[3 MIN READ]
The risks we face as acute care practitioners are not static—they evolve over time. Just as we master the approach to a longstanding high-risk problem, a new risky patient presentation rears its head to challenge us. Consider ectopic pregnancy. Now that we routinely obtain pregnancy tests on all women from age 10 to 60 and have access to or skills in ultrasound, the evaluation of possible ectopic pregnancy has become largely an algorithmically routine matter, and errors involving ectopic pregnancy have plummeted as a result.
On the other hand, consider TIA and stroke. While these conditions are very familiar, new and time-sensitive treatments continue to emerge. Delays or failures to treat TIA and stroke have resulted in increased stroke-related litigation. Consider that nearly 90% of malpractice litigation related to stroke involves the failure to consider thrombolytic therapy. We have identified stroke as one of the “four codes” that top the list of high-risk patient presentations.
The Four Codes
We hear the announcements all the time…Code Blue…Code Red…the dreaded Code Brown; and more.
From the standpoint of risk and safety, there are four acute care “codes” that you must master to deliver the best possible care in the safest manner, and thereby reduce risk to your patient and yourself:
In previous blogs I featured Code Sepsis, STEMI, and Stroke. Trauma “codes” or alerts are very familiar to most practitioners. In the daily routine of a trauma center, patients are evaluated by an efficient and well-choreographed team of experts. Even in the non-trauma hospital, a severely injured patient is likely to show up on a frequent basis.
We all know of the “Golden Hour”; that time in which, theoretically, we have the greatest opportunity to impact the outcome of those who are severely injured. The first step is assessing the injuries systematically, addressing life threats, and ultimately providing the patient with definitive care as quickly as possible. Even if you practice in a non-trauma center, it is your responsibility to quickly evaluate the patient and use your best judgment in determining where and how the patient will be cared for most appropriately.
Patients in Need of a Trauma Center
The overriding principle for trauma is to get patients to the appropriate level of care as soon as possible. Parameters used to determine the needed level of care include vital signs, mental status, and specific injury characteristics. The list below provides an outline of injuries that should be considered for transport to a trauma center; keep in mind that this is not a comprehensive list.
- HEAD INJURY
- Penetrating injury
- Depressed skull fracture
- GCS <14 or GCS drops two points from time of arrival
- Lateralizing signs
- SPINAL CORD INJURY
- Major chest wall injury or pulmonary contusion
- Wide mediastinum or other signs suggesting great vessel injury
- Cardiac injury
- Patients who may require prolonged ventilation
- Pelvic fracture with hemorrhagic shock or unstable pelvic ring
- Open pelvic injury
- Solid organ injury
- MULTIPLE-SYSTEM INJURY
- Head injury combined with face, chest, abdominal or pelvic Injury
- Multiple long-bone fractures
- Injury to more than two body regions
- HEMODYNAMIC INSTABILITY
- Blood pressure <90 systolic after two liters of crystalloid or initiation of blood transfusion
- MECHANISMS OF INJURY & OTHER CONSIDERATIONS
- Compromised airway
- Falls >20 feet for adults, >15 feet for children
- High-risk motor vehicle crash (e.g., ejection, death of passenger, significant intrusion)
- Auto-pedestrian collision
- Motorcycle crash
- Age >55 years
- Patient on anticoagulation medication
- Pregnancy >20 weeks
Cognitive Errors to Avoid in Trauma Care
- Anchoring (locking onto certain aspects of the patient’s presentation at the expense of other features of the presentation)
- Finding an open femur fracture in a patient thrown from a horse and failing to look for a cervical spine injury
- Premature Closure (tendency to stop the investigation process too early, creating a propensity to miss a diagnosis)
- Evaluating a patient involved in a rollover MVC who is awake with a GCS 15 and immediately calling for ground transport and having the patient code in transfer from an epidural hematoma after you missed skull fracture detectable on exam.
- Search Satisficing (tendency to stop looking for other diagnoses once something is found, leading to a potential missed diagnosis)
- Finding a hip fracture and having Orthopedics take patient to surgery when the patient has a concomitant pneumothorax that results in a tension pneumothorax in the operating room
Time is of the essence in evaluating the trauma patient. Avoid delays in evaluation, diagnostic testing, resuscitation, consultation and transfer. Be diligent. Patients may need transfer to definitive care, and the best thing you can do is get them out of your ED or up to the OR. But do not let speed cloud your ability to detect other land mines that threaten your patient.