transfers cedar 2014

8/11/2019 Transfers Cedar 2014

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The Trouble with Transfers

Douglas J.E. Schuerer, MD FACS

Director of Trauma

Department of Surgery

Section of Acute and Critical Care Surgery


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Department of SurgeryAcute and Critical Care Surgery

Disclosure

I have no disclosures.


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Transfer 1

21 y.o. female volleyball team captain for local college

Hit by truck while driving a scooter

Arrived to your Level 3 trauma center at 1514

GCS 4

Intubated on arrival

HR120 BP 128/65


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Transfer 1

After primary survey what would you do next?

A) CXR, pelvis x-ray

B) CT Head

C) A and then transfer D) CT Head, chest, abdomen, pelvis, face


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Transfer 1

What would you do now? A) Call neurosurgery

B) Call orthopaedics

C) CT angio of the Head and neck

D) Transfer to a Level 1 center


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Transfer 1

What timeline would youwork for your transfer?

How much should be done atyour center?

Does it matter if you haveneurosurgery available?


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Transfer 1

Ortho consult

NS consult

Mannitol

Lasix

CT angio of the head andneck

Pelvic films

Arrived 1514

Note to transfer at 1700

Report called to RN at1759

Departed 1902

Arrived BJH 1958


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Transfer 1

Arrives with heparininfusing on pressure baginto femoral A-line

OSH called to make sure

we know she got 3-4doses of contrast


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Transfer 1

What would you do next? Right craniectomy

ICP control

Pelvis fixed 5 days laterwhen ICP improved

1 week MRI showeddiffuse injury

What now?


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Transfer 2

You are an EMS provider and a come upon this scene:

MVC vs. Truck, high speed, significant intrusion.

Called 1911, Arrived on scene at 1940

4 victims

56 y.o female, complains of leg pain. HD stable

55 y.o. male, complains of abdominal tenderness, HDstable

27 y.o. obviously pregnant female, mild cramping

28 y.o. male, no apparent injuries Who goes where?


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Transfer 2

A) All to a level 1

B) All to nearest hospital

C) Older 2 to Level 1, younger to nearest hospital

D) Pregnant and abdominal pain to Level 1, others to

nearest hospital


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Transfer 2

More info

Family just picked up atairport. Parents in town tohelp with baby. Mom is 394/7 weeks.

Any differences?

How should they be leveled?


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Transfer 2

2 older patients are directly transferred to the Level 1center.

Both arrive about 2030.

Female is made a Level 1 as her BP dropped below 90.

Male is a level 2.

Turns out female has only a breast hematoma, nointervention needed.

Male has mesenteric hematoma. Requires laparotomy,resection and ostomy.

Pregnant female is taken to local hospital.


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Transfer 2

What next? A) Watch her in your ED for contractions fro 6 hours and then

discharge?

B) Call nearest OB available hospital and call for transfer?

C) Call a trauma venter and ask for transfer to a trauma center?

D) Call a trauma center and ask for OB?


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Transfer 2

OSH called OB. Mentioned minor trauma but asked fordirect transfer to OB floor for further monitoring.

MD: What is your protocol for such a case?

What imaging will they need?

Where is this best done?


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Transfer 2

Patient transported directly toOB. Arrives 2150.

FHT initially 120, but within15 minutes decrease to 90s.

What to do now?


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Transfer 2

STAT c-section

Baby with poor outcome

Mom had an abruption posteriorly

What imaging is needed now?


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Transfer 3

You are on call watching the newest civil disobediencegoing on in your city.

You see that the riot police cleared out part of the crowd toget to a protester who had been shot.

You wonder why you do not hear more as you are theclosest Level 1 center.

You drift off to sleep as your night is not so bad for achange


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Transfer 3

Your partner is at a small community hospital that is not atrauma center, just north of the disturbance.

At that hospital: Surgeons are not in house

ED is busy but not ready for trauma

At 0119 a car drops off a victim of shooting.

Complains of GSWs to the left flank, mid axillary line andthe left leg.

Initial vitals. SBP 40, HR 107 Awake and following commands.

What do we do?


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Transfer 3

A) Scream and run away

B) IVs, CXR, fluids

C) FAST (including chest), IVFs

D) IV, intubate, CXR, extremity films


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Transfer 3

Will you transfer the patient?

What absolutely needs to be done first?


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Transfer 3

IVFs started

CXR obtained

Pelvis film obtained

Extremity film obtained

Triple lumen placed in groin


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Do we need all of the other films?

Do we need to intubate?

What kind of line?


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Post intubation film

He is then sent to your Level 1 center.


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Transfer 3

Arrives at 218

91/75, 72, Intubated

Got 2 units PRBCs en route

GSW to the left flank and the left calf.

You get a CXR:


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Transfer 3

What next?

A) Thoracotomy

B) Chest tube and FAST

C) Sternotomy

D) Laparotomy


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Transfer 3

Taken to the OR Laparotomy, abdomen packed

Pericardial window done through the diaphragm, grossly positive

? What to do now?

Sternotomy

Hole in the right atrium at AC junction

Cardiac repair, PEA arrest with cardiac message andrecovery


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Transfer 3

In abdomen: Shattered kidney

Bleeding spleen

Gastric injury

Distal esophagus injury

What do you do?

Damage control?

Kidney and spleen removed, stomach and esophagus

repaired, chest tube placed, packed open Eventual return to OR in 2 days to close abdomen.

EBL 3 liters Got 14 PRBCS, 6FFP, 1plt

What do the MD think about that resuscitation?


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Pre and Post op films

What would you do next?


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Transfer 3

A) Bypass and bullet removal

B) TEE

C) VIR for removal

D) CT scan to localize


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CT, TTE and intracardiac echo all done.

CT says in RV, echoes say in pericardium.

What do you think?


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Transfer 3

Taken to OR by CTS

No bullet on exploration

Put on bypass, bullet was in the LV

Removed and recovered

Out of ICU post injury day 7.

Poor pulmonary toilet

UGI day 7 showed no leak

Diet started, tubes slow to come out. DC home post injury day 14.


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Transfer 4

You are at a non-trauma center but the only major hospitalin a county south of a large metro center.

You get a construction worker who fell 25-60 feet.

Arrives at 1350.

GCS 5, Denies complaints HR 103, BP 118/45


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Transfer 4

What are your priorities? A) Intubate

B) IVS and fluid

C) Blood

D) Above and xrays


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CXR


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Pelvis x-ray


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Transfer 4

When should you consider transfer?

When should this person have flown over this hospital to aLevel 1 center?


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Transfer 4

1411: Intubated

1420: Triple lumen line placed

1425: Discussing transport and helicopter called

1451: Helicopter arrived

1531: Patient arrives at your hospital


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Transfer 4

Was this a timely response and transfer activation? A) Yes

B) No


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Transfer 4

Should this person have a pelvic binder?

Should a triple lumen have been placed, it delayed thetransfer phone call?

Patient received 8 units of PRBCs en route, his temp was94.4 at the OSH. What should the patient have received?

A) Crystalloid only

B) Exactly the same amount of PRBCs and FFP? C) That blood and as much FFP as they could get form the blood bank

D) Why waste all that blood, he is dying anyway?


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Transfer 4

What would you do at your trauma center? Your INR just came back at 3.

BP is hanging at 80-90 with resuscitation.


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Transfer 4

Binder placed

Resuscitation tried to correct coagulopathy

Scan to see if head injury and decide VIR vs OR.

Patient did poorly.


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Transfer 5

OSH says, we have a lady hear with a GSW to the rightflank. We operated on her and packed her liver thenembolized it.

When she comes she is stable, open abdomen.

VIR records demonstrate common hepatic coil embolization

What now?


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Transfer 6

At the Level 3 center, she is found to also have a SAH.

The spine surgeon determines he cannot care for the C2fracture and ortho cannot take care of the tib/ fib fracture.

Patient transferred to Level 1 center for further care.

Arrives at 1303.

Good trauma system?


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Does she need any other studies?


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CT Angio


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Questions?

transfers cedar 2014

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