Category: Resus

TXA – Tranexamic Acid

TXA a bleeding wonder drug!

Crash 2 Study (2010)

  • Multi-Centre RCT of the use of TXA in trauma
  • Inclusion – Adult trauma patients with ≥1 of
    • Suspicion of significant haemorrhage
    • HR ≥110bpm
    • sBP ≤90mmHg
  • Treatment – 1g TXA IV over 10min then a second 1g TXA IV over 8hrs
  • Outcome – Significant reduction in Death, bleeding with NO increase in clots(thrombotic disease)
    • Most benefit seen if given early (<3hr – NNT 53)

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Acidosis & VBG’s

We are frequently asked to check the lactate on Venous Blood Gases (VBG’s), by the nursing staff. However, remember to look at the first result (pH) it is the most important.

Acidosis: Unless you have a good reason (e.g. you know its due to DKA) you should be investigating and performing an Arterial Blood Gas (ABG)

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1. HAZMAT – First Contact

REMOVE – REMOVE – REMOVE

Remove Them..

At reception ask them to go outside to designated area and staff will be with them shortly. Inform Nurse in Charge!

Remove Clothes..

Use the disrobing card to get the patient to safely remove and bag up clothes. Do your best to maintain privacy. CARD HERE

Remove Substance..

If we have ample warning or the number of patients will be significant, it may be worth deploying the decontamination tent but remember setting this up is time consuming.

0-12yrs WETFLAG

Tips: 

  • If particularly BIG – go up 1-2 yrs
  • If particularly SMALL – go down 1-2 yr
  • Prepare ET Tubes 0.5mm bigger and smaller
  • Chid’s weight known – specific calculations can be found after tables.

Boys 0-14yrs

AgeBirth1mth3mth6mth12mth18mth2yr3yr4yr5yr6yr7yr8yr9yr10yr11yr12yr14yrAge
Weight3.5kg4.5kg6.5kg8kg9.5kg11kg12kg14kg16kg18kg21kg23kg25kg28kg31kg35kg43kg50kgWeight
Energy20J20J30J30J40J40J50J60J60J80J80J100J100J120J130J140J150J150JEnergy
Tube 3.0/3.5mm3.5mm3.5mm4mm4.5mm4.5mm4.5mm5mm5mm5.5mm5.5mm6mm6mm6.5mm6.5mm6.5mm7.5mm8mmTube
Fluid-Medical70ml90ml130ml160ml200ml220ml240ml280ml320ml360ml420ml460ml500ml500ml500ml500ml500ml500mlFluid-Medical
Fluid - Trauma 35ml45ml65ml80ml100ml110ml120ml140ml160ml180ml210ml230ml250ml250ml250ml250ml250ml250mlFluid-Trauma
Lorazepam 0.4mg0.5mg0.7mg0.8mg1.0mg1.1mg1.2mg1.4mg1.6mg1.8mg2.1mg2.3mg2.5mg2.8mg3.1mg3.5mg4.0mg4.0mgLorazepam
Adrenaline 1:10'0000.4ml0.5ml0.7ml0.8ml1.0ml1.1ml1.2ml1.4ml1.6ml1.8ml2.1ml2.3ml2.5ml2.8ml3.1ml3.5ml4.3ml5.0mlAdrenaline 1:10'000
Glucose 10% (ml)10ml13ml19ml24ml28ml33ml36ml42ml48ml54ml63ml69ml75ml84ml93ml105ml129ml150mlGlucose 10%

Girls 0-14yrs

AgeBirth1mth3mth6mth12mth18mth2yr3yr4yr5yr6yr7yr8yr9yr10yr11yr12yr14yrAge
Weight3.5kg4.5kg6kg7kg9kg10kg12kg14kg16kg18kg20kg22kg25kg28kg32kg35kg43kg50kgWeight
Energy20J20J30J30J40J40J50J60J60J80J80J90J100J120J130J140J150J150JEnergy
Tube 3.0/3.5mm3.5mm3.5mm4mm4.5mm4.5mm4.5mm5mm5mm5.5mm5.5mm6mm6mm6.5mm6.5mm6.5mm7.5mm8mmTube
Fluid-Medical70ml90ml120ml140ml180ml200ml240ml280ml320ml360ml400ml440ml500ml500ml500ml500ml500ml500mlFluid-Medical
Fluid - Trauma 35ml45ml60ml70ml90ml100ml120ml140ml160ml180ml200ml220ml250ml250ml250ml250ml250ml250mlFluid-Trauma
Lorazepam 0.4mg0.5mg0.6mg0.7mg0.9mg1.0mg1.2mg1.4mg1.6mg1.8mg2.0mg2.2mg2.5mg2.8mg3.2mg3.5mg4.0mg4.0mgLorazepam
Adrenaline 1:10'0000.4ml0.5ml0.6ml0.7ml0.9ml1.0ml1.2ml1.4ml1.6ml1.8ml2.0ml2.2ml2.5ml2.8ml3.2ml3.5ml4.3ml5.0mlAdrenaline 1:10'000
Glucose 10% (ml)10ml13ml18ml21ml27ml30ml36ml42ml48ml54ml60ml66ml75ml84ml96ml105ml129ml150mlGlucose 10%

Calculations

  • Energy (J) [max 150J] =4 x Weight(kg)
  • Fluid Medical (ml) = 20 x Weight(kg)
  • Fluid Trauma (ml) = 10 x Weight(kg)
  • Lorazepam (mg) [max 4mg] = 0.1 x Weight(kg)
  • Adrenaline 1:10’000 (ml) [max 10ml] = 0.1 x Weight(kg)
  • Glucose 10% (ml) = 2 x Weight(kg)

Information from APLS Aide-Memoire

 

Domestic Abuse

Domestic abuse can affect anyone and often its not readily disclosed on an ED admission. We must be alert to the fact some of our patients may be attending with domestic abuse. Please explore concerns and escalate if you’re unsure. Our colleagues in the Pennine Domestic Violence Group have kindly drawn this a guidance up for us.

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EMBRACE & Paediatric Critical Care

In our trust we don’t have paediatric critical care beds. However, in our region we use EMBRACE (a paediatric critical care transport team), who can transfer critically  ill children to specialist centers (in or out of region).

EMBRACE

Y&H Paed Critical Care

Drugs:

  • Trust guide
  • Remember: Midazolam 10mg/2ml is used(not the 5mg/5ml we have  in ED)

 

Burns Referral Pathway

A new burns referral pathway has been developed with Mid Yorks to securely send images of the patients burn. Allowing the burns team to arrange the most appropriate follow-up for your patient.

This requires BOTH online referral & phone call

The Process

  1. GoTo –  Burns Homepage (NHS computers ONLY)
  2. Select – New Referral (NO login required)
  3. Complete – the following sections (* means required field)
    • Referrers Details – you will need an NHS email address
    • Patient Details
    • Injury Details – Answering “Yes” to airway burns or fluid resuscitation will open further boxes
    • Additional Details – Patient’s phone number and address (only appears if NO airway or resuscitation issues)
  4. Checklist – Ensure ALL completed and submit
  5. Sending an Image – After submission a QR code will appear to send an image you will need to us the SID App
    • Launch the SID App on mobile device – Yours or ED Co-Ordanator (apple/android)
    • Scan the QR code
    • Consent the patient – Patient Information Leaflet
    • Take Photo of Injury  – this will not be saved on the device
  6. Phone Burns team – They can review the details and images and better advise you on management.

Resources

Lateral Canthotomy

Like tension pneumothorax the biggest step is deciding to do it – Remember it it sight saving and they heal well

Retrobulbar Haematoma secondary to blunt eye injury is a a rare but potentially sight threatening injury.

  • Blood collects in the retrobulbar space
  • Pushing the eye forward to accommodate the extra volume.
  • The Orbital Septum (made up of the eyelids and ligaments that attach them to the orbital rim) restricts this forward movement, creating a compartment syndrome for the eye. Thus threatening the patients sight if not treated quickly.

Recognition

From Royal College Ophthalmologists

  • Severe pain
  • Red/Congested conjunctiva
  • Exophthalmos with proptosis – eye pushed forward
  • Internal ophthalmoplegia – impairment or loss of the pupillary reflex.
  • Visual flashes
  • Loss of vision – initially colour vision (esp. red), progressing to local visual loss.

However, this may only be recognised on CT if there is significant facial injury and altered conscious level.

Treatment

Call Ophthalmology immediately to attend. If there is going to be any significant delay, it may be necessary for ED to preform a Lateral Canthotomy, to allow the eye to move forward, reduce the orbital pressure & preserve the patients sight.

Kit needed

  • Lidocaine with adrenaline (needle & syringe)
  • Clamp – ideally curved to crush the tissues
  • Forceps
  • Scissors

Resources