The Advanced Trauma Life Support course lists “classes of hemorrhage”, and various other sources list a similar classification for shock. I’ve not been able to pinpoint where these concepts came from, exactly. But I am sure of one thing: you will be tested on it at some point in your lifetime.
Here’s the table used by the ATLS course:
The question you will always be asked is:
What class of hemorrhage (or what % of blood volume loss) is the first to demonstrate systolic hypotension?
This is important because prehospital providers and those in the ED typically rely on systolic blood pressure to figure out if their patient is in trouble.
The answer is Class III, or 30-40%. But how do you remember the damn percentages?
It’s easy! The numbers are all tennis scores. Here’s how to remember them:
||up to 15%
||Love – 15
||15 – 30
||30 – 40
||Game (almost) over!
Bottom line: Never miss that question again!
Tourniquets had been banished for several decades due to the misconception that they caused more harm than good. But thanks to the experience of the US military, they have made a resurgence again in civilian use. If handled properly, they can literally be a life-saver.
More and more often, our prehospital trauma professionals are applying a tourniquet in the field. The question once they arrive in your trauma bay is “now what?”
Well, obviously it’s got to come off. But there is a lot of nuance around how to do that. And I don’t just mean the technical aspects of releasing it. It’s important to understand what injuries your patient has, and what the capabilities of your trauma center are first. Here is a framework to help you think through the details.
- How long has the tourniquet been up? Hopefully that has been recorded somewhere, or written on the tourniquet. If you don’t know exactly, assume that medics applied it upon arrival at the scene.
- If < 90 minutes and you have surgical support available, call the surgeon! If they believe the patient needs to be in the OR right away, make it happen.
- If < 90 minutes and you do not have surgical support, transfer your patient ASAP to a center that has it. If the transfer will take more than 2 hours (due to distance / weather and not a slow transfer on your part, consider dropping the tourniquet as described below.
- If > 120 minutes regardless of transfer status, consider dropping the tourniquet as described below.
- Is there a contraindication to removal?
- Traumatic amputation with the tourniquet nicely placed just proximal to an amputation stump. It may slip off after releasing the tension.
- Decompensated shock or near arrest. The patient is trying to die and the tourniquet is helping to prevent them from doing just that.
- Inability to closely monitor for rebleeding. If the patient needs to be transported in a relatively unsupervised setting, new bleeding may not be treatable.
If there are no contraindications and there is a need to at least temporarily release the tourniquet, then prepare your area appropriately. Ideally, this should be done in an OR or ICU, but that is not always practical. Otherwise, make your trauma bay look like one. Make sure you have at least one new tourniquet in case the old one can’t be reapplied for some reason. Ensure there is plenty of hemostatic gauze and dressing materials. Have the crash cart nearby and make the ACLS drugs readily available, just in case.
Then release the tension on the tourniquet and note the time. Three things can happen:
- There is no bleeding. This happens about 80% of the time in my experience. Either there was no surgical bleeding in the first place, or it has clotted. Place a nice dressing that can be monitored easily.
- There is only “non-surgical” bleeding. This is typically oozing or pesky venous bleeding. These should be controlled with sutures or hemostatic dressings. Pressure dressings are also wonderful in the situation. Craft them carefully.
- Life threatening bleeding resumes. Reapply the tourniquet and get the patient to definitive care ASAP (OR or another center that has one).
Bottom line: There is very little magic to dealing with tourniquets on the receiving end. But get a very clear picture of what your patient needs and what your center has to offer them. If these factors don’t match up, initiate the transfer as fast as you possibly can. Otherwise move to your OR to fix the problem!
Reference: Removal of the Prehospital Tourniquet in the Emergency Department. J Emerg Med 60(1):98-102, 2020.
By now, we are all very familiar with the concept of the distracting injury. Some of our patients sustain injuries that are so painful that they mask the presence of others. The patient is so distracted by the big one that others just slip their notice.
This concept has been notoriously difficult to test, but there is a reasonable amount of data that suggests it is true. One of the more common and disturbing injury patterns occurs when there is a significant amount of chest wall trauma. When there are fractures focused around the upper chest, cervical spine injuries may be masked, then missed during the exam by trauma professionals.
I’d like to introduce a new concept: the ultimate distracting injury. This goes beyond an injury distracting the patient from another painful problem.
The ultimate distracting injury is one that is so gruesome that it distracts the entire trauma team! It could actually be so distracting that the team might miss multiple injuries!
It’s just human nature. We are drawn to extremes, and that goes for trauma care as well. And it doesn’t matter what your level of training or expertise, we are all susceptible to it. The problem is that we get so engrossed (!) in the disfiguring injury that we ignore the fact that the patient is turning blue. Or bleeding to death from a small puncture wound somewhere else. We forget to focus on the other life threatening things that may be going on.
What are some common ultimate distracting injuries?
- Mangled extremity
- Traumatic amputation
- Severe soft tissue injury
How do we avoid this common pitfall? It takes a little forethought and mental preparation. Here’s what to do:
- If you know in advance that one of these injuries is present, prepare your crew or team. Tell them what to expect so they can guard against this phenomenon.
- Quickly assess to see if it is life threatening. If it bleeds or sucks, it needs immediate attention. Take care of it immediately.
- If it’s not life threatening, cover it up and focus on the usual priorities (a la ATLS, for example).
- When it’s time to address the injury in the usual order of things, uncover, assess and treat.
Don’t get caught off guard! Just being aware of this common pitfall can save you and your patient!
The September issue of the Trauma MedEd newsletter is now available to everyone!
In this issue, get some tips on:
- Managing Penetrating Injury
- Nursing Tips For Pediatric Orthopedic Injury
- Abdominal Packing Tips
- Geriatric Trauma Management
- Tips For Trauma In Pregnancy
- Managing CSF Leaks
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The July issue of Trauma MedEd will be sent out to subscribers near the end of the month. It will review some topics that I find very interesting, and I hope you will to.
This issue is being released to subscribers by July 30. If you sign up any time before then, you will receive it, too. Otherwise, you’ll have to wait until it goes out to the general public at the end of next week. Click this link right away to sign up now and/or download back issues.
In this issue, learn about:
- The effect of ambulance deceleration on ICP in head injury patients
- An interesting technique for sealing vacuum systems applied around external fixators
- An analysis of thrombotic events following TXA administration
- The utility of a second head CT in patients taking DOACs
- And one or two more depending on space available!
As always, this month’s issue will go to all of my subscribers first. If you are not yet one of them, click this link right away to sign up now and/or download back issues.