2 nd Annual Spring Conference - PowerPoint Presentation

2 nd Annual Spring Conference May 11th 2018

CTN Agenda 2         2018 Spring Education Conference May 11 th 2018 Location:  Swedish Medical Center Conference Center   8:30 Registration/Light Breakfast provided by CTN   9:00 TPM/TNC PI Subcommittee Q &A   10:00 Cannabis in the Trauma Patient: What you need to know- Rachael Duncan   11:00 State Scoring Tool Update-Grace Sandeno   11:45 Lunch and Networking provided by Swedish Medical Center   12:45 Geriatric Trauma-Cecile D’Huyvetter   1:45 Case presentations                 Swedish/Montrose-Steve Clayton/Erin Houk                 Denver Health-Sherrie Peckham                 St. Anthony’s-Abbie Blackmore 2:45 Break 3:00 Breakout Sessions by Level                 Level 1 and 2- Regina Krell and Stephanie Vega Level 3- Adriana Heins and Erin Houk                 Level 4 and 5- Nancy Bartkowiak

2018 Elected Officers President: Mike Archuleta, Centura Trauma SystemVice President: Valerie Brockman, Castle Rock Adventist HospitalTreasurer: Robbie Dumond, University of Colorado Hospital Secretary: Wendy Hyatt, Swedish Medical Center 3

Educational Committee Educational ChairNancy BartkowiakSt. Thomas More Jodi GreenwoodSt. Mary’s Grand Junction Mike ArchuletaCentura TraumaSherry PeckhamDenver Health Rob Dumond UC HealthWendy HyattSwedish 4

5 This course is taught by physicians and nurses with the goal of  enhancing a trauma center system of care and improving patient care  . Whether a verified mature trauma center or a hospital preparing for designation, this course is designed to assist participants to create strategies, processes, and operations to support trauma center systems based upon their own environments.   The course is highly recommended for trauma medical directors, trauma program managers / coordinators, and administrators

TPM/TNC PI committee Chair :Stephanie Vega UC HealthWendy Erickson St. FrancisRobbie Dumond UC HealthValerie Brockman PenroseSherry Peckham Denver Health Missy Sorensen Swedish6

Injury Prevention CommitteeRobert Hayes St Anthony’s Angela Kedroutek Penrose HospitalRobyn Wolverton UC HealthDarcy Martin SwedishMike Archuleta Centura 7

Webpage MasterValerie Brockman Castle Rock AdventistJodi GreenwoodSt. Mary’s 8

End of the Year Celebration TBA TopicsVenue December 20189

CTN PI Subcommittee Q&ACTN Spring Conference 05.11.2018

Cannabis in the Trauma Patient: What you need to know Rachael Duncan, PharmD BCPS BCCCPClinical PharmacistSwedish Medical Center

Faculty Disclosure Conflict of Interest: None Commercial Support: None

Learning Outcomes Be informed about the current cannabis consumption trends in ColoradoExplain the pharmacologic effect of different forms and strains of cannabisSummarize existing literature for the use of cannabis and describe research limitations Understand the inpatient management of trauma patients that experience cannabis withdrawal syndrome

2016 Report Colorado Department of Public Health & Environment c olorado.gov/cdphe /marijuana-health-report

Public Health Approach Medical marijuana legal since 2000Viewed as an individual doctor/patient decision outside scope of public health policyColorado became one of the first two states in the nation to legalize retail marijuana Paradigm shiftGrouping marijuana with illicit drugsCocaine and heroinGrouping marijuana with other legal substances Alcohol, tobacco, prescription drugsc olorado.gov/ cdphe /marijuana-health-report

Marijuana Use Trends in Colorado Adults

Ever and current marijuana use among Colorado adults Retrieved from colorado.gov/ cdphe /marijuana-health-report

Current marijuana use among adults: NSDUH 2006-2015 and BRFSS 2014-2015 Retrieved from colorado.gov/ cdphe /marijuana-health-report

Current marijuana use among Colorado adults by age categories Retrieved from colorado.gov/ cdphe /marijuana-health-report

Current marijuana use among Colorado adults by gender Retrieved from colorado.gov/ cdphe /marijuana-health-report

Daily or near daily use of alcohol, tobacco, and marijuana among Colorado adults Retrieved from colorado.gov/ cdphe /marijuana-health-report

Summary of Trends Past month marijuana use among adults > national average1/4 adults age 18-25 reported past month marijuana use1/8 use daily or near-daily#s are consistent since legalization Continue to be disparities in marijuana use based on race/ethnicity for adolescents and sexual orientation for both adults and adolescents colorado.gov/ cdphe /marijuana-health-report

Pharmacology Mechanism of action, metabolism, drug interactions

Pharmacodynamics PhytocannabinoidsTHC (tetrahydrocannabinols), CBD (cannabidiols ), CBN (cannabinols), CBG (cannabigerols), CBC (cannabichromenes ), CBV (cannabivarins), THCV (tetrahydrocannabivarins)THC and CBD of primary interestTHC = very psychoactiveCBD = minimally psychoactive Bridgeman MB. P T 2017 42 (3): 180-188.

THC vs CBD Retrieved from zamnesia.com Jul 8, 2017

Receptors Cannabinoid receptor Type 1 (CB1) and Type 2 (CB2): Most common GPCRs in human brainCB1 = central nervous systemCB2 = immune systemVery high TI (LD50/TI50) Cannabis > 10,000EtOH = 10ASA = 20Morphine = 70 Bridgeman MB. P T 2017 42 (3): 180-188.

Endocannabinoid System Retrieved from marijuana.com Jul 7, 2017

Endocannabinoid System Retrieved from www.trichomelabs.com Jul 8, 2017

Review of Cannabinoids THC and CBDTHC: CB1, CB2 partial agonistVery psychoactive, psychedelicCBD: Cannabinoid antagonist, CB2 inverse agonistAlso serotonin, opioid, nuclear, and other effects Not directly psychoactiveVery pharmacologically active Bridgeman MB. P T 2017 42 (3): 180-188.

Cannabis Forms Synthetic cannabinoids (CB1 agonists)FDA-approved “medications”Spice, K2ExtractsBotanical cannabis Medical dispensariesRecreational dispensaries

Synthetic Cannabinoids DronabinolNabiloneBoth are pharmaceutical CB-1 agonists Bridgeman MB. P T 2017 42 (3): 180-188. Images retrieved from www.weedist.com Jul 8, 2017

Dronabinol (Marinol) Synthetic delta-9-THCNaturally occurring component of Cannabis sativa L. Reversible effects on appetite, mood, cognition, memory, and perceptionDose-related, increasing in frequency with higher dosages, subject to great interpatient variability Bridgeman MB. P T 2017 42 (3): 180-188.

Dronabinol (Marinol) Pharmacokinetics:Onset 0.5-1 hr Peak effect 2-4 hrsDuration 4-6 hrsAEs: Tachycardia, orthostatic hypotensionFDA-Approved Indications: Anorexia, chemotherapy-induced nausea Bridgeman MB. P T 2017 42 (3): 180-188. Image retrieved from www.weedist.com Jul 8, 2017

Nabilone (Cesamet) Synthetic delta-9-THCNatural occurring component of Cannabis sativa L. Similar PKs and AEs as DronabinolFDA-Approved Indications: Chemotherapy-induced N/V, chemotherapy-induced N/V prophylaxis Pergolizzi JV. Cancer Chemother Pharmacol 2017; 79 (3): 467-477. Image retrieved from www.weedist.com Jul 8, 2017

Synthetic Cannabinoids Originally experimentalEurope in 2005United States in 2009Spice, K2Schedule 1 as of March 2011 JWH-018, JWH-073, JWH-200, CP-47, 497, cannabicyclohexanol> 60 different known compounds

Synthetic Cannabinoids Full CB1, CB2 agonistsNausea, vomiting, increase in HR and BP, anxiety, agitation, hallucinationsMany different compounds = many different reactions Risk of rhabdomyolysis, seizures possibleWill not result (+) for THC on a urine drug test

Extracts Nabiximols (THC and CBD)Sativex oral mucosal sprayEpidiolex (CBD extract)2 ongoing Phase III studies in pediatric epilepsy Images retrieved from www.slideshare.net/ucsdavrc Jul 8, 2017

Botanical Cannabis Strains Cannabis SativaTHC > CBDIndicaTHC = CBDRhuderalis THC < CBD Retrieved from www.marijuanadoctors.com Jul 9, 2017

Botanical Cannabis Leaving the realm of medication:Established evidence base, clear indications, pharmaceutical preparations, clinical trials, established dosing, known side effectsEnter the realm of “medicinals ”:Evolving evidence base, few trials, no dosing, unclear side effects, exaggerated claims, and no clinical control

Routes of administration

Colorado Report Scientific literature review on potential health effects of marijuana use

EstablishCriteria for studies to be reviewedReview studies and other data Make recommendations for policies intended to protect consumers of marijuana or marijuana products and the publicCollect Colorado-specific data that reports adverse health events involving marijuana use from the all-payer claims database, hospital discharge data, and behavioral risk factors Literature review colorado.gov/ cdphe /marijuana-health-report

Important research gaps related to population-based health effects of marijuana use were identified during the literature and data review processBased on Common limitations of existing researchExposures or outcomes not sufficiently studiedIssues important to public education or policymaking Research gaps colorado.gov/cdphe /marijuana-health-report

Research gaps Common theme among research gaps = need for studies with better defined marijuana-use histories and practicesFrequency, amount, potency, and method of marijuana use, length of abstinence, and a standardized method for documenting cumulative lifetime marijuana exposure Separately evaluate effects for less frequent users vs daily or near-daily usersConsider evaluating separately by age group, sex, or other characteristics when health effect being studied could differ among groups Ex: by age for CV effects, by sex for mental health effects colorado.gov/ cdphe /marijuana-health-report

Research gaps Additional research using marijuana with THC levels consistent with currently available productsResearch to ID improved testing methods for impairment either through alternate biological testing methods or physical tests of impairmentResearch to better characterize the pharmacokinetics/ pharmacodynamics, potential drug interactions, health effects, and impairment related to newer methods of marijuana use such as edibles and vaporizing as well as other cannabinoids such as cannabidiol (CBD) colorado.gov/ cdphe /marijuana-health-report

Indications and Uses The evidence

National Report The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for ResearchThe National Academies of Sciences, Engineering, and MedicineExtensive search of literature databases to identify relevant articles published since the 1999 release of the National Academies report Marijuana and Medicine: Assessing the Science BasePublished January 2017 nationalacademies.org/ CannabisHealthEffects

Conclusion “Despite increased cannabis use and a changing state-level policy landscape, conclusive evidence regarding the short- and long-term health effects – both harms and benefits – of cannabis use remains elusive.” nationalacademies.org/ CannabisHealthEffects

Conclusive or Substantial Evidence Treatment for chronic pain in adults (cannabis)Antiemetics in the treatment of chemotherapy-induced nausea and vomiting (oral cannabinoids) Improving patient-reported multiple sclerosis spasticity symptoms (oral cannabinoids) nationalacademies.org/ CannabisHealthEffects

Moderate Evidence Improving short-term sleep outcomes in individuals with sleep disturbances associated with Obstructive sleep apneaFibromyalgia Chronic painMultiple sclerosis (cannabinoids, primarily nabiximols ) nationalacademies.org/ CannabisHealthEffects

Limited Evidence Increasing appetite and decreasing weight loss associated with HIV/AIDS (cannabis and oral cannabinoids)Improving clinician-measured multiple sclerosis spasticity symptoms (oral cannabinoids)Improving symptoms of Tourette syndrome (THC capsules) Improving anxiety symptoms, as assessed by a public speaking test, in individuals with social anxiety disorders (cannabidiol)Improving symptoms of posttraumatic stress disorder ( nabilone) nationalacademies.org/ CannabisHealthEffects

Insufficient Evidence Cancers, including gliomaCancer-associated anorexia cachexia syndrome and anorexia nervosaSymptoms of irritable bowel syndromeEpilepsy Spasticity in patients with paralysis due to spinal cord injurySymptoms associated with amyotrophic lateral sclerosisChorea and certain neuropsychiatric symptoms associated with Huntington’s diseaseMotor system symptoms associated with Parkinson’s disease DystoniaAchieving abstinence in the use of addictive substancesMental health outcomes in individuals with schizophrenia or psychosis nationalacademies.org/ CannabisHealthEffects

Recommendations Address current research gaps, highlighting the need for a national cannabis research agenda Identify actionable strategies to improve research quality and promote the development of research standards and benchmarksHighlight the potential for improvements in data collection efforts and the enhancements of surveillance capacity Propose strategies for addressing the current barriers to the advancement of the cannabis research agenda nationalacademies.org/ CannabisHealthEffects

Cannabis and Pain

Cannabinoids and pain More than “too stoned to feel pain”Multiple mechanisms at various levelsTissue: Modulation of inflammatory responsePNS: Afferent nociceptive thresholds CNS: Spinal (DH), supra spinal processing (Th, Amy PAG)Synergy: Mu opioid receptors in pain pathways Hill KP. JAMA 2015; 313 (24): 2474-83. Manzanares J. Curr Neuropharmacol 2006; 4 (3): 239-57.

Cannabinoids and pain Majority of the clinical literature is surrounding chronic pain conditions, malignancy, MSNot really applicable to our acute trauma populationAt this time, no recommendation for starting a cannabis product in the acute period after injury Top reported condition in CO for medical marijuana = severe pain (66.7%)Muscle spasm = 18.58% www.colorado.gov/cdphe/medicalmarijuana

Cannabis use with opioids Prevalence in chronic opioid patients: 6.2%-39%Overall prevalence: 5.8%Pros: No clear direct toxic synergy with opioidsEvidence of analgesic synergy with opioidsEvidence of opioid sparing effects25% fewer opioid overdoses in states with medical marijuana Cons:Aberrant opioid related behavior?MVA, falls, accidents?Distinguishing “use” vs “use disorder” may be relevant Abrams D. Clin Pharmacol Ther 2011; 90 (6): 844-51.Perron BE. J Stud Alcohol Drugs 2015; 76 (3): 406-13.Reisfield GM. Pain Med 2009; 10 (8): 1434-41.

Cannabis-Related Syndromes

Cannabis-related syndromes Cannabis hyperemesis syndromeCannabis use disorderCannabis dependenceCannabis addiction Cannabis withdrawal

Cannabis hyperemesis syndrome The rising rate of marijuana sales and consumption has led to the identification of a new clinical condition, cannabinoid hyperemesis syndrome (CHS) CHS is characterized by diffuse abdominal pain presenting in a cyclic manner + severe nausea and vomiting + daily consumption of marijuana Tell-tale sign is resolution of symptoms while bathing in hot water Duncan RW. AJEM 2017; DOI 10.1016.06.038.

CHS Treatment Haloperidol has been found to be effective in case seriesCapsaicin topical may also be of some use Duncan RW. AJEM 2017; DOI 10.1016.06.038.

Cannabis Withdrawal Syndrome SymptomsCommon: Irritability, nervousness, anxiety, dysphoria, sleep difficulty, decreased appetite, weight loss, depressed mood, restlessnessUncommon: GI upset, tremors, sweating, fever, chills, headache, seizure According to DSM-5, CWS is diagnosed if 3+ symptoms develop within 1 week of abrupt cessationCommon co-morbid disorders = alcohol abuse, tobacco abuse Lewis TF. J Drug Educ 2010; 40 (3): 299-314. Marshall K, et al. Cochrane Database Syst Rev. 2014; 12.

CWS Treatment Cannabis replacement therapy: Marshall K, et al. Cochrane Database Syst Rev. 2014; 12.

CWS Treatment Pain:Gabapentin 300 mg PO TID***No role for opioids in the treatment of CWS Sleep Aid:Quetiapine 25-100 mg PO QHSMirtazepine 15-30 mg PO QHS Marshall K, et al. Cochrane Database Syst Rev. 2014; 12.

CWS Treatment Anxiety:Lorazepam 1 mg PO/IV Q6h PRN Olanzapine 2.5-5 mg PO/SL Q6h PRNN/V/Gastroparesis: Haloperidol 1-2.5 mg PO/IV Q6h PRNPromethazine 12.5-25 mg PO/PR Q6h PRNMetoclopramide 5-10 mg PO/IV Q6h PRN Marshall K, et al. Cochrane Database Syst Rev. 2014; 12.

Other CWS Treatment Options Bupropion, nefazodone, divalproex, naltrexone, rimonabant , atomoxetine, buspironeLithium, lofexidine , dronabinol, entacapone, gabapentin, guanfacineNabiximols (THC, CBD) shows some promise300+ compounds in the research pipeline Weinstein AM. Curr Pharm Des 2011; 17 (14): 1351-1358. Marshall K, et al. Cochrane Database Syst Rev. 2014; 12.

Talking to Patients

Conversations with Patients Not the drug of “reefer madness”Talking as if it is:Threatens therapeutic alliance with patientFails to capture the insidious nature of cannabis Employ a non-judgemental, collaborative approach D’Amico EJ. J Consult Clin Psychol 2015; 83 (1): 68-80.Feldstein SW. Psychol Addict Behav 2013; (2): 510-25.

Handling common patient arguments Argument: Cannabis is naturalFallacy: Natural = safeConversation: Rattlesnake poison, opium, cocaineArgument: Cannabis is not addictive Conversation: Has anyone struggled? (9-50% succumb)Argument: Cannabis is less addictive than heroin, cocaine, methConversation: Similar to alcohol – i.e. not without risk D’Amico EJ. J Consult Clin Psychol 2015; 83 (1): 68-80.

Handling common patient arguments Argument: Cannabis is not “physically” addictiveFallacy: As opposed to “psychological addiction?”Conversation: What is addiction? (loss of control)Example: Nicotine, alcohol, cocaine Argument: So far no problemFallacy: No seatbelt no problemConversation: Do risks remain in absence of harm? D’Amico EJ. J Consult Clin Psychol 2015; 83 (1): 68-80.

Handling common patient arguments Argument: Cannabis is “medicine”Conversation: Do medicines have side effects?Argument: Cannabis is a miracle drugExample: Cannabis cures brain cancer Fallacy: Overgeneralizing from limited evidenceConversation:Grant potential of cannabinoid pharmacologyEmphasize standards clinicians must adhere to D’Amico EJ. J Consult Clin Psychol 2015; 83 (1): 68-80.

Conclusion

Conclusions The removal of barriers to research would greatly benefit our understanding on health benefits vs risks of cannabis useTrauma providers should be aware of the effects of routine cannabis use on patients and how to identify and treat cannabis withdrawal syndrome Healthcare professionals are in a unique position to provide informed care to patients that choose to consume cannabis

Other resources Emergency Medical MinuteOnline podcast educational resource for EM topics of interestCannabis in Medicine: Is the Grass Greener?https://emergencymedicalminute.com/cannabis-in-medicine-is-the-grass-greener /

Discussion

References Abrams D, Couey P, Shade S, Kelly M, Benowitz N. Cannabinoid-opioid interaction in chronic pain. Clin Pharmacol Ther 2011. 90 (6): 844-51.Bridgeman MB, Abazia DT. Medicinal Cannabis: History, Pharmacology, and Implications for the Acute Care Setting. P T 2017; 42 (3): 180-188.Centers for Disease Control and Prevention. Marijuana and Public Health. 2017. <www.cdc.gov/marijuana/health-effects.htm>Budney AJ, Vandrey RG, Hughes JR, Thostenson JD, Bursac Z. Comparison of cannabis and tobacco withdrawal: severity and contributions to relapse. J Subst Abuse Treat 2008; 35 (4): 362-8.Centers for Disease Control and Prevention (CDC). Alcohol-Related Disease Impart (ARDI). Atlanta, GA: CDC. 2012 WHO Data.Crean RD, Crane NA, Mason BJ. An evidence based review of acute and longterm effects of cannabis use on executive cognitive functions. J Addict Med 2011; 5 (1): 1-8.Dean A. Illicit drugs and drug interactions – a review. Pharmacist 2006; 25 (9): 684-9.

References D’Amico EJ, Houck JM, Hunter SB, Miles JN, Osilla KC, et al. Group motivational interviewing for adolescents: change talk and alcohol and marijuana outcomes. J Consult Clin Psychol 2015; 83 (1): 68-80.Di Marzo V, De Petrocellis L. Endocannabinoids as regulators of transient receptor potential (TRP) channels: a further opportunity to develop new endocannabinoid-based therapeutic drugs. Curr Med Chem 2010; 17: 1430-49.Duncan RW, Maguire M. AJEM 2017; DOI http://dx.doi.org/10.1016/j.ajem.2017.06.038.Elphick MR, Egertova M. The neurobiology and evolution of cannabinoid signaling. Philos Trans R Soc Lond B Biol Sci 2001; 356 (1407): 381-408.Feldstein SW, McEachern AD, Yezhuvath U, Bryan AD, Hutchison KE, et al. Integrating brain and behavior: Evaluating adolescents’ response to a cannabis intervention. Psychol Addict Behav 2013; (2): 510-25.Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet 2009; 374 (9698): 1383-91.

References (continued) Hayatbakhsh MR, Flenady VJ, Gibbons KS, Kingsbury AM, Hurrion E, et al. Birth outcomes associated with cannabis use before and during pregnancy. Pediatr Res 2012; 71 (2): 215-9.Hill KP. Medical marijuana for treatment of chronic pain and other medical and psychiatric problems. JAMA 2015; 313 (24): 2474-83.Lewis TF, Mobley AK. Substance abuse and dependency risk: the role of peer perceptions, marijuana involvement, and attitudes toward substance use among college students. J Drug Educ 2010; 40 (3): 299-314.The National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids. 2017. <nationalacademies.org/CannabisHealthEffects>Lopez-Quintero C, Perez de los Cobos J, Hasin DS, Okuda M, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: results of NESARC. Drug Alcohol Depend 2011; 115 (1-2): 120-30.

References (continued) Lynskey M, Hall W. The effects of adolescent cannabis use on educational attainments: a review. Addiction 2000; 96; 1621-30. Manzanares J, Julian MD, Carrascosa A. Role of the cannabinoid system in pain control and therapeutic implications for the management of acute and chronic pain episodes. Curr Neuropharmacol 2006; 4 (3): 239-257.Marshall K, Gowing L, Ali R, Le Foll B. Pharmacotherapies for cannabis dependence. The Cochrane Library 2014, Issue 12. DOI: 10.1002/14651858.CD008940.pub2.McGrath J, Welham J, Scott J, Varghese D, Degenhardt L, et al. Association between cannabis use and psychosis-related outcomes using sibling pair analysis in a cohort of young adults. Arch Gen Psychiatry 2010; 67 (5): 440-7. Meier MH, Caspi A, Ambler A, Harrington H, Houts R, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proc Natl Acad Sci USA 2012; 109 (40): E2657-E2664.

References Owen KP, Sutter ME, Albertson TE. Marijuana: respiratory tract effects. Clin Rev Allergy Immunol 2014; 46 (1): 65-81.Patton GC, Coffey C, Carlin JB, Degenhardt L, Lynseky M, et al. Cannabis use and mental health in young people: cohort study. BMJ 2002; 325: 1195.Pergolizzi JV, Taylor R, LeQuang JA, Zampogna G, Raff RB. Concise review of the management of iatrogenic emesis using cannabinoids: emphasis on nabilone for chemotherapy-induced nausea and vomiting. Cancer Chemother Pharmacol 2017; 79 (3): 467-77.Perron BE, Bornert K, Perone AK, Bonn-Miller MO, Ilgen M. Use of prescription pain medications among medical cannabis patients: comparisons of pain levels, functioning, and patterns of alcohol and other drug use. J Stud Alcohol Drugs 2015; 76 (3): 406-13.Pertwee RG. The pharmacology of cannabinoid receptors and their ligands: an overview. Int J Obes (Lond) 2006; 30 (Suppl 1): S13-8.

References Pope HG, Gruber AJ, Hudson JI, Huestis MA, Yurgelun-Todd D. Cognitive measures in long-term cannabis users. J Clin Pharmacol 2002; 42 (Suppl 11): 41S-47S. Reisfield GM, Wasan AD, Jamison RN. The prevalence and significance of cannabis use in patients prescribed chronic opioid therapy: a review of the existent literature. Pain Med 2009; 10 (8): 1434-41.Sewell RA, Poling J, Sofuoglu M. The effect of cannabis compared with alcohol on driving. Am J Addict 2009; 18 (3): 185-93.Thomas G, Kloner RA, Rezkalla S. Adverse cardiovascular, cerebrovascular, and peripheral vascular effects of marijuana: what cardiologists need to know. Amer J Cardio 2014; 113 (1): 187-190.Watanabe K, Yamaori S, Funahashi T, Kimura T, Yamamoto I. Cytochrome P 450 enzymes involved in the metabolism of tetrahydrocannabinols and cannabinol by human hepatic microsomes. Life Sci 2007; 80: 1415-1419.Weinstein AM, Gorelick DA. Pharmacological treatment of cannabis dependence. Curr Pharm Des 2011; 17 (14): 1351-1358.

Questions? rachael.duncan@healthonecares.com

83 State Scoring Tool Update-Grace Sandeno

84

85 Geriatric Trauma-Cecile D’Huyvetter

86 Case presentations                 Swedish/Montrose-Steve Clayton/Erin Houk                 Denver Health-Sherrie Peckham                 St. Anthony’s-Abbie Blackmore

Trauma Outreach andPI Process Steve Clayton, RN, TNCSwedish Medical CenterandErin Houk, MSN, RN, TPM Montrose Memorial Hospital

58 y/o motorcyclist, unhelmeted, hit by vehicle at 30 mphScene: LOC; physician from Montrose at scene ED arrival BP: 71/53, HR: 77, GCS = 15Evaluation/resuscitation in ED; received 7 RBC/6 FFP and one pack of plateletsTransfer delays due to FW availabilityAfter conversation about Aortic Injury and intraabdominal arterial bleed it was decided to stabilize at Montrose To OR for exploration /damage control operationAirlifted to Swedish Medical Center January 31, 2017

Arrival 0004 after stabilization in MontroseIntubatedInjury was at 5 p.m. that day Hit at the right side by another vehicleLOC at sceneOpen R femur, open bilateral wristOpen R tibial fracture Pelvic fractureAortic transectionMesenteric arterial bleeding on abdominal CT scan requiring damage control surgery with packs Trauma Activation SMC

Arrival At SMCBP: 172/94 CBC: 11.3/33.8/ plt 102ABG: 7.28/38/346/17.9/-8.3AntibioticsAortic Stent at 0800Damage control orthopedic surgery at 1100 I and D and ex fix of all fractures

Communication for all parties (Surgeons, Staff, TNC, Education) Communication between TNCs to review PI Fluid overload Transfer delay BP during transfer Communication for family support Communication

Thoracic Aorta Tear – hemorrhage into mediastinumMesentery rentInterspinous Ligament Tear C-spine ConcussionDiagnosed later:SDH, bilateralDAI Patient Injuries (ISS 38, 43 days in hospital)

FRACTURES:Bilateral rib fractures (R 10 th, L 12th)Right transverse acetabulumLeft superior ramus, highly comminuted Left Inferior parasymphyseal pubis Right sacrum Right femur shaft, open Right open olecranon Left distal radius, open, extraarticular, displaced Left ulnar styloid Right tib/fib shaft Right patella C4 SP and lamina and TVP C5 TVP, C7 TVP T2-7 TVP , T1 foramen transversarium T1 transversarium, Left T2-T7 TVP… More Patient injuries

Acute Kidney Injury ETOH withdrawalUpper GI bleedRespiratory failure – trach Cholecystitis, cholangitisPancreatitisRhabdomyolysis Complications

Transferred to Multi-Trauma Unit with trach on ventilatorTrach collarTolerating enteral feedsPlaced at an LTAC on 03/15 Following commands, trach downsizedInteracting with family at bedsideWaking now

Outreach

Case Review and Presentation to Montrose Memorial HospitalCase Presentation at Delta Trauma Conference Education

CommunicationInitial decision to OR Repeated surgical procedures Follow-up by TNCPI processLoop closure Great Job

Colorado Trauma System Rural Trauma CTN May 2018

Rural Trauma Case Presentation 100 ERIC 28 M 65- 75 mph collision with rear of semi 12/16/2016 @ 1100 Colby KS

Logan County Hospital, Oakley KS 12/16/2016 1152 101

Logan County Hospital Vital statistics 95/68 BP HR111Sats 92%GCS <8Open wound chest/armPotential injuries:L femur fx, openR elbow fx, openL ribs, hemo / ptx Transfer to Garden City……. InterventionsBilateral IV placementIVF hungLeft chest needle/ chest tubeAir splint left legIO placed R legRBC hungFoley placedIntubation attempts/ King airway placement102

St. Catherine Hospital Garden City KS 12/16/2016 1604 103

St. Catherine Hospital Vital statistics HR 109 BP 78/5991.4 THct 19To Level 1 trauma centerInterventions 9L pta …..#10, 11 up Blood startedTXA administeredETT to replace KingL chest tubeR chest tubeCentral line104

St. Anthony Hospital, Lakewood CO 12/16/2016 1934 105

Injuries 106 Injury ICD10 Dx Text(do not use in reports) CONTUSION, LUNGS, BILATERAL, L > R LAC, R KIDNEY, GRADE III LAC, SPLEEN, GRADE II FX, RIBS, L, 3-7 SAH, BILAT, + LOC FX, L ACETAB, TRANSVERSE, NON DISPFX, L FEMUR, DISPLACED, MULT FRAGMENTSFX, L RADIUS, OLECRANON, OPEN, NFSPSEUDOANEURYSM, R ICA PSEUDOANEURYSM, L ICA FX, T5, PEDICLE AND SUPERIOR ARTICULAR PROCESS LAC, CHEST WALL, NFS, 43 CM ISS = 34

Inpatient LOS = 28 Procedures Procedure ICD10 Text PLAIN RADIOGRAPHY OF CHEST COMPUTERIZED TOMOGRAPHY (CT SCAN) OF HEAD COMPUTERIZED TOMOGRAPHY (CT SCAN) OF CERVICAL SPINE COMPUTERIZED TOMOGRAPHY (CT SCAN) OF CHEST, ABDOMEN AND PELVIS USING LOW OS COMPUTERIZED TOMOGRAPHY (CT SCAN) OF HEAD AND NECK USING LOW OSMOLAR CONTRACOMPUTERIZED TOMOGRAPHY (CT SCAN) OF FACIAL BONES COMPUTERIZED TOMOGRAPHY (CT SCAN) OF ABDOMINAL AORTA USING LOW OSMOLAR CONTCOMPUTERIZED TOMOGRAPHY (CT SCAN) OF THORACIC SPINECOMPUTERIZED TOMOGRAPHY (CT SCAN) OF LUMBAR SPINEINSERTION OF INTRALUMINAL DEVICE INTO INFERIOR VENA CAVA, PERCUTANEOUS APPRULTRASONOGRAPHY OF ABDOMENMONITORING OF ARTERIAL PRESSURE, PERIPHERAL, PERCUTANEOUS APPROACHDRAINAGE OF RIGHT PLEURAL CAVITY WITH DRAINAGE DEVICE, PERCUTANEOUS APPROACINSERTION OF EXTERNAL FIXATION DEVICE INTO LEFT FEMORAL SHAFT, PERCUTANEOUSDRAINAGE OF LEFT ELBOW REGION, OPEN APPROACH REPOSITION LEFT RADIUS WITH INTERNAL FIXATION DEVICE, OPEN APPROACH MONITORING OF INTRACRANIAL PRESSURE, PERCUTANEOUS APPROACH MONITORING OF INTRACRANIAL SATURATION, PERCUTANEOUS APPROACH REPAIR CHEST SKIN, EXTERNAL APPROACH DRAINAGE OF LEFT ELBOW REGION, OPEN APPROACH DRAINAGE OF LEFT FEMORAL REGION, OPEN APPROACH REPOSITION THORACIC VERTEBRAL JOINT WITH INTERNAL FIXATION DEVICE, OPEN APP IRRIGATION OF RESPIRATORY TRACT USING IRRIGATING SUBSTANCE, VIA NATURAL OR INSPECTION OF TRACHEOBRONCHIAL TREE, VIA NATURAL OR ARTIFICIAL OPENING ENDO BYPASS TRACHEA TO CUTANEOUS WITH TRACHEOSTOMY DEVICE, PERCUTANEOUS APPROACH REPOSITION LEFT FEMORAL SHAFT WITH INTERNAL FIXATION DEVICE, OPEN APPROACH REPOSITION LEFT RADIUS WITH INTERNAL FIXATION DEVICE, OPEN APPROACH REPOSITION LEFT ULNA WITH INTERNAL FIXATION DEVICE, OPEN APPROACH RESPIRATORY VENTILATION, GREATER THAN 96 CONSECUTIVE HOURS MAGNETIC RESONANCE IMAGING (MRI) OF BRAIN MAGNETIC RESONANCE IMAGING (MRI) OF CERVICAL SPINE MAGNETIC RESONANCE IMAGING (MRI) OF THORACIC SPINE DRAINAGE OF LEFT PLEURAL CAVITY WITH DRAINAGE DEVICE, PERCUTANEOUS APPROACH COMPUTERIZED TOMOGRAPHY (CT SCAN) OF CHEST AND ABDOMEN USING HIGH OSMOLAR C Complications CVA VAP 107

Craig Rehab Hospital 1/12/2017 Patient was discharged from inpatient TBI rehab with a small field cut, but completely independent. 108 GREAT SAVE!!

Keys to success…. 109

110 Breakout Sessions by Level                 Level 1 and 2- Regina Krell and Stephanie Vega Level 3- Adriana Heins and Erin Houk                Level 4 and 5- Nancy Bartkowiak

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