Seems like a simple, silly question, right? I dare you to figure it out without reading this post!
On occasion, our brain injured trauma patients have sodium issues. You know, cerebral salt wasting. Trying to maintain or regain the normal range, without making any sudden moves can be challenging. There are a lot of tools available to the trauma professional, including:
- Hypertonic saline
- Salt tablets
- Fluid restriction
- Some combination thereof
Fun times are had trying to figure out how much extra sodium we are giving with any of the first three items. This is important as you begin to transition from the big guns (hypertonic), to regular saline, and then to oral salt tabs.
Below is a quick and dirty conversion list. I won’t make your heads explode by trying to explain the math involved changing between meq, mg, moles, sodium and sodium chloride.
- The “normal saline” bags we use are actually 0.9% saline (9 gm NaCl per liter)
- Hypertonic saline can be 3% or 5% (30 gm or 50 gm per liter)
- Salt tabs are usually 1 gm each (and yummy)
Therefore, a liter of 0.9% normal saline is the same as 9 salt tabs.
A liter of 3% hypertonic saline is the same as 30 salt tabs. The usual 500cc bag contains 15.
A liter of 5% hypertonic saline is the same as 50 salt tabs. The usual 500cc bag contains 30.
To figure out how many tablets you need to give to match their IV input, calculate the number of liters infused, then do the math! And have fun!
Although you may not agree with this at first, communicating with our patients is one of the most important things we do as trauma professionals. You can be the “best” doctor, nurse or paramedic in the world, but if you can’t communicate well your patients will have nothing good to say about your care of them.
The most important skill needed for good communication is empathy. You need to be able to put yourself in their position. Imagine what you would want if you were on the receiving end of the information you are about to deliver. What would you say if you were talking to your spouse, your mother, or your child?
Next, think about what kinds of things they would want to know. In trauma, they obviously want to know information about the injuries. Patients and families also need to hear about the short term and long term plans. What’s going to happen in the next few hours? Will surgery be needed? When? How long will I be in the hospital? How long will I be out of work?
Many of these questions are difficult to answer at the time of admission after trauma. If you don’t know or it’s impossible to determine, say so. Experienced clinicians can make some pretty good guesses, but should always qualify their answers. You should make it clear that you are giving an estimate, and that things may very well change. Also explain that as these changes occur and time passes, you will give better estimates.
One of the most important things to remember is the “keep it simple” mandate. Our patients and their families are smart. Although they may not know the lingo that we are familiar with, they can grasp the concepts of what is happening. Be careful to keep your explanations understandable, and don’t make the mistake of using any complicated medical terms. Imagine the surprise of the patient when they find out what “we’re going to insert a Foley catheter now, sir” really means. Also keep in mind that the patients and their families are stressed, and may not be able to concentrate on or remember everything you say. Repetition is good in these situations.
Communication after major trauma is challenging. Remember, if the families don’t get what you’re saying, it’s your fault, not theirs.
You’re dealing with some type of eye problem/injury in the ED. How do you know when to call the eye doctor? What problems need emergent attention? Which ones require a phone call only? Which ones can just be sent to the ophthalmologist’s office in a few days?
The link below provides a set of guidelines for you to use to help figure this out. As always, it’s a good idea to apply your own expert judgment as well.
When to call the ophthalmologist
Yesterday I posted an image of an unusual chest CT. The patient had been involved in a motorcycle crash weeks ago, and presented with new onset chest pain and weakness.
Exam of the chest showed a hint of diffuse swelling on the left side and moderate tenderness. Chest x-ray suggested a mild effusion on the left. I showed one slide of the CT yesterday, which showed a large amount of complex material in the chest wall. This is most likely a mixture of blood and clot.
Here is another slice of the CT that is more revealing:
Now you can see that there are multiple rib fractures present. While comparing the original and the recent scan, it is apparent that the fractures are more displaced on the recent one. Upon closer questioning the patient admits that he did fall down the day before the new pain and swelling occurred.
And by the way, he forgot to mention the fact that he had developed deep venous thrombosis and was taking warfarin! And also by the way, his blood pressures were becoming a bit soft.
I would consider this life-threatening bleeding! Crystalloid and blood resuscitate immediately. Reverse the anticoaguation quickly, using prothrombin complex concentrate (PCC, preferably 4-factor). Then send him to interventional radiology to see if there are any active bleeders that can be embolized. Finally, it’s off to the ICU to finish up the resuscitation and restore him to normal!
Here’s another one for you to figure out. Of course, I’ll give you minimal information and see what you can do with it.
A middle-aged male presents to your ED from home with left chest pain and weakness. There is a history of a motorcycle crash 6 weeks ago. Ultimately, a chest CT was obtained and here is a representative section:
Here are my questions:
- What’s going on?
- What should you do about it?
Leave a comment below or tweet your guesses. Answers tomorrow!