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BUILDING YOUR TRAUMA TOOL KIT-WHAT ADJUNCTS ARE RIGHT FOR YOU? AMY KOESTNER, RN, MSN OBJECTIVES • Identifying equipment or items needed in your trauma toolkit • Describe your process for evaluating the effectiveness of your trauma toolkit • Describe the role of your trauma toolkit beyond the ED IMPORTANT ELEMENTS OF A TRAUMA TOOL KIT • Communication • Hemorrhage Control • Anticoagulation HARDWIRING TRAUMA CARE • Patient focused care • Evidence based care • Bench marked • Exceeds ACS and State requirements COMMUNICATE EXPECTATIONS • Identify key areas of communication opportunities • Identify stakeholders • Identify priorities of care • Identify best practices currently in place • Identify knowledge gaps COMMUNICATION • Key concept in care – throughout the continuum • Pre hospital → Pre-arrival → Trauma bay report • ED resuscitation → ED hand off → In-patient TRAUMA COMMUNICATION TOOLS EMS checklist for trauma Basics: Age Complaint Priority Location (scene or transfer) ETA Trauma: Mechanism (energy involved) VS (BP,HR,RR) GCS LOC? Y or N Presumed/obvious injuries (deformities, open wounds, scene blood loss) Special circumstances (pediatric, pregnant, anticoag, spinal cord, long extrication, exposure, comorbidities, etc 7 RESPONSE TIME DOCUMENTATION Hardwire documentation process 8 TRAUMA TEAM TIME OUT & SAFETY BRIEFING • Standard work for roles • Team Leader – starts process • All team members identified and role announced • PTA information • EMS report TRAUMA TOOLS 10 TRAUMA ORIENTATION VIDEO 11 60 SECONDS OF SILENCE • Structured EMS report • All team members listening • Then patient moved to stretcher • Assessment / Interventions • Plan of care developed TRAUMA BAY CARE & BEYOND • Plan of care within the bay • Plan of care post bay SCENARIO • 45 year old male unrestrained driver involved in head-on MVC. Patient ejected from vehicle. EMS on scene atf unconscious, GCS = 6, BP 80/60, HR 132, RR 28 Pulse Ox 91% on NRB. • Assessment: Multiple facial lacerations and swelling, breath sounds decreased on left with crepitus, left arm large laceration with active bleeding, abdomen distended, and pelvis unstable when compressed. ON SCENE CARE • Airway → oxygen and intubation • Breathing → assess findings & interventions • Circulation → stop the bleeding, assess resuscitation needs • Disability → assess & evaluate intervention / resources HEMORRHAGE CONTROL: TOOL BOX • Tourniquet • Quick clot • Splinting • Pelvic binder • TXA • MTP TOURNIQUET USE • Utilized by EMS and hospital environment. • Criteria for application & removal • B-Con program POLICY & DOCUMENTATION HEMOSTATIC AGENT • Applied directly to area of bleeding SPLINTING • Assist with hemorrhage control • Promote perfusion TRANSEXAMIC ACID Purpose • Uncontrolled vascular hemorrhage • Initiation of MTP • Injury less than 3 hours Factors • Any age restrictions • No evidence of intravascular clotting disorder (PE, DVT) • Transport times • Avoid with pt on anticoagulation meds or receiving PCC, factor VIIa TXA DOSING Dosing: Loading dose: 1 gram (mixed in 50 cc saline) over 10 minutes Infusion can be started at the receiving facility and the dose will be 1 gram over 8 hours Loading dose and infusion should be documented and communicated at handoff PELVIC BINDER • Unstable pelvic fractures: • A-P fractures –open book • Shearing injury PELVIC BINDER • Placed by either EMS or trauma center staff • Good adjunct with resuscitation fluids / blood products • Early communication with orthopaedic surgery, OR and /or IR for definitive care • May be an indication for MTP activation MTP FACTS • Patient initially bleeds at scene • Receives crystalloid en-route • Receives blood in ED or surgery • What blood loss defines massive transfusion? MASSIVE TRANSFUSION • Early recognition, initiation, and management • Role in Prehospital • Triage to appropriately resourced trauma center • 1:1:1 ratio MTP FORMS 27 REASONS WHY PEOPLE ARE ON ANTICOAGULANTS • Atrial Fibrillation • DVT • Mechanical heart valve • Stroke prevention • Heart attack • Heart failure • Pulmonary Emboli • Angina • Stents • Orthopaedic procedure • Wound care • Just because……. EMS ARENA • Need for evaluation of all trauma patients for: any co-morbidities or significant medical history which would be a predictor of anticoagulation use(a fib, valvular replacement, DVT, stroke, etc) • EMS triage guidelines should consider triage to trauma center UNDER TRIAGE • Transported to nontrauma centers • under recognition of co-morbidities / meds • Lack geriatric specific training • False sense of security “they look good” • EAST guidelines recommend transport of pts > 70 yrs to a trauma center • PA state system reported EMS less likely to transport to trauma center UNDER TRIAGE IN ED • Co-morbidities or significant medical history –not obtained or under appreciated • Lack a system approach to evaluating pts • Timing of CT scan • Timing of initiation of reversal • Cumbersome process or approval needed to reversal medication use ANTICOAGULATION TOOL KIT • Guideline for reversal & early identification of patients • CT availability • Stat labs • Adequate thawed FFP available • Easy access to reversal medications • Good linkage with pharmacy team • Process in place to review cases and identify opportunities ANTICOAGULATION REVERSAL ANTICOAGULATION TOOLS • EMS assessment, early communication and transport to trauma center • System approach to triage of these patients • Develop & implement geriatric trauma criteria or guideline that activates resources • Geriatric specific training. CLOSING REMARKS • Communication with accountability • Collaboration across EMS and trauma centers is essential to providing best practice • Account for “geography” when looking at resources and options • Evaluate and re-evaluate tools and resources • Continue to question… QUESTIONS??