Part 1: Trauma Case Management

Hi all,
Hopefully everyone is having a great start to 2015. It has been a long time since I have had the opportunity to blog. A lot of good and bad has happened in my personal and professional life over these 4 months. I have finally learned how to utilize all the good from these experiences and make myself better for the future.
I still enjoy working independently and would never settle for anything less professionally. However, there have been some situations that made me realize that there are times when you just need an extra pair of hands and a fresh, fully-caffeinated brain.
This is especially true when you get a middle of the night call for a bad trauma case that is too unstable to be transported to a larger facility. That is when your mind needs to be fresh and running full force. I got caught off guard in similar scenario recently that really tested my knowledge of managing these complex cases. Even though, the trauma committee seemed impressed on the whole OR team's performance, there are always things that can be learned from such cases. So, I wanted to talk about what we need to consider dealing with these cases.

Preoperative
When the patient comes from emergency room in an unstable condition, it is sometimes difficult to assimilate all the information that is being reported off to you (if you get a report at all). There are some key details that should never be overlooked and are definitely important to know in order to manage a trauma.

• How much fluid has the patient received?- This can get out of hand very quickly in even well managed trauma cases. The transition from administering crystalloids to blood can easily get delayed further compromising patient outcome. A poorly resuscitated patient will also be poorly responsive to vasopressors. If blood transfusions have been started it is important to note if they were type and cross matched to avoid compatibility related reaction.
• Does the patient have adequate venous access? A trauma patient going to the OR should have at least 2 IV lines (if not a central line) regardless of how severe the trauma is. Things can change quickly so preparation is key.
• Is there an arterial line? This is especially helpful if the patient is expected to have massive transfusions. ABGs and continuous hemodynamic monitoring will be needed.
• What were the recent lab values? Electrolytes and blood count should be evaluated. 
• Radiology reports: Cervical spine stability must be maintained with a  C collar especially if radiology reports were not cleared. Placement of ETT should also be confirmed.
• Degree of trauma: Talk to the surgical team to get their view on how severe the trauma is. It might seem common sense but sometimes even the most important information tends to get lost in translation.

Preoperative Setup

• Hotline with blood tubing, arterial line setup, vasopressors such as phenylepherine drip, ephedrine and vasopressin (1u/ml), level 1 rapid infusor, bair hugger, central line kit with CVP monitoring set up.

Intraoperative
It can be a daunting task to prioritize things for a trauma case. Everything seems important and it may be difficult to organize appropriately in such a high stress time. Fluid and blood administration takes high priority for me (generally, depends on the case). If the patient is very unstable it may not be appropriate to hold off on making incision. However, if the patient is hemodynamically stable it may be wise to get properly set up with vasopressor drips, bair hugger, arterial line etc. Patient may lose significant amount of blood on incision depending on the degree of trauma. Resuscitation may be difficult especially if the patient is already fluid depleted.
Another important factor to consider is temperature. Hypothermia can severely increase trauma related mortality and is unfortunately, ends up being last thing on the to-do list. Use of hotline, air humidivent, and bair hugger should all be incorporated soon after patient arrive to the OR.
Massive transfusion is bound to cause severe electrolyte imbalances that could lead to possibly fatal outcomes such as arrhythmias, and vasodilation. Therefore, correcting abnormal laboratory values such as potassium, calcium, magnesium, and arterial blood gases should not be delayed. Hyperkalemia is often noted with massive transfusion so EKG changes should be noted carefully.


I have been researching this topic to ensure that I don't miss anything but even remembering all the details and writing it for the blog is a long tiring process. So, I will continue on this topic in Part 2 to follow.