Ep 119 Trauma – The First and Last 15 Minutes Part 2

This is EM Cases Episode 119 - Trauma, The First and Last 15 Minutes, Part 2 with Dr. Kylie Booth, Dr. Chris Hicks and Dr. Andrew Petrosoniak. In this podcast we answer questions such as: What should your resuscitation targets be in the first 15 minutes for trauma patients with hemorrhagic shock, neurogenic shock, severe head injury? When is a pelvic binder indicated? Is a bedsheet good enough? What are the most common pitfalls in binding the pelvis? What are the best ways to maintain team situational awareness during a trauma resuscitation? Should we rethink patient positioning for the trauma patient? What are the indications for transport to a trauma center? What is the minimal data set required before transfer? Which patients require a pelvic x-ray prior to transfer to a trauma center?  What are the key elements of a transport checklist? What does the future hold for trauma care and many more... Podcast production, sound design & editing by Anton Helman, Voice editing by Suchetta Sinha Written Summary and blog post by Anton Helman January, 2019 Cite this podcast as: Helman, A. Bosman, K. Hicks, C. Petrosoniak, A. Trauma - The First and Last 15 Minutes Part 2. Emergency Medicine Cases. January, 2019. https://emergencymedicinecases.com/trauma-first-last-15-minutes-part-2. Accessed [date]. Go to part 1 of this 2-part podcast on trauma Binding the Pelvis in Trauma: The Trochanteric Binder One important source of massive hemorrhage besides abdominal visceral organ damage and long bone fractures in trauma is the venous hemorrhage as a result of an unstable pelvic fracture. Consider laying out the pelvic binder on the stretcher in advance of patient arrival, and empiric early binding of the pelvis for patients with evidence of shock. Our experts consider it acceptable to bypass examining the pelvis bone and simply bind the pelvis on speculation. X-rays can be done after the binder has been placed. The phrase "pelvic binder" is misleading because the device is ideally placed around the greater trochanters, not the pelvis. Consider a rectal and genital exam to assess for bleeding and bone shards that suggest an open pelvic fracture before placing the pelvic binder as this may guide antibiotic therapy and surgical priorities. A study in 2001 showed that the rectal exam influenced management in only 1.2% of cases. While the rectal exam is no longer recommended to assess for "high riding prostate" there are 3 situations where a rectal exam is warranted: spinal cord injury (to assess for sacral sparing), pelvic fracture (to assess for open fracture) and penetrating abdominal trauma (to assess for gross blood). Do's and Don'ts of Binding the Pelvis If you choose to examine the pelvic bone, do not place outward pressure or assess for vertical instability. Do not rock the pelvis. Rather, do apply inward pressure on the iliac wings to assess for movement. If there is movement, do maintain the inward pressure immediately followed by application of the binder. When applying the trochanteric binder, do not apply the binder over the iliac crests. Do place the binder over the greater trochanters. Do place the legs in internal rotation and tape them together at the ankles. This will decrease the anatomic bleed space. Do obtain a post reduction x-ray if time permits. If a commercial pelvic binder is not available, it is important to apply a bedsheet properly. The force required to close an open book pelvic fracture cannot be attained by twisting a bedsheet and tying it in a knot across the pelvis. Rather, fold the sheet so that is about 18 inches wide,