Simulation Cases Cliff Notes - April 2018

Every month we summarize our simulation cases. No deep dive here, just the top 5 takeaways from each case.  

 

 

Double Trouble - Trauma in Pregnancy

1.  GET HELP EARLY.

• Obtain trauma and obstetric consultation as soon as possible for severe trauma in pregnancy.

2.  DO WHAT IS NECESSARY TO TAKE CARE OF MOM. 

• The principal cause of fetal mortality is maternal mortality (especially shock).
• Evaluation of the fetus comes during the secondary survey.
• Radiography - order indicated radiographic studies that are necessary but consider alternatives.

3.  EXAMINE AND RESUSCITATE AS YOU WOULD A NON-PREGNANT PATIENT, WITH A FEW IMPORTANT CAVEATS:

http://what-when-how.com/nursing/normal-pregnancy-maternal-and-newborn-nursing-part-4/

• Airway – Anticipate a more difficult airway (decreased O2 reserve, more airway edema, reduced neck motion from c-collar)
• Breathing
  • Ventilation will be more difficult due to gravid state
  • Place a chest tube two inter spaces higher
• Circulation
  • Anticipate and avoid shock, the principle cause of fetal mortality.
  • Pregnant patients start with lower blood pressures, bleed easier and have later changing vital signs.
  • Bump the patient (or better yet), displace uterus to the left to prevent supine hypotensive syndrome.
  • Be aggressive with fluid resuscitation to avoid shock.
  • For hypotension suspected to be due to hemorrhage, O-negative blood is preferred.

• Ask additional Obstetrical History
  • Direct trauma to abdomen?
  • Vaginal bleeding, leakage of fluid?
  • Abdominal cramping?
•  Additional Obstetrical Exam
  • Fetal assessment (fetal heart tones, echo for movement)
  • Significant intra-abdominal injury may be present without significant signs/symptoms.
    • The abdominal wall may be less sensitive to peritoneal irritation because of stretching of abdominal muscles from uterine growth.  
  • Begin cardiotocographic monitoring in the viable pregnancy (>24 weeks) as soon as possible

4.  ADMINISTER RHOGAM IF THE MOTHER IS Rh (-).

5.  CONSIDER PERFORMING A PERIMORTEM C-SECTION FOR VIABLE PREGNANCIES (> 24 WEEKS) IF MATERNAL CARDIAC ARREST OCCURS.

• Check out our earlier post on peri-mortem c-section. 

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Got your scuba gear for a deeper Dive?  watch Dr. Bloch Discuss Trauma in Pregnancy

References

1. American College of Emergency Physicians Practice Management guideline on Trauma in the Obstetric Patient.  https://www.acep.org/Clinical---Practice-Management/Trauma-in-the-Obstetric-Patient--A-Bedside-Tool/#sm.00005oew7r1ag6fdks3badptr2oe2

2. Smith, KA and Bryce, S.  Trauma in the Pregnant Patient:  An Evidence - Based Approach to Management.  Emergency medicine Practice.  April 2013.

3.  El-Kady D, Gilbert WM, Anderson J, et al. Trauma during pregnancy: an analysis of maternal and fetal outcomes in a large population.  Am J Obstet Gynecol. 2004; 190 (6): 1661-1668.[Pubmed]

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Hemophilia and Head Trauma

https://www.flickr.com/photos/pauli2990/4752996429

1.   THE MOST COMMON FORM OF INHERITED BLEEDING DISORDERS ARE:

• Factor VIII deficiency (hemophilia A)
• Factor IX deficiency (hemophilia B)

2.   THE SEVERITY OF FACTOR VIII AND FACTOR IX DEFICIENCIES IS DETERMINED BY THE FACTOR ACTIVITY LEVEL:

• Mild (5-40%)
• Moderate (1-5%) 
• Severe ( < 1%)

hemophilia of georgia April 2008

3.  INTRACRANIAL (SPONTANEOUS OR TRAUMA- INDUCED) HEMORRHAGE (ICH) HAS EXCEEDED HIV AS A LEADING CAUSE OF MORTALITY [1].

• ICH has been reported to have 20% mortality in the hemophilia population[2].
• Among surviving patients, 25-75% sustain permanent disability [2]

4.  INTRACRANIAL HEMORRHAGE CAN OCCUR WITH OR WITHOUT A HISTORY OF TRAUMA AND IS MUCH MORE LIKELY TO OCCUR IN PATIENTS WITH SEVERE HEMOPHILIA.

• In a French study, only 62% of patients younger than 15 years reported a history of trauma [3].
• Diagnosis was de­layed in 43% of these patients, and treatment was delayed in 37%.
• Significant headaches (even without trauma) must be taken very seriously in the hemophiliac.

5.  EMERGENCY MANAGEMENT OF HEMORRHAGE FOR PATIENTS WITH A CONGENITAL BLEEDING DISORDER CENTERS ON INCREASING THE CIRCULATING LEVELS OF DEFICIENT CLOTTING FACTORS.

• The goal of factor replacement is generally considered to be 40%-50% for minor bleeds and 80%-100% for major hemor­rhages [4]; for major hemorrhages, assume the patient has close to 0% activity.
• One unit/kilogram of factor VIII concentrate will increase factor VIII activity by 2%; therefore, to achieve 100% correction, 50 U/kg must be administered
• One unit/kilogram of factor IX concentrate will only increase factor IX activity by 1%; therefore, twice as much factor IX must be administered for the same effect: 100 U/kg are necessary to achieve 100% correction[4]
• If factor replacement is unavailable, cryoprecipitate (for factor VIII deficiency) or fresh frozen plasma (FFP) (for factor IX deficiency) may be used as a last resort.

References

1. Darby SC, Wan SW, Spooner RJ, et al. Mortality rates, life expectancy and causes of death in people with hemophilia
A or B in the United Kingdom who were not infected with HIV. Blood 2007 Aug;110(3): 815-826. [Pdf]

2.  Teitel J, Berntorp E, Collins, P, et al. A systematic approach to controlling problem bleeds in patients with severe congenital hemophilia A and high - titre inhibitors. Haemophilia 2007; 13(3): 256-263.

3.  Stieltjes N, Calvez SN, Demiuel V, et al. Intracranial haemorrhages in French haemophilia patients (1991-2001): clinical
presentation, management and prognosis factors for death. Haemophilia 2005 Sep;11(5):452-458 [Pubmed]

4.  Hemophilia of Georgia, World Federation of Hemophilia. Protocols for the treatment of hemophilia and von Willebrand
disease. April 2008, No. 14. [Pdf]

5.  Srivastava et al.  Guidelines for the Management of Hemophilia.  World Federation of Hemophilia, Haemophilia; Epub 6 JUL 2012. [Pdf]

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MANAGEMENT OF SEVERE THERMAL BURNS

1.  BURNS ARE A COMMON PRESENTATION AND THE EMERGENCY PROVIDER MUST BE COMPETENT TO HANDLE THEIR POTENTIAL COMPLEXITY.

• The American Burn Association (ABA) reports that nearly half a million people suffer thermal burns each year in the United States [1].

2.  INITIAL MANAGEMENT OF THE BURN PATIENT SHOULD FOCUS ON:

• Airway assessment
• Evaluating for signs of inhalational injury
• Evaluating for concomitant trauma 
• Preventing the burn process (remove all affected clothing, cool with cool water/saline)

 3.  YOUR HISTORY AND PHYSICAL EXAM SHOULD FOCUS ON THE TYPE OF BURN, BURN DEPTH, BURN SEVERITY AND % TOTAL BODY SURFACE AREA (TBSA).

• What type of burn was it? (Scald, flame, contact, electrical, friction, sun)
• Burn classification:
  • Depth as as established by American Burn Association
    • Superficial
      • Involves epidermis only
      • Painful, dry with blanching erythema
    • Superficial partial thickness
      • Involves upper epidermis and extends down to papillary upper dermis
      • Painful, wet and weeping, blanching erythema, often with blisters
    • Superficial full thickness
      • Involves lower dermis
      • Decreased sensation, yellow or white, dry, nonblanching
    • Full thickness
      • Involves subcutaneous structures
      • White or black/brown, nonblanching
      • Decreased sensation
        • The presence of pain cannot be used to exclude full a thickness burn.
        • A retrospective review of 507 patients found that patients with isolated full-thickness burns had only slightly decreased pain scores compare to those with partial-thickness burns[2].

http://www.forensicmed.co.uk/wounds/burns/burn-area/

• Severity as established by the Amercian College of Surgeons
  • Minor: < 10% TBSA or full thickness involving  < 2% TBSA
  • Moderate:  10-20% TBSA of partial thickness but < 10% full thickness TBSA
  • Severe:  > 20% TBSA partial thickness, > 10% full thickness burns
  • Percentage TBSA using Lund-Browder chart
    • Higher accuracy and interrater reliability than rule of 9’s and rule of palms (which tend to overestimate TBSA and result in excessive fluid administration) [3,4]
    • Only partial and full thickness burns count toward TBSA.

4.  EVALUATE FOR AND TREAT CONCOMITANT TRAUMA ASSOCIATED WITH BURNS.

• Was it an electrical burn with high voltage? (think myoglobinuria, edema, compartment syndrome, cardiac dysrhythmias) 
• Was it a structure fire with potential trauma from collapsing structures, carbon monoxide and cyanide poisoning?
• Hydrofluoric acid causing possible hypocalcemia?

5. THE PRIMARY PILLARS OF BURN TREATMENT INCLUDE AIRWAY MANAGEMENT, FLUID RESUSCITATION AND WOUND CARE.

• Airway management
  • Evaluate for stridor, hoarseness, shortness of breath, singed nasal hairs, cough, soot in oral cavity, history of being in fire in enclosed space.
  • Expert consensus endorses early intubation for burns to the upper airway, airway edema, stridor or other signs of respiratory compromise [5].
  • Use the largest tube possible to improve bronchoscopy later.
• Treat burns with > 20% TBSA with fluid resuscitation (lactated ringers preferred)
  • The Parkland formula is a common method to estimate appropriate volume of fluid resuscitation.
    •  (4 mL/kg)  X  (%TBSA)
    •  ½ given in first 8 hours after the onset of burn and remainder given in remaining 16 hours
  • The Parkland formula is a general guide and ongoing fluid requirements should be monitored/tailored with urine output (0.5-1 ml/kg/h for adults) and input/output hemodynamics. 
• Wound Care
  • Silver sulfadiazine is commonly available, but no evidence to show it has reduced healing time or infection rates when compared to petroleum jelly products [6-8].
  • Use sterile saline and gauze to gently remove sloughing epidermis.
  • General consensus regarding blister management:
    • If the blister is intact and < 1 cm2, leave intact.
    • Blisters > 1 cm2 can be debrided or left intact (there is contradictory evidence on topic).
    • If the blister is large, rupture is imminent, or it impairs with functional movement, it may be aspirated and debrided.
    • Debride devitalized skin from blisters that rupture on their own to reduce rate of infection and improve cosmesis.          
  • Once the burn cleaned, topical antimicrobial agent (SS, Mupirocin, polysporin, bacitracin) can be applied

• Consider amnion membrane and membranous dressings (eg. Biobrane®, DuoDERM®)
  •  They don’t have to be changed, they promote faster healing, and improve pain relief [8].
• Burns are painful.
  • Administer pain medication liberally
  • Intravenous ketamine showed some efficacy as an analgesic for burn injuries, with a reduction in secondary hyperalgesia when compared with opioid analgesia alone [9].

References

1.  American Burn Association. Burn incidence and treatment in the United States: 2016.  2016; Available at http://ameriburn.org/who-we-are/media/burn-incidence-fact-sheet/.

2.  Singer AJ, Beto L, Singer DD, et al. Association between burn characteristics and pain severity.  Am J Emerg med.  2015; 33(9): 1229-1231. [Pubmed]

3.  Wachtel TL, Berry CC, Wachtel EE, et al. The inter-rater reliability of estimating the size of burns from various burn area chart drawings. Burns. 2000; 26 (2): 156-170. [Pubmed]

4.  Hammon JS, Ward CG.  Transfers from emergency room to burn center: errors in burn size estimate. J Trauma 1987; 27 (10): 1161-1165. [Pubmed]

5.  Sheridan RL. Airway management and respiratory care of the burn patient.  Int Anesthesiol Clin.  2000; 38 (3): 129-145. [Pubmed]

6.  Aziz Z, Abu SF, Chong NJ. A systematic review of silver containing dressings and topical silver agents (used with dressings) for burn wounds. Burns. 2012; 38 (3): 307-318. [Pubmed]

7.  Heyneman A, Hoeksema H, Vanderkerckhove D, et al. the role of sulphadiazine in the conservative treatment of partial thickness burn wounds: A systematic review.  Burns. 2016.  [Pubmed]

8.  Vloemans AF, Hermans MH, Van Der Wal MB, et al. Optimal treatment of partial thickness burns in children: a systematic review. Burns. 2014; 40 (2): 177-190. [Pubmed]

9.  McGuinness SK, Wasiak J, Cleland H, et al. A systemic review of ketamine as an analgesic agent in adult burn injuries.  Pain Med.  2011; 12 (10): 1551-1558. [Pubmed]

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Severe Facial Fractures

http://www.wikiradiography.net/page/CT+Case+4+-+Le+Fort+Fractures

1.  BE READY TO ESTABLISH A DEFINITIVE AIRWAY EARLY.

• Concomitant head trauma can cause altered mental status.
• Active hemorrhage can compromise the airway.
• Significant mandible and midface fractures can lead to airway edema and obstruction.

2.  IF SIGNIFICANT HEMORRHAGE RESULTS FROM FACIAL FRACTURES, ESTABLISH INITIAL CONTROL WITH INTRASAL, NASOPHARYNGEAL AND OROPHARYNGEAL PACKING.

3.  THE RISK OF TRAUMATIC BRAIN INJURY, RANGING FROM A SIMPLE CONCUSSION TO SEVERE INTRACRANIAL AND EXTRA-AXIAL HEMORRHAGES, INCREASES IN THE SETTING OF FACIAL TRAUMA.[1]  

• Consider adding a CT head in addition to your facial bones CT.

4.  THE DENVER SCREENING CRITERIA FOUND A SIGNIFICANT ASSOCIATION OF BLUNT CEREBROVASCULAR INJURIES WITH  LE FORT II AND III FRACTURES. [2]

• Strongly consider CT angiography of the neck in Le Fort II and III Fractures to screen for blunt cerebrovascular injury.

https://www2.aofoundation.org/wps/portal/surgerymobile?contentUrl=/srg/93/01-Diagnosis/frontal_sinus.jsp&soloState=precomp&title=&Language=en&bone=CMF&segment=Cranium

5.  DON'T FORGET ABOUT THE FRONTAL SINUS. 

• Frontal sinus fractures that involve the posterior wall require neurosurgical consultation as they can lead to dural violation, CSF leak, disruptions of the anterior cranial fossa or CNS infections.

References

1. Gassner R, et al. Craniomaxillofacial trauma in children: A review of 3,385 cases with 6,060 injuries in 10 years.  J Oral Maxillofac Surg 2004;62(4): 399-407. [Pubmed]

2.  Burlew CC, et al. Blunt cerebrovascular injuries: Redefining screening criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg 2012;72(2):330-335; discussion 336-337, quiz 539. [Pubmed]

Written by Jeffrey A. Holmes, MD