Hemorrhage of the Ramus Lumbalis of the Iliolumbar Artery as a Cause for Shock in Blunt Trauma Victims on Therapeutic Anticoagulation
Table 1
Activation criteria.
Criteria
Category I activation
Category II activation
Physiologic criteria
Blunt or penetrating trauma with unstable vital signs
Blunt trauma with stable vital signs Penetrating extremity trauma not meeting category I anatomic criteria
Hemodynamic compromise as evidenced by (i) systolic or (ii) systolic
No hemodynamic compromise
Respiratory compromise as evidenced by (i) Respiratory or >29 or (ii) in an of age Needing ventilator assistance Altered mentation as evidenced by , persistent unconsciousness or focal signs (i.e., posturing), posttraumatic seizures, or pupillary anomalies All patients (with or without sedation) requiring ET intubation Inability to intubate and anticipation of surgical airway Blood infusing to maintain vitals
No respiratory compromise GCS of 11, 12, or 13 weeks (anything above is considered category I)
Anatomical criteria
Head and face (i) Open or depressed skull fractures (ii) Positive imaging for subdural hematoma, epidural hematoma, or subarachnoid bleed Chest & abdomen (iii) Chest trauma with instability/significant pain (i.e., flail chest and evidence of crush) (iv) Obvious signs of trauma (open pneumothorax, ongoing bleeding, extensive SQ emphysema) (v) Abdominal trauma with significant pain or obvious external signs (i.e., evisceration, open wounds, bleeding) (vi) Imaging evidence of tension pneumothorax or cardiac tamponade or a (+) E-FAST (vii) Signs of an unstable pelvis and/or bleeding Spinal cord (viii) Documented injury with sensory deficits or new-onset paralysis Extremities (ix) Crush or degloving injury (x) Pulselessness or evidence of impaired blood flow in the limb or ongoing bleeding (xi) Two or more proximal long bone fractures (xii) Traumatic amputation proximal to the wrist or the ankle Other injuries to include in category I trauma (i) Two or more body regions with potential life or limb threat (ii) Combination trauma with ≥20% TBSA burn (iii) Other injuries at the discretion of the ED MD
Blunt head trauma (except anticoagulation use: see below) History of blunt chest trauma with pain History of blunt abdominal trauma Blunt extremity trauma deemed significant but not meeting anatomic or physiologic criteria Penetrating extremity trauma not meeting anatomic or physiologic criteria
Mechanism of injury
Penetrating injury to the head, neck, chest, or abdomen with the suspicion of trauma to underlying structure or cavity and/with any of the physiologic criteria above Falls over 20 feet for adult patients Falls over 2 times the height or length of a pediatric patient MVC with any of the following: Prolonged extrication (≥20 min) (i) Rollover and/or ejection (partial or complete) (ii) Death in the same passenger compartment (iii) Intrusion into passenger inches at the driver side or >18 inches at any other side (iv) Motorcycle with a rider thrown from the vehicle (v) Estimated speed above 20 MPH Auto vs. pedestrian with significant impact (damage to the vehicle) or >20 MPH or pedestrian ran over or thrown at any distance
Blunt injury to the head, neck, chest, or abdomen with the suspicion of trauma to the underlying structure or cavity without any of the physiologic criteria above Ground level or standing height falls while on any anticoagulation not meeting category I anatomic criteria All deceleration injuries not meeting anatomic or physiologic category I criteria MVC without significant impact (damage to the vehicle) or <20 MPH Auto vs. pedestrian without significant impact (damage to the vehicle) or <20 MPH
Transfer in patients
Any patient that is transferred from another facility for further definitive care meeting the above criteria
Any patient that is transferred from another facility for further definitive care meeting the above criteria
Additional criteria
At the discretion of the ED physician for patients that do not strictly meet the above criteria
At the discretion of the ED physician for patients that do not strictly meet the above criteria
Sources: (1) Resources for Optimal Care of the Injured Patient 2014 (orange book)—ACS; (2) Guidelines for Field Triage of Injured Patients—CDC. BP: blood pressure; E-FAST: Focused Assessment with Sonography in Trauma with added limited echocardiography; ET: endotracheal; GCS: Glasgow Coma Scale; MVC: motor vehicle crash (including motorcycle crash); MPH: miles per hour of speed; SQ: subcutaneous.