Ruben Santiago, Pharm.D., BCPS, BCCCP, Emergency Medicine Clinical Pharmacist

Episode 11: The Role of an ED Pharmacist as Part of the Trauma Team with Ruben Santiago, Pharm.D., BCPS, BCCCP

The Trauma team members

There are many key members of the trauma team that include the trauma nurses, respiratory technicians, ED physicians, trauma surgeons, medical residents, PA/NPs, radiology techs, and anesthesiologists.

What is a trauma center and what makes them unique?

  • Trauma centers are centers that are equipped to treat the most critical of patients who suffer from traumatic injury.
  • This includes blunt trauma such as falls and motor vehicle crashes as well as penetrating trauma (like our gun and knife club members).
  • Trauma centers are usually designated by levels (level one, level two, and so on) and are defined based on the resources available and the number of patients treated annually.

What advice would you give ED pharmacists regarding training/certification that would help in trauma resuscitation?

Hands-on training is your best friend for these patients.

Being able to anticipate the team’s needs for trauma patients is key.

  • You have to know where your medications are stored, what medications are immediately available and which medications you need to expedite from your central pharmacy.
  • You also have to know where your supplies are stored such as your needles, IV pumps, IV tubing, etc.
  • Know your code cart and where it is located, so you are ready for any patients that either present in traumatic arrest or decompensate into cardiac arrest.

What is the Primary Survey?

The primary survey is a systematic way of evaluating a trauma patient. It consists of A for airway, B for breathing, C for circulation, D for disability, and E for exposure.

What parts are pharmacists involved in?

I believe the trauma pharmacist is a part of every single step in the primary survey:

A

  • Airway:
    • A pharmacist thinking about medications for RSI. Know the kinetics of your induction agent and paralytic agents including onset and duration of the medications used. Also, know what to expect from the medications used.

B

  • Breathing:
    • if the team thinks your patient has a pneumothorax and a chest tube is imminent, be ready for local analgesia or possible IV systemic analgesia for patient comfort

C

  • Circulation:
    • If the patient is found to be hypotensive while circulation is being assessed, think adjuncts to blood product replacement.
    • Any patient in the trauma bay who is hypotensive and tachycardic is in hemorrhagic shock until proven otherwise.
    • These patients will get blood. This includes getting ready to administer calcium to patients receiving multiple rounds of blood products as hypocalcemia may develop due to citrate toxicity.
    • For traumas that present early, plus/minus TXA, and if your patient is on anticoagulation, reversal strategies based on what your patient was taking.

D

  • Disability:
    • Think of traumatic brain injury and if present, Ruben anticipates the need for hypertonic saline or mannitol. He generally prefers 3% hypertonic saline as it does not affect hemodynamics and it is easier to get ready versus mannitol.

E

  • Exposure:
    • Finally, the patients are exposed, this is when Ruben thinks ahead about antibiotics for open fractures and of course, life-saving tdap.

What is a Secondary Survey?

An AMPLE secondary survey should be taken and includes (ample being the operative term):

  • A – Allergies
  • M – Medication History
  • P – Past illness/pregnancy
  • L – Last meal
  • E – Events/Environment related to injury

What parts of the Secondary Survey are pharmacists involved in?

Pharmacists play an integral role in obtaining allergies or past medication history such as myasthenia gravis where certain medications are contraindicated

  • A medication history may also be obtained from these patients.

Hemorrhagic resuscitation and pharmacist involvement

Pharmacists have an integral role in MTP.

  • Electrolyte Disturbances
    • Being prepared for complications associated with MTP are key aspects in the management of trauma patients receiving multiple blood transfusions.
    • These patients may suffer from hypocalcemia due to citrate toxicity.
    • Citrate located in blood products may bind with calcium, causing hypocalcemia.
    • Be ready with calcium replacement. Patients may also have hyperkalemia as a complication from MTP due to the age of the PRBCs used rate of infusion, underlying renal failure, and severe tissue injury.
    • Classic EKG changes associated with hyperkalemia such as peaked T waves may be present.
    • This should be treated similarly to other conditions that cause hyperkalemia.
  • Anticoagulation Reversal
    • Patients who are on oral anticoagulation present unique challenges.
    • At Rubens’s shop, They have developed an order set that helps streamline the ordering of anticoagulation reversal strategies based on the medication the patient was taking prior to presentation.
    • Kcentra is our reversal strategy for both VKA (including vitamin K) and factor Xa inhibitors (sorry Andexxa) and we use idarucizumab for dabigatran reversal +/- FEIBA.
    • Ruben’s role is ensuring the correct doses are ordered, and then expedited to the patient’s bedside.
    • Also, Ruben provides education to the receiving nurse on how the medication should be administered.

Pharmacists involvement with antibiotics with an open fracture

  • Pharmacists are integral in choosing the appropriate antibiotic for patients that present with open fractures.
  • This includes choosing the correct agent based on the type of open fracture (extremity vs. jaw. vs. skull), and environment (ex. aquatic traumas). Clarifying allergies prior to medication administration is another place that pharmacists have a role.
  • This includes choosing the correct agent based on the type of open fracture (extremity vs. jaw. vs. skull), and environment (ex. aquatic traumas). Clarifying allergies prior to medication administration is another place that pharmacists have a role.
  • Living in Miami, almost everyone says they have a penicillin allergy.
    • Letting the team know that you may use a third-generation cephalosporin routinely in this patients population and that it is safe as the R-side chains are different and there is little to no cross-reactivity (thank you, Bryan Hayes!).

Pharmacist involvement with pharmacologic agents in TBI

  • If suspecting TBI, Ruben generally goes for hypertonic saline.
  • In these situations, I recommend a 250 mL bolus of 3%.
  • I like it better cause I can give it fast, don’t have to worry about hemodynamic effects, and do not need a 0.2-micron filter like with mannitol.
  • Another aspect of care for these patients is if they are intubated, ensuring they receive appropriate sedation and analgesia post-intubation.
    • This will help with ICP management.

Ruben’s advice for new ED pharmacy practitioners responding to traumas that didn’t train at a trauma center?

Be open to learning new aspects of care you did not learn at your previous hospital.

Learn from your nurses and physicians leading the traumas. Do the little things (get blankets, help expose, etc.) and show up for every trauma.

Show them how much you care, and the team will appreciate and value how much you know.

Ruben’s Most Interesting Cases

  • There are so many!!!
  • There was an MVC where the patient needed an emergency cric, then placed on ECMO
  • Another was a truck driver who was on dabigatran and we used idarucizumab and FEIBA
  • Another was a boat propeller injury where I held the patient’s legs (still attached) and provided antibiotic recommendations due to the saltwater exposure.
  • Also, a couple of shark bites.

References

  • Hopkins TL, Daley MJ, Rose DT, et al. Presumptive antibiotic therapy for civilian trauma injuries. J Trauma Acute Care Surg. 2016 Oct;81(4):765-74.
  • Scarponcini TR, Edwards CJ, Rudis M, et al. The role of the emergency pharmacist in trauma resuscitation. J Pharm Pract. 2011 Apr;24(2):146-59.
  • Patanwala AE. Pharmacist’s activities on a trauma response team in the emergency department. Am J Health Syst Pharm. 2010 Sep 15;67(18):1536-8.
  • Amini A, et al. Effect of a pharmacist on timing of postintubation sedative and analgesic use in trauma resuscitations. Am J Health Syst Pharm. 2013 Sep 1;70(17):1513-7
  •  Lane JE, et al. Current Concepts of Prophylactic Antibiotics in Trauma: A Review. Open Orthop J. 2012; 6: 511–517.
  • Montgomery K, et al. Pharmacist’s impact on acute pain management during trauma resuscitation. J Trauma Nurs. 2015 Mar-Apr;22(2):87-90.
  • Rossaint R, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016; 20: 100.
  • Morrison JJ, et al. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2012 Feb;147(2):113-9. 

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