San Francisco High Risk EM titbits May 2012 Dr Cynthia Lim

Penetrating neck trauma by Dr Diane Birnbaumer (Prof 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 trauma Traditional Zone I – III doesn’t matter anymore Algorithm for penetrating injury through platysma Unstable – OT Stable – do CTA to determine disposition

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

Algorithm 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 trauma Dr Sanjay Arora (Assoc Prof USC) Give fluids – anything! 2L = critical Pt needs blood if unstable after 2L IV fluids When using 2nd unit RBC think “Do I need the massive transfusion protocol?” Problem with being reactive compared to proactive = trauma assoc coagulopathy

Trauma associated coagulopathy 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 crystalloid 5X higher rates AMI Increased mortality blunt trauma and severe/critical trauma

CRASH –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 Dr 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 canal with sternal notch

Airway medications Use total body weight Use ideal body weight Midazolam, Fentanyl Suxamethonium (eg 1.5mg/kg – 100kg –use 150mg) Use ideal body weight Propofol, Rocuronium, Vecuronium

Injury 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 weight Anticipate difficult airway

Pregnant trauma Uterus displacement FAST Kleihaur test 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 trauma 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 elderly Subdurals more common Epidural haematomas rare 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 bleeding 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)

Prothrombinex Don’t forget small risk prothrombotic effect

Plavix If heavy bleeding give platelets

Next thing - Xabans Factor Xa inhibitor Can’t be dialysed Antidote under construction Approved in USA

tPA reversal Give everything!

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

IV Bicarbonate Hogan SE. Am Heart J 2008 Meta-analysis 7 RCT, n=1307 Prehydration with nsaline vs bicarb Relative risk CIN 0.37 bicarb group No statistically significant impact on mortality or need for dialysis

Bottom line fluids IV better than oral Nsaline better than 0.5% saline Isotonic bicarb prob best Mannitol/diuretics not effective Goal urine output post procedure = 150ml/hr for 6-12 hours

Isotonic saline Start 1ml/kg/hr at least 2 preferably 6-12 hours prior procedure Continue 6-12 hours post contrast

Isotonic 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 contrast Continue 1ml/kg for 6 hours post contrast

N-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 saline Webb JG. Am Heart J 2004 N = 487 mean cr baseline 1.6mg/dL Isotonic saline 200ml prior, 1.5ml/kg/hr for 6 hrs after IV NAC 500mg immediately before No benefit Inconclusive – ?not enough saline used

Bottom 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