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Trauma Program IEP - 2012 Q1-2 1 of 28 Next ► Next ► ◄ Back ◄ Back Menu Trauma Institutional Education Program (Trauma IEP) 2012 Q1-2 Target Audience:

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Presentation on theme: "Trauma Program IEP - 2012 Q1-2 1 of 28 Next ► Next ► ◄ Back ◄ Back Menu Trauma Institutional Education Program (Trauma IEP) 2012 Q1-2 Target Audience:"— Presentation transcript:

1 Trauma Program IEP Q1-2 1 of 28 Next ► Next ► ◄ Back ◄ Back Menu Trauma Institutional Education Program (Trauma IEP) 2012 Q1-2 Target Audience: Physicians and nurses involved in the care of Trauma Service patients. Written by: J. Forrest Calland, M.D. Second Reviewer: J. Young, MD Date Written: October 2012 For questions regarding content, contact J. Forrest Calland, M.D., © 2010 by the UVa Health System Next ► Next ► Trauma Program IEP Q1-2 1 of 28

2 Trauma Program IEP Q1-2 2 of 28 Next ► Next ► ◄ Back ◄ Back Menu Agenda Quiz Responses: 2012 Quarter 1-2 Institutional Education Program Quiz Responses Trauma Bay Topics ED X-rays – What, Where, When and How Upgrading Alert Level Blunt trauma arrests ED Scopes King Airways ED Thoracotomy ICU Topics: ICU LIP Hand-of of care & Order Set Clean-up Trauma Program IEP Q1-2 2 of 17 General Topics Changes to Guideline Updating Process Outside Imaging & Internal Interpretations Expectations for pre-rounding Superficial Venous Thrombosis Propofol Cardiotomy EARLY, Aggressive Treatment of Hypothermia Simultaneous Procedures Next ► Next ► ◄ Back ◄ Back Menu

3 Trauma Program IEP Q1-2 3 of 28 Next ► Next ► ◄ Back ◄ Back Menu Objectives Upon completion of this module, the participant will be able to communicate the most current guidelines for optimal care of the injured patient at the University of Virginia. A grade of 80% on the Posttest is required to successfully complete the CBL.

4 Trauma Program IEP Q1-2 4 of 28 Next ► Next ► ◄ Back ◄ Back Menu What is important to have available prior to and during an Alpha or Beta alerted patient? If you do not have maintenance medications ready after intubation then you will find yourself in an unsafe situation when you get in the elevator / CT / angio. Consider having a fentanyl gtt & propofol infusion AND a long-acting neuromuscular agent with you at all times. DO NOT USE IV PUSH PROPOFOL or BENZO gtts if they can be avoided.

5 Trauma Program IEP Q1-2 5 of 28 Next ► Next ► ◄ Back ◄ Back Menu Immediately following trauma alert imaging completion, what disposition steps need to occur? The key neglected / inconsistent step in this algorithm is the surgery chief calling the bed center – this must happen IMMEDIATELY upon discernment of unit / acuity disposition.

6 Trauma Program IEP Q1-2 6 of 28 Next ► Next ► ◄ Back ◄ Back Menu Patients with sustained hypotension and unclear etiology need: We have underutilized DPL in recent years and have, as a result of this, occasionally missed hemoperitoneum as a cause of early / recurrent hypotension Do not hesitate to use DPL to triage the abdomen if you are AT ALL uncertain about the FAST results.

7 Trauma Program IEP Q1-2 7 of 28 Next ► Next ► ◄ Back ◄ Back Menu IV push propofol should NEVER be used in the care of the multi-trauma patient due to the high risk (>20%) for: Just don’t do it! The hypotension that PUSH propofol induces causes a lot of confusion as to whether these patients are bleeding and increases the mortality of comatose head injured patients by up to 50% !!

8 Trauma Program IEP Q1-2 8 of 28 Next ► Next ► ◄ Back ◄ Back Menu Injured patients with suspected aortic stenosis pulsus parvus et tardus, systolic murmur, syncope) need to be seen by cardiology when: Critical Aortic STENOSIS is a major determinant of adverse outcomes in our elderly patients – ESPECIALLY when it is undiagnosed / inadequately worked up prior to surgical procedures.

9 Trauma Program IEP Q1-2 9 of 28 Next ► Next ► ◄ Back ◄ Back Menu The information in this module advanced my understanding of the topics. It looks like 60% of you found this helpful. Remember, educational content only makes it to this IEP module if a knowledge gap was implicated in a serious adverse event or DEATH by our Trauma PI program. We will strive to make these modules more interesting and informative in the future!! (Forrest)

10 Trauma Program IEP Q of 28 Next ► Next ► ◄ Back ◄ Back Menu ICU LIP Hand off of care & Order Set Clean-up There is now a system-wide EPIC dot-phrase that must be completed before any patient transfers out to acute care from the ICU service (.tricutransfer) ― You will be asked to document that you cleaned up the orders and to whom you gave verbal report to on the acute-care service. ― The ICU nurse shall check the EPIC chart to make certain there is a recent transfer note before transporting the patient. Trauma Program IEP Q of 28

11 Trauma Program IEP Q of 28 Next ► Next ► ◄ Back ◄ Back Menu Changes to Guideline Updating Process Beginning in July 2012, mid-year changes to trauma guidelines will only be noted in the electronic version of the Trauma Handbook. A document listing changes will reside on the Trauma Intranet site. communication will go to PI Liaisons, notifying them of such updates. The hard copies will be replaced once per year before the resident change-over. Trauma Program IEP Q of 28

12 Trauma Program IEP Q of 28 Next ► Next ► ◄ Back ◄ Back Menu ED X-rays – What, Where, When and How In general, patients requiring ICU-level care should not be transported to plain film radiology except when ABSOLUTELY necessary to advance care. Trauma Program IEP Q of 28

13 Trauma Program IEP Q of 28 Next ► Next ► ◄ Back ◄ Back Menu Outside films and Timely reads: Preliminary Reads by 06:00 for Finals by 10:00 For acutely injured patients, the Department of Radiology provides internal interpretations of outside imaging when: 1)An order exists 2)The images are in PACS That is all that is required!! Obtaining timely final reads: ― For patients coming to our hospital after hours, in general, there must be preliminary reads available in EPIC within hours of arrival if you expect to see final reads by 10 AM. Call the reading room EARLY (by 0730) to notify them of spine films that have not yet been read for patients that are still presumptively immobilized / in spine precautions. No pain, tenderness, distracting injury, or deficit = clinically clear with prelim reads. Trauma Program IEP Q of 28

14 Trauma Program IEP Q of 28 Next ► Next ► ◄ Back ◄ Back Menu Expectations for pre-rounding ICU Pre-rounds MUST NEVER be performed solely by looking at a computer! ― The greatest potential of EPIC, at times, seems to be its capacity to perpetuate lies carried forward from previous days / encounters. BELIEVE NOTHING YOU FIND THERE! VERIFY it YOURSELF! SIGN-OUT IN THE ROOM, NOT OUTSIDE! VERIFY FINDINGS! Don’t be the reason why rounds are stopped to update the notes. Trauma Program IEP Q of 28

15 Trauma Program IEP Q of 28 Next ► Next ► ◄ Back ◄ Back Menu Superficial Venous Thrombosis Saphenous vein thrombosis is not DVT!! ― (it is SUPERFICIAL venous thrombosis.) That said, recheck in a couple of days to make sure it has not advanced INTO the sapheno-femoral junction. Trauma Program IEP Q of 28

16 Trauma Program IEP Q of 28 Next ► Next ► ◄ Back ◄ Back Menu Upgrading Alert Level When a patient deteriorates during a BETA or GAMMA alert and subsequently meets Alpha trauma alert criteria (e.g., for hypotension) the alert level should be upgraded to ALPHA so as to prepare the entire system for potential need for expedient operative care and intervention. Trauma Program IEP Q of 28

17 Trauma Program IEP Q of 28 Next ► Next ► ◄ Back ◄ Back Menu King Airways The Alpha Alert criteria is being modified to include patients with King Airways. Replace immediately if pt. hypoxic / airway unprotected otherwise wait until pt. is in OR, IR or ICU. Alternatively intubation could occur in such upon completion of diagnostic imaging

18 Trauma Program IEP Q of 28 Next ► Next ► ◄ Back ◄ Back Menu One Glidescope is available with stylet & various blades Two Bronchoscopes are available ― In the Difficult airway cart with separate light source, suction and injection port. The key for the cart is kept in the Pyxis by the ED charge RN desk. It is an approximate 4.0 scope. ― In the Express Care Pyxis with suction and separate light source. The ~2.8 scope itself is located in the bottom drawer of Pyxis under “Nasal scope”. ED Scope Availability

19 Trauma Program IEP Q of 28 Next ► Next ► ◄ Back ◄ Back Menu Out-of-hospital blunt arrest (never had vitals on UVA grounds) is a BETA level alert. Blunt arrest that occurs on the grounds of the hospital helipad to trauma bay, is considered IN-HOSPITAL / WITNESSED arrest and should perhaps be treated with thoracotomy. Assess A-B-C’s, assure proper placement of ETT, and then proceed with left thoracotomy / RIGHT chest tube Beta Alert for Out-of-Hospital Pulseless Blunt Arrest

20 Trauma Program IEP Q of 28 Next ► Next ► ◄ Back ◄ Back Menu ED Thoracotomy Resuscitative thoracotomy if: Witnessed blunt arrest ― Must have had a palpable pulse or peripheral SaO2 on UVA grounds !!!! Recent penetrating arrest May hold/withdraw thoracotomy if PEA, wide complex rhythm and HR < 40. Aggressive blood resuscitation, chest decompression, ACLS is indicated for blunt agonal scenarios.

21 Trauma Program IEP Q of 28 Next ► Next ► ◄ Back ◄ Back Menu Propofol… Must NEVER be administered IV PUSH during acute resuscitation due to the high rate of hypotension associated with this practice (>25%) which often CLOUDS the clinical picture. Should not be administered to those with metabolic or lactic acidosis due to increased risk for propofol infusion syndrome. Should NEVER be administered at rates > 85 mcg / kg / min for ICU sedation.

22 Trauma Program IEP Q of 28 Next ► Next ► ◄ Back ◄ Back Menu Cardiotomy When making decisions regarding whether to go “on-pump” in patients with cardiac wounds, the main determinants in decision- making are whether the heart can be adequately immobilized and repaired while beating AND whether there are injuries to the coronaries. That said, some (but not all) require the help of a perfusionist to adequately repair.

23 Trauma Program IEP Q of 28 Next ► Next ► ◄ Back ◄ Back Menu EARLY, Aggressive Treatment of Hypothermia Each year, 1-2 injured patients in our trauma center die solely due to the fact that their hypothermia (<36 degrees C) is not adequately appreciated or treated in the trauma bay, and more importantly, in the OR with subspecialists! Keep an eye on the temperature of freshly injured patients, and in those who are not moribund, treat their hypothermia FIRST before elective and urgent operative care.

24 Trauma Program IEP Q of 28 Next ► Next ► ◄ Back ◄ Back Menu Simultaneous Procedures Yes, it is possible (and desirable) to surgically intervene in two body cavities at once. We need to be very aggressive in triaging which body cavity the bleeding is coming from, AND operatively treating mass lesions in the head. For the most severely injured, this is their only shot at survival! Drape the head AND the entire torso!

25 Trauma Program IEP Q of 28 Next ► Next ► ◄ Back ◄ Back Menu Exit You have completed the information portion of this module. Select Take Test in left menu bar. After testing you may: Select My Records to view your transcript. To print a certificate, click on underlined credits or grade associated with a course. Select Exit to close. For questions regarding content, contact J. Forrest Calland, M.D., Trauma Program IEP Q of 28 ◄ Back ◄ Back Menu


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