POTD: Trauma Level 1 vs. Level 2 vs. Level 3

Hi everyone,

Today's Trauma Tuesday POTD is inspired by the upcoming rollout of new trauma activation aka "level" criteria in the MMC ED. Woohoo! Exciting! Change is fun!

In light of this, our main question today is, when EMS brings in a patient with a traumatic injury, how are we determining level 1 vs. level 2 vs. level 3?

As we all know, MMC is an adult level 1 and pediatric level 2 trauma center, and thus we get the whole host of traumatic injuries that roll into our ED, from sprained ankle to traumatic arrest to being on the South Side on a Monday afternoon (just kidding). But how does EMS determine if they are coming to a trauma center at all? How do hospitals determine what level those incoming traumas should be? And, with all that in mind, how is the MMC level criteria changing with our new rollout?

EMS Trauma Criteria

The goal of EMS trauma criteria is to determine the appropriate destination for the patient: trauma center vs. general ED. The criteria is determined by the Regional Emergency Medical Advisory Committee (REMAC - yes, that REMAC!) of New York City. The two main buckets to determine required transport to a trauma center are physical findings and mechanism of injury. The other bucket to determine possible transport to a trauma center is high risk patient. The options for a high risk patient are either transporting or contacting OLMC. The criteria they use is below.

It isn't the job of EMS to determine the level of the trauma or whether or not they are coming to North Side or South Side. Oftentimes they will call for a trauma notification to the North Side if the patient is giving bad vibes, but really their only job is determining transport to a trauma center or not.

Hospital Trauma Activation Criteria

Once a trauma notification is called in, or once the patient arrives to the ED, it is the job of the ED hospital staff to determine what level of trauma activation is indicated. Trauma activation criteria is determined by the hospital itself. This means that, though two hospitals may both be level 1 trauma centers, they may have different criteria that qualifies someone as a level 1 trauma patient. Trauma activation criteria revisions occur every so often after interdepartmental discussions and research-based committee decision-making, with MMC having just completed its own. 

But why are revisions even necessary? Well, both under-triage and over-triage of traumas come with their own risk, so we want to get our triage levels right.

Under-triage means that the patient had more severe injuries than the original level indicated (e.g. the trauma was called as a level 2, but, after assessing injuries, actually met criteria for a level 1). There are obviously serious dangers to under-triage, as the patient may not have the necessary resources, specialties, or expedited care to care for their injuries. Be aware that there are higher rates of under-triage in pediatric and elderly patients. The MMC goal is to have less than 5% under-triage given the morbidity and mortality associated with these cases. 

Over-triage, on the other hand, means that the patient had less severe injuries than the original level indicated (e.g. initially called as a level 1 but later determined to be a level 2). The risk of over-triage may seem less disastrous, but it does come with a cost, mostly with regards to inefficient resource mobilization. The MMC goal is to have 25-50% over-triage. Trauma surgery keeps track of these numbers closely, and the American College of Surgeons reviews our numbers as part of the verification process to remain a trauma center. The goal should really be to triage everyone into the correct trauma level to activate the correct resources immediately, but obviously there is a bit more leeway skewing us to over-triage rather than under-triage.

New MMC Trauma Activation Criteria

So EMS has transported a trauma patient to the MMC ED based on their trauma criteria, and the patient has arrived in the North Side in room 51. What level are we calling it?

Old Criteria

Our old trauma activation criteria is still hung up on the back wall of room 51. I know I still look to these boards as reminder for the detailed criteria. For adult patients, one very generalized way to think of it is that level 1 includes physiologic criteria, level 2 incorporates mechanism criteria, and level 3 is everyone else who likely needs admission for traumatic injury. For pediatric patients, it's quite similar, but blast explosion mechanism earns you a level 1 right off the bat. But what about our new criteria?

New Criteria

Here's the new trauma activation criteria that is being rolled out in the MMC ED, and it will soon physically replace the old criteria on the back wall of room 51. See if you can spot the main differences between the two...

New Criteria Differences from Old Criteria

Ok, I'll tell you.

Adult Level 1

• HR > SBP

  • No longer HR >120

• Respiration rate <10 or >29

  • No longer includes compromised airway

Adult Level 2

• Patients transferred in from outside hospitals should only be activated if they meet the above criteria

  • No longer transfer patients from other hospitals automatically level 2

• **Systolic blood pressure >110 over the age of 65 is a typo and should have always been systolic blood pressure <110 over the age of 65**

Adult Level 3/Consult

• No changes

Pediatric Level 1

• Traumatic arrest

• Significant neurologic deficit

  • No longer suspected spinal cord injury or paralysis

Pediatric Level 2

• No longer major peripheral neurologic deficit (sensory or motor), as was changed to level 1

• No longer drowning associated with trauma, as was changed to level 3

Pediatric Level 3/Consult

• Injured patients with GCS >13

• Hangings and drownings with injury

• Injured patients with bleeding disorders

• Multi-system trauma involving more than one surgical specialty

• Patients with complications of recent injuries

TLDR

As you can see, the old and new criteria are actually quite similar, but it's good to keep in mind the changes in HR and respiratory status criteria for adult level 1, transfer patients no longer automatically being an adult level 2, significant neurologic deficits qualifying as a pediatric level 1, and drowning with trauma qualifying as a pediatric level 3.

Look out for the new trauma activation criteria in room 51 coming soon, and happy leveling,

Kelsey

Resources:

- Dr. Nate Zapolsky's brain

- Dr. Dave Eng's brain, too

- https://www.maimonidesem.org/blog/ems-protocol-of-the-week-general-trauma-care-adult-and-pediatric

- https://www.aast.org/disaster-detail/acs-highlight-trauma-team-activation-optimizing-pr

POTD: MTP and OBH in 123

Happy Friday!

This week's Wellness POTD will be about what keeps all of us well and alive each and every day: blood! Ok so not as flashy and fun, but hopefully this is a relatively quick and dirty review of massive transfusion protocol (MTP) and OB hemorrhage (OBH) at MMC.

TLDR of MTP

• MTP is initiated if there is (1) >4 units of pRBC transfused in 1 hour OR (2) replaced all of the patient's total blood volume in 24 hours OR (3) replaced half the patient's total blood volume in 3 hours OR (4) bleeding faster than 150 ml/min

• MTP is un-crossmatched blood

• Adult MTP 1st round is 4u pRBC + 4u FFP + 1u platelets, then 2nd round is the same + 10u cryoprecipitate

• MTP is activated by an attending physician

• Notify the blood bank of MTP activation by calling 3-8400 or 3-7651

TLDR of OBH

• OBH is defined as (1) >1000 ml blood loss in any delivery OR (2) >500 ml blood loss in vaginal delivery with sxs of hypovolemia

• Call a Code H for concern for OBH

• Stage 1 think IV access/fluids/uterotonics, stage 2 think consult MFM, stage 3 think OR, stage 4 think ACLS

Ok now for the longer and more rambly (but hopefully helpful?!) details within our protocol at MMC...

Massive Transfusion Protocol

I will try to summarize the MTP protocol that Dr. Marshall shared via email, which I am also attaching to this email, and will highlight relevant facts for our clinical use in the ED.

Adult MTP Indication

1) Transfused >4 units of pRBC in 1 hour w/ more blood needed

2) Expected to transfuse >50% of a patient's total blood volume in 3 hours (most adults have around 10-12 pints/units of blood in their body)

3) Expected to transfuse >100% of a patient's total blood volume in 24 hours

4) Bleeding faster than 150 ml/min

Pediatric MTP Indication

1) Expected to transfuse >50% of a patient's total blood volume in 3 hours

2) Expected to transfuse >100% of a patient's total blood volume in 24 hours

3) Bleeding faster than 10% total blood volume/min

MTP Initiation/Termination

• Activated by an attending physician

• Initiate MTP by using the red phone by the North Side charge nurse desk or by calling blood bank at 3-8400 or 3-7651

  • Information that must be included on the call is name, MRN, sex, DOB, location, diagnosis, and contact physician info

• Have a physician fill out the "Emergency Blood Transfusion/Massive Transfusion Request" form, section B, and send it to blood bank by messenger or pneumatic tube

• Send a lavender top blood specimen for ABO antibody screening and crossmatching of continued future transfusions

• Blood bank does their magic prepping and getting us the blood...

• "Crack the fridge" in resus 51 for emergency blood to bridge us while awaiting MTP blood

  • Charge nurse has the code to the fridge

  • ED fridge contains 2 whole blood + 8 units O- pRBC + 4 units O+ pRBC + 4 units FFP (no platelets)

  • The attending physician can decide whole blood vs. components

  • Use O+ for males and O- for females

• Have the attending physician be in close contact with the blood bank to anticipate continued need

• Terminate MTP by the attending physician notifying the blood bank OR automatically terminates 4 hours after MTP started

MTP Components

MTP Tips

• Try to balance your transfusions by hour 1 or 2 into MTP (1:1:1 ratio of pRBC:FFP:platelets)

• The 1 unit of apheresis platelets in MTP is synonymous with ~6 units of individual platelets

• Use blood warmers to prevent hypothermia

• Consider TXA for trauma

• Consider calcium repletion after 3 units of transfusion

OB/Postpartum Hemorrhage

OBH Definition

1) Cumulative blood loss of >1000 ml in c-section or vaginal delivery

2) Cumulative blood loss of >500 ml in vaginal delivery with sxs of hypovolemia

OBH Stages

Stage 1: normal vital signs --> IV, fluids, fundal massage, pitocin, add other uterotonics

Stage 2: normal vital signs but blood loss up to 1500 ml OR pitocin and 2 uterotonics started --> consult MFM, transfuse, add TXA, foley, uterine balloon/packing

Stage 3: abnormal vital signs OR blood loss >1500 ml OR 2 units pRBC transfused --> go to OR, MTP

Stage 4: cardiovascular collapse --> ACLS

"Code H" aka alert the OB troops

Code H is the trigger to get more people involved for any stage OBH. It can be activated by anyone by dialing 33 and stating you have a Code H. The people notified are: OBGYN inside attending, OBGYN outside attending, anesthesia attending, anesthesia resident, chief OB resident, any individual on OB codes list, nursing leadership, blood bank.

OBH Tips 

• Consider the 4 T's of OBH when treating these patients: Tone (uterine atony), Trauma (laceration, hematoma, inversion, rupture), Tissue (retained products), Thrombin (coagulopathy)

• Use the red OB hemorrhage kit in the fridge of resus 52 which has pre-made uterotonic meds and a cheat sheet for when to use each

• Get the pitocin running early

Happy transfusing,

Kelsey

Resources:

- MMC MTP and OBH protocol

- Dr. Nicky Chung POTD from 10/8/24

- Dr. Kat Pattee POTD from 5/15/24

POTD: Anchor North Wall

Hi Maimo Family,

Today's POTD is dedicated to our lovely, kind, hardworking, powerful, competent, reliable, wicked smart interns. 

It's December now, which means we are exactly one month away from the 18 of you making your biggest transition of residency thus far: becoming the anchor North Wall residents on the 7a-7p and 7p-7a shifts. 

This means that, for at least part of these shifts, you will be the sole resident covering all of the patients on the North Wall. I know what you must be thinking: exciting! Exhilarating! Expletives! This is always a big change for the interns, and it’s Maimo tradition to send a list of recommendations on how to succeed on these shifts from anchor North Wall residents come and gone. As a senior resident of mine passed along to us, “being the anchor is more than learning and knowing the medicine. It’s identifying sick patients, working with your team, and having a birds-eye view of the department.” So without further ado, below are tips on how to conquer the anchor North Wall shift.

1. Try to see new patients within the first 20 minutes of their arrival. Assume these patients are on death’s door until proven otherwise.

2. If multiple patients arrive, do a few things quickly: put your name on them, check triage vitals, quickly eyeball them, and make sure initial orders are in to get the workup started. (Some example workups to throw in…Chest pain? EKG, CXR, trop. Fever? Labs, blood cx, urine, CXR. Old person with AMS? Labs, urine, CTH.) Once you have a moment, return back to the patient to get more of the story.

3. Review triage orders if they have been placed. Since most of North Side patients will get labs and imaging, it is easy to assume that all the orders were placed in triage. It’s best practice to review the orders placed and make sure it aligns with what you want after getting a more thorough history and physical from the patient. The triage doc is an insanely busy role and already helping us out by starting the workup, but it’s our responsibility to ensure it’s complete.

4. Nurses and PCTs will be your best friends. If it’s the first time interacting with someone, introduce yourself and try to remember their name. They are the difference makers in patients getting stabilized on the North Side, and also they are just amazing people. Get them in your corner, and be in theirs.

5. Dispo ASAP. The more patients you can cognitively offload by admitting or discharging, the better your brain will feel.

6. Call the consultant even more ASAP. Get in the practice of asking every patient you see on North Wall for their PMD, and, once you’re back to your computer, immediately put in the call to the PMD via the Contact Center. Usually the two questions you’ll be asking are 1) any clarifying history and 2) who you would admit to. Even if you don’t end up admitting the patient, get the information right off the bat to save you the hassle down the road. Same goes for consultants; get them on board early.

7. Attend the codes and traumas when you can. Not only is it good practice to be a part of these cases, but helping out your resus resident with the FAST, primary/secondary survey, and putting in trauma orders can be a huge help when the resus bay is packed. These shifts especially rely on teamwork. Which leads me to…

8. You may become the resus resident if things get bonkers with multiple sick patients in the resus bay! Don’t panic. Just start the initial stabilization: speak with patient/family/EMS for the story, ensure IV/O2/monitor, get orders in.

9. Learn the extra stuff. Putting patients on cardiac monitors, hanging fluids, drawing labs, setting up BIPAP; these seemingly non-physician tasks can often be the most emergent, and knowing how to do them yourself can be a huge stress relief and time saver.

10. Have a system of keeping track of your list of patients. I use a sheet of paper with name, age, one-word chief complaint, abnormal vitals in triage, then leave space right below that for any weird details about the patient that I pick up from the history (e.g. PMD name, phone number of family, date of recent surgery, etc.). Next to that I jot down the general to-dos for the patient (e.g. labs, urine, CT, MICU, call family, etc.). And finally across from the name I make two check marks: one check mark once I wrote the note, and one check mark once I dispo’ed the patient. I think we all have a variation of this that works for us, with some people scribbling entire histories and some people just writing down PMDs. Try to figure out the system that works best for you.

11. Run your list over, and over, and over, and over. And over. If you don’t know what to do, run your list. If you and your attending happen to both be on your computers at the same time, run your list. If you just got done running your list, eat then run your list. Identify what’s pending and keeping you from accomplishing tip #5. 

12. Run the board, too. This is the leveling up part of anchor shifts. Not only is it important to know your own active patients, but it’s helpful to have a general idea of the North Wall patients admitted, discharged, or coming your way from ambulance triage. Sometimes ambulance triage patients can sneak onto North Wall without you knowing, though usually you will get inkling based on the triage note, the vitals, or the name of the nurse assigned to the patient (making tip #4 all the more important). Run the board by yourself to make sure everyone has a dispo, and if they don’t, you’re working on it. Having this bird's-eye view will really help you achieve self-actualization as an EM resident and future attending.

13. Document on the go. This will be very different from South Side documenting flow, during which you can usually sit down, finish multiple notes, and see new patients when the chart documentation is all wrapped up in a bow. On anchor North Wall shifts, your documenting is going to be interrupted annoyingly often, but, unlike the South Side, it’s usually for something that does actually need to be addressed immediately (e.g. new patient, unstable vitals, agitated patient ripping out his only IV access, etc.) You’ll have to be flexible, and this means you’ll want to use F7 liberally. Document in F7 what you can, go fight the fire, and then return to finish your documenting when things calm down. Also utilize the ED Diagnoses portion of F7 to keep track of any labs, vitals, or workup that comes back abnormal. Adding diagnoses in there will help you on hour 12 of your shift when you’re trying to remember what the heck is going on.

14. You are truly never alone. The resus resident, the attending, the team triage doc, the South Side team, the Peds team, the charge nurses, any of us via phone…do not hesitate to grab us if you need help. Whether you’re worried, scared, overwhelmed, or just wondering where the best place to cry for a second is, we’ve been there. We get it. And we are here for you for whatever you need.

It sounds scary, I know. I can remember nearly hyperventilating while walking into my first North Wall overnight shift. But deep breaths. Because here’s the thing: you can do this. I know it might be terrifying, I know it might be hard, and I can promise that you will walk out of some of these shifts feeling more stupider than when you walked in. But you can do this. You got this. And we’ve got you, we promise.

You have spent the last 5 months showing us just how incredibly intelligent, curious, and driven you are; meet this challenge with that same energy and you will be the kick ass doctors we already know you to be.

Happy leveling up!

Kelsey