Trauma Case- Care in 2009

[BLADEMDA]

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Okay,

You guys want a real world trauma case. Here it goes:

A 24 year male presents to the trauma room. He has been shot 3 times with a small caliber weapon. 2 shots to the abdomen and one to the right biceps.

Patient is 245 pounds, 6'4" and in good health.(he was anyway). The time is 0100 and you are entering the trauma bay.

Trauma surgeon is there along with Medical Student, SRNA and CRNA.

What do you do next? What are you orders Captain Kirk?

Bp=83/45 P=136 Sat=100% on non rebreather. Patient is moaning on the table in the E.R.

 

[BLADEMDA]

SRNA suggests Ketamine for induction agent. E.R. Doc suggests Etomidate for induction. CRNA says it doesn't matter and says low dose propofol would be fine. Medical Student suggests Pentothal.

What do you think?

 

[jetproppilot]

Primary survey has already been done. Dude is moaning so he has an airway and he's breathing.

He's got a blood pressure, albeit a shaky one. Oxygen is on so thats good.

Call for O- blood. Call the OR and tell them we'll be up there likkity split.

Make sure you've got 2 large bore IVs in place. If not, place them.

Secondary survey. Head to toe. Cut off all clothes. Ask gangster to move all his extremities. Look at his scalp, ears, pupils, in his mouth. Look at his neck. Feel all this s h it as you're doing it for any extra Glock shots. Palpate his chest. Look for Glock holes. Listen to the lungs and heart.

You could skip the abdominal exam since the dude has bullet holes in it which means he's headed to the OR for an ELAP but you look anyway and you feel anyway. Look and feel his extremities for errant bullets. UH-OH....a bicep 9mm bullet....any arterial bleeding? If so (like all secondary survey indices) ya gotta stop and temporarily fix the problem. If not, well, a bullet to the bicep aint gonna kill him but the bullets in his belly very well may, so you move on.

Logroll the dude to look at his posterior body for any exit wounds or other injury.

Simultaneously have team members insert an NG, foley, rectal exam to make sure da bootie tightens and a hemoccult test, and hit the femoral vein for twenty mLs of lab blood.

Intubating in the ER or waiting 'til you get to the OR is your call based on mental status, hemodynamics, etc. Personally with the given scenerio I'd wait since he's protecting his airway and any pharmacologic intervention may bottom him out and I'd rather be on the OR table than the ER if that happens. Of course if he deteriorated further I'd intubate in the ER but he's a young dude and young trauma gangsta dudes can handle an 80 systolic BP in the short term.

TO THE OR.

The more time wasted between all this stuff and a scalpel hitting his belly is working against gangsta dude.

 

[BLADEMDA]

Induction Agent?

Just 0- blood? What else do you want Cross-Matched? How much of each?

After Da Tube is in the hole Med Student asks about 0- blood. How many units can you give before NEEDING to switch to type specific? Med Student asks about type and screen vs. type and cross. Can we use partially matched PRbc's?

SRNA not sure about the whole blood thing. just listening. CRNA asks which is better in this case? partial match or 0-?

What are your answers Captain?

 

[ozzie20]

why is it that med school and residency it seems people are teaching material like this:

when on here Jet and everyone else make this stuff look like this:

 

[BLADEMDA]

After Induction the SRNA checks the blood and yells, "the fraking blood bank sent us O positive blood. Now what?"

What sayeth ye?

CRNA says Level 1 device ready and armed Capatin. A-line in place. two large bore I.V.'s. SRNA asks to do central line. No can do partner. Attending/Senior Resident will place.

Surgeon asks about blood availability, cell saver, rapid infuser, central line and your "plan for massive transfusion of da gangsta."

We will discuss all aspects of trauma care in 2009.

I will wait for further feedback before proceeding with the case.

 

[ozzie20]

Given the pressure and pulse, I'd go with IVF's first, T&C for PRBCs later.

Check for the exit wounds for sure and assess for any possible lung trauma associated with the GSWs.

I'm assuming ketamine d/t hypotension, guessing though.

Another guess would be that the determination of which is better, Type O neg vs partial match by the clinical stability of the patient at hand. If he's not AAO, which I'm assuming he's not based on only moaning, and he's Hypotensive tachycardic, he's emergent, Type O neg would be faster so give that, draw the blood for a T&C while giving the Type O.

I'm sure I'm wrong on a lot of answers, but I'm replying so I can learn and get better when I go into my anesthesia years.

 

[ozzie20]

I think you can give O+ blood to this guy cause He's got a penis and not a vagina, but again could be wrong, haven't read much on this subject.

 

[jetproppilot]

I'm replying so I can learn and get better when I go into my anesthesia years.

With that attitude, SIR,

You're gonna be a great anesthesiologist. I'm sure you are a great resident.

Rokk on, Dude.👍

 

[huktonfonix]

Re: induction agent. Ketamine preferred for sympathetic stimulation with the caveat that myocardial depression may occur if limited reserve. Etomidate is acceptable with caveat of potential adrenal suppression and increased mortality risk. Slowly titrated propfol/pentothal probably isnt a great choice as a rapid sequence induction is indicated in the absence of any confounding airway factors. Given for a rapid sequence propofol/pentothal may cause vasodilation and contribute to hypotension. If patient is nonresponsive and isnt fighting much, brutane may also be an acceptable alternative. Given his vitals he is likely considerably intravascularly depleted at this point and will need rapid and aggresive fluid resuscitation. If available whole blood is good, if not the military literature supports a 1:1 prbc/ffp with varying opinions on PLT. The keys as in any resucitation are avoiding hypothermia, acidosis, and dilution of coagulation factors.

 

[huktonfonix]

Re: transfusion stuff

If the patient has not had a PREVIOUS Rh+ blood transfusion and doesnt have a uterus, O positive is ok, but it should be heavily documented that he has received such since he'll probably end up in this situation in the future if hes a banger.

Screen = pts plasma with generic RBC known antigens)
cross = donor RBC with pt plasma

In this situation since he appears to be approaching stage 3? (I think) shock he would benefit from blood and the risk of uncrossed type specific blood is low (0.5%) and screened but not crossed is even lower (0.2%). If he was stable then he may benefit from a more thorough trauma workup and be able to wait for the crossmatch.

Probably ask for 10/10/2 and keep 5-10 ahead on the PRBC/FFP. Might ask about availability of Factor 7 as well for possible later use.

 

[jetproppilot]

Induction Agent?

Just 0- blood? What else do you want Cross-Matched?

Uhhhhh, Lieutenant, crossmatching takes time. We're still in the ER, YES?

So YES, when you call the blood bank you ask for ONLY OH NEGATIVE BLOOD, PLEASE MA'AM.

This is done early.....crossmatch for other stuff will occur AFTER O neg is called for.

The cachectic, sixty-four-year-old-lady-in-the-bloodbank-working-the-night shift can't crossmatch gangsta dude yet since the team member is still in the process of drawing blood from the femoral vein.

In other words, she doesnt have a blood sample to crossmatch against yet.

But she CAN send four units of OH NEG to the ER RIGHT FU KKIN G NOW..

After she puts out her Marlboro Red.

 

[2win]

Uhhhhh, Lieutenant, crossmatching takes time. We're still in the ER, YES?

So YES, when you call the blood bank you ask for OH NEGATIVE BLOOD, PLEASE MA'AM.

This is done early.....crossmatch for other stuff will occur AFTER O neg is called for.

The little old sixty-four-year-old-lady-in-the-bloodbank-working-the-night shift can't crossmatch gangsta dude yet since the team member is in the process of drawing blood from the femoral vein.

But she CAN send four units of OH NEG to the ER.

After she puts out her Marlboro Red.

No - she's smoking with me on the porch... And the union is tolerant for a small delay.

 

[BLADEMDA]

Re: induction agent. Ketamine preferred for sympathetic stimulation with the caveat that myocardial depression may occur if limited reserve. Etomidate is acceptable with caveat of potential adrenal suppression and increased mortality risk. Slowly titrated propfol/pentothal probably isnt a great choice as a rapid sequence induction is indicated in the absence of any confounding airway factors. Given for a rapid sequence propofol/pentothal may cause vasodilation and contribute to hypotension. If patient is nonresponsive and isnt fighting much, brutane may also be an acceptable alternative. Given his vitals he is likely considerably intravascularly depleted at this point and will need rapid and aggresive fluid resuscitation. If available whole blood is good, if not the military literature supports a 1:1 prbc/ffp with varying opinions on PLT. The keys as in any resucitation are avoiding hypothermia, acidosis, and dilution of coagulation factors.

Hey Slim,

Good answer. But, can we go SLOW for the mentally impaired. What did you induce him with? Brutane ain't gonna work as he will bite off your fingers with his gold teeth.

What do you use in the trauma room? ICU case? Sick,elderly patient ASA4E with dead bowel?

 

[OB1🤙]

Deebo can have the O+ if necessary. You wonder if he's ever been blasted before (very possible) and gotten Rh+ blood (unlikely), but if his hemodynamics get worse than this, he can have what the blood bank sent.

I'd pick ketamine for this guy, but that's just me. Etomidate would be OK. With propofol, I'd start to worry about bottoming him out given his hypovolemia.

You have your big PIVs in place, get to the OR now. Central line can wait until things simmer down a little. If you're delayed for logistical reasons, throw in a MAC.

Activate your massive transfusion protocol.

This dude needs volume, hemoglobin, and a guy with a knife, not much more.

 

[BLADEMDA]

Uhhhhh, Lieutenant, crossmatching takes time. We're still in the ER, YES?

So YES, when you call the blood bank you ask for OH NEGATIVE BLOOD, PLEASE MA'AM.

This is done early.....crossmatch for other stuff will occur AFTER O neg is called for.

The little old sixty-four-year-old-lady-in-the-bloodbank-working-the-night shift can't crossmatch gangsta dude yet since the team member is still in the process of drawing blood from the femoral vein.

But she CAN send four units of OH NEG to the ER RIGHT FU KKIN G NOW..

After she puts out her Marlboro Red.

Exactly. So, she was low on O- blood and decided O positive was what gangsta dude was getting for minding his own business walking down the street.

She sent you 10 units of O positive cause that is what she had.
Blood was also sent to the lab with the femoral stick.

So, you gotta deal with 10 units of O positive. That is all you get until partial match type specific blood is ready. (at least that is what she says).

 

[BLADEMDA]

Deebo can have the O+ if necessary. You wonder if he's ever been blasted before (very possible) and gotten Rh+ blood (unlikely), but if his hemodynamics get worse than this, he can have what the blood bank sent.

I'd pick ketamine for this guy, but that's just me. Etomidate would be OK. With propofol, I'd start to worry about bottoming him out given his hypovolemia.

You have your big PIVs in place, get to the OR now. Central line can wait until things simmer down a little. If you're delayed for logistical reasons, throw in a MAC.

Activate your massive transfusion protocol.

This dude needs volume, hemoglobin, and a guy with a knife, not much more.

He also needs someone to run the show while the surgeon stops the bleeding. That my friend is you.

 

[jetproppilot]

So, you gotta deal with 10 units of O positive.

And thats MORE THAN LIKELY OK too.

 

[BLADEMDA]

Massive Transfusion Protocol??? Out in redneck country there ain't no such thing. The blood bank lady is willing to help as best she can though.

Now, what do you want ordered? Hint: Chicken wings isn't the answer

 

[huktonfonix]

Hey Slim,

Good answer. But, can we go SLOW for the mentally impaired. What did you induce him with? Brutane ain't gonna work as he will bite off your fingers with his gold teeth.

What do you use in the trauma room? ICU case? Sick,elderly patient ASA4E with dead bowel?

For this gentleman, I believe the appropriate spelling is TEEF. At least in LA.

 

[2win]

Why do u think that he needs a central line hawaiian?
Just in case?

 

[BLADEMDA]

 

[huktonfonix]

Why do u think that he needs a central line hawaiian?

doesnt need it, but if Im sitting around with my thumb up my a5$ may as well drop an introducer of some sort. Can give blood considerably faster than a single 14 gauge.

 

[jetproppilot]

Deebo can have the O+ if necessary. You wonder if he's ever been blasted before (very possible) and gotten Rh+ blood (unlikely), but if his hemodynamics get worse than this, he can have what the blood bank sent.

.

Heres another GANGSTA that may end up in wanna our trauma bays:

[/IMG]

 

[BLADEMDA]

JPP gets the guy to the Trauma room in the O.R. Blood Bank Lady with advanced COPD sends up 10 units of O positive. Two large bore IV's in place and A-line. What do you induce him with?

Etomidate or Ketamine? Hr=145 in the room. BP=67/36 on a-line. Still opening his eyes though.

Anyway, after Induction do you bother with central line? Rapid Infuser is ready. Do you want Cell saver? How about other products? Is there a limit to the number of O positive prbc units you are willing to give him?

 

[2win]

We are there (or here...) already...
Doesn't matter what you use, propofol versus ketamine if there is enough sux...Blood O is ok so far, fluids in, get anxious at HgB of 5, keep the body warm, don't pinch the OR nurse anymore, concentrate on the young CRNA,,,
O2 100%, a line check up blood q 30 min, ready platelets and FFP, change the music to ACDC, call the SO tell her that you have a "big" case, chill the beer and have ready the Patron.

 

[2win]

Heres another GANGSTA that may end up in wanna our trauma bays:

[/IMG][/QUO

 

[jetproppilot]

doesnt need it, but if Im sitting around with my thumb up my a5$ may as well drop an introducer of some sort. Can give blood considerably faster than a single 14 gauge.

ABSOLUTELY.

Certainly not a priority, but like HUK said,

sometimes theres a few minutes of downtime, even in dire situations like this.

See a chronologic opportunity?

DROP A NINE FRENCH INTRODUCER INTO GANGSTA'S NECK.

You can push a SWIMMING POOL OF BLOOD thru that thing.

In thirty seconds.

Again, not something needed.

But if opportunity arises, a deft attending or resident can literally complete the procedure in a few minutes.

So GO FOR IT if the opportunity arises.

If you have trouble, quit.

If it goes smoothly, just another adjunct in your future OR armamentarium for volume resuscitation.

 

[BLADEMDA]

I think you can give O+ blood to this guy cause He's got a penis and not a vagina, but again could be wrong, haven't read much on this subject.

Correct. Acceptable to use O positive blood in Trauma on male patients and female patients NOT of childbearing age.

Type Specific Blood still better than O positive or O negative. Use type specific blood when available (usually takes about 10 minutes) then full match when ready (usually 30-40 minutes)

 

[BLADEMDA]

We are there (or here...) already...
Doesn't matter what you use, propofol versus ketamine if there is enough sux...Blood O is ok so far, fluids in, get anxious at HgB of 5, keep the body warm, don't pinch the OR nurse anymore, concentrate on the young CRNA,,,
O2 100%, a line check up blood q 30 min, ready platelets and FFP, change the music to ACDC, call the SO tell her that you have a "big" case, chill the beer and have ready the Patron.

No. Data shows these dudes can have a 50% SURVIVAL rate with prompt, good medical care. For example, this dude made it.

 

[jetproppilot]

Hey Slim,

Uhhh, Blade, I've patented the utilization of the word SLIM here.

Every time someone uses Slim on this website I make a dollar.

Thanks very much.

 

[OB1🤙]

If they open the belly, un-tamponaded blood starts geysering out, then hell yeah, I want my MAC in the neck.

If they open the belly, get things under control quick, and things are hunky-dory, grab the med stud and teach him the fine art of 2AM central line placement.

 

[2win]

No. Data shows these dudes can have a 50% SURVIVAL rate with prompt, good medical care. For example, this dude made it.

No - means that not the trauma victim. Means US....

 

[OB1🤙]

Uhhh, Blade, I've patented the utilization of the word SLIM here.

Every time someone uses Slim on this website I make a dollar.

Thanks very much.

Now you know how Snoop felt when every white boy and his grandma in the country starting walking around saying "for shizzle."

 

[2win]

If they open the belly, un-tamponaded blood starts geysering out, then hell yeah, I want my MAC in the neck.

If they open the belly, get things under control quick, and things are hunky-dory, grab the med stud and teach him the fine art of 2AM central line placement.

Better a 14g than a triple lumen. And btw - why u guys are awake so late???

 

[jetproppilot]

now you know how snoop felt when every white boy and his grandma in the country starting walking around saying "for shizzle."

hahahahahahahahahahahahaha

 

[jetproppilot]

And btw - why u guys are awake so late???

I was late call yesterday (meaning I got there at 0630 and left when the on call doc could handle the OR, which translated to me leaving at around 7pm) so I got off today at 9am.

I tooka nap from 1-3pm, so I'm not sleepy yet.

NEXT QUESTION, SLIM.

 

[jetproppilot]

This dude needs volume, hemoglobin, and a guy with a knife, not much more.

That, my NO LIMIT HOLD'EM GURU-FRIEND,

is the foundation of TRAUMA ANESTHESIA CARE.👍

 

[huktonfonix]

Better a 14g than a triple lumen. And btw - why u guys are awake so late???

you realize of course, that some of us arent living in Louisiana (substitute EST state of your choice)

 

[OB1🤙]

Nobody said anything about a triple lumen.

I'm talking about a big old MAC.

AKA cordis on steroids.

 

[2win]

Nobody said anything about a triple lumen.

I'm talking about a big old MAC.

AKA cordis on steroids.

Here is SLIM - you said central line - sometimes I placed them through the basilic vein and for sure they are not 14 and for sure they are very long....
So when I see central line ( as for the board) I like to see more than that.
Of course just to piss you off - I know what u meant dude!

 

[2win]

I was late call yesterday (meaning I got there at 0630 and left when the on call doc could handle the OR, which translated to me leaving at around 7pm) so I got off today at 9am.

I tooka nap from 1-3pm, so I'm not sleepy yet.

NEXT QUESTION, SLIM.

So when u gonna get the Prius?

 

[DrRobert]

For quasi-stable traumas I like to induce with Etomidate.

For unstable traumas I like to induce with Versed and Ketamine.

For almost dead traumas I give them Scopolamine only.

 

[Planktonmd]

Intubation here can wait until you are in the OR but if he gets agitated or combative then plastic in the trachea becomes indicated.
Any induction agent is OK but if you use Propofol or STP add some Phenylephrine to the mixture.
Otherwise this is the simplest anesthetic you can do and as others said give volume and then give more volume.
Start using FFP early (preferably very early) and give platelets after 4-5 units of RBC.
Once you start using O negative or O positive don't switch.
Very simple 🙂

 

[Bertelman]

you realize of course, that some of us arent living in Louisiana (substitute EST state of your choice)

You know LA is CST, right?

 

[G0S2]

For induction, how about some Ketafol? Seems like some of the docs here love that mixture.

Again, just learning as I am about to embark on my intern year.

 

[Noyac]

My approach.
To OR for intubation unless pt loses airway.
Induce with scop and sux. He doesn't have any reserve left. With a HR of 146 if it gets any higher the heart won't have time to fill and the BP plummets. Prop and STP rely on increased HR to combat vasodilation. You can use some neo with them but you are going to be giving neo by the gallon anyway. If he remembers anything, then he can thank you for saving his life.
2 lg bores and an a-line. Rapidly infuse blood and crystalloid.
Give the O+ and don't switch to anything else. That is now his blood type after giving 10 units.
Get into the belly asap.

 

[BLADEMDA]

A year ago I too thought that you don't switch from O- after a few units. Is that still true? Hint: the answer is no.

I was trained in the old days that after 4-6 units of prbcs or 2-3 of whole blood you don't switch to type specific blood.

It turns out the trauma gurus in LA County where 1/4 of all trauma in the USA exists recommend TYPE SPECIFIC BLOOOD ASAP even if you have given 12 units of O- already.

Second, I too thought that you give FFP and then platelets after 4 or so PRBCs in a trauma. Again, is that still true?

This thread is trauma care in 2009 and we have new data from Iraq plus our Civilian trauma centers suggesting a more agressive course.

 

[BLADEMDA]

"Give the O+ and don't switch to anything else. That is now his blood type after giving 10 units. "



Sure about that Slim? New data coming out all the time. We need to be open to that data.

 

[BLADEMDA]

You see it turns out the blood bank guys love to sit around and debate the topic of when to switch back to type specific blood. They can't agree even after two six packs:

We are Level 1 trauma center and our policy for massive transfusion protocol states that, release O Positive unxm rbc for male patient. When specimen is received and if patient is Rh negative, we continue giving Rh positive xm or unxm rbc until rapid transfusion continues, eg. operating room but switch to Rh negative when patient is more stable and usage is lesser in ICU. For ABO, as soon as blood group is available we switch to patient ABO.