Boost your trauma patient's chance of survival with these interventions

ED nurses seeing outcomes previously 'unheard of'

When a man with a severe liver injury from blunt abdominal trauma arrived at Vanderbilt University Medical Center's ED, he had no recordable blood pressure and a barely palpable carotid pulse.

"His heart rate went to 30 when he hit the door. The next step is almost certain death," says Bryan Cotton, MD, assistant professor at Vanderbilt's Division of Trauma and Surgical Critical Care, located in Nashville, TN.

Immediately, the ED's new Trauma Exsanguination Protocol (TEP) was activated, and the man was given two units of packed red blood cells. "We went straight to the OR [operating room]," says Cotton. "His liver was cracked in half all the way to the cava."

The man's initial pH on an arterial blood gas was 6.8, and his base deficit was 28. Without the new protocol, the patient almost certainly would have continued bleeding and returned to the OR or needed interventional radiology embolization and consumed a large amount of blood products in the intensive care unit (ICU), says Cotton. "Instead, he was out of the OR in just over one hour and was extubated the following morning," says Cotton. "For him to come off the OR table alive is a miracle."

The new protocol, which begins with aggressive interventions done by ED nurses, has increased survival rates for severely injured trauma patients by more than 70%.1 "It was a mindset change that we're stopping the fluids, we are going straight to the OR, and we're mobilizing the blood bank for a massive amount of blood products, not just red cells," says Cotton. "There is a quicker utilization of blood products, a lowering of expectation on blood pressure, and less dependence on crystalloids."

The protocol reduces the amount of crystalloids the patient receives immediately post-trauma, says Stoney W. Greenlee, RN, an emergency nurse in Vanderbilt's adult ED. "This reduces the amount of time needed for uncrossmatched blood, increasing the patient's chances of a positive outcome by providing unlimited blood for volume resuscitation," he explains.

The earlier the protocol is activated, the better the patient's chances of survival, adds Cotton. "So we encourage nurses to use it quicker and then apologize if they jumped the gun," says Cotton. "We don't wait until the patient leaves the ED — that's a little too late. The outcomes seem to be a lot worse."

ED nurses now start blood products immediately via two large bore intravenous (IV) lines or a central line, says Michael Warnecke, RN, a charge nurse in Vanderbilt's adult ED. "These are usually placed on pressure bags," he says. "We will start an antibiotic and prep the patient for emergent transfer to the OR. We strive to be transporting to the OR within 17 minutes."

Previously, a decision would have to be made about the patient getting a computerized tomography (CT) scan while still in the ED, he explains. "Now based on the patient's condition and vital signs, we will expedite to the OR after starting blood and antibiotics," says Warnecke. "This makes the decision to OR faster, which results in better patient outcomes."

For the sickest trauma patients, there is no time to wait for a CT scan to be done in the ED, says Cotton. "You intubate them. You start fluids. You start blood. You make your decision, and you run to the OR," he says.

If physicians ask for the two packs of red blood cells to be hung while the patient still is in the ED trauma bay, that is a cue for nurses to start the protocol, says Cotton. The first step is making sure that the type and screen gets upstairs, so the blood bank can start choosing the product type specific instead of universal. "If the team is pulling blood products into the ED and reaching straight for the blood to begin with, this should prompt the trauma team to enact the protocol," says Cotton. "The ED nurse is key in identifying a patient that might benefit from this."

At this point, the normal priorities of the resuscitation team are "redirected," says Cotton. "This is a special one, so we're going to tolerate some hypotension, we're not going to give a lot of crystalloid, and we're going to make sure the type is crossed so we can minimize the amount of universal products that we have to utilize," he says.

Many trauma patients bleed to death because the transfusions given do not contain sufficient amounts of appropriate blood products to stimulate coagulation, explains Cotton. "Giving clotting factors and platelets with blood early in the care of patients with life-threatening hemorrhage — as opposed to the traditional method of saline, more saline, blood, then adding clotting factors and platelets later on — results in improved survival," Cotton says.

Glucose levels are key

Critically ill trauma patients have a better chance of survival if glucose levels are monitored while patients are still in the ED, says another study.2 Researchers found that high blood sugar levels were linked to higher mortality levels in 896 trauma patients.

"Emergency nurses may likely be initiating tight glucose control therapy earlier and more aggressively than they have in the past," says Kelly Bochicchio, RN, BSN, MS, co-author of the study and research manager for the Division of Clinical and Outcomes Research at the R. Adams Cowley Shock Trauma Center in Baltimore.

ED nurses now start insulin drips for early aggressive glucose control, instead of waiting until after the patient is transferred to the ICU, says Bochicchio. "ED nurses will be obtaining serum glucose levels more frequently as standard procedure and initiating insulin infusions earlier," she says.

This timing is important as patients are often kept in the ED for several hours before being transferred to the ICU due to bed availability or obtaining diagnostic tests, Bochicchio says.

Document the patient's glucose level and what insulin dose adjustments were made, she says. "It is standard procedure to check serum glucoses every hour during intensive insulin therapy to ensure patient safety," Bochicchio says. "Nurses will have to be highly vigilant to ensure accurate and close glucose monitoring to prevent the untoward effects of hypoglycemia."

Initial lab work includes electrolytes including glucose level, and if the patient is a known diabetic, a bedside glucose level is taken as a baseline, says Ellen Plummer, RN, senior partner and former trauma/emergency/critical care nurse at Cowley's Trauma Resuscitation Unit. "We repeat the glucose within an hour if it is elevated and initiate either subcutaneous insulin or an insulin drip based on the glucose level results," she says.

Even trauma patients with no known history of diabetes may have a significantly elevated glucose, which might have contributed to the patient's injury, says Plummer. "For example, the patient's elevated glucose may have caused them to have altered mentation or to pass out while driving, leading to a crash," she says.

Plummer recently cared for a man who had gone to an outside ED with a wound on his foot that worsened to a necrotizing fasciitis wound. The man had no known history of diabetes, but he had a glucose level in the 500 range. "By the time he transferred to us, he had received two doses of subcutaneous insulin," says Plummer. "On arrival, his glucose was in the 380 range with repeated glucoses still ranging in the mid-300s. We initiated the insulin drip protocol, started at three units per hour and, within three hours, had his glucose well below 200," she says.

References

  1. Cotton BA, Gunter OL, Au BK, et al. Damage control hematology: The impact of a trauma exsanguination protocol on survival and blood product utilization. J Trauma 2008 (In press).
  2. Bochicchio GV, Manjari J, Bochicchio KM, et al. Early hyperglycemic control is important in critically injured trauma patients. J Trauma 2007; 63:1,353-1,358.

Sources

For more information on ED trauma protocols, contact:

  • Kelly Bochicchio, RN, BSN, MS, Research Manager, Division of Clinical and Outcomes, R. Adams Cowley Shock Trauma Center, Baltimore. Phone: (410) 328-7488. E-mail: kbochicchio@stapa.umm.edu.
  • Bryan A. Cotton, MD, FACS, Department of Surgery/Trauma and Emergency Surgery, Vanderbilt University Medical Center, Nashville, TN. Phone: (615) 936-0189. Fax: (615) 936-0185. E-mail: bryan.cotton@Vanderbilt.edu.
  • Stoney W. Greenlee, RN, Adult Emergency Department, Vanderbilt University Medical Center, Nashville, TN. Phone: (615) 343-7373. E-mail: stoney.greenlee@vanderbilt.edu.
  • Ellen Plummer, RN, Senior Partner, Trauma Resuscitation Unit, R. Adams Cowley Shock Trauma Center, Baltimore, MD. Phone: (410) 328-3261. E-mail: eplummer@umm.edu.
  • Michael Warnecke, RN, Charge Nurse, Adult Emergency Department, Vanderbilt University Medical Center, Nashville, TN. E-mail: michael.b.warnecke@vanderbilt.edu.