Rosen & Barkin's 5-Minute Emergency Medicine Consult (729 page)

• Admit transplant recipients with fever, shortness of breath, signs or symptoms of rejection, abdominal pain, or other signs of organ infection, pneumothorax, and respiratory failure.
  
• Admit to the ICU patients who are septic, in acute renal failure, or have cardiopulmonary compromise.
  

Nontoxic patients in whom rejection or serious infection has been excluded may be discharged with close follow-up and in consultation with their transplant service.

Treatment decisions should be made in consultation with the patient’s oncologist, transplant surgeon, or organ specialist.

• The patient’s transplant team should actively participate in the follow-up plan:
  
• All attempts at verbal communication with the covering transplant physician should be made while the patient is in the ED with any symptoms suggestive of rejection.
  

• Transplant patients presenting with minor complaints are at high risk for rejection and require an in-depth assessment in the ED, in conjunction with their transplant team.
  
• Patients with signs of possible transplant rejection should also be considered for infection and drug toxicity.
  
• A high percentage require admission
  

• Ferrara JL, Levine JE, Reddy P, et al. Graft-versus-host disease.
  Lancet
  . 2009;373(9674):1550–1561.
  
• Patel JK, Kittleson M, Kobashigawa JA. Cardiac allograft rejection.
  Surgeon.
  2011;9(3):160–167.
  
• Razonable RR, Findlay JY, O’Riordan A, et al. Critical care issues in patients after liver transplantation.
  Liver Transpl
  . 2011;17(5):511–527.
  
• Schuurmans MM, Tini GM, Zuercher A, et al. Practical approach to emergencies in lung transplant recipients: How we do it.
  Respiration
  . 2012;84(2):163–175. doi:10.1159/000339345. Epub 2012.
  
• Venkat KK, Venkat A. Care of the renal transplant recipient in the emergency department.
  Ann Emerg Med
  . 2004;44(4):330–341.
  

CODES

• 996.80 Complications of transplanted organ, unspecified
  
• 996.81 Complications of transplanted kidney
  
• 996.82 Complications of transplanted liver
  

BASICS

• Standardized approach for rapid assessment of the trauma patient
  
• Although presented as a sequential method for gathering information, many of these steps can be performed simultaneously.
  
• In general, injuries must be prioritized in order of severity to increase survival. Life-threatening injuries, particularly when abnormal vital signs are present, must be immediately addressed and treated before going on to the next level of care.
  
• With any change in the patient’s status, the primary survey should be repeated.
  

Variety of causes such as:

• Motor vehicle/motorcycle crashes
  
• Falls from heights
  
• Assault
  
• Airplane crashes
  
• Train derailments
  
• Results of mass-casualty weapons
  
• Terrorism
  

DIAGNOSIS

• Triage to a major trauma center is determined by local protocols.
  
• Injured patients with a need for surgical, neurosurgical, or orthopedic intervention should be transported to a major trauma center.
  
• Recent recommendations from the American College of Surgeons suggest that trauma victims with unstable vital signs should be taken to a Level I trauma center, where a larger volume of critically injured patients are seen.
  
• Primary survey should be performed at the scene and en route.
  

• Primary survey (ABCDE):
  
  • Airway, cervical spine:
    
    • Look, listen, and palpate from nose/mouth to trachea/bronchial tree.
      
    • Assess airway patency.
      
    • Evaluate gag reflex.
      
    • Cervical spine must be immobilized with significant mechanism of injury and either altered mental status or distracting injuries or with signs and symptoms suggestive of neck injury.
      
    • Ability to speak or effective movement of air with respiration indicates patency.
      
    • Gurgling, stridor, wheezing, snoring, choking, or absence of air movement requires immediate intervention.
      
    • Manage airway compromise before next step in primary survey.
      
  • Breathing:
    
    • Awake, alert patient with normal speech and good air movement suggests effective breathing.
      
    • Symmetric chest wall rise/fall, equal breath sounds, normal respiratory rate, and oxygen saturation at 95% or more suggest effective breathing.
      
    • Asymmetric chest movement, unequal breath sounds, abnormal respiratory rate, decreased oxygen saturation, inadequate air movement, or an obtunded patient suggests ineffective breathing.
      
    • Decreased unilateral breath sounds, tracheal shift, hyperexpansion, hyperresonance to percussion, subcutaneous air, hypoxia, or hemodynamic compromise raises concerns about tension pneumothorax.
      
    • Decreased breath sounds with dullness to percussion suggest hemothorax.
      
    • Manage patients immediately with needle thoracostomy followed by tube thoracostomy.
      
  • Circulation:
    
    • Adequate circulating blood volume must be maintained.
      
    • Primary assessment includes BP, heart rate, pulse quality, and end-organ function (e.g., mentation, urine output, capillary refill).
      
    • Tachycardia and oliguria indicate early shock; hypotension is a late finding and necessitates a search for hemorrhage
      
  • Disability:
    
    • Assess level of consciousness, gross motor function, and pupillary size/reactivity.
      
    • Glasgow Coma Scale is most commonly used; score of ≤8 indicates severe head injury/coma.
      
    • Spinal cord injuries are grossly assessed by observing movement of all extremities.
      
    • Pupillary size and reactivity to light measure brainstem function.
      
  • Exposure:
    
    • Patient should be undressed completely.
      
• Secondary survey:
  
  • After the primary survey has been completed
    
  • Patient stabilized at each level
    
  • Complete physical exam from head to toe is performed.
    
  • “Tubes and fingers in every body cavity”
    

The mechanism of injury, initial clinical presentation, suspected injuries, and treatment rendered should be elicited from EMS personnel.

Initial stabilization should begin simultaneously with essential workup.

• Primary and secondary surveys
  
• Cervical spine and chest radiographs are mandatory for victims of major trauma.
  
• Pelvic radiographs should be performed with clinical suspicion of pelvic trauma or with hemodynamic instability.
  
• Hemoglobin/hematocrit, ABG, blood type; a toxicology screen may also be considered.
  
• Urine dip for blood
  
• UA if dip shows positive result
  
• Urine-based pregnancy test for any female patient of childbearing age
  

Baseline coagulation and chemistry studies with massive injury or hemorrhage

• Loss of consciousness, post-traumatic amnesia (anterograde or retrograde), or persistent altered level of consciousness is indication for head CT.
  
• Significant blunt and penetrating chest trauma requires objective evaluation of the heart and great vessels with echocardiography, CT scan, angiography, or direct visualization.
  
• Blunt abdominal trauma requires objective evaluation using US, abdominal CT, or diagnostic peritoneal lavage, depending on patient’s condition:
  
  • Hemodynamically stable patients should have an abdominal CT with IV contrast.
    
  • Unstable patients should have an abdominal ultrasound (FAST exam) or diagnostic peritoneal lavage.
    
  • Many centers now doing “Pan CT scan,” including head, neck, chest, abdomen/pelvis in a single pass with IV contrast
    
  • Pan CT lowers missed injury rate but involves significant radiation exposure
    
• Extremity injury:
  
  • Radiographs
    
  • Suspected vascular damage requires angiography or duplex ultrasound.
    

Some level of clinical suspicion should be maintained for other medical conditions leading to trauma (e.g., seizures, dysrhythmias).

TREATMENT

• The initial treatment should parallel the primary survey with injuries treated before addressing the next assessment level.
  
• Airway with cervical spine control:
  
  • Jaw thrust, suctioning, and oropharyngeal or nasopharyngeal airways provide initial airway support.
    
• Rapid sequence intubation is the airway management option of choice for multiple trauma patients:
  
  • Insertion of an extraglottic airway (e.g., Combitube, laryngeal tube, or laryngeal mask airway) or cricothyroidotomy may be necessary.
    
  • Use of video laryngoscopy may allow endotracheal intubation with minimal impact on potential traumatic brain injury or an unstable cervical spine
    
• Breathing:
  
  • 100% oxygen and respiratory monitoring
    
  • Tension pneumothorax should be diagnosed clinically and decompressed on an emergency basis with a needle thoracostomy below the axilla or above the 2nd rib in the midclavicular line.
    
  • Tube thoracostomy should follow.
    
  • Open chest wounds should be covered with an adherent dressing and a tube thoracostomy performed.
    
  • Respiratory distress from flail segment or pulmonary contusion should prompt early intubation with mechanical ventilation and positive end expiratory pressure.
    
  • Hyperventilation should be avoided except with impending herniation or intracranial HTN resistant to other therapies; end-tidal carbon dioxide monitoring should be used.
    
• Circulation:
  
  • 2 large-bore IV lines with constant hemodynamic and cardiac monitoring should be placed.
    
  • A thoracotomy may be considered in a previously stable patient with penetrating chest trauma and an acute deterioration in status
    
  • A Foley catheter can be placed to help monitor urine output but should be withheld if blood is present at the urethral open until additional imaging can be performed
    
• Alternatives include central lines, venous cut-downs (e.g., saphenous or femoral), or intraosseous lines:
  
  • Aggressive fluid replacement with 3 parts fluid for every 1 part circulatory volume loss remains most widely recommended care; adjust fluids based on ongoing assessment:
    
    • 2 L initial bolus in adults, 20 mL/kg in children
      
    • Whole blood or autotransfused blood for hemorrhagic shock or uncontrolled bleeding
      
  • Pericardial tamponade requires emergent pericardiocentesis/pericardial window.
    
  • External bleeding should be managed with direct pressure.
    
  • Unstable pelvic fractures should be treated with pelvic binding
    
• Disability:
  
  • Head injury with Glasgow Coma Scale score of ≤8 should initiate treatment for elevated intracranial pressure with mannitol or hypertonic saline, rapid-sequence intubation, oxygenation, and controlled ventilation to a PCO
    ₂
    of 35 mm Hg.
    
  • Elevate head 20–30°, maintaining spine immobilization.