All posts by The Trauma Pro

Laboratory, Resuscitation

Crafting And Refining Your Massive Transfusion Protocol – Part 1

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Every trauma center needs a massive transfusion protocol (MTP). It automates the preparation and delivery of critical blood products in seriously injured patients. Unfortunately, there are many moving parts, so numerous things can go wrong.

This series of posts will break down the entire MTP process, step by step. Although it is designed for centers developing their first MTP, it also provides valuable information for established centers that want to tweak and optimize theirs. I’ll start today with tips on how to build a solid MTP at your center.

Your massive transfusion protocol is a complex set of processes that touch many, many areas within your hospital. There are five basic components (and a few sub-components) to any MTP, so let’s dig into them one by one. They are:

  • Universality
  • Activation
  • Logistics
    • Components
    • Runners
    • Documentation
    • Coolers
  • Deactivation
  • Analysis

Let’s scrutinize each one, starting with the first two today.

Universality. This means that there should be one, and only one MTP in your hospital. I’ve seen some hospitals that have one MTP for trauma, one for cardiothoracic surgery, one for OB, one for GI, and on and on. Yes, each of those services deals with patients who are suffering from blood loss. But it’s the same blood that your trauma patients lose! There’s no need to create a protocol for each, with different ratios, extra drugs, etc. This can and will create confusion in the blood bank which may lead to serious errors.

Activation. This consists of two parts: how do we decide to activate, and then how does everyone involved find out that the MTP is actually being activated? I’ll discuss activation criteria later in the series. But what about the notification process? Phone call? Order in the electronic medical record (EMR)? Smoke signals?

The most reliable method is a good, old-fashioned phone call. Do not use your EMR except for documentation purposes. Unless there is a very reliable system in the blood bank that translates an EMR order into an annoying alarm or flashing lights, don’t rely on this at all.

Then decide upon the minimum amount of information that the blood bank needs to begin preparing blood products. This usually consists of a name or temporary patient identifier, sex, and location of activation. Ensure that an ID or transfusion band is affixed to the patient so that wrong blood products are not given in multiple patient events.

In my next post, I’ll continue with the logistics of the MTP.

Prehospital, What the heck?

What The Heck! You Make The Diagnosis – The Answer

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In my last post, I detailed the following case:

This male patient was brought to the trauma center after a high-speed car crash. He was unresponsive with GCS 3. A bleeding facial laceration was present, as was vomitus in the airway.

Prehospital providers rapidly intubated the patient and inserted an orogastric tube. They rapidly packaged and transported him to the nearest trauma center.  The facial laceration was stapled for bleeding control. The airway was checked with a CO2 color change indicator and was positive. OG was hooked to suction with return of gastric contents.

And here was a lateral cervical spine image:

The main problem is that, if you look closely there are three tubes on the image!

Look carefully at the anterior pharynx and trace the radiopaque markers back. There are two nearly overlapping lines. One extends posteriorly, down into the esophagus. This is the orogastric tube. The distal tip of the other (an endotracheal tube which is only inserted to 12 cm at the teeth) stops where it touches another tube. Another endotracheal tube, the proximal end of which is sitting at the epiglottis!

What the heck??! The medics were interviewed, and the patient was initially intubated successfully. The intubator turned his attention to finding a tube securing device, and when he turned back the tube was gone! So he intubated again but met some resistance. This explained the shallow position of the tube.

The patient was oxygenated well and the “outside” ET tube was removed. Then ring forceps were passed under direct vision and the “inside” tube was removed. A well-positioned ET tube was then reinserted. The patient did well afterwards.

Teaching point: When inserting anything that is partially in and partially out of the body (e.g. guidewires, and now ET tubes) always anchor them with your fingers so they don’t just “disappear.” And if you need more hands, ask for assistance!

Source: personal collection. Not treated at Regions Hospital or even in Minnesota.

What the heck?

What The Heck! You Make The Diagnosis

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Please help figure out what is wrong here. I’m not going to give you much information, though.

This male patient was brought to the trauma center after a high-speed car crash. He was unresponsive with GCS 3. A bleeding facial laceration was present, as was vomitus in the airway.

Prehospital providers rapidly intubated the patient and inserted an orogastric tube. They rapidly packaged and transported him to the nearest trauma center.  The facial laceration was stapled for bleeding control. The airway was checked with a CO2 color change indicator and was positive. OG was hooked to suction with return of gastric contents.

This case occurred in the old days when lateral cervical spine films were initially used to evaluate the c-spine in the trauma bay. Here is the image:

What is your diagnosis? And what does the team need to do?

Please post your answer in the Disqus comment box below, or email me. You might consider Twitter (or is it X now), but it seems somewhat flaky.

Answers in my next post!

Source: personal collection. Not treated at Regions Hospital or even in Minnesota.

 

Extremity

Novel Hip Reduction Technique: The Captain Morgan

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I wrote about posterior hip dislocation and how to reduce it using the “standard” technique quite some time ago (see link below). Emergency physicians and orthopedic surgeons at UCSF-Fresno have published their experience with a reduction technique called the Captain Morgan.

Named after the pose of the trademark pirate for Captain Morgan rum, this technique simplifies the task of pulling the hip back into position. One of the disadvantages of the standard technique is that it takes a fair amount of strength (and patient sedation) to reduce the hip. If the physician is small or the patient is big, the technique may fail.

In the Captain Morgan technique, the patient is left in their usual supine position and the pelvis is fixed to the table using a strap (call your OR to find one). The dislocated hip and the knee are both flexed to 90 degrees. The physician places their foot on the table with their knee behind the patient’s knee. Gentle downward force is placed on the patient’s ankle to keep the knee in flexion, and the physician then pushes down with their own foot, raising their calf. Gentle rotation of the patient’s hip while applying this upward traction behind the patient’s knee usually results in reduction.

Some orthopedic surgeons use a similar technique, but apply downward force on the patient’s ankle, using the leverage across their own knee to develop the reduction force needed. The Captain Morgan technique use the upward lift from their own leg to develop the reduction force. This may be gentler on the patient’s knee.

The authors report a series of 13 reductions, and all but one were successful. The failure occurred due to an intra-articular fragment, and that hip had to be reduced in the operating room.

Reference: The Captain Morgan technique for the reduction of the dislocated hip. Ann Emerg Med 58(6):536-540, 2011.