Trauma transport decisions

[RedAirplane]

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?

 

[BobBarker]

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.

 

[E tank]

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.

 

[Handsome Robb]

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]

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.

 

[Tigger]

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.

 

[E tank]

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

 

[EpiEMS]

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.

 

[StCEMT]

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.

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.

 

[Handsome Robb]

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.

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.


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.

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]

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.



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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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.

 

[SpecialK]

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.

 

[EpiEMS]

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

 

[E tank]

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.

 

[NomadicMedic]

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?

 

[E tank]

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.

 

[LaAranda]

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.

 

[StCEMT]

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.

 

[RocketMedic]

I'd deploy the dreamcatchers.

 

[RocketMedic]

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.