So, the objectives is to recognize the symptoms of extremity compartment syndrome and urgency of intervention, outline three risk factors for venous thromboembolism, list benefits of early mobilization and nutrient support in the intensive care unit, and recall the difference between unstable and stable spinal fractures and associated spinal precautions. So again, the topics in GIST are compartment syndrome and fasciotomy management, venous thromboembolism prophylaxis, early ambulation in the ICU, early nutrition in trauma patients and spinal precautions with spine fractures. So a typical scenario, maybe this is something if you work in the emergency room or in a trauma center you're very familiar with. This is 3 a.m. on a Saturday night and I'm wearing my pager, I'm vetting phone calls and the next thing I get is an ATC1 or an adult trauma code one page to my pager. We don't get a whole lot of information if you work in a trauma center regarding the pages of what we are to expect in the trauma bay, but as soon as I get down there and put on my lead and my personal protective equipment, the patient rolls in and it looks pretty bad. It's a 22-year-old male, status post MVC or motor vehicle accident, rollover with ejection, there was a death on scene. Multiple mini bottles of alcohol were also found at the scene. It's, you know, early weekend morning, why not? His GCS in the scene was very low, he was intubated and had unequal pupils noted and some facial trauma. Patient gets in the room, we get the initial report, we hook him up to a monitor and he's bradycardic on examination and hypotensive. The emergency room physicians in our institution usually do the ultrasonography at the bedside and his VASC scan is grossly positive and he has limb shortening on the right. His left leg is also grossly deformed and it kind of looks like he has swelling of multiple extremities. He also doesn't have notable rectal tone or any kind of flexion of pain. So in GISS, the patient gets stabilized, eventually goes to the operating room for exploratory laparotomy, we get him to the CT scan, find a multitude of injuries with other subspecialty services and transfer him to the ICU. If you work in the ICU and you are a nurse, you're well aware of how complicated this can get with multitude of teams involved. So I get a call from orthopedics and they're saying that there's something wrong with his leg and they emergently want to take him for a repair of his right lower extremity. So the first topic of interest is compartment syndrome and fasciotomy management. So in GISS, what is compartment syndrome? Well, all the muscle groups within the body are divided into sections or compartments formed by strong unyielding fascial membranes. The GISS is Dr. Mattson who is an orthopedic surgeon out of the University of Washington and first defined this syndrome in 1980. And it's a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space. This often can occur in the legs and the forearms, but can also occur in the foot, thigh and gluteal region. Basically, the tissue ischemia and eventual necrosis can lead to multi-system organ failure and in particular acute tubular necrosis from rhabdomyolysis of the kidneys, which is just a fancy word for saying we need to intervene early and as quick as possible. So one of the main causes of acute compartment syndrome are long bone fractures and as you can see up top there, that's a pretty significant fracture. These are more often seen in, compartment syndrome is more often seen in young males under the age of 35 years old. And this is usually due to the physiological differences between younger men and women. Younger men have larger muscle mass and they're contained within fascial compartments that do not change in size once growth is complete. Long bone fractures are attributed to about 75% of compartment syndrome cases and comminuted fracture, which is kind of seen there in the radiograph on the left hand side with multiple splinters in the fracture itself at the diaphysis or the middle of the bone. The tibial diaphysis in particular in the distal radius are also primarily responsible for compartment syndrome locations. There can also be trauma without fracture that causes compartment syndrome. Forceful direct trauma to a tissue or compartment such as a crush injury. We actually have a gentleman on our service who works with granite and was just crushed by a 2,000 pound granite slab, so something to think of when he rolls in. Also, severe thermal burns as demonstrated in this picture here, that's an escharotomy to try to kind of relieve the compression from the compartments in the chest. And burns are unique, there are a lot of fluid shifts within the different compartments that kind of contribute to the edema and the swelling seen here. The penetrating trauma such as a gunshot wound or knife injury, or even stabbed with a beer bottle or whatever you can think of, can also cause vascular structures to be compromised and this can lead to compartment syndrome. Patients that are left down, possibly from an overdose or abundant for a long period of time, say assault patients that were kind of left in the field for a long time, and again, vascular arterial injuries as well. So in summation, there's also non-traumatic causes, and these are medically, medical patients in general, medical surgical patients with vasculopathies, thrombosis, and bleeding disorders, maybe a fem-pop bypass or something of that nature. But also include animal envenomations and bites, extravasation of IV fluids which is iatrogenic and preventable, and injection of recreational drugs such as heroin or others. So signs and symptoms of compartment syndrome are kind of basically more or less subjective and objective findings. The five P's that we might have learned in school are pain, pallor, pulselessness, paresthesia, and paralysis, but often pain is the highlighted main symptomology that'll present. You may be an ACP or a physician or even a nurse that is hearing persistently from your patient that his pain is not well managed, but do your due diligence in a physical exam to make sure that one of his extremities, in particular, alarm bone fracture, hasn't kind of gone down the way of compartment syndrome. Pain is usually early and common, paresthesia is within the first 30 minutes to two hours, and pulselessness is often late, so if you're losing pulses, that's probably a surgical emergency at that point. So diagnosis, mostly based on history and examination findings without obtaining measurements, however, our orthopedic surgeons often use this Stryker device as pictured here to measure intra-compartment pressures, and again, operative management is per the orthopedic team in our institution but comprised of a physical examination and frequent visualization and neurovascular checks of the extremity, so it just kind of depends on the situation. So the treatment of compartment syndrome involves a fasciotomy. A fasciotomy is an incision in the skin and fascia to release the pressure as you can kind of see in the photo on the right here. The vessels below are no longer compromised and tissue ischemia ceases. The fasciotomy is a two-incision, four-compartment fasciotomy, meaning that you have two main incisions around the lateral and medial of the lower extremity as pictured here to kind of release the four compartments, which are the anterior, lateral, deep posterior, and superficial posterior compartment. Anatomy, if you are a surgeon or anybody taking care of these patients, is imperative to know before these are performed because oftentimes tissue ischemia can persist if the anterior and deep posterior compartment are missed on initial fasciotomy. So wound management, depending on your institution and physician preference, you may have a multitude of fasciotomy dressings to manage. Sometimes there are bulky compression dressing and splint devices. Wound vacs, if people are familiar with those, are often used too, making sure to prevent a patient's foot drop by putting the foot in neutral position. And a quinus contracture involves physically, after the patient has recovered, kind of looking like a horse when you step. The wound is not closed in initial surgery and incision is usually left open around two to five days, but it can be longer than that, pending healing. And it's closed by delayed primary closure without intention by traction techniques or split thickness skin graft, depending on how big the incision was. So a quick word about wound vacs, this is actually a patient on our service we're taking care of at the moment. His story in a few, well, it's a very long story, but he's been there for a while, a 20-year-old male. This was a suicide attempt. He actually flipped the car intentionally into a field with equipment in it. The car actually landed on top of him and the muffler burned him substantially. This is a picture of his abdomen. He had full thickness burns to his abdomen, pretty significant. So wound vacs are actually instrumental for wound care in our institution. You can tell this is a huge area and a very thin male to kind of cover. It helped with removing the edema from the wound through suction. As you can see, we had to get creative in the middle photo because he'd lose suction every three days, kind of making our nurses crazy if you've ever heard that noise. The third picture depicts, though, how well the wound vac works to kind of promote healing and you have great granulation tissue. And his split thickness skin graft was placed now four or five days ago and has taken about 95%. So it looks great. But, you know, ACPs or nurse practitioners, PAs, and nurses, you know, if you're interested in wound care, it's definitely something to take advantage of. Don't just let wound care do it. I love doing it. It's kind of arts and crafts if you're into that. So spinal precautions. Our gentleman who I described earlier came in with bradycardia and hypotension. He could have been hypobolemic, but he could have also had a spinal fracture that we weren't thinking of initially or a spinal cord injury. You know, the biggest thing is the gentleman here on the picture is probably someone you may have seen if you work on a floor. He probably did this to himself. So I hope that our nurse practitioners, PAs, and health care workers on the floors know how to put a C-spine collar, but if you don't, please ask. But he'll do it himself for you. Primary survey with any patients with a suspected spinal cord injury, one of the biggest things is their mechanism of injury. You should suspect a spinal cord injury in most trauma patients, especially if it's a motor vehicle accident, assaults, falls, and sports-related injuries. As you can see, the gentleman pictured here is wearing a football helmet. High rate of speed accidents greater than 35 miles per hour have a high velocity and usually correlate with spinal fractures. If there's a death at the scene, that's probably a high velocity injury, too. Fall from any kind of height greater than two stories is usually associated with death. Inclosed head injury or intracranial bleed on the CT scan. Neurosymptoms or signs referred to the C-spine, so maybe they can't move their arms or their legs on initial survey. And pelvic or multiple extremity fractures usually kind of clue you into spinal fractures. Immobilization needs to be initiated as soon as possible at the scene of the accident. And as you can see here, you can actually leave the helmet on to perform interventions. If you take advanced trauma life support, they will actually teach you how to remove the helmet while maintaining C-spine precaution with two people. So the biggest thing with these patients are maintaining your ABCs and Ds while also maintaining C-spine precautions. Trauma patients are notorious for maybe not thinking clearly prior to the accident, so maybe a gross intoxication, head injuries make people combative, shock can kind of make people combative if they're hypoxic. And so making spinal immobilization a priority on your initial examination is huge. Sometimes we will need to sedate people in order to get them calm enough to maintain their spinal precautions. So the anatomy of the human spine, there's 33 bony vertebrae, 7 cervical, 12 thoracic, 5 lumbar, and 5 sacral, as well as 4 cotidio. 26 individual units are separated by intervertebral discs connected by ligaments. The spinal cord extends from the midbrain the whole way down to the region that we get a little bit scared about, the cotta equina region. So the cervical spine, due to its exposed location at the very top of the spine above the torso, and its inherently and notorious flexibility, is the most commonly injured primarily at C2, C5, C6, and C7, so most of the C-spine. The next region down is the thoracic spine. It's very rigidly fixed. Injuries in this location are rare because of the anatomical features. Thoracic ribs articulate with the respective transverse processes in the sternum, so it's a more, I guess, caged in and stable area, less prone to injury. So if someone has a very bad injury to this location, likely their mechanism of injury was a high-impact crash or some kind of bladder or a twisting injury or something kind of significant. Lastly, the TL spine, or the thoracolumbar spine. These often occur in the region between T11 and L4. However, these injuries rarely result in a complete cord transsection or lesions, unlike the C-spine. And additionally, any patient that has a seatbelt sign, you should kind of be concerned that there is an L-spine fracture as well. They do go hand-in-hand. Lap belts are no longer as common in cars and such like that, but if your patient wasn't wearing a cross-shoulder seatbelt, they could have an L-spine injury. So this is the blue sheet, a little picture that we use at our institution to perform the primary and secondary exam on our patients. They're kind of like our patient's best friend in terms of paperwork for the first 24 hours. Gets them in, has a lot of their injuries and such on it, and the plan also is their OR clearance. But the gist is with the spinal fractures is, in our secondary survey, kind of like Oprah with the episode where she gave everybody a car, everyone gets a rectal. So basically, if you're a trauma patient at CMC or most institutions, you're going to get a rectal exam. Our ED residents have gotten very creative with how they like to glove in order to do so, but you will be getting a rectal. You also will be doing a spinal examination where you're going to walk your hands down the patient's spine to discern if there's any kind of tenderness to palpation. This is difficult in those patients with ultramental status or those that are uptunded to kind of discern, and you're looking for step-offs as well, which is an anterior slippage of the vertebrae is from pretty much a high-impact injury. And actually, most recently, we were in the ED, and we had orthospine come and talk to us, and we assessed the patient and found a step-off before orthospine did, just from doing a very complete physical examination. And you can see here, too, there's a little man in the corner, which is better visualized here with the ASIA exam. The ASIA exam is performed with patients with a suspected or confirmed spinal cord injury. It's the American Spinal Injury Association, and they have this little testing procedure that we do on patients that maybe have a motor deficit to one arm or the other, a confirmed spinal exam. This is done about every two to four hours, depending on the patient's, I guess, level of care and how concerned we are. Usually, it takes about 30 minutes to an hour to perform each time, so you have to allocate the time. It is comprised of 28 specific sensory locations that you not only use your hand to kind of discern light touch, but also usually we use a paper clip for pinprick sensation as well. And you can see the little gentleman here on the right has to do with movement. So it's pretty complex. We have a lot of ASIAs floating around the patient's charts that need it, but it also can kind of help discern patients with real injuries versus maybe those that are perseverating or malingering, too. Signs and symptoms of spinal trauma, depending on what the patient presents with, are pretty vague. There's respiratory distress, but if they have blunt chest trauma, that could kind of overshadow that. Tenderness at the site of the injury on the spinal column is pretty indicative, like I said, from the secondary exam. Pinging along the spinal column with movement, but often they're immobilized in the trauma base, so this may be seen on additional examination. Deformity or step-offs of the spine. Numbness, weakness, or tingling in the arms or legs, and loss of sensation or paralysis in the upper or lower extremities. Incontinence or loss of bowel or bladder is usually indicative of cauda equinus syndrome, again, with the L-spine fractures, we usually see these. And so, again, look for that seat belt sign and kind of correlate. Trauma is a very unique kind of science, so it's not always perfect, but be cognizant of if your patient is incontinent. So the classifications of spinal injuries, because for the sake of time, we could really get into this. It may be hard to see on there. This is from up-to-date. The first category is flexion injuries, where there's sudden forcible movement of the head. The head recoils forward and stops on impact, such as hitting a windshield. EMS referred to it as the bullseye kind of sign, where you will see the spattered glass with someone's head smacking into it, is the way I kind of remember it. If the posterior ligament is intact, wedging of the vertebral body occurs, and may lead to subluxation or slippage. This often results in damage to the vertebrae, and the most significant fracture in this category is the flexion teardrop fracture, which involves, again, the flexion of the spine with vertical axial compression, and causes a fragment that is displaced anterior and resembles a teardrop, and it is considered unstable and requires halo traction, which I actually saw somebody has in the hallway currently. The flexion rotation kind of injuries, I think of people falling down stairs. Not only is it kind of a flexion injury, but also you're rotating the side and maybe impacting one side or the other of the spinal column. The extension injury is sudden backward acceleration of the skull, creating severe extension of the cervical spine. This is common in neck, anterior ligaments, and the disc may be damaged. I think of injuries of people diving into pools in shallow waters, kind of extension injuries, and vertical compression or burst fractures. They, pieces of burst fractures, because they're often fragmented, can go into the spinal cord and cause spinal cord compression, if not damage, and I think of jumps off the balcony or axial loading kind of injuries with that. This slide's a little bit wordy, but it kind of goes into the different types of fractures. Compression fractures usually don't generally require surgical intervention, and a Jewett or extension type brace is placed. The biggest thing is to ensure that if any of these braces, such as a TLSO or Jewett type brace is placed, that you obtain post-mobilization films to ensure the fracture is stable while the patient kind of bears weight by standing. The burst fracture, which I mentioned previously, indicates a high velocity impact and usually has severe trauma to the spine. If there is more than 25 or 50 percent height loss, there could be canal compromise as well, and generally it's per neurosurgery if these patients go to the OR. I had somebody the other day who had an L2, or she had more of a higher injury burst fracture, and she was walking around the hallways in her TLSO like nothing was bothering her. And then the next day I had somebody else who required surgical intervention. The chance fracture is a flexion injury. This is treated again with a TLSO brace, and always suspect a ligamentous injury. It's not always just about the bones. That could also happen with the dislocation or disruption of the facet. And the fracture dislocation you may see with a lot of spinal cord injuries, these often require fusion and surgical intervention. We have a great relationship with our neurosurgeons, and oftentimes if I'm perplexed on the treatment plan, it's kind of nice to sit there with them and go through the scans, and they like to talk about these things with you. So if you ever have questions, feel free to reach out to alternate teams because they'll definitely answer them for you, hopefully. So management, again, is just kind of every traumatic injury is like snowflakes. A burst fracture here could require a repair, and a burst fracture somewhere else may not. So again, I had a younger patient, but an older patient may not be able to function that way, or if the patient's critically unstable. We recently had a patient for 120 days that had an unstable L2 burst fracture, but could never be repaired because his critical injuries kind of usurped the whole hospital process. So every trauma patient's a little bit different, and keep that in mind. This is RC spine collar removal protocol for Carolinas Medical Center. It's not only imperative to maintain spinal precautions, but also remove them in a timely fashion. Our protocol that we've developed goes through the litany of, you know, if the CT scan is negative and the patient is no longer intoxicated or has any other distracting injuries, then you're more than welcome to clear it. Now, if the patient still has residual pain, we do have a pathway for that as well, but under these guidelines, the CT scan is pretty diagnostic of any kind of orthopedic injury to the spine, but not necessarily of any kind of ligamentous injury. So keep that in mind. Your patient may have residual pain even when the C-spine is clear. That may warrant further C-spine management. So as you can see in our little flowchart here, you would obtain a flexion extension x-ray if they're able to tolerate that. And I've tended to patients as of 2015. EAST guidelines do say that you can remove C-spine collars, and there's a little more information on their website regarding that. Just for the sake of time, we won't go into it. But to illustrate, I did have a patient the other day who has a GCS of 4T, has been that way for three weeks. And so we did remove it just because it just can't be comfortable, no matter if he can tell us that or not. So early nutrition in trauma patients, people get hungry even if they can't tell you that. Their body needs the caloric contents of tube feeds or any other kind of early nutritional intervention. Increased catabolism and resultant acute protein malnutrition is a frequent condition in trauma, especially in high stress. You've heard of people comfort eating or high stress environments. I'm sure people want something greasy and not looking for a salad. So kind of same thing, catabolism, stress on the body. Systemic inflammatory response syndrome, or SERS, is often seen in the traumatic population where they may come in with a leukocytosis, a white count of 15 to 17. And it's mainly due to inflammation. So think about what that's doing in terms of your body and wasting your weight and catabolism. If nutrition is early and is adequate, this will prevent impaired healing immunoparalysis. Ultimately, multiple organ system dysfunction will be prevented. And the goal of nutrition therapy is to decrease the early loss of lean mass, provide calories, and improve the patient's community and healing. So here's a little more of a flow chart of that. As you can see, the traumatic injury occurs, the SERS response happens, and the traumatic inflammatory response happens. And don't definitively exclude infection because a patient may come in with an aspiration pneumonia that you're immediately treating due to being full-bellied on a traumatic day. Also, patients may be suspect to meningitis if they have certain open skull fractures and other septic regions. One of our interns actually did a surgery on a gentleman who has significant intra-abdominal content where she was plucking ramen noodles out of places that shouldn't have had ramen noodles in them in the abdominal compartment. So something to think about as well. Unregulated hypermetabolism leads to protein calorie malnutrition, but also multiple organ failure. So F is for feed. My colleague put this in. This is actually the American Sign Language symbol for F. So after the initial measures dictated by the Advanced Trauma Life Support in the airway, breathing, circulation, disability, and exposure, F is to feed your patient. So this emphasizes how important this is in terms of management of the acute traumatic injury patient. Nutritional therapy is just as important as resuscitation for patient management with polytraumatic injuries and severe burns. And even though their hospital stays are prolonged, often complicated by multiple infections and bounce backs to the ICUs or further interventions, it's just important that we're keeping an eye on their nutritional status. So rapid acquisition of a route for nutritional support is important to start early nutritional therapy within 48 hours of care. If the patient's intubated, usually you can even do trickle feeds via an OG tube if it's intra-abdominal injuries. However, and say the patient's intestines are left in discontinuity or not repaired and re-hooked up, you may have to look to TPN or Peripheral IV Clinomex Administration. But just don't forget about the patients that you can't feed via the Antero route and make sure that their nutrition is getting addressed as well. So early ambulation in the ICUs is an incentive that we are getting multidisciplinary, I guess, standardization on at Carolina's Medical Center. The benefits of early ambulation, pending your patient's activity status, granted with multiple orthopedic injuries, can't be understated. So it improves respiratory function, it reduces adverse effects of immobility, increases the levels of consciousness, increases functional independence, improves cardiovascular fitness, increases psychological well-being and reduces risk of delirium, which is just a lengthy way of saying make sure your patients are at least sitting on the edge of the bed. I know in one of the units that I work in, it's called the Progressive Care Unit, we get a lot of traumatic brain injury patients. And as they start to kind of wake up from this comatose, abundant state, we put them on delirium schedules. So they wake up, the lights are on, we play some music, get the family involved. If we can, we sit them at the edge of the bed, scoot them over. If they're off the ventilator and have a trach, the nurses love me, and I was a nurse, so I know how this goes, but take them outside, get sunlight on their face. And it actually makes you feel better as a provider seeing your patient enjoy these things and kind of wake up out of this state. So early ambulation or just early movement, pending what their activity status is, critical. So again, the ABCD bundle under the SCCM involves the following, awakening trials for ventilated patients. This is more ICU-level care, just making sure you're having pauses in sedation, spontaneous breathing trials, and C is coordinated care, basically, between A and B. So interdisciplinary rounds in the ICU are pretty pivotal to ensuring A and B and C are getting done, because without the respiratory therapist, without the nurse's coordination, breathing trials may kind of be null and void. D is a standard delirium assessment program. A lot of patients in the ICU, or even when I see them in progressive or on the floor, have delirium no matter what age you are. So kind of coming up with a daily schedule and involving families is huge with the delirium prevention. I find my families like to have more of an active role in the patient's care, which is very gratifying for them to be able to play the patient's favorite music or something of that latter, which is huge in terms of comprehensive care. And again, early mobilization, ambulation of critical care patients kind of falls into that. So barriers, as we well are aware, hospitals, staffing, and right now we have 93 to 94 patients on our service between a multitude of units. Not only are we staffed as we best can, but I know our nurses are too. I'm very cognizant of that, and I try to coordinate with them, timing even to assess patients or help them get out of bed myself and make time for them too. Knowledge of the importance of this, sometimes new ICU nurses aren't aware of, and I wasn't, and I was guilty of this too, you can mobilize a person on a ventilator. So it's just a matter of coordinating care, making sure their lines are tight and everything like that, and being able to provide the time for that patient. Provider referrals for PT, we are a teaching service, so our residents sometimes forget that ICU patients need a physical therapy consult. The PT list can get very, very list very, very early, so it's important to make sure, even as nurses and other healthcare disciplines kind of look through their chart that we're auditing for that. Delirium, again, is a huge thing in that. If your patient's agitating, won't comply with basic instruction, it's kind of unsafe to get him to mobilize to the side of the bed. Neuromuscular weakness can occur in 25 to 50% of ICU patients and can last for years after hospital discharge. This can be a medication side effect, such as with paralytics, but also related to atrophy, and that's why nutrition also plays a huge role in this. Early mobilization is the evidence-based intervention recommendation to prevent and ameliorate ICU-acquired weakness as well. So early and progressive rehab and with traumatic brain injuries, once they've kind of gotten out of that very, very critical state where you can't stimulate them, it's important to kind of get a schedule for them, and we've been very creative in the progressive care unit with what we need to do. One patient in particular wouldn't wake up for a while, so his family started playing Slayer for him. If anyone knows who Slayer is, it's a metal band. So, and now he's eating pancakes living on our floor and he's kind of the ambassador right now while we get him a plan for discharge. It's pretty cute. So developing an ICU system and culture to achieve these are often challenging, and we, as healthcare providers, need to be more understanding of each other's silos and kind of make accommodations to provide the best patient care we can possibly perform. So this kind of goes over what was said already. Mechanically ventilated patients are confined to a bed, atrophy of the muscles, protein catabolism from the various nutritional deficits they're suffering from, sedation, and acute illness kind of keeps them down again, and they lose up to 25% of peripheral muscles within four days. So we're kind of trying to fix all of their other problems, but address things like immobility as well. So this is something that's going on at Carolina's Medical Center currently. It's a nurse-driven, stepwise approach to early mobility. As a nurse, sometimes I felt it was hard to get my voice heard, but in this institution, especially Carolina's healthcare system, I rely heavily on my nurses and respect everything that they do and listen to them and try to coordinate as best as possible within a very busy day. Obviously, there's a lot of pieces to coordinate with an ICU patient with early mobility that we mentioned, but if the standardized approach can happen, at least all members of the team, even if there's agency nurses or other people involved, can at least know how we like to mobilize our patients and effectively, so we've kind of done that at Carolina's. And again, a little bit more into that, but it's kind of hard to read, and for the sake of time, we'll just continue plugging on. So venous thromboembolism prophylaxis, so the patient I mentioned earlier that came in, if he had multiple pelvic fractures, required an interventional radiology procedure to stop a bleeder, he had intra-abdominal injuries. It's kind of hard for VTE prophylaxis, especially with the fact that he has a TBI, say an unstable spinous process fracture or other kind of fractures in his back that requires surgery. You kind of need to get creative with this, and obviously, the risk factors of VTE are a lot of things we see in the trauma population, immobility, potentially pregnancy, a pregnant trauma patient is very possible, we have seen that, so don't disclude that, even though babies aren't something we typically see in the ICU in that setting. Stroke patients and medical patients, patients have pre-existing factors, and as Dr. Christmas mentioned, they may be on various blood thinners, new and novel that we don't necessarily know about or have a heart attack that prompts you to crash into a wall. So you need to kind of be cognizant of that. Total hip arthroplasty patients, even of traumatic etiology and spinal cord injury. So this is Virchow's triad, which you might have seen in any kind of school setting. It's the three factors that are primary influences for thrombosis formation, hypercoagulability, which is often seen in trauma patients that was discussed already this morning, stasis from immobility, and vessel wall injury, which is often prominent in the trauma population that predisposes these patients to pulmonary embolism and DVT. So why do we care about VTE prophylaxis? Because it's a big deal. So I guess that's kind of a rhetorical question. VTE is comprised of both deep vein thrombosis as well as a pulmonary embolism. The cost of each VTE event in 2013, granted, is considerable, ranging from $7,500 to $16,000 per event. DVT has been described to occur in about 15% of trauma patients, even despite chemoprophylaxis, with either heparin or lobinox. And oftentimes, serial screenings were described in literature, but at this point in time not really indicated because some of these kind of clear up spontaneously with the VTE chemoprophylaxis. And we typically use mechanicals such as SCDs or sequential compression devices or compression stockings, which I haven't seen as much anymore with our population, and correct me if I'm wrong, as well as low and just kind of early ambulation. Patients that are able to talk to you and don't have orthopedic injuries and can get SCDs often ask me what these big hot sweaty boots are, and I say they simulate walking that you can't do currently. So it's pretty, when you think of it that way, everything is kind of gearing them towards early mobility and preventing DVTs. The other thing to mention here with the prophylactic agents even though they're on the medical record doesn't mean they're given. I had a patient for whatever reason refuse about eight or nine doses of heparin for no apparent reason besides her own, and my nurses said nurse, you know, patient refused and hadn't called me about it. So it's also our responsibility to be auditing this because, you know, these can cause PEs and DVTs. We want to make sure that we're doing process improvements to figure out how we can encourage compliance. Can't necessarily make a grown woman comply, but she should have the education and the mindset to understand what the implications could possibly be. So DVT prophylaxis contraindications, active intracranial hemorrhage, this is a gunshot wound to the head, so obviously he's gonna have some bleeding, incomplete spinal cord injury with associated paraspinal hematoma or epidural hematoma, ongoing and uncontrolled hemorrhage, say the patient was managed non-operatively for an intra-abdominal injury and then has to go back to the OR and still has hemorrhage that we can't control, uncorrected collagulopathy, as well as for lovanox, at least, low creatinine clearance or elevated creatinine, and with lovanox in particular, make sure you're looking for other meds such as catorlacatoradol and ibuprofen, which may also be elevating the creatinine in addition to pre-renal etiology such as being dry. So these are our Red Book guidelines, so just because a patient has a brain injury doesn't mean that they can't get chemoprophylaxis or even an IVC filter to prevent the DVT and PEs, so just don't discard this population. Again, this is just about interdisciplinary communication with neurosurgery. They get a little bit annoyed when I call them on the third day, the patient's always there, and say, hey, can they have additional VTE prophylaxis? But it provides great communication and an open stream of communication, and these patients, even though a common complication of spinal cords and TBIs is, DVTs often don't present with that. Our facility in particular has a big hole in the IVC filter early intervention for these patients, and we actually do remove them three to four months later, and the ACPs often see them in clinic to kind of see if we can take them out earlier rather than later. So signs and symptoms. Most people are familiar with this. With the pulmonary embolus, it's shortness of breath, problems breathing, chest pain, hemoptysis, coughing, tachycardia, low-grade fever, and increases in supplemental O2 needs. DVT is swelling of the leg along a vein. There's pain or tenderness in the leg, a feeling of increased warmth in the area of the leg that's swollen or tender, and red or discolored skin that affects that leg. Often than not, though, sometimes patients can present totally asymptomatic. Maybe a patient's having anxiety, and I get a lot of calls for benzodiazepines, but then at the same time, I'm auditing the chart and see the oxygen needs have gone from five to 10 liters or a non-rebreather, and kind of scratching my head at the fact that he's also tachycardic now and maybe has a temp of 99.5 with ortho injuries. Just something to consulate that a benzodiazepine wouldn't be as effective as seeing the forest through the trees per se, but I know it is hard if you're not really looking for it. Additionally, with the DVTs, if the patient has ortho injuries or say a sprained leg or edema, maybe difficult to discern if they are actually having swelling or redness that kind of correlates with the vein. This is what a PE that was removed at autopsy looks like, and it actually is a calf's leg in which they originated from, so I thought that was pretty interesting, albeit a little bit gross. So the diagnosis and treatment, again, they're often asymptomatic, mild, nonspecific symptoms, and with a patient with polytraumatic injuries, it's imperative that a physical exam and a review of systems as well as objective findings are kind of consolidated to include this diagnosis. Lower extremity ultrasound for DVT can also indicate a PE as well if your lower extremity ultrasounds are positive and your patient's having the respiratory symptomology, you can pretty much infer that they have a PE. The gold standard, though, is a CT pulmonary angiography. However, there is a significant contrast load that does go along with that, so if you have a geriatric patient with an elevated creatinine or those with end-stage renal disease, consider an ultrasound first. Treatment is oxygenation and stabilization, which is, again, going back to the ABCDs, and anticoagulation depending on the risk of bleeding. So, with the risk of bleeding, again, we had a patient recently who was a motorcycle crash, and as very common with motorcycle crash, had a very significant pelvic fracture that was gonna warrant about eight hours of intervention, and simultaneously, he started having these cramping pain in his legs, he was a little bit younger, and kind of, I call him a little bit of a slug, even though I try to get in there and motivate him and beef him up and say, like an athlete, you have to get up and move and do these things, and he was found to have bilateral femoral DVTs. Well, he still hadn't had his pelvis fixed, and he has these bilateral DVTs, and he had to have an IR intervention for a bleeder in his pelvis, so he's kind of an anticoagulation nightmare. What we actually did was collaborated with the orthopedic team, and we gave him an IVC filter, but also gave him therapeutic Lovenox, and the therapeutic Lovenox was held about 12 to 24 hours prior to his surgery. He had an eight-hour pelvic repair, and then he went home within a couple days of that, so obviously, even though it's a significant complication, we still try to do our best with being creative with what we need to do to get these patients VTE prophylaxis. So, additionally, as was mentioned in Dr. Christmas' lecture, we have the newer agents, the new novel oral anticoagulants, so if a patient doesn't have a PE in the acute care setting, our institution will transition them to Eliquis. We do have a prescription program that we can give them discounts, because Eliquis is rather expensive, and they're on that for about three to six months pending what the thrombus was. Additionally, with non-operative management of solid organ injuries, if your patient has a liver laceration or a splenic laceration, depending on the grade, we may not do an intervention such as taking them to the operating room and may conservatively manage them with frequent abdominal exams, lactates, and hemoglobins, as long as you're following up with that. If those remain stable with a couple lab values and he's not having perinatic symptoms or a difference in his abdominal exam, you can start heparin or lobinoxin. Obviously, the risk of bleeding doesn't outweigh the benefit of VTE prophylaxis. So pediatric DVT prophylaxis, this photo's really cute, it's relatively low in the older, greater than 13 years, and more severely injured patients are at a higher risk for VTE. Additional factors including injury type or central venous catheterization also puts a patient at higher risk. Implementation of a risk-based clinical practice guideline has been associated with reduced symptomatic VTE at one institution, so it's kind of vague in the pediatric population what you exactly do with VTE prophylaxis, so new things are coming down the pipelines every day. I did want to mention towards the end of this presentation a little bit about a tertiary exam. Our institution is piloting on one of our units, which is a primarily nurse practitioner PA run unit that does tertiary exams in a standardized fashion, where most of our patients within 48 to 72 hours want traumatic injuries, so not your gunshot wounds or not your penetrating injuries, all get a tertiary exam in the chart. These are things that you probably already do but didn't realize it had a name, which is review all of the radiographs since the patient's been admitted, the lab values, and go in and perform a very thorough examination of the patient to discern if there was any missed injuries. For instance, we had a patient who was a cop who had a known history of seizures. He actually had a seizure and hit the accelerator and ran into a wall. We saw his tib-fib fracture, he felt his tib-fib fracture, and what ended up happening is he started complaining of shoulder pain days later, and the shoulder pain wasn't really addressed. We looked at films, there was nothing really going on, but God, the shoulder pain hurts. Until his fracture was stabilized in his leg and he mobilized, we really didn't think much of it. He mobilized, completely almost collapsed. Then we thought something of it, and we scanned him head to toe, and we did find a missed C-spine injury that he had that required surgical fixation. The tertiary exam can't be understated enough, and frequent visualization of your patients and really getting to know them in a physical sense. Actually, with almost 200 patients, we've had about four or five missed injuries and a whole lot of incidental findings. Even if you scan a patient head to toe, be cognizant of what you order, because you do have to follow up with it, even if that means delivering bad news There's a pancreatic lesion we saw in a younger gentleman, or a pulmonary nodule that could be suspect for cancer in the follow-up. So, any questions for me? I know this was a condensed version. This is actually one of our physicians. I swear, I talk a lot at work. This is a typical day in the life, and it's a very busy service, so it's a lot of fun. Thank you for your time, I truly appreciate it, and I'm filling in for Ms. Casey Scully, so she'll be here tomorrow. Any questions? Thank you. All right, if there's no other questions for me, I appreciate all of your time, but feel free to come and ask me. I'll be around for a little bit, or my colleague, Casey Scully, who also helped to develop this lecture. Appreciate it. Have a great day. Bye.

trauma care

extremity compartment syndrome

venous thromboembolism prophylaxis

early mobilization in the ICU

early nutrition in trauma patients

spine fractures

precautions

interdisciplinary collaboration