All posts by TheTraumaPro

How To Remember To Give The TXA!

The CRASH-2 study did a good job of demonstrating the value of giving tranexamic acid (TXA) in patients with major hemorrhage. The kicker is that the data seemed to show that the effect was best if given early, and might even be detrimental after 3 hours.

The reality is that most patients with major hemorrhage will present as a trauma activation. And if they really are bleeding badly, they will probably trigger your massive transfusion protocol (MTP). But at the same time, they will probably keep you very busy, and it’s easy to forget to order the TXA.

How can you make sure to start the TXA promptly on these patients? Easy! Check out this picture:

Yes, that’s a cheat sign right on top of the first cooler for the MTP! Have the blood bank include this sign in the cooler, so that everyone can see it when you crack the cooler open to give the first units of blood products.

In most hospitals, TXA is a pharmacy item. It should be stocked in the ED, and not in a far away pharmacy satellite. And don’t forget that TXA is given twice, 1 gram given over 10 minutes (or just IV push for speed), followed by another gram infused over 8 hours.

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Best Practice: Laundry Basket In The Resus Room?

How do you get patients out of their clothes during a trauma resuscitation? Most of the time, I bet your answer is “with a pair of scissors.” And once they are off, what do you do with them? Admit it. You just throw them on the floor. And sometime later, someone’s job is to find it all, put it in a bag, and store it or hand it over to the police.

There are more problems than you might think with this approach. First, and most importantly to the patient, their stuff can get lost. Swept up with all the other detritus from a trauma activation. And second, their belongings may become evidence and it’s just been contaminated.

So here’s an easy solution. Create a specific place to put the clothes. Make it small, with a tiny footprint in your trauma room. Make it movable so it can be kept out of the way. And make sure it is shaped so it can contain a large paper bag to preserve evidence without contamination.

And here’s the answer:

Yes, it’s a plain old laundry basket. The perfect solution. And best of all, these are dirt cheap when you are used to seeing what hospitals charge for stuff. So your ED can buy several ($14.29 ea on Amazon.com) in case they can’t be cleaned anymore or just disappear.

Why Did The Trauma Team Cut Off My Clothes?

The fifth highest priority taught in the ATLS course is exposure. This generally means getting the patient’s clothes off so any hidden injuries can be identified. Early in my career, I was called to see a patient who had a gunshot to the chest that had been missed because the consulting physician had neglected to cut off her bra. A small caliber wound was found under the elastic strap in her left anterior axillary line after a chest xray showed a bullet in mid-thorax.

The usual trauma activation routine is to cut off the clothes. There are several tips and tricks we use to do this quickly. And a number of commercial products are out there to make it even easier.

But do we really need to cut everyone’s clothes off? I’m not disputing the fact that it’s important to be able to examine every square inch. But do we need to destroy everything our patient is wearing? I once saw a sequined wedding dress cut off (it’s almost as bad as cutting off a down jacket).

The answer is no. The key concept here is patient safety. Can you safely remove the clothing in a less destructive way? For most victims of major blunt trauma, we worry a lot about the spine. Unfortunately, it’s just not possible to allow the patient to wriggle out of their clothes and protect their spine. The same goes for fractures; it may be too uncomfortable to remove clothing because of fracture movement so scissors are required.

Penetrating trauma is a bit different, and in many cases it’s a good idea to try to get the clothing off intact. Once again, if spinal injury is a consideration (gunshots only), the involved clothes should be cut off. A patient with a gunshot to the chest can probably have their pants safely and gently pulled off, but their shirt and coat must be cut.

The police forensic investigators like to have intact clothing, if possible. This is another good reason to try to remove clothing from penetrating injury victims without cutting.

Bottom line: Think before you cut clothes! Major blunt trauma and bad injuries require scissors. Lesser energy blunt injury may allow some pieces of clothing to be removed in the usual method. Most penetrating injury does not require cutting. But if you must (for patient safety), avoid any holes in the fabric so forensics experts can do their job.

Air Embolism From an Intraosseous (IO) Line

Intraosseous (IO) lines are a godsend when we are faced with a patient who desperately needs access but has no veins. The tibia is generally easy to locate and the landmarks for insertion are straightforward. They are so easy to insert and use, we sometimes “set it and forget it”, in the words of infomercial guru Ron Popeil.

But complications are possible. The most common is an insertion “miss”, where the fluid then infuses into the knee joint or soft tissues of the leg. Problems can also arise when the tibia is fractured, leading to leakage into the soft tissues. Infection is extremely rare.

This photo shows the inferior vena cava of a patient with bilateral IO line insertions (black bubble at the top of the round IVC).

During transport, one line was inadvertently disconnected and probably entrained some air. There was no adverse clinical effect, but if the problem is not recognized and the line is not closed properly, there could be.

Bottom line: Treat an IO line as carefully as you would a regular IV. You can give anything through it that can be given via a regular IV: crystalloid, blood, drugs. And even air, so be careful!