hey how's it going I'm Alan and I'm an
emergency and trauma physician and I'm
sue I'm a pediatric emergency and trauma
physician and we both work with the
University of Toronto are you a
physician or nurse in a community
hospital we know it's tough out there
when you're managing trauma patients
alone in your Edie in Canada we face a
bunch of challenges when it comes to
caring for our patients in the great
white north geography weather and vast
distances present unique challenges in
getting your patient where they need to
be no matter what it's often a stressful
situation and if it's something that you
rarely see it's easy to find yourself
lost in a sea of management decisions
and inconsistent expectations from
receiving hospitals things like imaging
choices and disposition well we are
trauma focused physicians and we want to
help you manage your patients trauma has
been around since the very beginning but
it hasn't been until this past century
that we've been able to study it how we
think about trauma in modern times was
born out of the creation of a TLS and
its ability to provide a framework when
dealing with trauma patients let's start
with a fairly common scenario a
motor-vehicle patient we have two
general patient populations to consider
so you find these two patients in your
IDI recess Bay in this stressful
environment what are the decisions you
need to keep in mind that will provide
the most benefit for your patients get
them where they need to be and take some
of the uncertainty out of what can only
be described as a very challenging
situation first off know where you stand
be good at your primary survey you may
be all of the roles involved in a trauma
resuscitation wrapped into one but know
the order you want to assess and address
catastrophic bleeding airway breathing
circulation deficits exposure and think
about family presence that's really
important for kids especially as it
makes our job easier by decreasing their
normal fear and anxiety as well as
having important psychological benefits
for their parents you don't have to be
good at everything but some things are a
must know how to put in an IO and chest
tube know how to use a tourniquet and a
pelvic binder and how to reduce a long
bone fracture if you have an ultrasound
learn how to use it for an e fast exam
but remember its limitations a positive
fast is helpful where it can expedite
the decision to transport and provides
important information for your
accepting' dog who may mobilize services
and resources early remember a negative
fast does not rule out intra-abdominal
injury
especially in kids keep in mind that
repeating the fast improves the utility
of this dynamic test as does combining
it with other pieces of clinical
information know your hospital's blood
availability and how to get it
check out U of T's trauma app to find
up-to-date guidelines for implementing
or updating your site's massive
transfusion protocol and other trauma
related guidelines in the adult world
damage control resuscitation can help
prevent severe downstream pathology and
coagulopathy that potentially worsens
patient outcomes being comfortable with
minimizing saline palpable pulses and a
person who is coherent can be stressful
but ultimately best for hemostasis
giving TXA as early as possible and
keeping the patient warm helps support
clot stability but ultimately blood and
blood products are what should be given
to achieve a perfusing blood pressure
the key indications include any
suspected bleeding especially with a
systolic blood pressure of less than 90
or an altered level of consciousness
this remains a controversial topic in
pediatric trauma giving 10 to 40 mils
per kilo of warm crystalloid prior to
blood is reasonable in pediatric poly
trauma patients who present and
compensated shock but early
administration of blood components is
absolutely vital in patients who present
in decompensated shock
remember hypotension is a late finding
in pediatric hypovolemic shock that you
want to avoid as it truly signifies a
peri-arrest situation remember if a kid
is a Daulton size treat them like an
adult but permissive hypotension is not
an accepted principle and young children
and txa is a consideration
we encourage calling a pedes trauma doc
early with so many elements to keep
track of during a trauma finding ways to
streamline our decision-making and
remove some of that cognitive workload
can be extremely valuable when it comes
to the airway significant morbidity can
occur early without a strong focus on
basic airway management once the
decision to intubate is made evaluate
the potential difficulties and
complications and have your back-up plan
on hand if an RSI is indicated we
recommend keeping things simple
ketamine at 1 to 2 milligrams per
kilogram and rocuronium at 1 milligram
per kilogram is a good place to start
some things to keep in mind for kids we
don't routinely pretreat with atropine
anymore but having it available in case
of a bradycardic response to intubation
is not a bad idea when you're managing
the airway of an infant or a toddler
definitely remember post intubation
sedation and analgesia is best to have a
plan upfront for ongoing needs if a head
injury is present in a child or adults
some key points must be taken into
consideration
avoid hypotension and hypoxia avoid
hypercarbia consider osmotic agents like
hypertonic saline or mannitol elevate
the head of the bed to 30 degrees but be
mindful of your potentially spine
injured patients sedate and treat
seizures aggressively you may consider
using fentanyl here in your RSI as a pre
induction agent lastly avoid
hypoglycemia and check this early in the
altered child trauma hurts a lot it's
tough sometimes to know how much pain
medicine to give what's it going to do
to that blood pressure will it mask any
neurological deterioration while
analgesics can have physiologic effects
that we are worried about in sick trauma
patients please do remember to also
treat your patients pain both in your
recess bay and during transport options
include morphine fentanyl and low-dose
ketamine in kids managing pain and
anxiety will help significantly with
your ability to assess them sending
physicians are often given mixed
messages about went to image and when to
simply package and send this can be
frustrating and lead to delays and care
at both ends so to simplify in the
potentially sick patient do imaging that
you can act on like a chest x-ray to
guide chest tubes long bone films to
identify fractures that can is should be
reduced
pelvic x-rays if you're suspicious for
fracture but if your patient is unstable
just buying the pelvis point of care
ultrasound is quick dynamic and can help
guide management at the bedside it's a
great tool to have for any IDI community
physician but do remember its scope and
limitations in Ontario critical care
services Ontario guidelines provides a
straightforward list of indications for
contacting a trauma doc for potential
transfer to be clear we also recommend
contacting a trauma physician for a
support when faced with uncertainty in
your department we as trauma physicians
accept that we may receive some false
positives but knowing this we'll get
sick patients where they need to go
faster the extremes of age should lower
your threshold to transfer a serious
injury may be much more subtle in these
people as their physiology and
comorbidities may present unique
challenges to diagnosis and treatment
for patients needing c-spine
immobilization make sure the collar fits
appropriately immobilization is self
carries risk and guidelines around
spinal motion restriction protocols are
changing back boards are meant for
extrication consider scoop stretchers
for transport and realized that patients
can spend a long time on these devices
which leads to complications
don't let your patient lay around on a
backboard get them off it as soon as
possible having a transport checklist
provides a tool to ensure your patient
has everything they need to be moved out
of your department establishing
alliances with your local trauma network
to access feedback on performance and
patient outcomes will make your team
better equipped for the next trauma call
that rolls through your door and will
help trauma centers improve their
overall care as well so hopefully this
information better prepares you for that
next trauma till next time
you