This is EM Cases Episode 119 – Trauma, The First and Last 15 Minutes, Part 2 with Dr. Kylie Bosman, Dr. Chris Hicks and Dr. Andrew Petrosoniak.

In this podcast we answer questions such as: What should your resuscitation targets be in the first 15 minutes for trauma patients with hemorrhagic shock, neurogenic shock, severe head injury? When is a pelvic binder indicated? Is a bedsheet good enough? What are the most common pitfalls in binding the pelvis? What are the best ways to maintain team situational awareness during a trauma resuscitation? Should we rethink patient positioning for the trauma patient? What are the indications for transport to a trauma center? What is the minimal data set required before transfer? Which patients require a pelvic x-ray prior to transfer to a trauma center?  What are the key elements of a transport checklist? What does the future hold for trauma care and many more…

Podcast production, sound design & editing by Anton Helman, Voice editing by Suchetta Sinha

Written Summary and blog post by Anton Helman January, 2019

Cite this podcast as: Helman, A. Bosman, K. Hicks, C. Petrosoniak, A. Trauma – The First and Last 15 Minutes Part 2. Emergency Medicine Cases. January, 2019. https://emergencymedicinecases.com/trauma-first-last-15-minutes-part-2Accessed [date].

Binding the Pelvis in Trauma: The Trochanteric Binder

One important source of massive hemorrhage besides abdominal visceral organ damage and long bone fractures in trauma is the venous hemorrhage as a result of an unstable pelvic fracture. Consider laying out the pelvic binder on the stretcher in advance of patient arrival, and empiric early binding of the pelvis for patients with evidence of shock. Our experts consider it acceptable to bypass examining the pelvis bone and simply bind the pelvis on speculation. X-rays can be done after the binder has been placed. The phrase “pelvic binder” is misleading because the device is ideally placed around the greater trochanters, not the pelvis.

Consider a rectal and genital exam to assess for bleeding and bone shards that suggest an open pelvic fracture before placing the pelvic binder as this may guide antibiotic therapy and surgical priorities. A study in 2001 showed that the rectal exam influenced management in only 1.2% of cases. While the rectal exam is no longer recommended to assess for “high riding prostate” there are 3 situations where a rectal exam is warranted: spinal cord injury (to assess for sacral sparing), pelvic fracture (to assess for open fracture) and penetrating abdominal trauma (to assess for gross blood).

Do’s and Don’ts of Binding the Pelvis

If you choose to examine the pelvic bone, do not place outward pressure or assess for vertical instability. Do not rock the pelvis. Rather, do apply inward pressure on the iliac wings to assess for movement. If there is movement, do maintain the inward pressure immediately followed by application of the binder.

When applying the trochanteric binder, do not apply the binder over the iliac crests. Do place the binder over the greater trochanters. Do place the legs in internal rotation and tape them together at the ankles. This will decrease the anatomic bleed space. Do obtain a post reduction x-ray if time permits.

If a commercial pelvic binder is not available, it is important to apply a bedsheet properly. The force required to close an open book pelvic fracture cannot be attained by twisting a bedsheet and tying it in a knot across the pelvis. Rather, fold the sheet so that is about 18 inches wide, have one team member hold the sheet that has been wrapped around the contralateral trochanter at the ipsilateral trochanter while another team member secures the sheet at the other trochanter with towel clips (see image below). With this technique there is no convincing evidence that commercial pelvic binders are more effective at binding the pelvis than a bedsheet.

bedsheet pelvic binder

Note that one team member is holding down the sheet across the patient’s right trochanter while the other team member is tightening the sheet across the opposite trochanter which will then be held in place by towel clips.

Keeping track of your trauma resuscitation progress

Three techniques that help to maintain team situational awareness and keep track of your progress in a trauma resuscitation are:

  1. The tactical pause/periodic situation report – approximately every 5-10 minutes, team leader vocalizes what has been accomplished thus far and what actions still need to be accomplished and in what order, articulating priorities and seeking input from the team.
  2. Write down a brief patient history, vital signs and list of confirmed and suspected injuries on a whiteboard in the trauma bay so that any team member joining in can be directed to read it, rather than the team leader needing to re-explain the details for every new person who joins the team.
  3. Activate a digital stopwatch that the entire team can see.

Resuscitation targets in the first 15 minutes of trauma resuscitation

There are two targets to be considered in early trauma trauma resuscitation presumed to be caused by hemorrhagic shock:

  1. Adequate tissue perfusion – presence of peripheral pulses in the blunt trauma patient, central pulses in the penetrating trauma patient and mentation in the absence of major head injury.
  2. Adequate hemostasis

While there are no evidence-based absolute BP targets in early trauma resuscitation that can be applied to all trauma patients, a reasonable guide is the following:

Presumed hemorrhagic shock: Systolic BP ≥ 70 mmHg

Presumed neurogenic shock: MAP ≥ 80-90 mmHg

Shock in the severe head injured patient (GCS < 8, lateralizing findings, depressed skull fracture): MAP ≥80 mmHg

There is an association between hypotension and worse outcomes in patients with severe head injury. It is reasonable to avoid hypotension in severely head injured patients, however there is no convincing evidence that this improves outcomes. Hypoxemia and hypercarbia should also generally be avoided in the patient with severe head injury.

Vasopressors are only indicated in presumed neurogenic shock in the setting of trauma. Norepinephrine is the vasopressor of choice based on current guidelines.

When two or more of these causes of shock are identified, our experts recommend targeting the one that is the more immediate threat to life.

Airway considerations in trauma the first 15 minutes

The concept of resequencing the trauma resuscitation was discussed in Part 1. Aside from critical airway compromise (critical/refractory hypoxia – <90% oxygen saturation despite maximal noninvasive ventilation OR dynamic airway  – anticipate evolving disruption of airway, head/neck injuries that are expected to worsen over the next few minutes), circulation should take priority over airway. Endotracheal intubation can usually be delayed until adequate hemodynamic resuscitation has occurred.

Because our early resuscitation targets often involve low blood pressures, and because some trauma patients are “sympathetically deplete” usual doses of induction agents may precipitate post intubation hypotension and cardiac arrest. It is thus recommended by our experts to lower the induction agent dose by 50-75% of the usual RSI induction agent dose for all patients with a shock index of ≥ 1, even when using ketamine.  A higher paralytic dose is recommended because the drug may not circulate as readily in the shocked patient.

Patient positioning in trauma: Avoid laying flat throughout the resuscitation

Consider placing the trauma patient in reverse Trendelenburg immediately after the FAST exam to maximize respiratory emergency management of pediatric seizuresphysiology and CNS physiology, especially for the high BMI patient and/or the severely head injured patient.

If a patient is more comfortable sitting up and/or refuses to lay flat, consider maintaining them in the sitting up position rather than laying them flat throughout the resuscitation. Forcing a patient to lay flat who is more comfortable sitting up may precipitate airway compromise.

Breathing considerations in trauma the first 15 minutes

Consider bilateral finger thoracostomies in the 5th intercostal space (approximately the level of the nipple) just anterior to the mid-axillary line in any trauma patient with unexplained shock and suspected chest injury.

For video by Cliff Reid on finger thoracostomy see EMcrit episode 62

Trauma – The Last 15 Minutes: Preparation for Transport to a Trauma Center

Indications for transport to a trauma center

Any time your patient outstrips your ability to take care of a trauma patient, consider transport to a trauma center. This decision has regional variation and depends on several factors:

  • Patient physiological factors including current and anticipated hemodynamic status, age, anticoagulation, immunosuppression, pregnancy, hypothermia, GCS < 10
  • Patient anatomical factors including suspected spinal cord injury with paraplegia or quadriplegia, severe head injury, amputation above the wrist or ankle, unstable pelvic fractures, major crush or vascular injury, trauma with significant burn or inhalation injury, significant injuries involving two or more body systems (eg. abdominal and head injury)
  • Surgical/procedural capabilities of the sending institution
  • Transport logistics (distance, weather, expertise of transport team etc)

Minimal workup prior to transfer to a trauma center

Consider whether each test prior to transfer will change your management or management immediately upon arrival to the trauma center. The minimal data set should include:emergency management of pediatric seizures

  • POCUS FAST +/- extended FAST exam
  • CXR
  • Pelvis x-ray (may help determine need for angiography which often takes time to arrange)
  • Trauma blood work drawn (usually includes CBC, lactate, VBG, fibrinogen, liver enzymes, BhCG, INR/PTT); note that there is no standard trauma blood panel and regional variation exists

There is little role for CT imaging prior to transport to a trauma center. CT imaging done prior to transport will often be duplicated at the trauma center and may cause delays to definite care. Nonetheless, there are some situations (eg. low suspicion for serious injury so that if the CT is negative transport would not be necessary) when it is reasonable to do CT imaging locally. This should be discussed with the trauma center.

Transport checklist (ABCDEFGHIJKLMN)

Adapted from: Mattu A. Damage Control: Advances in Trauma Resuscitation. Emerg Med Clin North Am. 2018;36(1):xv-xvi.

Airway: Secured endotracheal tube verified on CXR

Breathing: Oxygen saturation +/- ETCO2, chest tube(s) functioning and secured

Circulation: Documentation of serial BP and HR, timing of tourniquets, volume/type blood products given, pelvic binder for suspected or confirmed pelvic injury

Disability: Documentation of serial GCS or AVPU, neurologic exam prior to paralysis, timing of paralytic

Exposure: Splint fractures, dress wounds, then cover patient and keep them dry

Fluids: Measure urine output, chest tube output, IV fluids given

Gut: NG tube placed and confirmed

Heme: Tranexamic acid or prothrombin complex concentrates given, INR drawn

Infusions: Sedation and analgesia

JVP: Signs of tension pneumothorax/tamponade

Kelvin: Initial and current temperature. Keep patient warm.

Lines: Two lines minimum, check all lines (IV, IO, foley, chest tubes)

Micro: antibiotics and tetanus as needed

Next of Kin: Family made aware of plan, contact information documented

References

  1. Mattu A. Damage Control: Advances in Trauma Resuscitation. Emerg Med Clin North Am. 2018;36(1):xv-xvi.
  2. Brohi, K. The Ideal Pelvic Binder. Trauma.org. http://www.trauma.org/index.php/main/article/657/. Accessed Aug 2018.
  3. Fiechti JF, Gibbs, MA.  An Evidence-Based Approach To Managing Injuries Of The Pelvis And Hip In The Emergency Department. EBMedicine.net. December 2010 Volume 12, Number 12.
  4. Petrosoniak A, Hicks C. Resuscitation Resequenced: A Rational Approach to Patients with Trauma in Shock. Emerg Med Clin North Am. 2018;36(1):41-60.
  5. Schreiber MA, Meier EN, Tisherman SA, Kerby JD, Newgard CD, Brasel K, Egan D, Witham W, Williams C, Daya M, Beeson J, McCully BH, Wheeler S, Kannas D, May S, McKnight B, Hoyt DB; ROC Investigators. A Controlled Resuscitation Strategy is Feasible and Safe in Hypotensive Trauma Patients: Results of a Prospective Randomized Pilot Trial. J Trauma Acute Care Surg. Apr 2015;78(4):687-95.
  6. Consequences of increased use of computed tomography imaging for trauma patients in rural referring hospitals prior to transfer to a regional trauma centre. Injury 45:835-839, 2014.
  7. Unnecessary imaging, not hospital distance, or transportation mode impacts delays in the transfer of injured children. Pediatric Emerg Care 26(7):481-486, 2010.
  8. Rate and Reasons for Repeat CT Scanning in Transferred Trauma Patients. Am Surg 83(5):465-569, 2017.
  9. Petrosoniak, A. Hicks, C. Beyond crisis resource management: new frontiers in human factors training for acute care medicine. Curr Opin Anaesthesiol. 2013 Dec;26(6):699-706.
  10. Kaufman EJ, Richmond TS, Wiebe DJ, Jacoby SF, Holena DN. Patient Experiences of Trauma Resuscitation. JAMA Surg. 2017;152(9):843-850.

Drs. Helman, Bosman, Hicks and Petrosoniak have no conflicts of interest to declare

Now Test Your Knowledge:

1. When managing a patient with trauma, which of the following is false regarding the rectal exam?

A. Perform a rectal exam in patients with spinal cord injury to assess for sacral sparing

B. A study in 2001 showed that the rectal exam influenced trauma management only 1.2% of the time

C. In all trauma patients, a rectal exam should be done to assess for “high riding prostate”

D. In patients with pelvic fractures, a rectal exam is useful to check for signs of an open fracture

Answer: C

While the rectal exam is no longer recommended to assess for “high riding prostate”, there are 3 situations where a rectal exam is warranted:

  1. Spinal cord injury (to assess for sacral sparing)
  2. Pelvic fracture (to assess for open fracture)
  3. Penetrating abdominal trauma (to assess for gross blood)

2. Which of the following is true when examining the integrity of pelvic bones in a polytrauma patient?

A. Apply outward pressure over the pelvic bone and assess vertical instability. Avoid applying inward pressure over the iliac wings or rocking the pelvis

B. Apply inward pressure over the iliac wings and maintain it if there is movement. Avoid applying outward pressure over the pelvic bone, assessing for vertical instability, or rocking the pelvis

C. Apply inward pressure over the iliac wings and rock the pelvis. Avoid applying outward pressure over the pelvic bone or assess vertical instability

D. Apply outward pressure over the pelvic bone, assess for vertical instability, and rock the pelvis. Avoid applying inward pressure over the iliac wings

Answer: B

The following are the Do’s and Don’ts of examining the pelvis in trauma patients:

Do:

– Apply inward pressure on the iliac wings to assess for movement. If there is movement, maintain the inward pressure immediately followed by application of the binder

Do not:

– Place outward pressure or assess for vertical instability

– Rock the pelvis

3. Which of the following is false when binding the pelvis in a polytrauma patient?

A. With proper technique, there is no convincing evidence that commercial pelvic binders are more effective than a bed sheet

B. After applying the binder, placing the legs in internal rotation and taping them together at the ankles may improve pelvic open fracture reduction

C. Twisting a bed sheet and tying it in a knot across the pelvis is unlikely to generate enough force to close an open book pelvic fracture

D. Apply the binder over the iliac crests

Answer: D

The following are the Do’s and Don’ts of binding the pelvis:

Do:

– Place the binder over the greater trochanters

– Place the legs in internal rotation and tape them together at the ankles. This will decrease the anatomic bleed space

– Obtain a post reduction x-ray if time permits

Do not:

– Apply the binder over the iliac crests

4. An 80-year-old was brought into the emergency department by ambulance after being struck by a car while crossing the street. He struck his head against the windshield. Which of the following is false in the management of patients with major head trauma?

A. One aspect of the assessment of adequate tissue perfusion in the trauma patient is mentation

B. It is reasonable to target MAP of ≥ 80 mmHg and avoid hypotension

C. There is convincing evidence that treating hypotension improves patient outcomes

D. It is generally considered advisable to avoid hypoxemia and hypercarbia

Answer: C

There is an association between hypotension and worse outcomes in patients with severe head injury but no evidence that treating hypotension improves patient-oriented outcomes.

5. A 23-year-old male is brought in to the emergency department after suffering a back injury during a football game. His initial vitals showed a BP 80/40, HR 60, O2 sat 97%, RR 16. Which of the following is true in the management of trauma patients with neurogenic shock?

A. Target MAP ≥ 60 mmHg

B. Vasopressors are indicated in presumed neurogenic shock in a trauma patient

C. Epinephrine is the vasopressor of choice

D. None of the above

Answer: B

For trauma patients with neurogenic shock:

– Target MAP ≥ 80 mmHg

– Vasopressors are only indicated in presumed neurogenic shock in the setting of trauma, and norepinephrine is the vasopressor of choice.

6. During which of the following trauma resuscitation scenarios would it be appropriate to delay endotracheal intubation until adequate hemodynamic resuscitation has occurred?

A. < 90% oxygen saturation with maximal noninvasive ventilation

B. Significant burns to the oropharynx

C. Neck injury with expanding hematoma

D. None of the above

Answer: D

With critical airway compromise (critical/refractory hypoxia – <90% oxygen saturation despite maximal noninvasive ventilation OR dynamic airway  – anticipate evolving disruption of airway, head/neck injuries that are expected to worsen over the next few minutes), circulation should not take priority over airway.

7. A 45-year-old male is brought in by ambulance after being involved in an MVC. He presents with GCS of 4 and has HR of 140 and BP of 100/60. He was found to have a pelvic fracture and received a pelvic binder and appropriate resuscitation. How would you modify the RSI medication doses in this patient?

A. Decrease the induction agent by 50 – 75%, increase the paralytic dose

B. Increase the induction agent by 50 – 75%, decrease the paralytic dose

C. Increase the induction agent by 50 – 75%, increase the paralytic dose

D. Decrease the induction agent by 50 – 75%, decrease the paralytic dose

Answer: A

Because our early resuscitation targets often involve low blood pressures, and because some trauma patients are “sympathetically deplete” usual doses of induction agents may precipitate post intubation hypotension and cardiac arrest. It is thus recommended by our experts to lower the induction agent dose by 50-75% of the usual RSI induction agent dose for all patients with a shock index of ≥ 1, even when using ketamine.  A higher paralytic dose is recommended because the drug may not circulate as readily in the shocked patient.

8. Which of the following is true regarding breathing considerations in trauma patients?

A. In patients with unexplained shock and suspected chest injury, consider bilateral finger thoracostomies in the 5th intercostal space just posterior to the mid-axillary line

B. In patients with high BMI or severe head injury, consider placing them in Trendelenburg position

C. If a patient is more comfortable sitting up or refuses to lay flat, consider maintaining them in the sitting up position throughout the resuscitation

D. None of the above

E. A and C only

Answer: E

– Consider bilateral finger thoracostomies in the 5th intercostal space (approximately the level of the nipple) just anterior to the mid-axillary line in any trauma patient with unexplained shock and suspected chest injury.

– Consider placing the trauma patient in reverse Trendelenburg immediately after the FAST exam to maximize respiratory physiology and CNS physiology, especially for the high BMI patient and/or the severely head injured patient.

– If a patient is more comfortable sitting up and/or refuses to lay flat, consider maintaining them in the sitting up position rather than laying them flat throughout the resuscitation. Forcing a patient to lay flat who is more comfortable sitting up may precipitate airway compromise.

9. Which of the following is an indication for transfer of a trauma patient to a trauma center?

A. Suspected spinal cord injury with paraplegia

B. Amputation of the wrist or ankle

C. Unstable pelvic fracture

D. Major crush or vascular injury

E. All of the above

Answer: E

While there are no universal indications for transfer to a trauma center, and regional variation exists, some patient anatomical factors that should be considered for transfer include suspected spinal cord injury with paraplegia or quadriplegia, severe head injury, amputation above the wrist or ankle, unstable pelvic fractures, major crush or vascular injury, trauma with significant burn or inhalation injury, significant injuries involving two or more body systems (eg. abdominal and head injury).

10. Which of the following is NOT a part of the minimal workup done prior to transferring a trauma patient to a trauma center?

A. POCUS FAST

B. CXR

C. Trauma blood work

D. CT imaging

Answer: D

There is little role for CT imaging prior to transport to a trauma center. CT imaging done prior to transport will often be duplicated at the trauma center and may cause delays to definitive care. Nonetheless, there are some situations (eg. low suspicion for serious injury so that if the CT is negative transport would not be necessary) when it is reasonable to do CT imaging locally. This should be discussed with the trauma center.