# Trauma Activation



## jaksasquatch (Nov 22, 2016)

Dispatched to "rollover with entrapment". You read your CAD notes and realize that it actually states that patient is trapped in between a vehicle and a building (in this case a double wide trailer). You arrive on scene to find a mid sized SUV sitting extremely close to said building. You see a patient on the ground in the supine position. She is alert and oriented X 4 and you immediately establish contact while your partner asks the patient's mother (who is freaking out) about the incident. Patient's mother states she found the patient (a 38 y/o female) wedged between the SUV and the double wide. The vehicle was in drive. Your patient states she was trying to stop the vehicle because she "left it in drive" when the vehicle pinned her pelvis and left arm against the house. She says that she was pinned for "2 minutes but it could have been longer".

   On assessment you find the patient is CAO X 4 with a GCS of 15 her primary complaint is pain to the right hip and pain to the left arm. On inspection the left arm has significant swelling and is extremely tender halfway between the elbow and the wrist. She is tender on palpation of the right pelvis along the ischial border but no crepitus or instability is noted. The pelvis is so tender that palpation elicits a sustained grimace and patient relates it is a 7/10. CSM is intact in all extremities. Left arm is very tender and you highly suspect a fracture due to the swelling and amount of tenderness. Deformity is mild. The rest of the assessment reveals no other significant findings.

Any trauma activation? Mode of transport? Treatment?

This was a call I just ran today.


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## Tigger (Nov 22, 2016)

jaksasquatch said:


> Dispatched to "rollover with entrapment". You read your CAD notes and realize that it actually states that patient is trapped in between a vehicle and a building (in this case a double wide trailer). You arrive on scene to find a mid sized SUV sitting extremely close to said building. You see a patient on the ground in the supine position. She is alert and oriented X 4 and you immediately establish contact while your partner asks the patient's mother (who is freaking out) about the incident. Patient's mother states she found the patient (a 38 y/o female) wedged between the SUV and the double wide. The vehicle was in drive. Your patient states she was trying to stop the vehicle because she "left it in drive" when the vehicle pinned her pelvis and left arm against the house. She says that she was pinned for "2 minutes but it could have been longer".
> 
> On assessment you find the patient is CAO X 4 with a GCS of 15 her primary complaint is pain to the right hip and pain to the left arm. On inspection the left arm has significant swelling and is extremely tender halfway between the elbow and the wrist. She is tender on palpation of the right pelvis along the ischial border but no crepitus or instability is noted. The pelvis is so tender that palpation elicits a sustained grimace and patient relates it is a 7/10. CSM is intact in all extremities. Left arm is very tender and you highly suspect a fracture due to the swelling and amount of tenderness. Deformity is mild. The rest of the assessment reveals no other significant findings.
> 
> ...


Some vital signs would be in order to determine if an activation is necessary, the mode of transport, and treatments.


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## FLMedic311 (Nov 22, 2016)

Given strictly the info provided I would have to say yes, at very least a Modified Trauma activation and would not want to go to anything less then a level 2 as a surgical pelvis sounds likely.  Thanks for sharing!


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## VentMonkey (Nov 22, 2016)

jaksasquatch said:


> Any trauma activation? Mode of transport? Treatment?


1. Trauma consult at least, most likely what would equate to a Step 3 trauma here, which is basically still the whole shebanger minus the sense of urgency with higher acuity patients.

2. Ambulance, no L/S so long as V/S are WNL.

3. Standard ALS workup: vitals, O2, saline lock(s), liberal pain medication, again assuming V/S are WNL. 

Was there any shortening or rotation to the affected extremity(ties) secondary to the pelvic injury?


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## Akulahawk (Nov 23, 2016)

jaksasquatch said:


> On assessment you find the patient is CAO X 4 with a GCS of 15





jaksasquatch said:


> She is tender on palpation of the right pelvis along the ischial border but no crepitus or instability is noted. The pelvis is so tender that palpation elicits a sustained grimace and patient relates it is a 7/10


When I do as complete a trauma exam of a patient as I can do, I usually do AP compression of the pelvis, lateral compression, and Open Book Tests. Any crepitus or instability will make me very suspicious of a pelvic ring fx. The last patient I had that had significant instability (and crepitus actually) shattered the right side of his pelvis from a fall from a height of about 14 feet. Our scenario patient is tender only apparently along the border of the iliac crest so I'm not all that concerned about the possibility that the pelvic ring is disrupted. 


jaksasquatch said:


> Left arm is very tender and you highly suspect a fracture due to the swelling and amount of tenderness. Deformity is mild. The rest of the assessment reveals no other significant findings.


I wouldn't be all that concerned about calling this a patient a major trauma victim simply because of what's likely an arm fx. 

I would probably do a trauma consult and determine, in consult with a trauma base hospital whether or not to send this patient to a trauma facility with significant capability (none exists in my county). Around home, it'd be a no-brainer. I'm going to a L-II or L-I facility because this patient will likely (eventually) need an eval there. Better to bypass the local facilities at this point. 

As far as transport goes, where I work, they'd probably fly the patient to a L-II TC because the local TC capabilities are very limited at best (L-IV). If that's not an option, this one goes by ground, Code 2, unless the patient begins to decompensate. 

Actual treatment goes something like this: IV x 2 (at least one 18ga) saline locked, O2 only if SpO2 <94%, VS q 5 min x3 then q 15. Pain control as authorized. No spinal precautions as there's no mechanism for it. Splint the left arm once everything else is accomplished. If I'm trained to check for abdominal hemorrhage via US and it's available, I'll do it. I'm going to keep this patient "dry" and only provide sufficient fluid volume to maintain SBP around 90 if I MUST begin fluid resus.


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## SpecialK (Nov 23, 2016)

I would transport her directly to a major trauma hospital.  I don't know how far away that is in the information you gave so can't say if it would be by road or air.

We either active the trauma team, or we do not.  There are no "partial activations" or "consults"; it's either everything or nothing.  If you are going to do something do it proper and not half measures.

There is no role for examining the pelvis for signs of instability or crepitus because the pelvis may be severely unstable without these signs being present and the force required to elicit the signs may cause harm.


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## jaksasquatch (Nov 23, 2016)

Tigger said:


> Some vital signs would be in order to determine if an activation is necessary, the mode of transport, and treatments.



Vital signs: BP 106/68, HR 95-105 Sinus w/ no ectopy, 98% on room air


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## jaksasquatch (Nov 23, 2016)

VentMonkey said:


> 1. Trauma consult at least, most likely what would equate to a Step 3 trauma here, which is basically still the whole shebanger minus the sense of urgency with higher acuity patients.
> 
> 2. Ambulance, no L/S so long as V/S are WNL.
> 
> ...



No shortening or rotation secondary to the injury. Vitals remained WNL except for a mildly elevated HR at 95-105. BP remains as such that you don't have to administer any fluids


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## jaksasquatch (Nov 23, 2016)

Posted this scenario to see how everybody's systems handle these patient's who need a trauma consult but don't meet high acuity "alert" criteria. In my neck of the woods it is "all or nothing". In this case the LII trauma center was 30 minutes away. I called the alert simply because of the potential for future bleeding or ischemic conditions within the bowel and pelvis are itself. We also have to transport Code 3 if we call the alert. Definitely was a case of overtriage where I felt like I got "stuck" on the mechanism and made a snap judgment to call the activation.


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## Ensihoitaja (Nov 23, 2016)

I think it's interesting that so many places call trauma activations prehospital. We don't. I call my report and the ED doc makes the call. Granted, pretty much all of our trauma goes to a Level I trauma center.


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## MonkeyArrow (Nov 23, 2016)

Ensihoitaja said:


> I think it's interesting that so many places call trauma activations prehospital. We don't. I call my report and the ED doc makes the call. Granted, pretty much all of our trauma goes to a Level I trauma center.


You talk to an ED doc when you call report?


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## VentMonkey (Nov 23, 2016)

jaksasquatch said:


> In my neck of the woods it is "all or nothing"....We also have to transport Code 3 if we call the alert. Definitely was a case of overtriage where I felt like I got "stuck" on the mechanism and made a snap judgment to call the activation.


It doesn't sound like there's a whole lot of provider judgment/ discretion where you're at. I can't fault you for getting "stuck" when they want a full response for what sounds even like a "based mainly on mechanism" call.


SpecialK said:


> We either active the trauma team, or we do not.  There are no "partial activations" or "consults"; it's either everything or nothing.  If you are going to do something do it proper and not half measures.


We have one Level 2 where I am that may easily be overwhelmed with "half measure" traumas should we take any, and all patients based on mechanism with stable V/S to our regional trauma center.

To me it shows inability to properly assess, use critical thinking skills, and provider judgment when you constantly slam them with a full response because you can't, won't, or don't want to do your job properly. It's completely within our protocols so as not to over triage.

Can they have internal injuries that manifest later? Absolutely, but either way they're getting a ride, and should anything happen en route there's diversion. Also, by involving the trauma center for an initial consult, they can decide to accept it as a trauma or not. If they don't based on my report, I can then call the receiving give them that info, and the rest of my report. Again, any Step 1 (physiological) or 2 (anatomical) is an automatic activation.


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## DrParasite (Nov 23, 2016)

definite transport to a trauma center, probably with a level 2 activation.  IIRC, the only difference between level 1 & level 2 is anesthesia on call doesn't come to level 2.

The extremity issues don't both me as much as the possibility of a pelvic Fx.  Probably wouldn't be a code 3 transport, however they will need some pelvic x rays taken, and depending on what it shows, some surgery.  Even if they don't need imminent surgical intervention, the trauma center has the resources to monitor and work on having the person recover from their injuries.


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## Akulahawk (Nov 23, 2016)

Incidentally, note that in my comments above I specifically did NOT (and still wouldn't) activate a Trauma Alert based on mechanism. If anything, this patient isn't getting put on a spine board for the purpose of spinal motion restriction because of mechanism. MOI can, and does, alert me to the _possibility_ of certain injuries but it doesn't tell me that certain injuries _exist_. In short, it tells me what I might expect and where to look but that's it.


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## SpecialK (Nov 23, 2016)

DrParasite said:


> IIRC, the only difference between level 1 & level 2 is anesthesia on call doesn't come to level 2



ACH doesn't even include an anaesthetist in their trauma calls; it's EM consultant and reg, ICU reg, surgical reg and three resus nurses.  I don't see the need either especially considering the anaes reg is probably in theatre and their house surgeon/SHO isn't going to be much bloody good.



VentMonkey said:


> We have one Level 2 where I am that may easily be overwhelmed with "half measure" traumas should we take any, and all patients based on mechanism with stable V/S to our regional trauma center.  To me it shows inability to properly assess, use critical thinking skills, and provider judgment when you constantly slam them with a full response because you can't, won't, or don't want to do your job properly. It's completely within our protocols so as not to over triage.



You're right, we don't want to overwhelm major trauma hospitals with "non-major trauma" but just as important we do not want to "underwhelm" major trauma patients by taking them to an inappropriate hospital.  There is irrefutable evidence major trauma does best when it is taken directly to a major trauma centre and that's been seen for decades in the United States, as well as Australia (Victoria) and more recently in England, or more specifically, London.  

There is also no real evidence "mechanism of injury" without objective correlation is a good indicator of predictor of severity of injury.  I have seen people fall down one step and die yet people who have fallen from thirty feet and pretty much walked away.  

It sounds like this patient has a pretty nasty pelvic fracture.  I would bind her pelvis and take her to a major trauma hospital.  

Our new national major trauma triage guidelines do not include physiologic criteria other than "shock" but have moved away from tightly defining "shock" as specific vital signs.  I think this is pragmatic and sensible.  Just like Nana might get along just fine with BP of 90 and for her shocked is 70, somebody else might have a regular BP of 150 and for him shocked is 120 .... however, noting I have used BP as an example, which is a poor guide to severity of shock!  More specifically, the trauma triage guidelines state:_

"Shock is a clinical diagnosis and cannot be tightly defined using specified vital signs. Clinical signs include: tachycardia (unless the patient is beta-blocked or has ‘end stage’ shock when the heart rate is falling), a narrowed pulse pressure, vasoconstriction and an altered level of consciousness (usually with a preserved motor score and agitation). Hypotension is a late sign and severe shock may be present without hypotension, particularly if the patient is young. If an IV fluid bolus is clinically indicated the patient has shock."_


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## VentMonkey (Nov 23, 2016)

SpecialK said:


> ACH doesn't even include an anaesthetist in their trauma calls; it's EM consultant and reg, ICU reg, surgical reg and three resus nurses.  I don't see the need either especially considering the anaes reg is probably in theatre and their house surgeon/SHO isn't going to be much bloody good.
> 
> 
> 
> ...


Significant trauma? Without a doubt. Major? Debatable. We're not allowed to take patients to "major" trauma centers (i.e., Level 1's) as they're out of county, over a 2 hour drive, and roughly a 1 hour flight.

We do the best we can with what we got. I understand and respect literature and studies, but I refuse to rely on them to the point that I begin to second guess any decisions made. 

Why? Because they're ever evolving. I absolutely believe in staying up to date with the latest and best EBM to benefit the patients admit to discharge times. What we read today will most likely change in a week, a month, a year, so collectively we must figure what works as a whole and go from there (again, just my spin on it).

Like I initially stated, I'm going to our level 2, I will discuss with the MICN what am I seeing, and let them decide how far into it they would like to pursue it. And, again chances are they'll get the full work up and if the injury is in fact devastating well then they'll have gotten the appropriate care from the appropriate place unless an underlying injury that is out of their specialty, capabilities, or other is found, in which case they'll be transferred most likely via HEMS to a level 1. 

Interesting to see how others practice though and their thoughts processes, cheers.


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## jaksasquatch (Nov 23, 2016)

VentMonkey said:


> Significant trauma? Without a doubt. Major? Debatable. We're not allowed to take patients to "major" trauma centers (i.e., Level 1's) as they're out of county, over a 2 hour drive, and roughly a 1 hour flight.
> 
> We do the best we can with what we got. I understand and respect literature and studies, but I refuse to rely on them to the point that I begin to second guess any decisions made.
> 
> ...


I like what you said regarding EBM. It is amazing to see the changes and how quickly things develop. However as a new medic I've allowed it to cloud my thinking at times and make me second guess myself

Sent from my VS986 using Tapatalk


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## Ensihoitaja (Nov 24, 2016)

MonkeyArrow said:


> You talk to an ED doc when you call report?



Yes, mostly. Only attendings or R4s answer the phone at Denver Health. For all of our emergent transports, we call Denver Health and if we're transporting to a different hospital they call them for us. For non-emergent transports, we call the receiving hospital direct (unless it's Denver Health, then we just show up).

For what it's worth, any emergent trauma transport means an automatic trauma alert, at a minimum.


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