1. San Francisco High Risk EM titbits
May 2012
Dr Cynthia Lim

2. 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

3. 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

4. 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

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

6. 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

7. 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

8. 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

9. Polyheme vs crystalloid
5X higher rates AMI
Increased mortality blunt trauma and severe/critical trauma

10. 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)

11. 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

12. Ramping – line up ext auditory canal with sternal notch

13. 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

14. 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

15. 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

16. 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…

17. 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

18. 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)

19. Prothrombinex
Don’t forget small risk prothrombotic effect

20. Plavix
If heavy bleeding give platelets

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

22. tPA reversal
Give everything!

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

24. 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

25. 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

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

27. 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

28. 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 had renal impairment

29. 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

30. 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