San Francisco High Risk EM San Francisco High Risk EM titbitstitbits

May 2012

Dr Cynthia Lim

Penetrating neck trauma by Dr Penetrating neck trauma by Dr Diane Birnbaumer (Prof Diane Birnbaumer (Prof

UCLA)UCLA) Penetrates the platysma <0.5% have an unstable C-spine

– Only apply c-collar if altered GCS/neuro signs

If bleeding profusely apply pressure but don’t clamp

CTA = diagnostic imaging of choice for stable zone 2 injuries

Standard of care no longer surgical exploration

Penetrating neck traumaPenetrating neck trauma

Traditional Zone I – III doesn’t matter anymore

Algorithm for penetrating injury through platysma– Unstable – OT– Stable – do CTA to determine disposition

Hard signsHard signs

Hard Signs Expanding Hematoma Severe active bleeding Shock not responsive to IVF Decreased/absent radial pulse Vascular bruit or thrill Cerebral ischemia Airway obstruction

Soft signsSoft signs

Soft Signs Hemoptysis/hematemesis Oropharyngeal blood Dyspnea Dysphonia/dysphagia Subcutaneous/mediastinal air Chest tube air leak Non-expanding hematoma Focal neurologic deficit

AlgorithmAlgorithm

If not through platysma – wound care/DC If through platysma – unstable/hard signs to OT Stable – CTA

– CTA injury – OT– CTA nad but trajectory suggests possible injury-further

imaging /intervention– CTA nad and trajectory away from vital structures –

observe/DC

Volume resuscitation in Volume resuscitation in traumatrauma

Dr Sanjay Arora (Assoc Prof USC)Give fluids – anything!2L = critical

– Pt needs blood if unstable after 2L IV fluidsWhen using 2nd unit RBC think “Do I need

the massive transfusion protocol?”Problem with being reactive compared to

proactive = trauma assoc coagulopathy

Trauma associated Trauma associated coagulopathycoagulopathy

Up to 50% trauma If assume 30-40% blood loss, after 2L fluids/2

units RBC, clotting is down to 50% Decrease mortality with increased platelets given Proactive approach recommended

– Retrospective studies show marked reduction mortality if 1:1:1 ratio given (vs 1:4)

– Current trial in USA comparing 1:1:1 to 1:4– 1:1:1 = 6u RBC:6u FFP:1 bag platelets

Polyheme vs crystalloidPolyheme vs crystalloid

5X higher rates AMIIncreased mortality blunt trauma and

severe/critical trauma

CRASH –2 trialCRASH –2 trial Tranexamic acid lower 4 wk mortality

– 14.5% vs 16% (placebo) But higher vasoocclusive rates(17% vs 2%) and no

difference in blood products given (50% vs 51%) 2nd trial – tranexamic acid given >3/24 lead to

increased mortality– 4.4& mortality vs 3.1% mortality (placebo)

Some evidence for tranexamic acid if given within 1st hour trauma– 5.3% mortality vs 7.7%(placebo)

Challenging trauma cases by Challenging trauma cases by Dr Diane BirnbaumerDr Diane Birnbaumer

Obese pt– Issues with applying c-collar– Imaging – arrangements with zoo?– How to lie pt flat – “ramping”– BP measurement – only inaccurate if high, any

hypotension is REAL

Ramping – line up ext auditory Ramping – line up ext auditory canal with sternal notchcanal with sternal notch

Airway medicationsAirway medications

Use total body weight– Midazolam, Fentanyl– Suxamethonium– (eg 1.5mg/kg – 100kg –use 150mg)

Use ideal body weight– Propofol, Rocuronium, Vecuronium

Injury patternsInjury patterns

Increased risk multiorgan failure post sever trauma

Cushion effect– More thoracic, pelvic and lower limb injuries– Less abdominal and head injuries (less severe)

Resuscitate to actual body weight Ventilate to ideal body weightAnticipate difficult airway

Pregnant traumaPregnant trauma Uterus displacement

– Tilt pt on spinal board or use manual uterus displacement

FAST – Morison’s pouch and fetal HR

Kleihaur test– 20% positive in well pregnant pts

Admit, serial CTG and examination Rhogam for Rh negative

Specific injuries in pregnant Specific injuries in pregnant traumatrauma

Uterine rupture Placental abruption

– US misses 50%, therefore if >32/40 most obstetricians consider emerg LSCS

Maternal fetal haemorhage Preterm labour (even minor trauma)

– At least 4/24 CTG to rule out Amniotic fluid embolism

– Order DIC screen if sick Beware normal Hb- dec haematocrit/inc total blood

volume. Normal till pt crashes…

Trauma in elderlyTrauma in elderly

Subdurals more common– Dural sticks to skull so space obliterated, but bigger

epidural veins so inc risk subdurals Epidural haematomas rare Cspine injuries – C1-3 esp dens

– Due to osteophytic/fused spines– Compare to younger pts – Cspine # usually C4-6

Airbags can cause aortic disruption Med hide clinical vital signs Trauma exacerbates underlying disease

Reversing meds that cause Reversing meds that cause bleeding by Dr Sanjay Arorableeding by Dr Sanjay Arora

Heparin – Protamine (binds heparin)– Made from fish sperm/testes - anaphylactoid– Actually anticoagulant so >50mg used will

have anticoagulation effect dominating– 1mg per 100units heparin (no more than 50mg)

ProthrombinexProthrombinex

Don’t forget small risk prothrombotic effect

PlavixPlavix

If heavy bleeding give platelets

Next thing - XabansNext thing - Xabans

Factor Xa inhibitorCan’t be dialysedAntidote under constructionApproved in USA

tPA reversaltPA reversal

Give everything!

Contrast induced nephropathy Contrast induced nephropathy (CIN) by Dr Diane Birnbaumer(CIN) by Dr Diane BirnbaumereGFR < 60 – increased risk CINeGFR better than creatinine to measure

renal function

IV BicarbonateIV Bicarbonate

Hogan SE. Am Heart J 2008Meta-analysis 7 RCT, n=1307Prehydration with nsaline vs bicarbRelative risk CIN 0.37 bicarb groupNo statistically significant impact on

mortality or need for dialysis

Bottom line fluidsBottom line fluids

IV better than oralNsaline better than 0.5% salineIsotonic bicarb prob bestMannitol/diuretics not effectiveGoal urine output post procedure =

150ml/hr for 6-12 hours

Isotonic salineIsotonic saline

Start 1ml/kg/hr at least 2 preferably 6-12 hours prior procedure

Continue 6-12 hours post contrast

Isotonic bicarbonateIsotonic bicarbonate

3 amps bicarb in 850ml sterile water (equals 150mEqsodium/L)

Or 1.5amps bicarb in 1L 0.5NS (equals 152mEq sodium/L)

Bolus 3ml/kg 1 hour before contrastContinue 1ml/kg for 6 hours post contrast

N-acetyl cysteineN-acetyl cysteine

ACT trial N = 2308 undergoing angiography 1200mg NAC bd vs placebo on day before and

after angio Acute kidney injury defined as > 25%increase

serum creatinine 48-96Hrs post angio No difference – 12.7% in both groups Underpowered – only 3672308 had renal

impairment

IV NAC vs salineIV NAC vs saline

Webb JG. Am Heart J 2004N = 487 mean cr baseline 1.6mg/dLIsotonic saline 200ml prior, 1.5ml/kg/hr for

6 hrs afterIV NAC 500mg immediately before No benefitInconclusive – ?not enough saline used

Bottom lineBottom line

Identify high risk pts– Creat > 1.5+/- eGFR < 60– Diabetics, hypotension, CHF, age > 70

Avoid concurrent use nephrotoxic drugs (NSAIDS, gent,diuretics)

Ensure adequate IV hydration– n/saline– Isotonic bicarb may be better

Consider NAC in high risk pts