CRITICAL CARE: HROB NEONATE EMERGENCIES, PEDIATRIC TRAUMA AND GERIATRIC TRAUMA

PROVIDES FOUR (4) HOURS OF CONTINUING EDUCATION CREDIT

DATE | TIME

August 1, 2018 Registration: 7:45 AM Conference: 8:00 AM – 12:00 PM

LOCATION

American Legion Hall Post 108 11401 American Legion Drive Sutter Creek, CA 95642

COST

This event is offered at no cost thanks to the generosity of Sutter Amador hospital.

SCOPE | OBJECTIVE

This seminar is appropriate for physicians, nurses, paramedics and first responders. Conference topics and materials will help attendees assess the treatment of trauma and high-risk patients in both prehospital and hospital settings.

TOPICS & INSTRUCTORS

High Risk OB Neonatal EmergenciesYvette Gonzalez, MS, RN, C-EFM, E-NPTREACH Air Medical Services

Pediatric TraumaRyan Donlin, BSN, RN, CCRN, Flight NurseREACH Air Medical Services

Geriatric TraumaMichelle Moss, FP-CREACH Air Medical Services

CANCELLATION NOTIFICATION

If the event is canceled for any reason, registered participants will be notified immediately upon cancellation of the class through the email address provided at the time of registration. If an email address was not provided, a voice message will be left at the number provided at the time of registration.

CONTINUING EDUCATION

REACH is an approved provider by the California Board of Registered Nursing, Provider Number CEP #9697 for 4 contact hours. This course has been approved for 4 hours of continuing education by an approved California EMS CE Provider, #49-0008.

QUESTIONS?

Margaret Franklin Education Services Manager margaret.franklin@reachair.com (916) 921-4066

REGISTER ONLINE

https://criticalcareaug2018.eventbrite.com

High Risk OB & Neonatal EmergenciesPre-Transport Stabilization & Transport Considerations

Yvette Gonzalez, MS, RN, C-NPT, C-EFM, RMH High Risk Obstetric & Neonatal Transport Clinical Manager

This outreach education presentation is intended as an overview of basic concepts surrounding assessment of the

pregnant patient, OB complications and stabilization priorities for maternal and newborn patients.

Follow your designated hospital and county protocols, policies and guidelines for actual care of obstetric and newborn patients.

Objectives

• Review normal physiologic changes in pregnancy

• Review basic assessment of pregnant patients

• Review high risk obstetric clinical presentations, pretransport & transport clinical considerations

• Review postpartum hemorrhage and interventions

• Review high risk obstetric & neonatal transport stabilization priorities

• Review in-utero resuscitation measures for pre-transport and transport clinical application

• Review clinical considerations for preeclampsia, HELLP syndrome and eclampsia

• Discuss clinical implications surrounding maternal cardiac arrest.

60% of Maternal Deaths

PREVENTABLE

https://www.youtube.com/watch?v=I5Dsn4obCa4&feature=youtu.be

Source:1. Maternal Mortality Review. https://www.cdcfoundation.org/sites/default/files/files/ReportFromNineMMRCs.pdf. Accessed March 2018.2. https://www.cdcfoundation.org/building-us-capacity-review-and-prevent-maternal-deaths. Accessed July 2018

Causes Of PREVENTABLE MaternalMortality & Severe Morbidity

Failed Communication

Lack Of Recognizing Signs & Symptoms

Misdiagnosis & Ineffective Treatment

Failure In Care Systems & Processes

Sources:1. Maternal Mortality Review. https://www.cdcfoundation.org/sites/default/files/files/ReportFromNineMMRCs.pdf. Accessed March 2018.2. Preventing Maternal Death. TJC Sentinel Event Alert. Sentinel Events. https://www.jointcommission.org/assets/1/18/SEA_44.PDF. Accessed March 2018

US Maternal Morbidity & Mortality Leading Causes & Regions

For every American woman who dies from childbirth, 70 nearly die

rom childbirth, 70 nearly die n who dies from childbirth, 70 nearly die

Source: 1. National Vital Statistics Maternal Morbidity. https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_04.pdf. Accessed March 2018.2. Meeting the Challenges of Measuring and Preventing Maternal Mortality in the United States. https://www.cdc.gov/grand-rounds/pp/2017/20171114-maternal-mortality.html. Accessed April 2018. 3. Sentinel Event Alert: Preventing Maternal Death. TJC. https://www.jointcommission.org/assets/1/18/SEA_44.PDF. Accessed April 20184. https://www.npr.org/2018/05/10/607782992/for-every-woman-who-dies-in-childbirth-in-the-u-s-70-more-come-close

Image Source: www.propublica.org/article/lost-mothers-maternal-health-died-childbirth-pregnancy. Accessed March 2017

Sources:1. Image Source: World Health Organization, 2014 2. Maternal Early Warning Criteria. http://safehealthcareforeverywoman.org/patient-safety-tools/maternal-early-. Accessed March 20183. Sentinel Event Alert. Preventing Maternal Death. https://www.jointcommission.org/assets/1/18/SEA_44.PDF. Accessed March 20184. Preparing for Clinical Emergencies In Obstetrics. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Patient-Safety-and-Quality-Improvement/co590.pdf?dmc=1&ts=20180426T2325399798. ACOG. Accessed March 2018

Maternal Early Warning Criteria

HR

RR

SBP

DBP

SP02

SOB

UOP

LOC

Causes of Arrest in OB Patients

B –E –A –U –C –H –O –P –S

Bleeding-DIC, Embolism, Anesthetic complications, Uterine atony, Cardiac

disease, Hypertensive disease, Other, Placental, Sepsis

Source:1. The American Heart Association 2010 Guidelines for the Management of Cardiac Arrest in Pregnancy: Consensus Recommendations on Implementation Strategies. http://www.jogc.com/article/S1701-2163(16)34991-X/pdf . 2. American Heart Association: AHA. Maternal Cardiac Arrest. http://circ.ahajournals.org/content/132/18/1747. Accessed March 20173. Direct Causes of Maternal Mortality. Dartmouth.edu. Countdown to 2015 Decade Report (2000-2010), World Health Organization (2010).

OB Cardiac Arrest &Perimortum Cesarean Delivery

Recognition, CRM & Teamwork• 2+ Patients—Are you ready?

• CRM: ER, ICU, Code Team, OB & Neonatal Teams

• Every Minute Matters!!

BLS, ACLS & ATLS• Positioning LUD-Improved Hemodynamics!

Primary Impression & Delivery• Quick Assessment: Fetus Viable & Alive?

• Maternal Death Imminent?

• Prepare for Delivery & NRPSource: 1. Aortocaval Compression Conundrum in Obstetrics. https://journals.lww.com/anesthesia-analgesia/Citation/2017/12000/The_Aortocaval_Compression_Conundrum.7.aspx. Accessed March 2018.2. Cardiac Arrest In Pregnancy. AHA Scientific Statement. https://doi.org/10.1161/CIR.0000000000000300 Circulation. 2015;CIR.0000000000000300. Accessed March 2018. Originally published October 6, 20153. Preparing For Clinical Emergencies In Obstetrics. ACOG. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Patient-Safety-and-Quality-Improvement/co590.pdf?dmc=1&ts=20180426T2325399798. Accessed March 2018

The Point Of Viability 23 weeks (some centers use 22 weeks)

0.5kg 1Kg 2Kg 3Kg 4KgSource:1. NEJM. Survival and Neurodevelopmental Outcomes among Periviable Infants. February 2017. Accessed May 2017. 2. ACOG & Society For Maternal-Fetal Medicine. Periviable Birth. https://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Periviable-Birth. October 2017. Accessed November 2017.

Normal Physiologic Changes In Pregnancy

Cardiovascular • Hemodynamics: High Flow & Low SVR

Hematologic • Circulating Blood Volume, Hct, & Coagulation

Respiratory• Compensated Respiratory Alkalosis: pH 7.4-7.45 & PaCO2 27-32

• O2 Consumption, MV, & Tv

• Delayed gastric emptying---risk for aspiration!

Sources:1. Hayes, Meghan; Larson, Lucia (2012). "Chapter 220. Overview of Physiologic Changes of Pregnancy". Principles and Practice of Hospital Medicine The McGraw-Hill Companies.

https://accessmedicine.mhmedical.com/content.aspx?bookid=496&sectionid=41304210 March 20182. Cardiac Arrest In Pregnancy. AHA Scientific Statement. https://doi.org/10.1161/CIR.0000000000000300 Circulation. 2015;CIR.0000000000000300. Accessed March 2018. Originally published October 6, 2015

Pregnancy Vital Signs & Labs

Pregnant

• HR: 85

• SBP: 114

• DBP: 70

• Goal: vital organ perfusion

• MAP > 70

• Ensure adequate preload before initiating vasoactive drugs

Labs

• Hct 34

• Platelets > 150

• AST/ALT ~ 35

• Creatinine < 1.0

• WBC < 16

Source: Hayes, Meghan; Larson, Lucia (2012). "Chapter 220. Overview of Physiologic Changes of Pregnancy". Principles and Practice of Hospital Medicine The McGraw-Hill Companies. https://accessmedicine.mhmedical.com/content.aspx?bookid=496&sectionid=41304210 Accessed March 2018

Intrauterine Resuscitation Measures

Lateral Positioning• Optimize CO & perfusion to uteroplacental unit

IV Fluid Bolus: Based on clinical condition

• Correction of maternal hypotension is essential!!

Oxygen Supplementation :• May optimize fetal oxygen delivery

Reduction of Uterine Activity: Tocolysis

Source: Maternal Oxygen Administration As An IntraUterine Resuscitation Measure During Labor. Simpson, Kathleen Rice. MCN: The American Journal of Maternal/Child Nursing: March/April 2015 - Volume 40 - Issue 2 - p 136http://www.sfnmjournal.com/article/S1744-165X(08)00061-9/abstract. Accessed March 2018.

OB Blood Flow & Bleeding Risk

Source: 1. ACOG. Bleeding During Pregnancy. https://www.acog.org/Patients/FAQs/Bleeding-During-Pregnancy. Accessed March 2017.2. https://www.acog.org/-/media/Districts/District-II/Public/SMI/v2/he-06b-AF-140516-HemChecklist-Binder.pdf?dmc=1&ts=20171212T2152159656. Accessed March 2017.

#1Cause of Maternal Death: OB Trauma

Primary Causes: MVA, IPV Abuse, & Falls

Physiologic Changes Can Mask Signs of Shock

Uteroplacental Unit: Maternal Fetal Hemorrhage & Fetal Compromise Risk

Source: Trauma In The Obstetric Patient. American College of Emergency Physicians. https://www.acep.org/Clinical---Practice-Management/Trauma-in-the-Obstetric-Patient--A-Bedside-Tool/. Accessed March 2018

OB Trauma: Stabilization, Assessment & Transport

• Notification & CRM: ED/Trauma, OB & Neonatal Teams

• BLS & ATLS• Primary & Secondary Survey

• ABCDE

• LUD & Fetal Assessment-FHR

• Viability?

• Labs & Diagnostics

• Transfer or Transport?1. ACOG. Bleeding During Pregnancy. https://www.acog.org/Patients/FAQs/Bleeding-During-Pregnancy. Accessed March 20172. High Risk & Critical Care Obstetrics. N. Troiano, C. Harvey, B. Flood Chez. AWHONN 2013, 3rd Edition.

Ectopic Pregnancy: 11% Of Maternal Deaths

Pregnancy implantation outside the uterus

Suspect with childbearing age and abdominal pain

Leading cause of 1st trimester maternal death---risk of hemorrhage!!

Source: Tubal Ectopic Pregnancy. ACOG. https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Gynecology/Tubal-Ectopic-Pregnancy. Accessed March 2018

Abnormal Placental Implantation

• Previa: Bright red, painless bleeding with or without UC’s

• Invasive Placental Implantation: C/S & Hemorrhage Risk

•Rapid surgical & MTP capability

Source: Placenta Previa-Obstetric Risk Factors & Pregnancy Outcome. https://www.ncbi.nlm.nih.gov/pubmed/11798453. Accessed March 2018

Placental Abruption: Bleeding RiskRisk Factors?

Placental Detachment• May present with dark red & painful bleeding, OR

• Bleeding may be occult, rigid abdomen with severe pain & shock!!

Source: Bleeding During Pregnancy. ACOG. https://www.acog.org/Patients/FAQs/Bleeding-During-Pregnancy. Accessed March 2018

Maternal SepsisCauses:

Septic Abortions, Chorioamnionitis, Urosepsis, Retained Placenta PP

Early Recognition, Evaluation & Treatment•Sepsis Bundle, Activation of RRT & Labs•Timely broad spectrum antibiotics•Maintain perfusion parameters

1. Early Recognition and Management of Maternal Sepsis. https://nwhjournal.org/article/S1751-4851(16)00073-8/pdf?code=nwh-site. Accessed March 2018

High Risk OB Case Study:Code 3 Full Arrest Into The ED

OB Code 3 Into ED: ETA 7 minutesWitnessed Arrest CPR In Progress

Priorities?What & Who Do You Need?

The Pressure Is On…..OB Hypertensive Emergencies

Defined: SBP >160mmHg, or DBP > 100mmHg, acute-onset, & persistent (>15 min)

Severe systolic hypertension--most important predictor of cerebral hemorrhage in OB patients• Goal B/P: Range of 140-160/90-100 mmHg to preserve fetal perfusion!!• Severe hypertension can occur antepartum, intrapartum or post-partum

Stabilization Considerations: • Magnesium Sulfate, Antihypertensives, Anticonvulsants, Transport & Delivery

Source:1. California Maternal Quality Care Collaborative: CMQCC. https://www.cmqcc.org/. Accessed August 20172. ACOG. Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. April 2017. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co692.pdf?dmc=1&ts=20171212T2343034025.

Accessed May 2017

Image Source: https://www.thirdstopontheright.com/may-is-preeclampsia-awareness-month-do-you-know-the-signs-and-symptoms/. Accessed April 2018

Preeclampsia, HELLP & Eclampsia

Cerebral Effects Cardiac/Vascular

Pulmonary Liver Renal Fetal

Labs: Obtain Hct, Platelets, LFT’s, Cr, Coags

Preeclampsia Assessment

Treatment-Stabilization: Magnesium Sulfate, Antihypertensives, Anticonvulsants, Delivery

Source: 1. California Maternal Quality Care Collaborative: CMQCC. https://www.cmqcc.org/. Accessed August 20172. https://www.propublica.org/article/die-in-childbirth-maternal-death-rate-health-care-system. Accessed December 2017

Putting A Face On Maternal Mortality

Image Sources: 1.Putting A Face On Maternal Mortality. Lauren Bloomstein. https://www.propublica.org/article/die-in-childbirth-maternal-death-rate-health-care-system. Accessed March 2017

Tick Tock...Every Minute Matters

Preterm Labor &

Preterm Premature Rupture of Membranes

• Primary Impression?, Consult, & Pre-transport Stabilization

• Optimize Tocolysis

• Fetal Protection: Magnesium Sulfate, Antenatal Steroids & Antibiotics

• Transfer To Higher Level Of OB & Neonatal Care—as needed Source:1. Society For Maternal Fetal Medicine. Implementation of the Use of Antenatal Corticosteroids in the Late Preterm Birth Period in Women at Risk for Preterm Delivery. August 2016. Accessed March 2017. 2. ACOG. Management of Preterm Labor. https://www.acog.org/Womens-Health/Preterm-Premature-Labor-and-Birth. October 2016. Accessed March 2017 3. The American College of Obstetricians and Gynecologists Committee on Obstetric Practice Society for Maternal-Fetal Medicine. Magnesium Sulfate In Obstetrics. January 2016. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co652.pdf?dmc=1&ts=20171212T2253317113. Accessed August 2017.

Delivery Outside Of OB Unit : Now What??

• Place infant on mothers abdomen after birth

• Clamp cord 8-10 inches from baby• 2 clamps several inches apart: cut between clamps

• Delayed Cord Clamping X 30-60 seconds IF VIGOROUS

• Immediate Cord Clamping IF NONVIGOROUS

• Provide basic newborn care• Clear Airway & Optimal Airway Positioning

• Dry Thoroughly & Provide Warmth

• Continuous assessment of ABC’s

• Thermoregulation & Blood Glucose

Source: Neonatal Resuscitation Program. AAP. 7th Edition

Tiny Ones: Preterm Delivery

Delayed Cord Clamping:

IF vigorous DCC reduction of IVH

IF NONVIGOROUS immediate umbilical cord clamping & NRP

Thermoregulation & Neuroprotection:

Warming mattress, isolation bag, hat, nesting, & head alignment with gentle handling

NRP Guidelines:

Sp02 & ECG, CPAP, PPV, airway & perfusion support, careful fluid administration, glycemic control, early activation of neonatal & transport teams!

Source:1. AAP. Neonatal Resuscitation Program. 7th Edition.

Delivery of Placenta: Now What?

Anticipate within 20 min after delivery• Do not pull on cord

Normal blood loss ~ 500ml

Provide vigorous fundal massage!!

• Support lower uterine segment

• Ensure uterus stays contracted-firm

• Uterotonics: as needed

Source: ACOG Guidelines For Management Of Hemorrage. https://www.aafp.org/afp/2007/0401/p1101.html. Accessed 3/2018.

Postpartum Hemorrhage • #1 Intervention: Provide Vigorous Continuous Fundal Massage• Leading cause: uterine atony after birth• Goal: uterus remains contracted & firm

Adequate Vascular AccessContinuous Fundal MassageUterotonicsConsider TXAD&C -- Removal of Placental PartsOR --- Looking For BleedersActivate Massive Hemorrhage Protocol

Source: OB Hemorrhage V2 Toolkithttps://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit. CMQCC. California Maternal Quality Care Collaborative. Accessed 3/20/2018

Image Source: dailymom.com

OB Case Study: 23 weeks, +HA 8/10

Neonatal EmergenciesLeading Indicators?

Neonatal Resuscitation & Stabilization Priorities

NRP versus PALS: Differences

Stabilization Measures: The S.T.A.B.L.E. Program

• S: Glycemic Control• T: Thermoregulation• A: Airway Support• B: Perfusion Support• L: Consider Antibiotics• Prepare For Transport • Transfer to Higher Level of Care

Source: AAP. Neonatal Resuscitation Program. 7th EditionThe S.T.A.B.L.E. Program. 6th Editionhttp://www.abclawcenters.com/wp-content/uploads/2014/11/original_resuscitation_with_bagging_and_chest_compressions.jpg. Accessed August 2017.

Neonatal Airway ManagementBabies Are Different…

•Anatomical Challenges

•Ventilation Devices

•Establishing Effective Ventilation

•Oxygenation

•Ongoing Airway Support

•Alternative AirwaySource1. AAP. Neonatal Resuscitation Program. 7th Edition2. The S.T.A.B.L.E. Program. 6th Edition

Neonatal Vascular AccessEmergent UVC:

o18-20 gauge IV catheter: Prep—Tie—Cut--Cannulateo Single lumen UVC catheter 3-5 cm, obtain blood return o <1500 Grams/30 weeks 3.5 F and >1500 Grams/30 weeks 5.0 F

PIV Placement

• 24g

IO Placement

• EZ IO >3kg

Fluid Resuscitation

• NRP versus PALS

Source1. AAP. Neonatal Resuscitation Program. 7th Edition2. The S.T.A.B.L.E. Program. 6th Edition

Neonatal Hypothermia Treatment: Protecting Babies BrainsHypoxic Ischemic Encephalopathy (HIE)

Inclusion CriteriaoPost criteria in L & D - Nursery

Time SensitiveoEarly Recognition is Vital

oTarget Tx Initiation by 6 hours

Early ConsultationoRegional Neonatal Cooling Center

Source:Hypothermia and Neonatal Encephalopathy. AAP (2014). http://pediatrics.aappublications.org/content/pediatrics/133/6/1146.full.pdf. Accessed May 2017https://i.pinimg.com/236x/ef/50/f3/ef50f3f7f9ee2fdfc533270415471c1e.jpg. Accessed December 2017. http://www.rchsd.org/wp-content/uploads/2014/05/Neonatal-cooling-blanket.png. Accessed December 2017 http://jlgh.org/JLGH/media/Journal-LGH-Media-Library/Past%20Issues/Volume%206%20-%20Issue%203/Larsonfig3.jpg. Accessed December 2017

Bowel Obstruction: Clinical Priorities

• Rapid Consult, Stabilization & Transport to Pediatric Surgical Center

• Airway & Perfusion Support

• Abdominal Decompression: Orogastric Tube 8F or 10F

• IV Fluids, Glycemic Control, ThermoregulationSource1. AAP. Neonatal Resuscitation Program. 7th Edition2. The S.T.A.B.L.E. Program. 6th Edition

3. Journal of Obstetric Gynecologic and Neonatal Nursing. JOGNN. Lockridge, Caldwell, Jason (2003). Neonatal Surgical Emergencies: Stabilization & Management. Volume 31, Number 3.

Free Air On Xray Is A Surgical Emergency

Neonatal Case Study:OB Patient Arrives To Your Unit Labor-No PNC

2 Minutes Later….You Have 2 PatientsThis Is One of Them---Now What?

Final Thought…

Questions?

For Additional Information Contact: Yvette Gonzalez, RN, MS, High Risk OB & Neonatal Transport Clinical Manager

Yvette.Gonzalez@REACHAir.com

Pediatric TraumaRyan Donlin, BSN, RN, CCRN

“If a disease were killing our children in the

proportions that injuries are, people would be

outraged and demand that this killer be stopped.”

-C. Everett Koop, MD

Objectives

• Review the current prevalence and leading types

of Pediatric Trauma

• Review and discuss the Pediatric trauma

assessment - “Slow is smooth, smooth is fast”

• Identify and evaluate Pediatric vs. Adult trauma

differences

• Examine injuries more commonly seen in the

pediatric population

• Analyze pediatric trauma prevention practices

• Recognizing Child Abuse/Maltreatment

Pediatric Trauma

Trauma is the leading

cause of childhood

death and disability in

the US.

On average 12,175

deaths annually

CDC Statistics – (2000-2006)

Injury Deaths:

• Death rate in Males were almost 2x that of females

• #1 Leading cause of death for children were due to

transportation related incidents (Occupant, Ped vs.

Vehicle, Bicycle vs. Vehicle)

• Leading cause of death by age group:

< 1yr = Suffocation

1-4yr = Drowning

5-19yr = Occupant in MVC

Death Rate Per 100,000 Population

Buckle Up! And Buckle Up Correctly!

CDC Stats (cont.)

Non-Fatal Injuries:

• An estimated 9.2 million children annually have an

initial emergency department visit for an

unintentional injury

• Males > females

• Injuries due to falls were the leading cause of non-

fatal injury for all age groups < 15yrs

More Nerd Stats

• Blunt trauma accounts for more than 80% of all pediatric fatal injuries

Body Part Rankings

• #1 - Traumatic brain injury (TBI)

• #2 – Thoracic

• #3 – Abdominal

Mechanism of Injury (MOI)

Knowledge of the MOI allows for a high index of

suspicion for the resultant injuries in the child.

•MOI often reflects the age

and developmental status of

the child

•External evidence of injury

may be minimal as energy is

often absorbed by

underlying structures

•MUST suspect underlying

potential injuries!!

Mechanisms of Injury

The transfer of kinetic energy arises from several sources:

• Blunt (injury to internal organs),

• Penetrating (disruption of skin and organ integrity),

• Acceleration-Deceleration (abrupt, forceful back and forth movement),

• Crushing (direct compression of body structures).

Pediatric Trauma Assessment

Initial Trauma Assessment and Intervention

Primary Assessment

Identify life-threatening injuries to the airway,

breathing, circulatory and neurologic systems

Secondary Assessment

Identify injuries to the remaining body systems.

Primary Assessment

1. Assess the Airway and Cervical Spine

2. Assess Breathing

3. Assess Circulation

4. Assess Disability (Neurologic System)

Airway

Cervical Spine ~ Immobilization

Full Spine Immobilization

Spinal Alignment

Breathing

• Rate and depth of respiration

– RR – Infants > Children > Adults

– More reliance on diaphragm to breath

– Newborns are obligatory nose breathers until approx

4-6mths

• Breath sounds, Effort to move air

- Accessory muscle use?

• Crepitus, Tracheal position

• Oxygen saturation

Circulation

• Tachycardia early

• Capillary refill / Skin color

• External blood loss

– Control life threatening hemorrhage!!!!!

• Hypotension is a late finding

– Kids can lose up 25-30% of circulating blood

volume before hypotension presents

• Use SPO2 as a loose guide

How’s the dome? (Disability)

Secondary Assessment

5. Expose the patient / Environmental Control

6. Full Set of VS & Family presence!

7. Get ready for resuscitation measures

• IV access – largest bore possible

• IO access – don’t hesitate to use if IV unavailable

8. Head-to-Toe Assessment/ History.

• SAMPLE, MIVT

9. Inspect the Back.

General Vital Signs and Guidelines

Head Injury – Quick Case vs. Case

CASE #1

7YOF rear middle seat unrestrained passenger of a 4-door sedan who

was involved in a single vehicle vs tree MVA traveling approx 35-

45mph. Per EMS the vehicle sustained significant front-end damage

w/ starring of the windshield, and + airbag deployment, + LOC for

unknown amount of time. Pt was mobile prior to BLS EMS arrival

at scene. Pt began to vomit during primary assessment.

Head Injury – Quick Case vs. Case

CASE #2

3YOF s/p fall from a

stationary motorcycle

while playing on the

seat. Immediately

following the fall, the

patient vomited w/

additional c/o head

pain.

Head Injury – Quick Case vs. Case

CASE #1

+ facial fractures and moderate concussion

CASE #2

CT revealed ICH in the 3rd, 4th ventricles and

temporal horns.

Head Injury

• Traumatic brain injury (TBI) is the most common

cause of traumatic childhood death and disability

in the US.

• #1 cause of traumatic death for peds

• Major cause of TBIs are motor vehicle related

incidents in which the child is a passenger, a

pedestrian or on a bicycle.

• Other head injuries result from falls, sports/play

injuries.

Head Injury (cont.)

• In 2012, an estimated 329,290 children (age 19 or

younger) were treated in U.S. EDs for sports and

recreation-related injuries that included a diagnosis of

concussion or TBI.

• From 2001 to 2012, the rate of ED visits for sports

and recreation-related injuries with a diagnosis of

concussion or TBI, alone or in combination with

other injuries, more than doubled among children

(age 19 or younger).

Not funny Nerd Chart

TBI – Initial Management

• Airway

– Normo-ventilation vs hyperventilation?

– ETCO2 = 35-40mmHg

• Maximize cerebral perfusion (age appropriate goal)

– SBP/MAP (age specific) + O2 (SPO2 > 90%)

• Intracranial pressure monitor

– Goal = REDUCE secondary brain injury

Head CT’s

How are we doing?

Protecting the dome! Prevention Measures

Spinal Cord Injury

Cervical Spine Injury

• Uncommon in young children and are associated with multiple injuries.

• Child’s large head takes most of impact.

• Highly elastic neck ligaments and incompletely calcified vertebral bodies allow for more pliancy of the neck.

• Subluxation is more common in children.

Bony Structures

Spinous process

Lamina

Transverse process

Pedicle

Vertebral foramen

Posterior Arch

Superior articulating process

Spinous process

Inferior articular process

Transverse process

Superior articular process

McQuillan, K., Von Rueden, K., Hartsock, R., Flynn, M., & Whalen, E. (eds.).

(2002). Trauma Nursing: From Resuscitation Through Rehabilitation.

Philadelphia: W. B. Saunders Company. Reprinted with permission.

Spinal Nerves

Spinal Nerve Area Innervated

– C4 Diaphragm

– C5 Deltoids and biceps

– C6 Wrist extensors

– C7 Triceps

– C8 Hands

– T2 – T7 Chest muscles

Types of Spinal Injury

• Fracture

• Fracture with subluxation

• Subluxation alone

• SCIWORA ~ Spinal cord injury without

radiographic abnormality

Mechanism of Injury

Hyperflexion

Hyperextension

Axial loading or vertical compression

Rotation

Penetrating trauma

Classification of SCI

• Complete

A total motor and sensory loss distal to the injury

• Incomplete*

There is a partial preservation of sensory and/or motor function below the level of the injury

*classified as spinal cord syndromes

Classification of SCI

Unstable Spine injury

• Anatomic elements of the spine are disrupted,

with deformity.

• The spine can no longer maintain normal

alignment

• The vertebral and ligamentous structures are

unable to support or protect the injured area

Cervical Spine Fractures

• All patients involved in traumatic injury must be

immobilized

– Assume injured unless cleared

– Hard collar (Aspen) / Miami-J

– Log roll, Circulation, Motor, Sensory (CMS) exams

– Steroids?

– Spinal cord center for children

• The upper cervical spine C-1 and C-2 accounts for

20% of all C-spine fractures and the lower C-3 thru

C-7 accounts for 80%.

Cervical Spine Clearance

• Conscious patient– Alert, cooperative, no neck pain, no neck tenderness,

distracting injury?

• Unconscious patient– Plain film – Lateral C-spine with collar on

• If unable to visualize to T1 on lateral film, obtain multi-detector complete cervical spine CT

– Maintain in collar

– Follow guideline: "Routine Management of the Patient in a cervical collar”

– MRI if not expected to awaken

SCI

• One study that looked at 122 injured children

birth to 16 years old revealed

– 41% had fracture alone

– 33% fracture with subluxation

– 10% with subluxation alone

– 16% with SCIWORA

• When subdivided further by age: Subluxation and

SCIWORA are more likely to affect younger

children and fractures being more common in

older children(Proctor, 2002)

Neurological Assessment

• Sensorimotor exam

• Reflex function

• Early recognition of Spinal /

Neurogenic Shock

Spinal Shock

• Spinal shock is manifested by

– Flaccid paralysis

– Absence of cutaneous and/or

proprioceptive sensation

– Loss of autonomic function

– Cessation of all reflex activity below the

site of injury

Neurogenic Shock

Loss of sympathetic innervation Increase in venous capacitance

Decrease in venous return

Injury to T6 and above

Hypotension

Bradycardia

Decreased cardiac output

Decreased tissue perfusion

Cardiovascular component of Spinal Shock

Cardiovascular Implications

• Hypotension

– Maintain SBP > 90 mmHg for transport

– establish adequate pressure for systemic perfusion

• Bradycardia

– Treat only if symptomatic

• Temperature regulation

– Will become hypothermic

– Requires continuous monitoring

– Warming strategies

Surgical Intervention

• Physician preference

• Decision driven by mechanism of injury,

neurological deficit, and structural dysfunction

• Timing is controversial

– Within the first 72 hours

– After 7 days

• Emergent surgical intervention is required for

neurologic deterioration with evidence of cord

compression (bone or disc fragments,

malalignment, or hematoma)

Critical Care Phase

• Respiratory

Complications

• Cardiovasular

– Bradycardia

– Vasovagal response

• Poikilothermia

• Gastrointestinal

• Pain and anxiety

Abdominal and Thoracic Trauma

Thoracic & Abdominal Injuries

• Musculature of the child’s chest and abdomen is less developed than in the adult.

• Ribs are flexible and more anterior, thus are less protective of underlying organs.

• Child’s protuberant abdomen along with its thin abdominal wall places organs close to impacting forces during a traumatic event.

• Child’s small body size is predisposed to multiple injuries rather than isolated injury.

Mechanism of Injury

• Should heighten

suspicion regarding

certain injuries

• Blunt injury and types of

forces

• Penetrating trauma

• Use of restraint devices

– Safety seat vs. seat-belt

only

Quick Case Study

• 10YOM who was riding his BMX bicycle, when he went full

send off a jump and landed on the handlebars.

• Pt sustained penetrating trauma to the RLQ resulting in a

deep laceration approximately 6"x3"x2" (LxWxD).

• Not wearing a helmet at the time of injury, denies any LOC,

able to recall all events leading up to TT arrival.

• Rapid trauma assessment reveals no other injuries.

• Pt able to MAE w/ CMS intact x4. VS stable @ scene

Thoracic Trauma

Penetrating

Open Pneumothorax

Hemothorax

Blunt

Pulmonary Contusion

Pneumothorax

Hemothorax

Rib Fracture / Flail Chest

Traumatic Asphyxia

Traumatic Diaphragmatic

Hernia / Rupture

Pericardial Tamponade

Pulmonary Contusion

• Results from blunt trauma to the chest that transmits energy to the underlying lung tissue.

• Pulmonary edema, alveolar hemorrhage, desquamative alveolitis and subsequent RDS may result.

– RDS generally within first few hours of injury

• Impaired gas exchange

• VQ mismatch

• ↓ lung compliance

• Positive pressure ventilation with PEEP and oxygen support may be required.

Pneumothorax

• Collection of air into the pleural space with partial or complete collapse of the lung.

– Usually caused by blunt trauma to the chest causing alveoli rupture with a resultant escape of air, thus collapsing the lung.

• This injury is closed and the lung seals, preventing further leakage.

– May progress to tension pneumothorax.

Hemothorax

• Blood collection in pleural space as a result of blunt or penetrating injury

• Clinical presentation

– Respiratory distress

• ↓ breath sounds on affected side

• Dullness with percussion

• Management

• Chest tube

• Volume resuscitation

• Thoracotomy for continued blood loss

Open Pneumothorax

• Results from penetrating thoracic injury

• May lead to tension pneumothorax or hemothorax

• There is progressive air entry into the pleural space without a means of escape

• Lung on affected side collapses and pushes toward the unaffected side producing a mediastinal shift and compression of heart and great vessels

• Treatment: 3-sided occlusive dressing over the wound and chest tube placement.

What do we have here?

Pericardial Tamponade

• Occurs when a significant amount of blood, fluid or air accumulates in the pericardial sac.

• In children, as little as 25 to 50 mL can compromise ventricular function.

• Findings include hypotension, neck vein distention, elevated CVP, muffled heart sounds, pulsus paradoxis (fall in BP 8-10 mm Hg during inspiration).

• Pericardiocentesis provides temporary relief until surgical repair is performed.

Pericardial Tamponade

Abdominal Injury

• Most common MOI is blunt trauma from an MVC-related event whether as an occupant, pedestrian or bicycle rider

• Other causes include sports injuries, falls and child abuse

• Organs usually involved are the Spleen, Liver, & Kidneys

• Injuries to the major vessels and the Pancreas are less common

Abdominal Trauma

• Injury to the Solid Organs –

• Dense and less strongly held together

• Prone to contusion – bleeding – fracture (rupture)

• Often referred to as “The Kill Zone”• Area is extremely vascular

• At risk for unrestricted hemorrhage if organ capsule is

ruptured

• Injury to Hollow Organs –

• Children are at greater risk because of their

protuberant abdomens, thin wall, and propensity to

swallow air.

Abdominal Trauma

Rapid Assessment of the “Kill-Zone”!

Physical assessment –

• “Hot Belly”

• Firm abdominal distention

• Rebound tenderness

• Dermal evidence of trauma

Patient complaints –

• Pain!!!

For referred pain – right

(Liver) vs. left (Spleen)

• Nausea/Vomiting –

• Bowel, Pancreas ?

Organ Injury Scaling

Injury scale

• Grades I – V

– Injury description

• Hematoma

• Laceration

• Rupture / Avulsion

• Dependent on severity and location of injury (organ involved)

Quick Hit Case Study

• 12YOM c/o diffuse left sided ABD/Rib pain for approx. 3 days

• Pt sustained a “hard hit to the gut” area while at football

practice. “Toughened up” and continued to play/practice thru

the week

• Over the last 24hrs has been experiencing increased fatigue,

light-headedness, and decreased oral intake d/t continued

nausea.

• VS – HR 110, BP 108/60, RR 14, SPO2 92%, Temp 36C

Splenic Injury

• Most commonly injured organ during blunt traumatic event.

• Located on left side of abdomen below the ribs.– Generally not palpated at any age

• Signs / Symptoms –– flank ecchymosis (Turner’s sign)

– umbilical ecchymosis (Cullen’s sign),

– left abdominal or flank pain with referred left shoulder pain (Kehr’s sign)

• Treatment includes observation with serial HCTs and/or surgery

Splenic Injury

Liver

Largest intra-abdominal organ

in the body

• Extremely Vascular!

• 75% of blood to the liver

is delivered by the portal

vein

Function

• Stores products helpful to

digestion of food

• Filters toxins from the

bloodstream

2nd Most Commonly injured organ

• MVC - #1 culprit

Mortality Rate: 10-15%

• Uncontrolled hemorrhage is

the primary cause of death

Liver Injury

Kidney Injury

• Children have relatively large kidneys, underdeveloped abdominal wall and lesser rib cage protection.

• Directly related to the blunt force trauma.

• Clinical findings –– Hematuria, abdominal pain and bruising, palpable flank

mass and hypovolemia.

• Treatment may include observation, surgical repair or nephrectomy.

Kidney Injury Grading

Indications for

Non-operative Management

• Hemodynamically

stable

• Appropriate

monitoring

• Experienced

personnel

Bowel Injury

• Result from direct blunt trauma or penetrating forces.

• Children are at greater risk because of their protuberant abdomens, thin wall, and propensity to swallow air.

• A full stomach is more prone to injury.

• Injuries include bowel transection, laceration and perforation.

• Clinical findings include abdominal pain, vomiting and pneumoperitoneum (free air in abdomen).

• Treatment may include observation and/or surgical repair.

Traumatic Diaphragmatic Hernia

• Results from severe abdominal

compression.

• Diaphragm ruptures, allowing

abdominal contents to enter

the chest cavity.

• Common MOIs include a lap

belt injury and pedestrian

injury where the child is run

over by the vehicle.

• Treatment is immediate

surgical repair.

Drowning / Submersion Injury

Drowning / Submersion Injury

• Ranks 5th among the leading causes of

unintentional injury death in the US

• #1 for ages 1-4yrs old (Bucket Drowning)

• For every child who dies from drowning, another

five receive emergency department care for

nonfatal submersion injuries

• Most common in summer months

• 50% in swimming pools

• Bathtub drowning is most common in children

with seizure disorders

Drowning Defined

• Drowning

– Death from asphyxia by water submersion

• Near-drowning

– Survival after asphyxia from water submersion

• Dry-drowning

– Non-aspirating asphyxia during water submersion

Drowning

• Pathophysiology

– Pulmonary effects

• Persistent Hypoxemia/Hypercarbia; VQ Mismatch

– Cardiovascular effects

• Arrhythmias / Cardiogenic Shock

– CNS Effects

• At risk for severe brain damage d/t prolonged

hypoxia

• Management

– First Responder / Pre Hospital EMS – CPR!!!

– Emergency Department / ICU

Infant Swimming Resource –

Drowning Prevention

Troubling Statistics

• 1 in 4 U.S. children experience some form of maltreatment in their lifetimes

• Girls > Boys

• Children < 1yrs old have the highest rate of victimization

• Special needs kids at greater risk d/t increase caregiver burden

• Approx. 2.2 /100,000 cases result in fatalities

• 80% of perpetrators/offenders are parents

• 40% of females will experience some form of sexual violence before the age of 18.

Abuse

• Words or overt actions that cause harm, potential harm, or threat of harm

• “Acts of commission”

• 3 Types:

– Physical

• bruises, hitting, choking, cigarette burns

– Emotional

• constant criticism, rejection, threats

– Sexual

• fondling, penetration, indecent exposure, exploitation

Neglect

• Failure to provide needs or to protect from harm or

potential harm

• “Acts of omission”

Physical neglect

Emotional neglect

Medical and dental neglect

Educational neglect

Inadequate supervision

Exposure to violent environments

Ripple Effects of Abuse

• According to a 1992 study sponsored by the National Institute of Justice (NIJ), maltreatment in childhood increases the likelihood of arrest as:

– A juvenile by 53 percent

– An adult by 38 percent and for a violent crime by 38 percent

– Being abused or neglected in childhood increases the likelihood of arrest for females by 77 percent.

• A related 1995 NIJ report indicated that children who were sexually abuse were 28 times more likely than a control group of non-abused children to be arrested for prostitution as an adult

Abusive Head Trauma

• “Shaken Baby Syndrome”

• Babies < 1yr at greatest risk

• Most notable trigger is due to inconsolable crying

• Accounts for approx. 1/3 of all child maltreament deaths

• Long-term health consequences:

• Vision problems

• Developmental delays

• Physical disabilities

• Hearing loss

Fabricated or Induced Illness by Carers

• A.K.A. – Munchausen Syndrome by Proxy (MSBP)

– Parent simulates or causes disease in a child

• Usually preverbal children

• Pattern/response doesn’t correlate with disease

• Symptoms associated with proximity of parent

• Symptoms falsified/created by a variety of methods

• partial suffocation, toxins, salts

• Diagnosis –

– Obtain records if seen at another hospital recently/

continuous surveillance

Mandatory Reporting

• Verbal Report immediately upon suspicion

– Police or Sheriff’s Department (Does not include a

school policy or security department)

– County Probation Department (If County

Designated)

– County Welfare/County CPS Department

• Follow up in writing

– General Standard within 48 hours or as soon as

possible

– California Form 8572

Mandated Reporting

• Good Faith reporters are protected under the law

from civil or criminal liability

• Failure to report may result in fine up to $1,000

Additional Information and Training:

http://mandatedreporterca.com

Questions

Credits

• Reid AB. Letts RM. Black GB. Journal of Trauma. [JC:kaf] 30(4):384-91,

1990 Apr

• Diagnostic Imaging in Infant Abuse, Am J Roentgenol, Kleinman 155

(4):703

• The metaphyseal lesion in abused infants; a radiologic-histopathologic study,

PK Kleinman, SC Marks, and B. Blackbourne, AM J Roentgenol., May

1986; 146; 895-905.

• https://www.cdc.gov/traumaticbraininjury/get_the_facts.html

• https://www.cdc.gov/safechild/pdf/cdc-childhoodinjury.pdf

• https://emedicine.medscape.com/article/435031-overview#a4

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3500003/

• https://www.cdc.gov/homeandrecreationalsafety/water-safety/waterinjuries-

factsheet.html

• https://www.cdc.gov/violenceprevention/childabuseandneglect/index.html

• https://www.cdc.gov/motorvehiclesafety/child_passenger_safety/cps-

factsheet.html

Evaluation and Management of Geriatric Trauma

Michelle Moss NRP, FP-C

REACH Air Medical

Sierra Sacramento Valley EMS Agency

Objectives

• Look at trauma statistics and talk about the impact of elderly trauma on EMS and hospital systems of care

• Discuss issues related to the assessment and management of elderly trauma patients

• Review recommendations from trauma specialty organizations for the initial management of significant geriatric trauma

• Discuss how better field assessment, destination determination and ED evaluation can improve mortality for elderly trauma patients

• Review the benefits of trauma center admission for elderly trauma patients

Is it just me or are we all getting older?

2018 – 5.3 million (14%) Californians are 65 or older

2030 – 9 million (21%) will be 65 or older

2014 CA Trauma injuries Statistics

253,000 hospital admissions

• 107,000 (42%) are >65yo

18,000 trauma deaths

• 4,500 (25%) are >65yo

Sierra-Sacramento Valley LEMSA

• 49% of 911 calls are pts >65yo

Significant Mechanisms of Injury

Falls• Account for 75% of all geriatric trauma

• 2014 Amador, El Dorado, Calaveras = 3,055

Vehicle Accidents• Highest mortality rate = patients struck by vehicle

• 2014 Amador, El Dorado, Calaveras = 264

Burns• Median lethal dose (LD50): 60-70yo = 43.1% TBSA

70-80yo = 25.9% TBSA

> 80yo = 13.1% TBSA

• 2014 Amador, El Dorado, Calaveras = 33

Determining Severity of Trauma

ISS Score• Assesses severity of trauma from 0-75

• Six body regions

• Abbreviated Injury Scale (AIS) classifies severity

1 = Minor injury … 6 = Maximal injury (unsurvivable)

• Highest AIS from 3 most injured body regions squared then added together

• Correlates to mortality, morbidity and length of stay

• ISS >15 considered major trauma

Probability of Survival Tools• TRISS (Trauma Injury Severity Score) - Evaluates RTS, ISS, age and type of trauma

• GTOS (Geriatric Trauma Outcome Score) – Considers age, ISS and blood product use

• GTOS II – Looks at probability of unfavorable discharge to SNF, LTAC or hospice

Effects of Age and Comorbidities on Length of Stay

• 81% of patients 65 or older have at least one comorbidity

• Hypertension, heart disease most common

• Liver disease, renal insufficiency and cancer have greatest mortality risk

• Result in increased length of stay

• Mean length of stay for trauma increases significantly with age

Age Adjusted mean length

of stay (days)

14-54 11.555-64 12.965-74 21.175-84 33.7

85-100 38.7

Significant impact on specialty resources!

Oral Anticoagulants (OAC)

• 6 million adults in the US take oral anticoagulants

• By 2024 projected US expenditure of $27 billion• Vitamin K antagonist (VKA) – Warfarin

• Associated with higher mortality in TBI than DOACs

• Direct oral anticoagulant (DOAC) Pradaxa, Xarelto, Elliquis

• Higher efficacy and lower fatal bleeding rates

• Less frequently reversed in trauma

• Patients with blunt trauma and ISS >15

• VKA mortality rate: 29.5%

• DOAC mortality rate: 8.3%

So what’s the real problem?

• Triage tools used to determine the severity of trauma don’t reliably identify severe trauma in the elderly

• Age-related physiology, comorbidities, and medications make trauma assessment challenging

• Social and cultural determinants may result in less aggressive evaluation and treatment

Clinical Assessment Challenges in Evaluating Degree of Shock

“Normal” Respiratory effortDiminished respiratory reserve and blunted response to hypoxia, hypercarbia and acidosis leads to normal RR despite significant shock

“Normal” Blood PressureIncreased systemic vascular resistance results in baseline hypertension which leads to a delay in recognizing signs of shock

“Normal” Heart rateBeta blockers and a stiff myocardium compromise CO and lessen response to catecholamines leading to less profound tachycardia despite significant shock

“Baseline” Mentation• Dementia may complicate

establishing baseline mental status

• 30% reduction in brain

size by age 70 increases the space

for blood to accumulate which can

delay signs and symptoms of a bleed

Case Study

Patient:

• 78yo male, 79kg

• History of HTN

• Unknown meds, denies thinners

Mechanism:

• 1970’s pickup truck

• Lap belt only

• Headlights of oncoming vehicle obstructed his vision

• Off the road head-on into a tree @55mph

• 2 feet of intrusion into engine compartment

• Deformity to steering wheel

Patient Complaints:

• 10/10 Chest, face, leg pain

• Pain with breathing

Case Study

Assessment Findings:

• 2” laceration and edema to nose, bleeding from nares

• Crepitus to R chest w/deceased breath sounds

• Deformity, shortening and outward rotation to L leg

• 3” contusions and swelling bilaterally to both lower legs

Initial Vitals @0127:

• BP 124/76 HR 90 RR 20 Sat 98% GCS 15

EMS Treatment:

• C-Collar without long board

• Warming measures

• PIV 14g @ TKO

• EKG monitor

• Oxygen 15lpm NRBM

• Transport to trauma center – TTC for age

Repeat Vitals @ 0139:

• BP 96/70 HR 90 RR 20 Sat 98% GCS 15

• 250ml NS for drop in SBP

Case Study

ED Vitals @ 0155:

• BP 108/70 HR 84 RR 19 Sat 100% GCS 15

Injuries:

• Spleen laceration

• Pneumothorax

• Femur fx

• Sternum fx

• 3 rib fxs

• Multiple facial fxs

• Facial laceration

• ISS 22

• GTOS – 15% probability of dying

• GTOS II – 26% probability of unfavorable d/c

Hospital Course:

• IR - splenic embolization

• OR - ORIF of femur fx, chest tube, facial repairs

• 2 Units RBC

• LOS – 10 days

• Discharged to rehab

ACS-COT Trauma Triage Guidelines for EMS

Under Triage

Factors Contributing To Prehospital/ED Undertriage

• Masked physiologic response due to age/comorbidities

• Difficulty in determining baseline mental status

• Not establishing patient anticoagulant use

• Poor historian/unwitnessed event

• Age bias

VS

But why?Undertriage of Elderly Trauma Patients to State-Designated Trauma Centers Chang, etal

• 10 year review of 26,565 trauma patients, 49% under triage of patients >65yo

• 166 providers responded to follow-up surveys

• Mean provider age - 41.0 years

• Mean number of years of service was 12.0

Factors causing elderly patients to be transported to non-trauma center:

• Inadequate training for managing elderly trauma patients – 25.3%

• Unfamiliarity with protocol - 12.0%

• Transport not being worth it because of age - 13.4%

• Not being welcomed at the receiving trauma center - 9.5%

• Transport not being worth it because of poor prognosis - 5.4%

What can we do about it? - Prehospital

Consider augmentation of field triage to a trauma center for geriatric patients

Ohio Geriatric Trauma RulesPhysiologic

• GCS <15 with suspected TBI

• SBP <100mmHg

Anatomic

• Any suspected long bone fracture in an MVC

• Injuries sustained in two or more body regions

Mechanism

• Ground level falls with evidence of TBI

• Auto vs. pedestrian at any speed

What can we do about it? - Prehospital

Obtain a comprehensive history at scene:• What happened immediately before the trauma

ALOC, vision changes, difficulty breathing, chest pain?

• What medications is the patient taking

Anticoagulants, antiplatelets, beta blockers, calcium channel blockers?

• Previous medical history

Cardiovascular or renal disease?

• What is the baseline level of motor and cognitive function

Is a Trauma Center a better destination?

What can we do about it? - ED

Employ an “aggressive” approach to geriatric trauma

• Use elevated base deficit and lactate as indicators of shock

• Prioritize c-spine clearance• Early mobilization and head of bed-up reduces aspiration and respiratory

decompensation risks

• Consider chest and pelvis X-rays for mild trauma• Consider hospitalization even for minimal rib fractures

• Mortality rate for geriatrics 22% compared to 10% for younger adults

• Screen for antiplatelet and anticoagulant medications• STAT head CT for patients with suspected head injury

• If required, INR correction should begin within 2 hours of injury

What can we do about it? - EDPain management and sedation

• Minimize use of benzodiazepines in non-intubated patients• Increased body fat + decreased lean body mass = prolonged duration of effect

• Contributes to ICU delirium and ongoing cognitive impairment

• Increases risk of falls

• Use multi-modal pain therapy• Limit opioids when appropriate

• Consider NSAIDS and Tylenol for acute pain

• Evaluate for hypoxia, hypoventilation and shock before sedatives

• Consider PCA, epidurals and nerve blocks for long-term management

What can we do about it? – ED/ICU

Fluid Resuscitation

• Volume overload associated with high mortality in the elderly• Coagulopathies

• Chronic diuretic therapy = decreased vascular volume and low serum K+

• Over-resuscitation may lead to electrolyte imbalances and pulmonary edema

• Assessment• Monitor fluid status in the ED hourly

• Lactate and base deficit are better shock indicators than HR and BP

• Operative intervention or transfer should be considered for shock

• Use of non-invasive hemodynamic monitoring

• NIRS, bioimpedance (Cheetah), transcutaneous monitoring

What can we do about it? - Transfer

Advanced age should not be a sole criterion in denying or limiting care or transfer to trauma center

• Early transfer or EMS diversion for major geriatric trauma

• Generally an initial aggressive approach should be pursued unless…

• Persistent GCS<8 following aggressive resuscitation, and

• Significant comorbidities – especially previous MI, and

• Advancing age

• Up to 85% will return to pre-injury level of function

Benefits of Trauma Center Admission

Resources For Optimal Care of the Injured Patient “Orange Book” • Establishes expectations for trauma center performance• Sets optimal undertriage rate of <5% for injured patients

• A 2008 study of 26,565 trauma patients showed a 49% undertriage for patients >65

• Specialist advocates recommend ALL trauma patients 70 or older be trauma activated regardless of trauma mechanism

• One study – 16% mortality rate in 660 “stable” patients 70 or older who did not meet any standard trauma team activation criteria

• Another study - 87 geriatric patients with significant pelvic fractures had fewer complication rates when transported directly to a Level I trauma center

• And another - Elderly trauma patients with an ISS score >15 had a 1.89 time higher mortality rate when not admitted to a trauma center

Recommendations from EAST(Eastern Association for the Surgery of Trauma)

Level I and II Trauma Centers

• Level I - Must admit 1200 trauma patients annually or 240 admissions with ISS >15

• Level I - ICU Director must be a board certified surgeon

• ICU MD coverage in house (Level I) or within 15 minutes (Level II)

• 24/7 Neurotrauma, Orthopedic, Radiology at bedside within 30 minutes

• 24/7 Anesthesia, IR, MRI in house

• OR staffed and available within 15 minutes

• ICP monitoring capability

• All ED MDs must have 16 hours per year of trauma CE

• In house rehab services: physical, occupational, speech therapy

• Protocolized trauma management

Benefits of Trauma Center Admission

Emergent Trauma Specialty Services

• Established criteria for full/partial trauma team activation

• Mitigates late recognition of significant injuries• Typically age >65yo elevates level of activation by one tier

• Standard protocols for anticoagulation reversal• At minimum, partial trauma team activation

Benefits of Trauma Center Admission

Geriatric Trauma Services

• Standard criteria for early geriatric consultation on the trauma care team

• Comprehensive geriatric assessment (CGA) by geriatrician• Evaluates medical, psychosocial, and functional capabilities and

limitations in developing follow-up plans

• Increases likelihood of being alive and still at home one year following discharge by 25%

Benefits of Trauma Center Admission

Palliative Care Specialists• Aimed at improving quality of life and well-being

• Person (rather than patient) centered, Family-oriented

• ACS – Palliative care should be initiated and advance directive status should be determined within 24h of admission

• Many geriatric trauma patients will return to independent living

Palliative Care Is Not Hospice

Palliative care begins at diagnosis• Pain management

• Nutritional guidance

• Explain complex terms and treatment options

• Counseling for patient and family

• Assistance with family needs

• Spiritual guidance

Hospice begins when treatment ends• Patient is considered terminal

• Usually provided at home or hospice residence

• Pain management

• Spiritual support – moving towards acceptance and peace

Both are directed towards providing comfort and holistic care

Case Study

Patient:

• 93yo female, 49kg

• SNF resident, active in community

• History of hypothyroid, COPD, “cardiac”

• Synthroid, Norvasc, Relafen, Ventolin

Mechanism:

• Walking on kitchen floor, slipped and fell

Patient Complaints:

• 10/10 pain to L shoulder, scapula and ribs

Assessment Findings:

• No findings noted

Initial Vitals @1704:

• BP 193/104 HR 89 RR 24 Sat 92% GCS 15

EMS Treatment:

• C-Collar without long board

• PIV 20g, 200ml infused

• Fentanyl 75mcg

• Oxygen 4lpm NC

• Transport to non-trauma center

Case Study

ED Vitals @ 1745:

• BP 148/78 HR 77 RR 18 Sat 99% GCS 15

Injuries:

• Flail segment, L side rib fxs 2-8

• Hemopneumothorax

• Pelvic ring fxs

• L scapula fx

• Liver laceration

• ISS 24

• GTOS - 30% probability of dying

• GTOS II - 50% probability of unfavorable d/c

Hospital Course:

• Acute transfer to trauma center

• Ortho consult for fxs

• Family made patient DNR/DNI

• Palliative care w/focused pain control

• LOS – 2 days

• Discharged to Kaiser

Summary

• Elderly trauma is a growing problem

• Improved assessment tools and pain management strategies are needed for elderly trauma patients

• An aggressive approach to evaluation and treatment should not be limited secondary to patient age

• For geriatric patients with major trauma consideration should be given for transport to a trauma center

Questions?