The Portable Tina - Emergency medicine



Portable Trauma Doc rev 6/2012

Trauma Code

• Any CPR

• SBP 12 inches into patient compartment or >18 inches into any compartment

• Adult Falls >20ft, Child (10’ or 2-3x/height

• Auto vs pedestrian or bicycle with significant impact

• MCC > 20 mph or with separation of rider from motorcycle

Stable Intubated Blunt Trauma

• ABCs, expose, restrain

• Confirm ET tube, 2 large bore ivs (≥18g) or cordis

• Trauma series, trauma labs, ABG

• Secondary survey (Head to Toe exam)

• Rectal, Foley, OG or NG tube

• CTH, CT C spine, CT chest, CT A/P

• X-ray extremities with evidence of injury

• Hgb x3 (15 min apart) and then q1h, repeat for >1pt drop

• Utox/udip, if + send u/a, hematuria w/u if grossly + or microscopically positive (>3+ on dipstick or >30 RBC/hpf) with any period of SBP 65

• TLS films (unless CT reconstruction of T spine from chest CT or L spine from Abd CT)

• X-ray extremities with evidence of injury/pain

• Hgb x3 (15 min apart) and then q1h, repeat for >1pt drop

• Gen surg consult for abd diagnostics for: abd pain, intoxicated, altered MS, distracting injury, LOC, evidence of abdominal injury

Low Mechanism Event

• ABCs, Secondary survey

• Roll and palpate TLS spine; remove backboard if non-tender, fully alert and without distracting pain; otherwise TLS films

• CTH for LOC or altered mental status

• C-spine series unless meets Canadian C-spine criteria below

• Hgb x2 q 15 min, repeat for >1pt drop

• Utox/udip, if + send u/a, hematuria w/u if grossly + or >3+ on dipstick

• No need for general surgery consult unless concern for chest/abdominal injury

Establish Stability Before Patient Goes To CT

• This is based on combination of vital signs, mechanism, and hgbs

• 2 stable hgbs are NOT REQUIRED before going to CT

Abnormal mediastinum

• Repeat CXR in R-trendelenberg

• Still abnormal: chest CT w/ aortic protocol

Criteria for CT head

• Any h/o LOC or amnesia

• Intubated / altered MS / abnormal neuro exam

• Intoxicated & evidence of head trauma

• Coumadin & evidence of head trauma

• Heads take priority in CT, then abd

Criteria for CT C-spine

• High mechanism event AND pt needs head CT

• Pelvic fractures or multiple extremity fractures

• Major Axial Load (i.e. diving accident)

• Patient with traumatic ICH

• Focal neurologic symptom

• Skull Fracture

• Elderly (Age>65)

SCIWORA = Spinal Cord Injury without Radiologic Abnormality

MRI of spine (usually cervical) is indicated if patient has focal neuro symptoms, even if delayed or transient. Consider neuro consult to help confirm/localize exam.

Criteria for CTA Neck

• Cervical hemorrhage of potential arterial origin

• Expanding cervical hematoma.

• Carotid bruit, patient < 50 years

• Cerebral infarction on CT or MRI

• Unexplained central or lateralizing neurological deficit, TIA or Horner’s syndrome.

• High Energy mechanism with any of the following:

a) LeFort II or III fracture

b) Complex mandible fracture

c) Punctate hemorrhage in the brainstem, corpus callosum, and/or basal ganglia (with GCS < 6)

d) Cervical spine subluxation

e) C-spine fractures extending to the transverse foramen

f) Any fracture of C1, C2 and C3

• Hanging (or strangulation) resulting in cerebral anoxia (i.e. LOC)

• Skull base fracture involving the carotid canal.

Hematuria W/U

• Pelvic ring fx and (gross hematuria or >3+ on dipstick) => CT-Cysto

• No pelvic ring fx and gross hematuria and CTAP is needed => write “CT-cysto if indicated” on requisition

Canadian C-spine rule

Do films (c-spine series or CT neck, see above) if any of these are present:

• “dangerous mechanism” (our “high mech” plus fall>9 feet, fall>5 stairs, ATV or snowmobile crash, MVC>60mph, rollover)

• >65 years old

• Not alert (includes intoxicated)

• Paresthesias in extremities

• Neck pain present immediately after event

• Can’t rotate head 45 degrees left and right

Back Pain

• Detailed neuro exam with rectal tone

• Abnormal exam = TLS films, neuro consult, admit

• Normal exam

o Robaxin 1g po x1 & Toradol 30mg IV or 60mg IM x1

o NSAIDs, ice, physical therapy

o Robaxin 1g po qid x3d

o Consider spine films if point tenderness; history of trauma, cancer, or IVDA; fever; age >50

• Neuro deficits (w/in 8hrs of injury) = Solumedrol 30mg/kg loading dose, then 5.4mg/kg x 24-48h

Intoxicated Patients

• 2-point restraints if falls risk

• Thiamine 100mg IM/IV

• BAL

• Evidence of head injury = assault workup

• Haldol IV/IM in 5mg increments prn

• X-ray anything w/ evidence of injury

• Detailed neuro exam when patient cooperative

• EtOH falls by ~50/h. D/c when BAL 13 consider admit IV abx

• IVDU plus fever = medicine admit (unless needs GS for abscess/NSTI)

• GS consult for

o NSTI

▪ Low threshold to suspect for: Na 18, HCO3 < 22, SBP 5mm midline shift, obscured basal cisterns, or neurologic deterioration.

• Unequal, or bilat blown pupils

• Trauma pt with neurologic deterioration

• Neurologic deterioration = pupil change, lateralizing motor signs, posturing, change in mental status without other cause.

• Call NS before arrival for these pts, esp if images are available. Call again when pt arrives. NS should go to scanner with pt. If NS, radiology, and GS all agree, can substitute “CT trauma survey” (a rapid scan from neck to knees) for usual trauma CT. This expedites crash crani.

• Evidence of elevated ICP = Mannitol 1g/kg if not hypotensive

• Elevate head of bed 30 degrees

Medicine/Geri (>65) pre-op consults

• Medicine consult 0800-1600 M-F

• Anesthesia 1600-0800 or weekends

Emergent MRI (must discuss with radiologist)

Acute appendicitis in a pregnant woman

Acute aortic dissection (thoracic or abdominal) and unable to go to CT

Acute stroke needing clarification (initial stroke imaging is CT)

Acute cord compression non-traumatic

Acute cauda equina syndrome

Cord injury-traumatic requiring operative reduction

Deteriorating cord function under observation

Ankylosing spondylitis/DISH with neurologic deficit

Ankylosing spondylitis DISH without neurologic deficit

Possible epidural abscess with cord dysfunction

Possible epidural abscess with back pain

Phone Numbers

Paging…………………………………….43000

Trauma Code/ STAT page………………..222

HMC ER…………………………..……x4074

Blood Bank………………………….292-6525

Spine pager ………………………… 559-9070

Transfer Center……..744-3597 / 888-744-4791

Crisis Triage Unit………………….……x3076

Inpatient Pharmacy……………………..x3220

Laboratory………………………………x3451

Trauma X-ray…………………………...x3346

Urgent Care Clinic……………………...x5867

Nursing Stations

2WH MICU…………………………….x3257

2WH MICU…………………………….x5935

9MB TICU……………………………..x3510

3WH Epilepsy…………………………..x3365

3WH Neuro/NS…………………………x3347

3EH Tele………………………………..x3351

4WH Rehab……………………………..x3201

4EH Geri………………………………...x3331

5EH Ortho……………………………….x3550

6EH Ortho……………………………….x3273

7EH Surgery…………………….………x3354

8EH BPS…………………….….……….x8704

9EH BICU………………….……..……..x3127

Radio / Phone Protocol

P = medics on phone, R = medics on radio

• “TD standing by for medic #.” Rpt everything back (starting w/ “Medic X from the Trauma Dr understand you have…”), repeat blood run number to avoid blood error

• Phone = "This is Dr. Smith, the trauma doctor. I understand you have _________. Permission for _____. Trauma doctor standing by."

• When given blood run #, give it to charge nurse

Labs

• Red: ESR

• Lime Green: chemistries, EtOH, ß-hcg, bili, amy, lft, drug levels

• Blue: coags

• Lavender: CBC, ESR

• Pink: type & crossmatch (only do with RN help)

Pediatrics (Use Broselow Tape))

• Peds consult all kids < 18 years

• 20cc/kg IVF x 2, then consider blood.

• If ................
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