# Trauma transport decisions



## RedAirplane (Dec 20, 2016)

I did PHTLS over the weekend. It was good for me to see some trauma scenarios and transport decisions since I don't usually do that, but I will be in the future. 

I struggled a little bit with the thought process of deciding which hospital to go to in some of the scenarios. Can anyone give insight?

Case I:
7 year old male with MOI suggesting TBI. Unconscious, inadequate respirations, bradycardia at 56/min. SpO2 comes from 85 to about 93 with BVM on O2. Choices are level 2 trauma center 12 minutes away, or level 2 pediatric trauma center 20 minutes away. 

Case II:
25 year old male with a carotid hemorrhage secondary to a knife wound. It cannot be controlled and he is profusely hemorrhaging. I said we need to go to the nearest hospital for immediate blood and some sort of emergency wound control. However, it would appear that the correct answer is to go to the trauma center further away. I forget his vitals but I think his BP was around 130/80. 

Thoughts?


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## BobBarker (Dec 20, 2016)

Case I- Tough one, I am going to say Pediatric Trauma center only if the closer trauma center does not have pediatrics at all at the facility.
Case II- Closest hospital. I believe LA County protocols are going to be closest hospital for an arrest, uncontrolled airway or uncontrolled bleeding. Any emergency room should have blood and the doctor should definitely be able to help with emergency wound control as you mentioned.


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## E tank (Dec 20, 2016)

Pedi trauma center...time it took to go from ER to OR for an emergency crani would more than make up for the longer transport time to the peds place.

I'd say trauma center for the stabbing as well because, I'd guess anyway,  the odds favor  that vascular injury/bleeding are not the only problem. Again, my thinking here is that in the time it would take to mobilize a massive transfusion protocol and vascular team at the nearest facility, the guy could be getting more of what he needs at the trauma center. Especially if the hole in the artery  is behind the clavicle or lower.


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## Handsome Robb (Dec 20, 2016)

Case 1 is going to the pediatric TC. Going to the regular TC is only going to delay their care because they'll be transferred to the pediatric TC. 

Case II needs a TC too. Ideally you can scoop him and boogy with him. This is a case where I'd be doing everything I could to control the bleeding, probably with direct pressure from a fingertip inside the wound, and definitely be allowing hypotension. Dude needs a vascular surgeon ASAP. 


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## SpecialK (Dec 20, 2016)

The bloke with the uncontrolled carotid haemorrhage needs to go to the closest hospital, *and *there needs to be an appropriate doctor standing in ED ready to meet him when get there.  This means a very early RT call to the hospital, preferably before leaving the scene.  Shouldn't be that hard to control, put an artery clamp on it and send him to a vascular surgeon rapidly (noting the majority of our hospitals do not have vascular surgeons).  I doubt most ED Consultants would have a go at suturing an artery, probably something they'll either never do or only do once or twice in their entire career.

The only exception to taking him to the closest hospital would be if the closest hospital did not have an appropriate doctor; for example our small rural hospitals (of which they aren't that many anymore anyway) only have a GP or a "rural hospitalist" which is basically a super GP with a bit of training in emergency and internal medicine.  If I was in the situation of only having a little rural hospital to transport to, I'd honestly just call for a helicopter and have a go at clamping it myself.

Hypotension? Eh, maybe.  I'd give him at least one to two litres of fluid unless I had access to blood in which case I'd give him blood.


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## Tigger (Dec 20, 2016)

Pedi case goes to pedi trauma center. A more secured airway would be nice, but if the difference is eight minutes I want to be at the proper specialty center.

I am not sure about the second one. If I took him to our local hospital, he would die. If I took him 30ish minutes to a real trauma center with vascular surgery, he might die on the way too.


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## E tank (Dec 21, 2016)

Tigger said:


> I am not sure about the second one. If I took him to our local hospital, he would die. If I took him 30ish minutes to a real trauma center with vascular surgery, he might die on the way too.



But he needs to die at the right hospital


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## EpiEMS (Dec 21, 2016)

These are interesting cases but I do think my response would be greatly different if I'm an ALS unit vs. BLS for the first and whether I've got PRBCs or not in the second.

In the first case, if I don't have a good real time measure of respiratory status (ETCO2), and I cannot be sure the airway is secure/cannot secure it myself (BLS) shouldn't I be more conservative and go to the nearest facility? Even if it's only 8 minutes, it seems not impossible that I might lose the airway if I only have BLS measures.


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## StCEMT (Dec 21, 2016)

Ped goes to the pediatric trauma center, I'll take the extra time. Preferably intubated, but guess that's not the case based on the info. 

Depends on if the closest can handle it. I would prefer the closer hospital.



SpecialK said:


> If I was in the situation of only having a little rural hospital to transport to, I'd honestly just call for a helicopter and have a go at clamping it myself.



What do you have you could clamp it with? Only thing in my truck I can think of is the clamp from the OB kit.


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## Handsome Robb (Dec 21, 2016)

EpiEMS said:


> These are interesting cases but I do think my response would be greatly different if I'm an ALS unit vs. BLS for the first and whether I've got PRBCs or not in the second.
> 
> In the first case, if I don't have a good real time measure of respiratory status (ETCO2), and I cannot be sure the airway is secure/cannot secure it myself (BLS) shouldn't I be more conservative and go to the nearest facility? Even if it's only 8 minutes, it seems not impossible that I might lose the airway if I only have BLS measures.



If you can't control their airway that's one thing, since a single episode of hypoxia in TBI/CHI patients doubles their mortality, the closest facility might be appropriate if you can't get an intercept with a unit who can control it. 

For me it's a moot point because the kiddo would get RSId and an iGel placed. 



StCEMT said:


> Ped goes to the pediatric trauma center, I'll take the extra time. Preferably intubated, but guess that's not the case based on the info.
> 
> Depends on if the closest can handle it. I would prefer the closer hospital.
> 
> ...



Thumb and forefinger?  

I've had two carotid bleeds from knife wounds to the neck and each was a total mess BUT it actually was relatively easy to control the bleeding with direct pressure from my fingers. Granted I wouldn't want to have to do it for a long period of time. 


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## StCEMT (Dec 21, 2016)

Handsome Robb said:


> If you can't control their airway that's one thing, since a single episode of hypoxia in TBI/CHI patients doubles their mortality, the closest facility might be appropriate if you can't get an intercept with a unit who can control it.
> 
> For me it's a moot point because the kiddo would get RSId and an iGel placed.
> 
> ...


Guess I kinda assumed this was a longer transport in the scenario.  I wouldn't wanna sit like that for 20 minutes, but the areas I am most likely to see this I am not far from a hospital at all.


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## SpecialK (Dec 21, 2016)

StCEMT said:


> What do you have you could clamp it with? Only thing in my truck I can think of is the clamp from the OB kit.



One of the clamps in the pouch on my belt.


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## EpiEMS (Dec 21, 2016)

Any thoughts on the use of a hemostatic agent (Quikclot, etc.) on a carotid hemorrhage?


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## E tank (Dec 22, 2016)

EpiEMS said:


> Any thoughts on the use of a hemostatic agent (Quikclot, etc.) on a carotid hemorrhage?



All of those products are for troublesome  generalized oozing after active bleeding is controlled. Even then, many surgeons don't use them at all. The only way to address major vessel trauma is with a stitch.


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## NomadicMedic (Dec 22, 2016)

E tank said:


> All of those products are for troublesome  generalized oozing after active bleeding is controlled. Even then, many surgeons don't use them at all. The only way to address major vessel trauma is with a stitch.



What? Wait... WHAT?


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## E tank (Dec 22, 2016)

DEmedic said:


> What? Wait... WHAT?



Mispoke there...was refering to the products that where independent of a pressure dressing, applied directly into the wound for hemostasis. But in the scenario presented, ie, uncontrolled carotid bleeding, a hemostatic agent, on a pressure dressing or not, is as good as just adding more pressure.


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## LaAranda (Dec 25, 2016)

RedAirplane said:


> Case I:
> 7 year old male with MOI suggesting TBI. Unconscious, inadequate respirations, bradycardia at 56/min. SpO2 comes from 85 to about 93 with BVM on O2. Choices are level 2 trauma center 12 minutes away, or level 2 pediatric trauma center 20 minutes away.



Peds facility. I would get skewered for bringing this very sick kid to a non-peds center. Ideally we would intubate but I'm scared just thinking about it. What are others' thoughts re: airway management?



> Case II:
> 25 year old male with a carotid hemorrhage secondary to a knife wound. It cannot be controlled and he is profusely hemorrhaging. I said we need to go to the nearest hospital for immediate blood and some sort of emergency wound control. However, it would appear that the correct answer is to go to the trauma center further away. I forget his vitals but I think his BP was around 130/80.
> 
> Thoughts?



Uncontrolled arterial bleed? Closest.


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## StCEMT (Dec 26, 2016)

LaAranda said:


> Peds facility. I would get skewered for bringing this very sick kid to a non-peds center. Ideally we would intubate but I'm scared just thinking about it. What are others' thoughts re: airway management?


I would take the time to try to tube them. I wont waste time screwing around if I can't, but I will at least try once.


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## RocketMedic (Dec 26, 2016)

I'd deploy the dreamcatchers.


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## RocketMedic (Dec 26, 2016)

On a serious note, #1 gets intubated if at all possible. The fact that adequate BVM is _not_ working for maintaining saturation is strongly indicative of hemodynamic compromise, which is reflected in the bradycardia. Oxygen. potentially chest compressions, and a sprint to a good trauma center. If I'm in CA or a place where intubation is frowned upon, SGA if able and sprint.

#2 gets wound packed, direct pressure, run to closest (capable) hospital. I'm not as concerned about levels as I am about what they're willing to do, and I'll take a high-functioning L3 that is willing to pump me to the head of the line and get in for some emergent vascular exposure and repair over the L2 or L1 that won't do those things.


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## Brandon O (Dec 30, 2016)

Please do not go around clamping carotid arteries, friends.


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## SpecialK (Dec 30, 2016)

Brandon O said:


> Please do not go around clamping carotid arteries, friends.



In all seriousness, if direct pressure doesn't work, I can't put a tourniquet on it, don't have haemostatic gauze or vascular surgical facilities close to hand, then how are we supposed to stop the bleeding? You're saying it's better to let the guy continue to bleed? 

And as for that whole brain needing oxygenated blood thing (probably important) ... well he's got two of them?


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## Brandon O (Dec 30, 2016)

SpecialK said:


> In all seriousness, if direct pressure doesn't work, I can't put a tourniquet on it, don't have haemostatic gauze or vascular surgical facilities close to hand, then how are we supposed to stop the bleeding? You're saying it's better to let the guy continue to bleed?
> 
> And as for that whole brain needing oxygenated blood thing (probably important) ... well he's got two of them?



He has two, but not with reliable collateral circulation.

Look, I realize this is a hypothetical scenario, but this is a "what if I absolutely can't control the abdominal bleeding, should I cut out his spleen?" sort of question. If the bleeding doesn't stop with direct pressure, keep trying or do it better. I highly doubt anybody is going to have any kind of success clamping or ligating a carotid artery in the field (I cannot even imagine how this would go), and if they did I don't think they would like the result. That is not the treatment for this condition.

I mean, I suppose if it was completely transected, and the proximal stump was just flapping there at you, fully exposed and begging to be secured, but at some point this is entering the realm of fantasy.

(I am happy to defer to any vascular or trauma folks here, of course.)


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## E tank (Dec 30, 2016)

SpecialK said:


> In all seriousness, if direct pressure doesn't work, I can't put a tourniquet on it, don't have haemostatic gauze or vascular surgical facilities close to hand, then how are we supposed to stop the bleeding? You're saying it's better to let the guy continue to bleed?
> 
> And as for that whole brain needing oxygenated blood thing (probably important) ... well he's got two of them?



You're correct of course...but, VERY hypothetically speaking, if someone were faced with that consideration however unlikely, you might want two clamps, one distal and proximal...circle of willis and all...but direct pressure would probably be all that was needed distally...


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