Category Archives: General

How To Identify Sick Pediatric Trauma Patients Before They Get Too Sick

We all have a pretty good idea of when an inpatient adult trauma patient is getting into trouble. Most rapid response teams have a set of criteria that are used by nursing personnel to initiate an RRT response. However, children who are beginning to decompensate can show it in more subtle ways. Fortunately, there is a tool that can be used to identify children who are showing early signs of developing problems.

The Pediatric Early Warning Signs tool (PEWS) is an objective system for assessing the potential for deterioration in a child. It can be customized based on institutional needs, and typically has behavioral, cardiovascular, and respiratory components. At our pediatric trauma center, we added a urinary output component as well. Scoring for each component ranges from 0 (best) to 3 (worst).

The total score is calculated, and is used to classify the child as green (benign) to red (immediate action needed). Again, these thresholds can be adjusted by each hospital. At our center, nursing calculates the PEWS score every 4 hours on non-ventilated patients.

Score category and actions are as follows:

  • Green (0-3 points) – no action, reassess as ordered
  • Yellow (4-6 points) – notify charge nurse, resident and attending physician
  • Red (7 or more points) – call rapid response team, resident and attending physician
  • A score of 3 in any category – call resident and attending physician

We implemented this system earlier this month and will be validating it during the coming year. Our hope is that it will reduce the number of RRT and code calls by identify deterioration at a much earlier stage.

You can download a copy of our PEWS instrument here. Thanks to Tracy Larsen RN, our pediatric Trauma Program Manager, for providing information on this system.

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Trauma Care on the Largest Cruise Ship in the World

During my recent cruise on Royal Caribbean’s Allure of the Seas, I had the opportunity to visit the medical center and check out the ship’s trauma care capabilities.

The major cruise lines, including Royal Caribbean, abide by the “Health Care Guidelines for Cruise Ship Medical Facilities” published by the American College of Emergency Physicians (ACEP). This document outlines the staffing, space, equipment and administrative capabilities needed to provide the highest quality of care at sea.

The ship is staffed by three emergency physicians and five nurses. Each physician is on call for a 24 hour period and has the following day off. The doctors and nurses provide comprehensive medical coverage to passengers and crew for both emergent and non-emergent problems. All of the physicians are ATLS certified, and some are ATLS instructors.

The medical staff responds to medical emergencies around the ship (code alpha) and have regular clinics in the medical facility for patients with less urgent problems. There is a specific treatment room for surgical / trauma problems that is well stocked with equipment for all procedures that might be required. This includes chest tubes, airway equipment, fracture care and more. A separate treatment room for medical patients can also be used as an ICU, with ventilators, invasive monitoring, and vasoactive medication drips. There are a number of other exam and treatment rooms that are used for patients with less urgent problems.

Digital xray equipment is available for conventional imaging, and the laboratory can do most routine tests as well as a few more exotic ones. Many of the tests are performed using iStat type equipment. The pharmacy carries a wide variety of medications. Due to space constraints, only one drug of each particular class is carried, which is sufficient for the majority of medical issues.

If patients sustain significant injuries that require services not available in the medical facility, they can be airlifted off the ship if it is within 150 miles of a port. If not, the medical treatment room is converted to an ICU and the patient remains there until they can be moved off the ship.

I was quite impressed with the facility and how much can be done in the available space. The staff is quite skilled and personable, and very aware of their capabilities. They are also in tune with the capabilities of the hospitals in the various ports of call, and have well thought out procedures regarding who can be taken care of on the ship and who needs to be transferred ashore.

Being a paranoid trauma surgeon, I always think about which trauma centers are nearby when I travel. After seeing the medical facility on the Allure, I am quite comfortable that they can handle the vast majority of traumatic injuries that might arise on the ship.

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Not All Plasma Is The Same

Trauma patients who either have, or are at risk for coagulopathy, routinely have plasma administered. This provides coagulation factors to make up for lower levels in the injured patient and promotes the ability to clot. All hospitals with a blood bank have fresh frozen plasma (FFP) on hand, and busier ones may have thawed plasma (TP) available so that the patient does not have to wait the 45 minutes or so that it takes to thaw FFP.

But does freshly thawed FFP behave like thawed plasma that’s been sitting around for a while? The University of Texas – Houston trauma group presented some work that looked at this issue at the AAST conference last September. They looked at differences between freshly thawed FFP and plasma that had been thawed for 5 days. They examined the plasma’s ability to generate thrombin, the kinetics of clot formation along with the clot’s strength and stability, and clotting factor assays.

They found that the older thawed plasma showed decreased clotting potential, as well as diminished amounts of coag factors, especially V, VIII, von Willebrand factor and Protein S. The clotting response (measured by TEG) was slower and took longer to develop the maximum amount of clot.

Bottom Line: Older thawed plasma does not function the same as freshly thawed FFP in the lab. We don’t know if this difference has clinical significance in the coagulopathic trauma patient. However, it seems prudent to ask for the freshest bags of thawed plasma during massive tranfusion in hospitals that use it.

Reference: Multiple levels of degradation diminish stored plasma’s hemostatic potential. Holcomb et al. Oral presentation #10, 69th Annual Meeting of the AAST, September 22, 2010.

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How To Read A Stab Wound

Most emergency departments do not see much penetrating trauma. But it is helpful to be able to learn as much as possible from the appearance of these piercing injuries when you do see them. This post will describe the basics of reading stab wounds.

Important: This information will allow some basic interpretation of wounds. It will not qualify you as a forensics expert by any means. I do not recommend that you document any of this information in the medical record unless you have specific forensic training. You should only write things like “a wound was noted in the midepigastrium that is 2 cm in length.” Your note can and will be used in a court of law, and if you are wrong there can be significant consequences for the plaintiff or the defendant. This information is for your edification only.

1. What is the length of the wound? This does not necessarily correspond to the width of the blade. Skin stretches as it is cut, so the wound will usually retract to a length that is shorter than the full width of the blade.

2. Is the item sharp on one side or both? This can usually be determined by the appearance of the wound. A linear wound with two sharp ends is generally a two sided knife. A wound with one flat end and one sharp end is usually from a one-sided weapon. The picture below shows a knife wound with one sharp side.

Single edge knife wound

3. Is there a hilt? This can usually be detected by looking for bruising around the wound. The picture below shows a knife wound with a hilt mark.

Knife wound with hilt mark

4. What is the angle? If both edges are symmetric, the knife went straight in. If one surface has a tangential appearance, then the knife was angled toward that side. You can approximate the direction of entry by looking at the tangential surface of the wound edge.

Angled knife entry

5. How deep did it go? You have no way of knowing unless you have the blood stained blade in your possession. And yes, it is possible for the wound to go deeper than the length of the knife, since the abdominal wall or other soft tissues can be pushed inwards during the stab.

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