Traumagram Winter 2016

1. Greetings,
Welcome to the internal educational program (IEP) of the Vanderbilt University Division of Trauma,
Emergency Surgery and Surgical Critical Care. Our goal is to provide an opportunity to pursue topics
germane to trauma from all aspects of the team. My hope is to explore all areas of interest throughout the
course of the year including pre-hospital care, acute care issues, post-discharge requirements, as well as
injury prevention. We will attempt to outline the care provided to our trauma patient population from
point of injury until the patients care is completed.
As you know, the trauma team consists of the Chief of the Division, Dr. Rick Miller, our Trauma Program
Manager, Melissa Smith, RN, the Performance Improvement Director, Dr. Tim Nunez, the Outreach and
Prevention coordinator, Cathy Wilson, RN, the Trauma Resuscitation Manager, Kevin High, RN, as well as
the entire trauma faculty and Acute Care Surgery Fellows. Our multidisciplinary liaison team includes
Tyler Barrett (EM), Robert Boyce (Ortho), Joe Neimat (Neurosurgery), Shannon Kilkelly (Anesthesia),
Peter Bream (Radiology) and the LifeFlight team. Our goal is to improve the care of the trauma patient in
a caring and consistent manner and to help minimize injury in the Middle Tennessee region through
outreach and prevention efforts determined by the needs of the community. Please take the time to
review this material and complete the test and evaluation.
Yours Truly,
Oscar Guillamondegui
The ACS trauma education requirement (for faculty
who are not liaisons) may be met by documenting
acquisition of 16 hours of trauma-related CME per
year on average or by demonstrating participation in
an internal educational process (IEP) conducted by
the trauma program based on the principles of
practice-based learning and the PIPs program.
A Message from the
TraumaMedical Director,
Oscar Guillamondegui,MD
Winter 2016

2. 2
ACS Filming for the Rural Trauma Team Development
Course (RTTDC)
On November 14th, the American
College of Surgeons was at
Vanderbilt to film the
communication videos for the
RTTDC. Vanderbilt was selected
as the host site thanks to the
Division of Trauma putting on
over 13 courses over 1.5 years
(18 total since it’s inception), the
most in the country. Dr. Richard
Sidwell (ACS-RTTDC Chair) got
wind of this and selected our site.
The Rural Trauma Team
Development Course (RTTDC)
emphasizes a team approach to
the initial evaluation and
resuscitation of the trauma
patient at a rural facility. The
course assists health care
professionals in determining
the need to transfer the patient
to a higher level of care. The
one-day course includes
interactive lectures on both
medical procedures and
communication strategies and
three team performance
scenarios.
Recently Dr. Brad Dennis had the opportunity to present a paper on the Rural Trauma Team
Development course and how Vanderbilt was able to decrease time to transfer for Trauma patients. Dr.
Dr. Dennis presented this paper at the 74th Annual AAST meeting in Las Vegas on September 10th. The
authors who worked on this paper and helpd coordinate these courses were: Brad Dennis, MD; Oliver
Gunter, MD; Melissa Smith, MSN, RN; Cathy Wilson, MSN, RN; Michael Vella, MD; Mayur Patel, MD; Tim
Nunez, MD; and Oscar Guillamondegui, MD.

3. 3
1. 1. The risk of requiring hospitalization after a fall in an 85 year old is how many times more likely than fora
65 year old?
a. 1
b. 2
c. 5
d. 10
e. 15
2. All of the followingare perceptions that elderly have about the use of fall prevention measures such as canes
or walkers, EXCEPT
a. They underestimate their fall risk
b. Bracing on a piece of furniture or the wallis just as accessible as a cane
c. They only need the walker when they are leaving their home
d. They don’t believe useof a caneor walkercanreducetheirriskof fall
3. Age related changes in gait include whichof the following:
a. Shorter strides
b. Decreased cadence
c. Wider strides
d. Decreased powerduring toe-off phase
e. All of the above
4. Whichof the following statements is true regarding elderly patients that fall?
a. They are likely to be dead in less than a year
b. COPD may bea contributingfactor
c. The risk of traumatic brain injury after a fallis 55%
d. Canes definitively reduce the risk of a fall
5. All injury types in the elderly are problematic, the one with the highest impact on life or lifestyle
a. Humerus fracture
b. Hip fractures
c. TraumaticBrainInjuries
d. Grade 2 spleen injury
Answer Key for Summer 2015 Trauma IEP Newsletter
(answers are in bold and Italics below)

4. 4
Presented By: Michael Krzyzaniak, MD
Transfusion reactions are rare events in the modern era of trauma resuscitation or during any blood
product resuscitation for any reason. The symptoms of a transfusion reaction can be subtle to profound and
life threatening. The most frequently occurring symptoms are urticaria, pruritis, flushing, fever or chills,
and a maculopapular rash. Some more serious symptoms indicating a severe transfusion reaction are chills
with rigors, hypotension, back or abdominal pain, hematuria, severe shortness of breath, and loss of
consciousness.[1]
The cause of acute transfusion reactions in situations of blood type mismatch favors a two-hit model,
which can lead to a hemolytic process or TRALI. Human error leading to the administration of an incorrect
ABO blood type to an incompatible recipient remains the most common cause of transfusion reaction.[2] In
this scenario, if not stopped quickly enough, as little as 50mL of transfused incompatible ABO blood has a
lethality rate of 20%.[3] In the two-hit model, the first hit is an underlying patient factor like infection or
systemic inflammation which primes inflammatory cells, both of which frequently apply to the severely
injured trauma patient. The second hit is the result of transfused blood products leading to activation of
primed cells.[4, 5] Hemolytic transfusion reactions occur in two forms. If IgM is the driving mediator,
complement fixation occurs with ensuing large scale intravascular hemolysis which can be life threatening.
If IgG is the predominant mediator, this typically leads to red blood cells getting tagged for destruction or
eliminated by the reticuloendothelial system causing a much more indolent and less severe form of
hemolysis.[3, 4] Although, IgG can cause complement fixation under rare circumstances, this is far less
common than IgM.
Transfusion-related acute lung injury or TRALI is clinically uncommon, but remains a risk of blood
product transfusion with a high associated mortality. TRALI is reported to occur in anywhere from 0.1% to
15% of transfused patients at time periods anywhere from 6 to 72 hours after product transfusion with
mortality rates from 5 to 8%.[6] Because of the ill-defined time period of diagnosis as well as nonspecific
diagnostic criteria, the true incidence of TRALI is unknown. The two-hit model of neutrophil sequestration
and pulmonary endothelial priming followed by transfusion of blood products is accepted as the etiology.
That said, despite knowing the etiology, the treatment strategy remains supportive.
Identification of a transfusion reaction demands increased awareness and vigilance by the team of
health care providers. The mainstay of therapy is to immediately stop the transfusion and notify the
responsible physician caring for the patient. Detailed information about what processes to initiate in the
instance of a transfusion reaction are outlined in section VII of the Vanderbilt Blood Product Adminstration
policy available online at http://www.mc.vanderbilt.edu/root/vumc.php?site=vmcpathology&doc=39142.
Much is known and has been written on prevention strategies to avoid transfusion reactions. Vamvakas and
Blajchman nicely summarize 6 strategies to reduce transfusion-related mortality. They include: 1) avoid
Blood Transfusion Reactions

5. 5
unnecessary transfusions using evidence-based guidelines, 2) reduce the risk of TRALI associated with
platelet transfusion by using single male donor or nulliparous female donors, 3) augment patient
identification procedures to prevent hemolytic transfusion reactions, 4) avoid pooled blood products, 5)
WBC reduction of cellular blood components administered to in cardiac surgery, and 6) pathogen reduction
of platelet and plasma components.[7]
What to do if you suspect a blood transfusion reaction at Vanderbilt:
A. Monitor and observe for signs and symptoms of Transfusion Reaction which include: Urticaria, chills,
headache, flushing rigors, jaundice, oliguria, fever (1 degree centigrade or 2 degrees Fahrenheit rise
in temperature from the pre-transfusion temperature), back pain, abdomen pain, or chest pain, heat
or pain at the infusion site, respiratory distress, anaphylaxis, wheezing, laryngeal edema, dyspnea,
hyper/hypotension, peripheral circulatory collapse, brady/tachycardia, hemoglobinuria (red or pink
urine), excessive bleeding, or shock.
B. If a Transfusion Reaction is suspected:
1. Stop the transfusion immediately.
2. Obtain vital signs.
3. Disconnect the blood tubing directly at the vascular access device hub and preserve the sterility of
the blood tubing. Flush the vascular access device.
4. Confirm (recheck) patient identification and verify against blood product and TAR.
5. Notify the provider.
6. If the provider chooses to continue the transfusion in the presence of symptoms consistent with a
Transfusion Reaction, a provider’s order is obtained from the provider authorizing the continued
transfusion and documented. Continue the transfusion as ordered.
Do not proceed to the following steps. See References for policy on Physician Notification of Change
in Patient Condition.
7. If the provider chooses NOT to restart the transfusion, proceed to the following steps.
8. Notify the Blood Bank (extension 2-2233) and obtain a Suspected Transfusion Reaction form from
E-Docs.
9. Document in the medical record that a suspected Transfusion Reaction has occurred.
10. Send the following to the Blood Bank:
a. Remainder of the blood product, including the IV solution and IV set (needle removed);
b. Scan or copy of the TAR;
c. Completed Report of Suspected Transfusion Reaction form; and
d. Post-transfusion patient blood product sample, purple top (EDTA), properly labeled for
Blood Bank.
11. Contact the provider for further instructions. Some additional interventions may include:
Obtaining a chest x-ray, placing a urinary catheter to track urine output and sending a urine
sample (urinary analysis), peripheral blood smear, lactate dehydrogenase (LDH) bilirubins,
haptoglobin, repeat CBC to the laboratory, giving a diuretic, and administering IV fluids,
antihistamines, antipyretics, or steroids.

6. 6
References:
1. Squires, J.E., Risks of transfusion. South Med J, 2011. 104(11): p. 762-9.
2. Linden, J.V., et al., Transfusion errors in New York State: an analysis of 10 years' experience.
Transfusion, 2000. 40(10): p. 1207-13.
3. Flegel, W.A., Pathogenesis and mechanisms of antibody-mediated hemolysis. Transfusion, 2015. 55
Suppl 2: p. S47-58.
4. Zimring, J.C. and S.L. Spitalnik, Pathobiology of transfusion reactions. Annu Rev Pathol, 2015. 10: p.
83-110.
5. Reddy, D.R., et al., Transfusion-Related Acute Lung Injury After IVIG for Myasthenic Crisis. Neurocrit
Care, 2015. 23(2): p. 259-61.
6. Kim, J. and S. Na, Transfusion-related acute lung injury; clinical perspectives. Korean J Anesthesiol,
2015. 68(2): p. 101-5.
7. Vamvakas, E.C. and M.A. Blajchman, Blood still kills: six strategies to further reduce allogeneic blood
transfusion-related mortality. Transfus Med Rev, 2010. 24(2): p. 77-124.
8. Vanderbilt University Blood Administration Policy found at
http://www.mc.vanderbilt.edu/root/vumc.php?site=vmcpathology&doc=39142
Melissa Smith – Trauma Program Mgr
melissa.d.smith@vanderbilt.edu
Oscar Guillamondegui – Trauma Medical
Director
Oscar.guillamondegui@vanderbilt.edu
Tim Nunez – Trauma PI Director
Timothy.c.nunez@vanderbilt.edu
Cathy Wilson – Trauma Outreach & Injury
Prevention Coordinator
Catherine.s.wilson@vanderbilt.edu
Michael Krzyzaniak– ACS Fellow/IEP
editor
michael.krzyzaniak@vanderbilt.edu
This year the 7th Annual TQIP Scientific Meeting
and Training was held in Nashville. The Trauma
Quality Improvement Program is a
benchmarking program for trauma centers that
works to elevate the quality of care for trauma
patients in their institution.
Oscar Guillamondegui (Trauma Medical
Director and Melisa Smith (Trauma Program
Manager were on hand to give the Opening
Ceremonies and to represent Vanderbilt
Trauma.
Cathy Maxwell, PhD (Vanderbilt School of
Nursing) was on hand as well to present her
work on Geriatric Trauma. She was invited as a
speaker and to sit on a panel about Palliative
Care. After her session on Geriatric Trauma and
the Need for Proactive Palliative Care, she was
awarded the TQIP Best PI Abstract Award!!
Help us in congratulating our very own Cathy
Maxwell!!

7. Division of Trauma and Surgical Critical Care
For any questions in regards to the IEP or Trauma cases
please contact:
Melissa Smith: 322.6745
or
Oscar Guillamondegui: 936.0180