ten Topics 9 . Current indications for an ED thoracotomy
  61. 61. Patient in Extremis – Undergoing CPR Penetrating Trauma EDT ECG: Any Rhythm? Yes CPR < 5 min Blunt Trauma Dead No Yes Yes No Cardiac Rhythm? No Tamponade? No Repair Heart SBP > 70 mmHg? Yes OR Yes No Thoracic Hemorrhage Air Emboli Tamponade Extrathoracic Hemorrhage Aortic X-clamp Hilar X-clamp Control CPR < 15 min CPR < 5 minNon-torso Torso No No Yes
  62. 62. Top Ten Topics 10. What is the minimum workup needed in the multiply injured patient who needs to be transferred to a higher level of care?
  63. 63. Top Ten Topics • 1. Appropriateness of helicopter transport • 2. Surgeons won’t come in to see trauma patients • 3. Massive transfusion protocols – transfusion ratio • 4. Volume resuscitation in trauma penetrating vs blunt • 5. Blunt neck trauma • 6. Pelvic fracture management • 7. Termination of resuscitation; when to stop • 8. When to return to sports and play in minor TBI • 9 . Current indications for an ED thoracotomy • 10. What is the minimum workup needed in patient who needs to be transferred

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