MDSO - Trauma

Question 1

Clinical Guidelines Trauma:

TXA dosing, and timeline

Answer 1

1 g > 10 min , then repeat in 1 hr (consider 2 g up front) - if any possibility of significant bleed. ….MUST BE WITHIN 3 hrs of ONSET

Question 2

Clinical Guidelines: TRAUMA:

Define GCS of “Severe Head Trauma”

Answer 2

GCS < 9

Question 3

Clinical Guidelines: TRAUMA:

General Measures for prevention and treatment of ICP (ENLS Tier 0 / 1)

Answer 3

HOB 30
Neck in neutral position (to optimize venous drainage)
Loosening C collar
Analgesia, Sedation and Nausea Tx
Reduce Stimulation
Target PaCO2 35-40
ETCO2 33-38 with ICP
ETCO2 30-35 with Herniation (PaCO2 32-35)
Avoid Hypo/Hyperoxemia - target 94-98%
Consider 3% or Mannitol with Signs of Herniation
Avoid Hypo Na+

Question 4

Clinical Guidelines: TRAUMA:

Signs of Herniation:

Answer 4

Pupils - dilated or unreactive or asymmetric
Motor Exam - posturing or no response
Neuro Deterioration > 2 (of baseline < 9)
Cushing’s Triad - (Wide PP, Bradycardia, Irregular Resp)

Question 5

Clinical Guidelines: TRAUMA

When should Mannitol be used / not used.

Answer 5

Used when signs of Herniation…..assuming MAP > 70…..not to be used in patients with suspected hypovolemia (elevated HR, and/or Hypotension)

Question 6

MDSO : TRAUMA CARDIAC ARREST

How many Rhythm Analysis on scene before patching ?

Answer 6

1 analysis - shock or no shock

Question 7

MDSO ; Cardiac Arrest Trauma

Reversible Causes ? And Immediate Treatment / Considerations in Major Trauma

Answer 7

Pneumo ? ——> Bilateral Chest Needles
Hypotension / Hemorrhagic - - - > 20 cc/kg to 1 L, PRBC
Routinely Bind Pelvis
Routinely Consider C-Collar
Routinely Manage TEMP - avoid Hypothermia ( cold, coagulopathy, acidosis)
Aim for at least 2 large IV’s - remember you can do IO in humoral head or tibial. - more fluid faster in humoral head.

Question 8

MDSO: Trauma Cardiac Arrest.

When do you patch ? What do you do after the 1st analysis ?

Answer 8

Patch after 1st analysis.

Shockable - Shock IT and Transport - Continue Treatment en route as if was NON-TRAUMATIC CA. (Like a Medical VSA)

NON SHOCKABLE - PEA/Asystolye - don’t forget Bilateral check needles, pelvic binding, fluids and bloods, but get going …..and keep treating as per Medical CA - PEA

Question 9

MDSO: Adult: TBI

Meds, Dosage, Condition, Patch Status, other considerations.

Answer 9

1) NE - 0-0.5 mg/kg/min target MAP > 80 - IP

2) 3% @ 3 mL/kg > 20 min - if signs of Herniation - OR. Mannitol 1g/kg bolus IF MAP > 80

*Keep Warm , min 35 C

Question 10

MSDO: Adult : TBI : Flowchart:

O2 targets, Temp Targets, TBI/ICP ETCO2 Targets non herniation, with Herniation

Answer 10

02 - 94-98% ; TEMP > 35 C ; No Herniation - ETCO2 33-38; Herniation - 30-35

Question 11

MDSO: TBI:

Other things not to forget ?

Answer 11

Check BS, rule out as cause of LOA change and Fix as needed
Consider Need for Intubation - Neuro Protective Intubation
KEEP MAP > 80
IF HYPOTENSIVE —> treat bleeding + Hemorrhagic Shock (PRBC fist, if available), NS/RL at 10 cc/kg (try not to dilute)
Consider TXA if within 3 hrs of incident
Keep Warm
Anticoagulant Reversal ?
Don’t forget about SMR (needs C collar )

Question 12

Clinical Guidelines: Spinal Cord Injury:

What is the first treatment priority of SCI with Hypotension ? Then next priority ? And MAP Target ?

Answer 12

Crystalloids first
Then VASOPRESSORS
Target MAP > 80

Question 13

Clinical Guidelines: SCI:

Considerations when Intubating ?

Answer 13

*Minimize C-spine movement - use MILS assistant, consider Hyperangulated blade
*In patients with high SCI, hypoxia or manipulation may cause profound bradycardia even cardiac arrest; if patient is already bradycardia prior to the intubation , consider Atropine prior to intubation.
* Sux CAN be used in context of SCI for the first 72 hrs

Question 14

MDSO: SCI - See flow chart

Risk to ventilation in SCI?

Answer 14

Nerve control of diaphragm / intercostal muscles etc…..?
May need to take over ventilation due to impending Resp Failure
These patients can have good SPO2 with Oxygen,but not good ETCO2 - it’s more of a ventilation issue - so don’t equate good o2 with problem solved

Question 15

MDSO : SCI

What is treatment in SCI with hypotension ?

Answer 15

Go To : NEUROGENIC SHOCK MDSO, the SCI MDSO is mostly about intubating to protect against resp failure.

Question 16

NEUROGENIC SHOCK MDSO:

Tx ? cc/kg, drugs, doses, consideration and patch

Answer 16

1) 20-40 cc/kg Target > 80 - no patch
2) NE - 0 - 0.5 mcg/kg/min - IP
3) Atropine 0.5mg q 3-5 min PRN, MAX 3mg - IP
4) Dopamine (ACP >) 5-20 mcg/kg/min OR EPI Infusion (CCP) - MPatch - 0 - 0.5 mcg/kg/min. (MAP > 80)

RISK of NE - unopposed alpha, and significant reflex bradycardia - - - may use dopamine instead if sudden decrease in HR / pressure.

Question 17

MDSO: Traumatic Hemorrhagic Shock

Indications ?

Answer 17

MAP <65 and ongoing bleeding

Question 18

MDSO: Traumatic Hemorrhagic Shock

Tx, Meds, Dose, Conditions, Patch

Answer 18

1) NS or RL at 20-40 mL/kg - target MAP 65 - no patch
2) PRBC - 1:1:1 (PRBC, PLT, FFP), TXA 1 g > 10 min, repeat in an hour, injury under 3 hrs (consider 2 g up front) - Initiate then Patch
3) Keep Temp above 35 C

Accept MAP 60 / SBP 90 or “ adequate cerebral perfusion and palpable pulse”
If associated TBI - then need MAP of 80
If Possible Pelvis - don’t forget to use w Pelvic Binder - TPod

Question 19

MDSO: Blood Products

Indications

Answer 19

MAP < 65 ; Hg < 70 ; TMP Judgment

Question 20

MDSO Blood Products

Tx - Patch

Answer 20

1:1 PRBC and FFP (although newer version is 1: 1: 1)
CCP - Initiate then patch. (But will most likely order products and then patch)
Don’t forget to replace Ca++ for each 4 units
Don’t forget to keep warm
Don’t forget to document consent
Don’t forget to watch for reactions for 15 min
Goals are Hg > 70 +
Remember potential need to reverse anticogulants