Everybody is looking for good algorithms. They’re very helpful in standardizing care and they are a great teaching tool to show one good way to do something. All trauma centers have at least a few, like the Massive Transfusion Protocol.
Well, as the population ages and more of our elders are placed on drugs like warfarin, they run the risk of life-threatening bleeding if an accident occurs. Why reinvent the wheel? Don’t spend the time combing through the literature and designing your own protocol if someone else has already done the leg work!
Here’s a copy of our protocol for rapid reversal of warfarin with prothrombin complex concentrate (PCC) when life-threatening bleeding is present (e.g. blood in the head). Please note that the INR must be 2 or above to use this protocol, or the risks of giving the drug begin to outweigh the benefits.
Once the patient is found to be eligible, a single dose of PCC based on INR is given, as well as 10mg of vitamin K. The INR usually returns to near normal within about 30-45 minutes. If it’s still elevated, then begin administering plasma.
Feel free to copy and share. Also, any and all comments are welcome!
Download the protocol by clicking here
Formalizing The Prehospital to In-Hospital Handoff
I’ve written quite a bit about the benefits and pitfalls of the handoff process. Handoffs involving critical trauma patients is particularly important, because the receiving team needs to know a lot of information about what happened before patient arrival. All too often, the patient gets moved to the bed, and the medics are pushed to the side as the team descends upon him.
A number of hospitals around the US and the world have come up with solutions to strengthen this process. The regional trauma advisory committee here in the Twin Cities codified and implemented a formal handoff process to be used by emergency medical services providers any time they deliver a trauma activation patient to one of the area trauma centers.
I’d like to share our solution with you. This 4 minute video describes and demonstrates the process. Our expectation is that once things really get going, EMS will want to do this with just about every patient they deliver to the hospital.
Have a look, and feel free to comment or describe what you do!
Here’s a link to a Word document with the contents of the poster that can be placed in your trauma bay. Feel free to add your logos or change it in any way you wish. Download the poster here.
I first started writing about this project over a year ago. See these related posts on how it progressed:
You’ve heard the statistics about the graying of our society. The proportion of older people is growing rapidly. Well, there are only about 4400 neurosurgeons in the US, and they are aging as well. Nearly a third are older than 55 years.
This leaves a relatively small number of neurosurgeons tasked with helping to take care of trauma patients. Many Level II centers are hard pressed to maintain their neurotrauma services. Even basic procedures like ICP monitor placement may require transfer to another center.
The group at Miami Valley Hospital in Dayton looked at their experience with training surgeons to insert intraparenchymal ICP monitors (not EVD devices) over a 6 year period. Their trauma surgeons, as well as surgical residents were trained by watching a video, practicing in a cadaver lab under the supervision of a neurosurgeon, and being proctored by a neurosurgeon while placing them in three patients. Surgical residents could place the monitor if directly supervised by a surgeon.
Here are the factoids:
- Of 410 monitors placed, 298 were placed by surgeons and 112 by neurosurgeons
- The surgeons placed 188 Licox monitors and 91 Caminos. The type was not recorded in 19.
- Surgeon complication rate was 3% (9 patients), and the neurosurgeon rate was 0.8% (1 patient). None were major of life-threatening.
- Most of the complications were malfunction of the device. There were 2 dislodgements in the surgical group, and 1 in the neurosurgeon group.
Bottom line: This one’s a little tough to interpret. Yes, the number of complications (malfunction) is higher with the surgeons. But the numbers are small, and this difference does not reach statistical significance. I do worry that the training is a bit too sketchy. But I think that this procedure will soon enter the skillset of many acute care surgeons, especially those working at hospitals in more rural settings. This will be the quickest way to begin high quality neurotrauma care for patients who are injured in areas not served by highest level trauma centers.
Reference: Successful placement of intracranial pressure monitors by trauma surgeons. J Trauma 76(2): 286-291, 2014.
The patient underwent DPL and had an abnormal result, with weird sediment in the tubing.
Since this is, by definition, a positive result, they were taken to the OR. The DPL catheter was left in place to help localize what was going on. This is particularly helpful if an iatrogenic injury to a hollow organ is suspected. Otherwise it may be very difficult to find a tiny puncture wound.
It turns out that the catheter made a beeline for the cecum, resulting in a DCL (diagnostic colonic lavage), not a DPL. The particulate material was stool!
Since the catheter had been left in place, there was no contamination. It was removed under direct vision and a single stitch was placed to close the defect. Finally, a formal exploration was carried out to find the source of the patient’s abdominal pain. A low grade liver laceration was found that did not need any specific therapy. The ultimate source of her initial hypotension? Multiple long bone fractures with attendant bleeding into soft tissue. The abdomen was closed and the patient did well after fixation of her fractures.
It pays to know a little bit about DPL, even though it is seldom used these days. It can be useful, particularly when trying to rule the abdomen in or out as a source of bleeding where FAST is unavailable, indeterminate, or the result is suspect.
Check out this post for some tips and tricks on DPL:
This is a continuation of yesterday’s interesting case involving an unusual DPL result. As you recall, the tap was negative, but the lavage effluent slowly began to show some particulate material.
By definition, this is a positive result, which then requires a trip to the operating room. The catheter was capped and left in place. The patient was then taken to surgery, prepped and draped. Here’s what was found:
What’s your diagnosis now? And what needs to be done about it?
Final answers tomorrow!