POTD: What type of blood transfusion do I order?

This POTD was inspired by a CED that we recently did on a level 1 trauma in the ED. Special shout out to RN Mel Besett for answering some of my questions I had about this topic.

The trauma case went something like this...an EMS note was called, stating that a man had stabbed himself in the abdomen with a kitchen knife. He was tachycardic, BP was stable, GCS 15. 

When the patient arrived, he was noted to have HR of 120-130s, BP initially 130s systolic. eFAST positive for free fluid in the RUQ. Throughout the trauma, he remained tachycardic and his BP started to trend downwards - SBP 130s...then 120s...110s...100s. 

It was decided that the patient should receive a blood transfusion, but...what type of blood should we order? How emergent was this?

Let's dive into it. There's a few different types of blood transfusions we can initiate in the ED:

Regular, cross-matched blood:

- For patients who are stable enough to wait. Typically, with waiting for the T&S, requesting blood, and starting blood, this could take more than 1-2 hours. 

- Requires 2 type and screens in the chart - if patient has a previous one in their chart, you can order just 1 

- Blood transfusion consent on Taylor Health

Emergent blood:

- Can take 10-15minutes depending on if there is someone available to run to the blood bank and back. Otherwise, the blood bank will have to send the blood through the chute, which can also take around that amount of time

- Requires a "Emergency Blood Transfusion Request" on Taylor Health

- Also requires patient consent. If patient is unable to be consented, requires 2 attending consent. 

"Cracking the fridge":

- There is a fridge in resus 51 stocked with pRBCs, platelets, and plasma

- Charge RN has code to the fridge

- The fridge also has whole blood (which is all the elements combined), but only the trauma attending can call for whole blood from the fridge

Massive transfusion protocol (MTP):

- At least 6 units of blood, comes from the blood bank

- If starting MTP, typically we start giving units of blood from the fridge, then call for MTP from the blood bank 

To end the case, given the patient's BP was declining, he was taken emergently to the OR. Because the OR was ready and patient couldn't wait ~10-15 minutes for emergent blood to arrive, he received his first unit of blood from the fridge while being transported to the OR. 

POTD: Procedural sedation for ortho reductions

This POTD was requested by one of our sim fellows and new attendings, Vishnu Muppala, who wanted to know what the literature was on different medications for procedural sedation, particularly for orthopedic reductions (fractures/dislocations). So let's dive in.

To start off, let's talk about procedural sedation. There's a few agents that we commonly use in the ED.

The doses and pros/cons of each are nicely summed up in this table from our very own Reuben Strayer:

(https://emupdates.com/emergency-department-procedural-sedation-checklist-v2/)

The above link also has a bunch of info on how to set up for a procedural sedation and what to do if things go wrong.

But today, we're diving into the literature on which one is best for orthopedic procedures. In my experience, our ortho colleagues often times want us to use midazolam, but we often want to use propofol or "ketofol", which is a mix of ketamine and propofol. So is one better than the other?

In a 2015 RCT from Hatamabadi et al., they examined the safety profile and the time it takes from induction to fully awake (aka probably good for dispo) between propofol vs midazolam. In this study, it was found that the safety profile was similar between the two, but propofol had a significantly shorter time from induction to awakening. 

In another RCT (Taylor et al., 2005), propofol was compared with midazolam/fentanyl in shoulder dislocation reductions. Again in this study, propofol was found to have shorter time to awakening. Also, this study found that propofol led to easier shoulder reductions and fewer reduction attempts. There was no statistically significant difference between their safety profiles. Another point for propofol!

One last RCT I found compared a combination of ketamine and propofol to a combination of midazolam and fentanyl (Nejati et al., 2011). In this study, the ketofol group had lower perceived pain compared to the midazolam/fentanyl group. In this study, both groups had similar sedation time and safety profiles. 

However, in the only systematic review I could find comparing the two, there was no difference in safety nor in the effectiveness between the two (Holh, et al., 2008). Of note though, they could only find 4 RCTs looking at effectiveness, and only 2 of them were graded as "good" by the authors. Also, this wasn't specifically for ortho procedures but for all procedural sedations. So maybe not the best sample for our clinical question. 

My conclusions that I gathered from this quick lit review is that is seems like propofol is more effective, takes less time for the patient to wake up, and (ketofol) leads to less pain than midazolam. Both medications, in the purposes of these RCTs, seem to have similar safety profiles. However, as with many things, more data is required to make a stronger conclusion.

Resources:

Hatamabadi HR, Arhami Dolatabadi A, Derakhshanfar H, Younesian S, Ghaffari Shad E. Propofol Versus Midazolam for Procedural Sedation of Anterior Shoulder Dislocation in Emergency Department: A Randomized Clinical Trial. Trauma Mon. 2015;20(2):e13530. doi:10.5812/traumamon.13530

Taylor DM, O'Brien D, Ritchie P, Pasco J, Cameron PA. Propofol versus midazolam/fentanyl for reduction of anterior shoulder dislocation. Acad Emerg Med. 2005;12(1):13-19. doi:10.1197/j.aem.2004.08.039

Nejati A, Moharari RS, Ashraf H, Labaf A, Golshani K. Ketamine/propofol versus midazolam/fentanyl for procedural sedation and analgesia in the emergency department: a randomized, prospective, double-blind trial. Acad Emerg Med. 2011;18(8):800-806. doi:10.1111/j.1553-2712.2011.01133.x

Hohl CM, Sadatsafavi M, Nosyk B, Anis AH. Safety and clinical effectiveness of midazolam versus propofol for procedural sedation in the emergency department: a systematic review. Acad Emerg Med. 2008;15(1):1-8. doi:10.1111/j.1553-2712.2007.00022.x

POTD: Traumatic brain injuries (part 2)

Welcome to Trauma Tuesday! This will be a continuation of my first POTD on TBIs, but today, we will be talking more about the public health implications of TBIs.

According to the CDC, there were over 210,000 TBI-related hospitalizations and a little under 70,000 TBI-related deaths in 2021 in the United States. In addition to direct health-related statistics, there are many long-term effects of TBIs that have an impact on the individual's quality of life and on society as a whole. For example, patients with a history of TBIs are more likely to have difficulties with finding work and holding down a job, dysregulated behavior that can lead to challenges in social relationships, and substance use disorders.

Additionally, vast health disparities exist on who suffers from a TBI. Statistics show that adults aged 75 years or older, racial/ethnic minorities, veterans, people who are incarcerated, people experiencing homelessness, and victims of domestic violence are both more likely to get a TBI and to suffer worse long-term consequences from it. Many of the people who fall under the above mentioned categories also have more difficulty accessing healthcare, which can put even more barriers in their road to recovery, as some patients require long-term services such as physical/occupational therapy and mental health support. 

Given everything I mentioned above, it is tremendously important that we do our best in the acute management of head injuries in the ED. However, perhaps even more important is TBI prevention before the primary injury ever happens. While our time and our resources are limited in the ED, we have the opportunity to do some quick education with our patients and their families on how to prevent (more) TBIs - everything from wearing helmets to assessing the fall risk of a patient who may have mobility issues. While we can't control what happens to our patients outside of the ED, we can at least take a few minutes to talk to them about this topic in hopes of saving them a (potential) lifetime of further complications.

Resources:

https://emcrit.org/ibcc/tbi/#coagulation_management

https://www.emdocs.net/neurotrauma-resuscitation-pearls-pitfalls/

https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-trauma/closed-head-injury

https://www.cdc.gov/traumatic-brain-injury/health-equity/

Thurman DJ, Alverson C, Dunn KA, Guerrero J, Sniezek JE. Traumatic brain injury in the United States: A public health perspective. J Head Trauma Rehabil. 1999;14(6):602-615. doi:10.1097/00001199-199912000-00009

Peterson AB, Zhou H, Thomas KE. Disparities in traumatic brain injury-related deaths-United States, 2020. J Safety Res. 2022 Dec;83:419-426. doi: 10.1016/j.jsr.2022.10.001. Epub 2022 Oct 18. PMID: 36481035; PMCID: PMC9795830.

Wilson MH. Traumatic brain injury: an underappreciated public health issue. Lancet Public Health. 2016;1(2):e44. doi:10.1016/S2468-2667(16)30022-6