UVa Trauma Pearls

University of Virginia Health System

LEVEL ITRAUMA CENTER

TRAUMA HANDBOOK

Final Editing by:

Jeffrey S. Young, MDProfessor of Surgery

Medical Director, Quality andPerformance Improvement

Medical Director, Trauma Center

James Forrest Calland, MDAssistant Professor of Surgery

Associate Medical Director, Trauma Center

http://tinyurl.com/uvatraumamanual

2 6/11 UVA TRAUMA HANDBOOK

This handbook is also available online via theClinical Portal, Trauma web pages, and the EPIC link

from the Trauma Admission Order Set.

A summary of changes and additions in this version of theTrauma Handbook can be found in the reference section.

http://www.healthsystem.virginia.edu/clinician-portal/index.cfm

http://www.healthsystem.virginia.edu/internet/trauma-center/

UVA TRAUMA HANDBOOK 6/11 3

MAJOR CONTRIBUTIONS BY:

Kathy M. Butler, RN, CCRNTrauma Center Manager

Kristi Kimpel, RN, MSN, CCRN, CCNSSurgical / Trauma / Burn ICU

Julie Haizlip, MDAssistant Professor of Clinical Pediatrics

Division of Pediatric Critical Care

David Mayo, B.S., RRTRegistered Respiratory Therapist

David Volles, Pharm.D., BCPSClinical Pharmacy Specialist

Susan MurphyLynn Welch

Production Support

Acknowledgements

Mary Deivert, RN, MSN, ACNP, CCRN

Suggestions for revisions and additions are encouragedand should be emailed to [email protected]

Produced by the Trauma ProgramAll rights reserved.

Fifth EditionJune 2011

Fourth EditionAugust 2010; Revised February 2011

Third EditionJuly 2009; Revised October 2009


INTRODUCTION“The term ‘cookbook medicine’ is much maligned. However, fewchefs would attempt a complex dish without a recipe to guidethem, and few musicians would attempt a complex piece withoutwritten music to direct them. These guidelines are not meant tomandate rigid adherence, but are meant to provide a framework,based on extensive experience and knowledge. Revisions to theseguidelines are welcomed, but these revisions should be evaluatedduring a period of intellectual reflection, and not in the ED at2AM. The clinician should use these guidelines to provide safeand effective care to injured patients.”

To the many individuals who have contributed to the TraumaCenter Handbook, thank you.

Jeffrey S. Young, M.D.Professor of SurgeryMedical Director, Qualityand Performance ImprovementMedical Director, Trauma Center


Guidelines are general and cannot take into account allof the circumstances of a particular patient. Judgmentregarding the propriety of using any specific procedure orguideline with a particular patient remains with that patient’sphysician, nurse or other health care professional, takinginto account the individual circumstances presented by thepatient.


2011-12 CHIEFS & FELLOWS

PAGER PAGER

GENERAL SURGERY VASCULAR & TCV3393 Butler, Paris 3870 Adams, Joshua2241 Dengel, Lynn 6895 Carrot, Phil6164 Stokes, Jayme B 4679 Gazoni, Leo3291 Taylor, Matthew D 3396 Griffiths, Eric

2266 Grubb, KendraTRANSPLANT 3167 Isbell, Jay2923 Dorn, Harry 4627 Tesche, Leora6234 Kane, Bart 2925 Zamora, Alvaro

4TH YEARS6623 Flohr, Tanya R 6582 Nagji, Alykhan4422 Hennessy, Sara 2880 Parker, Anna4882 Hranjec, Tjasa

3RD YEARS4061 Campbell, Kristin T. 4705 Shada, Amber L.4853 LaPar, Damien J. 3158 Walters, Dustin M.6594 Riccio, Lin 3119 Mericli, Alexander F Plastics

2ND YEARS4992 Davies, Stephen CAT 2276 Guidry, Christopher CAT2995 DeGeorge, Brent Plastics 2685 Newhook, Timothy CAT3767 Gillen, Jacob CAT 2744 Pope, Nicholas CAT

1ST YEARS3024 Balireddy, Ravi ANES 4063 Hu, Yinin CAT6181 Davila-Aponte, Jennifer URO 4038 Mehta, Gaurav NDP6954 Davis, John CAT 4345 Nadar, Menaka RAD6994 Dieth, Zachary CAT 6682 Sheeran, Daniel RAD6177 Doerr, Matthew OPHth 4630 Timberlake, Matthew URO2146 Edwards, Brandy CAT 6742 Ugas, Marco RAD6121 Haddad, Zeina OPHth 6442 Wagner, Cynthia CARD3921 Hankins, Jeanette RAD 4715 Willis, Rhett CAT6178 Hanna, Kasandra Plastics 4782 Yount, Kenan CARD

RESEARCH6963 Johnston, W Forrest 4088 Politano, Amani (Sawyer)

6552 Judge, Joshua (Slingluff) 6635 Rosenberger, Laura (Sawyer)

6966 Lindberg, James M. 6988 Salerno, Elise P.6554 McLeod, Matt (Slingluff) 6939 Stone, Matthew (Kron)

6587 Petroze, Robin (Calland)


CONTINUED

CONTACT DIRECTORY

Phone Pager

TRAUMA ALERT GROUP MEMBERS

9162 Adult Trauma Alert Intern1294 Trauma Alert 2nd yr

531-3494 1560 Trauma Chief1459 Trauma Alert Backup Chief1311 Anesthesia Resident9248 Consult & PACU1564 Trauma Attending1450 Trauma Intern – Acute Care1294 Trauma Resident – ICU1297 Trauma Consult – Day1824 Pediatric Trauma Chief1356 Peds Trauma Intern1707 Peds Trauma Attending

531-5703 ED: 2nd yr (consults)3-6341 3-6317 ED: Attendings

1391 Chaplain1576 NSGY Resident 21822 Nursing Supervisor1371 OR Charge Nurse1616 Respiratory Therapy-Adult1716 1684 (RT Back-ups)1742 Respiratory Therapy-Pediatric1989 Radiology Portables (no charge)

4-2120 1384 Social Worker-ED

CONTACT DIRECTORY

284-2845 3462 Trauma Center Director, Jeff Young, MD2-3549 Administrative Assistant, Amy Bunts

242-9458 Assoc. Trauma Director, Forrest Calland, MD2-4278 Administrative Assistant, Cynthia Carrigan

465-5152 3404 Trauma Attending: Rob Sawyer, MD227-1278 6151 Trauma Attending: Carlos Tache Leon, MD

4-8000 3868 Trauma Center Manager, Kathy Butler, RN284-1923 Cellular

1908 Back up Trauma Attending


CONTINUED

CONTACTSCONTINUED FROM PREVIOUS PAGE

Phone Pager9520 Floor Attending

Trauma Service Nurse Practitioners4334 Deborah Baker, ACNP2471 Jennifer Edwards, ANP6744 Gabriele Ford, FNP-C4676 6 East SW - Beverly Pitts

531-5839 ED Charge Nurse531-5701,02 ED Attending #1, #24-9295 ED Reg Fax4-1201 ED “back” Fax4-5227 (1) LAB

4-2273 Blood Bank3-9218 Bed Center RN

3142 Neuro CNS

RADIOLOGY3-9296 CT

1234 CT Tech1404 Head CT Resident–ED Board

Body CT Resident–ED Board4-9338 Diagnostic Work Area4-9400 Image Management (choose options 3, then 2)

1844 IR Resident (Request on-call IR Nurse also)3-9535 IR Department2-3155 MRI2-2526 4701 MSK Reading Room Coordinator (even months)2-3432 1492 Neuro Reading Room Coordinator (odd months)

CONSULTS1415 Acute Pain Service1251 Orthopedics ED1609 Consultants: ENT1518 Plastics- Consult ER1800 Plastics Intern6811 Psych Nurse - Brenda Barrett1288 TCV night1847 Thoracic Chief1847 Thoracic Day Consult1253 Urology1378 Vascular Day Consult1818 Vascular Chief


TRANSFER HOSPITALSHospital Main Phone Film RoomAugusta 800-932-0262 540-932-4483Culpeper 800-232-4264 540-829-4144 or 4145Lynchburg 877-635-4651 434-200-4139Martha Jeff. 434-654-7000 434-654-7104Roanoke 540-981-7000 540-981-7126Rockingham 800-543-2201 540-433-4380 or 4386

QUALITY CONCERNS

284-1923 3868 Kathy Butler, RNPlease share adult or pediatric trauma concerns with the traumacenter manager promptly (within 72hrs) by phone or pager.

TRAUMA REGISTRY REPORT REQUESTS

3-4858 Michelle Pomphrey RN4-1770 Sera Downing

Extensive adult and pediatric injury data are available.Please allow 7 business days for report generation.

CONTACTSCONTINUED FROM PREVIOUS PAGE

Phone Pager


TABLE OF CONTENTS PAGE

TRAUMA ALERT PROCESS 12-16CT Algorithm for Pregnancy 15

TRAUMA ALERT CRITERIA 17-18Trauma Alert Considerations 19

PEARLS 20-21Trauma Service Communications 22-23Discharge Planning 24Discharge Summary Guidelines 25-26

TRAUMA PRACTICE GUIDELINES – ADULT (Alphabetical)Abdominal Penetrating Trauma 27Airway Management – Emergent 28ARDS Patients - Ventilated STBICU 35ARF Tracheostomy Planning 29

Tracheostomy Patients In Adult Acute Care 30-31Ventilator Paralysis Trial 32Ventilation – Proning 33-34

Brain Injury –Brain Injury: Initial Assessment 36-37Brain Injury Sedation 38Intracranial Pressure Management Guideline 39-40Guidelines for Craniotomy / Craniectomy 41

Burn –Major, Respiratory Management 42-43Adult Burn Fluid Resuscitation Guidelines 44-49

Cardiovascular Failure, Non-Hypovolemic 64-65Chest Trauma

Blunt Myocardial Injury 50Blunt Thoracic Trauma 51Epidural Protocol 52-53Penetrating Central 54

Deep Venous Thrombosis 55Extremity Trauma – Penetrating or Blunt 56Hematuria 57Pelvic Fracture Algorithm 61Pulmonary Embolism Workup & Treatment 62Resuscitation 63Rhabdomyolysis 58Sepsis Alert 70Definitions for Inflammatory Response, Sepsis 71Spine Clearance Algorithm 66-69Spleen and Hepatic Trauma, Non-operative Management 59-60

CONTINUED


PAGE

REFERENCES 72-90Overview of Guideline Changes 72Injury Scales 73-78

Lung 73Spleen 74Liver 75Kidney 76Heart 77-78Diaphragm 78

PT / OT Service Guidelines 79Long Term Acute Care Hospital 80-81Assignment of Palliative Care Code to Patient Med. Record 82-83Organ Donation 84-85Discharge Against Medical Advice Checklist 86Sedation Guideline – Adult Critical Care Units 87

High-Risk Agitation Guideline 88Richmond Agitation-Sedation Scale (Rass) 89-90Trauma: Pain and Sedation Guidelines 91-92

PEDIATRIC GUIDELINES 93-119Sedation Service 96Brain Injury 97-113

Guidelines for the Management of Intracranial 98Hypertension in Children with Closed Head Injury

I. Standard Therapy for All Children 98-99II. Sequential Treatment of Elevation in ICP 100-102III. Severe, Abrupt Elevation in ICP and/or

Manifestation of Impending Herniation 103IV. Sequential Treatment of Decreased MAP / CPP 103-104

Sequential Treatment for ICP >20 mmHg (All Ages) 105Second Tier Treamtnet for ICP > 20 mmHg (All Ages) 106Severe, Abrupt Elevation ICP and/or Manifestationof Impending Herniation 107Treatment of Decreased MAP → Decreased CCP 108Sequential Treatment for ICP >20 mmHg (All Ages) 109Severe TBI Standard Therapy Checklist 110-111Clinical Pathway Evaluation of the Pediatric

Cervical Spine 112-113Near Drowning/Submersion Injury 114-115Non-accidental Trauma (Abusive Injury) 116-117Hemostatis in Pediatric Neurotrauma 118-119ADULT MEDICATION REFERENCES 120-130

TABLE OF CONTENTSCONTINUED FROM PREVIOUS PAGE


TRAUMA ALERT PROCESS

PRE-ALERT CONSIDERATIONS• Team conference with introductions, review of roles and

responsibilities, and contingency planning when time allows• Reference trauma indicators for activation criteria• Standard for notification of team: immediately upon meeting

criteria• Trauma team response – immediate based on expected

arrival, to be in ED prepared for patient prior to arrival• Chief needs to reference outside hospital imaging prior to

patient arrival whenever possible

BASIC EVALUATION• ABCDE assessment• 2 large bore IV’s• CXR, pelvis x-ray (if patient hemodynamically stable, pelvis

may be withheld if patient A&Ox4 and non-tender), andtrauma labs

INDICATIONS FOR IMMEDIATELY SECURING AIRWAY• Inability to follow commands• Inability to protect airway• Inability to safely complete workup• Shock• Severe inhalation injury

BREATHING• Decompress chest if decreased breath sounds or

subcutaneous emphysema with Sa02 < 90%• Bilateral chest decompression for blunt agonal or

anterolateral thoractomy if indicated

CIRCULATION• Hemorrhage control (consider suture, pelvic binder, BP cuff,

splints)

CONTINUED


CONTINUED

TRAUMA ALERT PROCESSCONTINUED FROM PREVIOUS PAGE

• Consider resuscitative thoracotomy if:

witnessed arrest (blunt)

recent arrest (penetrating)• Aggressive volume resuscitation (± PRBC) indicated for blunt

agonal• May hold/withdraw thoracotomy if PEA, wide complex and

HR <40

DEFICITSAssess neurologic status (GCS) and extremity movements,sensation x 4.

EXPOSURE• Mark penetrating wounds with paperclips where appropriate

(open= posterior)

FAST EXAM

RADIOGRAPHY IMAGING• CXR - All patients• Pelvis xray – all blunt trauma (may be withheld if patient

A&Ox4, non-tender and hemodynamically stable)• Head CT

Loss of consciousness Altered LOC Significant trauma above clavicles

• Facial CT Severe facial injuries

• CTA Neck Fractures through C1 - C4 Seat belt sign or extensive bruising on neckCerebral infarct Acute anisocoriaNeuro deficits / decline / clinical picture not consistent

with injury Petrous fracture GCS < 8 w/out explanatory findings on CT of the head



CONTINUED

• CT Thorax Significant thoracic injuries on CXRRapid deceleration mechanism Abnormal mediastinal contour

• Abdominal CT Abnormal CXR Abnormal pelvis x-ray Spine fracture Abnormal abdominal exam Abnormal labs (HCT, LFT’s, amylase)Hematuria or GU injury Inability to examine patient for the next 4 hours Any prior hypotension

- mechanism (?) (if any of above criteria are not met,likelihood of intraabdominal injury is <1%)

• Mediastinal Evaluation The trauma service will be responsible for mediastinal

evaluation Patients with low-risk (mechanism only, obese, no

significant thoracic injury (single rib fractures) get adynamic chest CT with their abdominal CT Patients with significant thoracic injuries (high-risk) will get

a CTA with their abdominal CT Positive dynamic chest CT will get a CTA

• Spine Evaluation If known fracture anywhere in the spinal column, perform a

complete spine work-up.OSH process: All OSH spine films will be read for Trauma

Alerts. An order must be placed indicating this need.

• Admission to the Trauma Service Any of the criteria noted in the trauma consult or alert Any situation where the good of the patient would be

served


CT ALGORITHM FOR PREGNANCY

Avoid CT through pelvis to avoidradiation exposure to

cranial vault / fetal brain.

Consider CT options for lower radiationdosing (consult with radiologist),

Or alternative to CT imaging of pelvis:

e.g., CT IVP / cystogram for imaging ofGU system, or MRI of pelvis.

No

Yes

Obtain routine traumaimaging.

Consider obtainingpre-imaging Beta-HCGif not otherwisecontraindicated bypatient status.

Known pregnancy?

or

Fetus visible on plain film/TorsoScout Images on CT?

➤

➤

Is pt hemodynamicallyunstable and / or have abdominal

tenderness and / or aknown pelvis fx?

Obtain routine traumaimaging.

Consider obtainingpre-imaging Beta-HCGif not otherwisecontraindicated bypatient status.

➤

Yes

No

➤



STBICU ADMISSION• Any intubated multiple trauma patient• Any intubated acute post-op trauma patient (except

neurosurgery for isolated head injury) e.g. patient withisolated femur fracture who cannot be extubated post-op

• Any trauma patient at significant risk for respiratorycompromise because of their injuries OR BECAUSE of theirbaseline medical fraility.

• Any trauma patient at significant risk of bleeding• Any trauma patient with evidence of active bleeding• Any trauma patient with multiple rib fractures who cannot

blow 1000cc on incentive spirometry (especially elderlypatients)

• Any of these patients who cannot be admitted to the STBICUmust have their admission location cleared by the traumaattending before confirming bed assignment

NNICU ADMISSION• Patients initially admitted to Neurosurgery with reason for ICU

admission• Patients with isolated head or spinal cord injury, with no

evidence or risk of hemorrhage (negative abdominal, chest,and pelvic evaluation), admitted to trauma service

6 WEST ADMISSIONS• Acute care spinal cord and head injury

6 EAST ADMISSIONS• Trauma/orthopedics

CONSULTATIONS

• For patients transferred to other services or admitted to otherservices, the Trauma Service will no longer sign off on anypatient until the Trauma Attending signs off, in writing.


CONTINUED

ALPHA ALERT - Attending Trauma Surgeon presence within 15minutes of patient arrival

1. Airway obstruction or respiratory compromise including intubatedpatients who have been transferred from another facility withongoing respiratory compromise.

2. Confirmed hypotension

a) SBP < 90 on 2 consecutive measurements

b) age-specific hypotension in children [SBP < 80 + (2* age)]

c) Absense of peripheral pulses

d) Transfer patients receiving blood to maintain SBP >90

3. Gunshot wounds to the neck, chest, or abdomen

4. Advanced pregnancy (fundus above umbilicus) with abdominaltrauma

5. Mass casualty incident: >2 patients with Beta Alert Criteria

6. Or per Emergency Medicine Physician / Trauma Service discretion

BETA ALERT - Full Team response - Discretionary Trauma Attendingpresence. Patient has NO Alpha Alert Criteria and one or more of thefollowing:

1. Severe single system injury (including penetrating head trauma)

2. Respiratory

a) Intubated at scene or < 2 hours prior to arrival at UVA withNO ongoing respiratory compromise

b) Mechanically assisted ventilation and NOT intubated

c) Facial Burns or singed facial hair with altered phonation

3. Cardiovascular

a) Cardiac Arrest – blunt mechanism

b) Relative Hypotension: SBP > 90 but < 100 mm Hg(<110 mm Hg in > 65 yrs)

c) Active hemorrhage (with stable vital signs)

4. Neurological

a) GCS < 13 or GCS > 1 point below baseline or N / V

b) Tetraplegic, hemiplegic, or persistent neurologic deficit

c) Open or depressed skull fracture

d) Known intracranial bleeding from outside study withknown or suspected history of injury (including GLF)

TRAUMA ALERT CRITERIA


TRAUMA ALERT CRITERIACONTINUED FROM PREVIOUS PAGE

CONTINUED

5. MSK

a) Two or more proximal long-bone fracturesb) Amputation proximal to wrist or anklec) Crushed, degloved, or mangled extremity

6. Stab wounds to neck, chest, or abdomen7. Burns: Adults > 40%, Pediatric > 25% TBSA8. Concomitant thermal / multi-system injury9. Or per Emergency Medicine Physician / Trauma Service

discretion

GAMMA ALERT - Surgical Chief presence within 30 minutes ofactivation; Patient has NO Alpha or Beta Alert Criteria and has one ormore of the following:

1. Altered mental status (GCS lower than baseline by only 1 point)and/or intracranial blood present on in-house CT (even if from GLF)

2. Severe pain in chest, abdomen, neck, or back3. Significant solid organ injury4. Pelvic fractures5. 2 or more organ systems/body areas significantly injured6. Operative therapy anticipated / planned by subspecialty service7. Moderately injured with severe medical co-morbidities8. Time-sensitive extremity injury9. Early Pregnancy with abdominal pain / signs of abdominal trauma

10. High energy mechanism:High-risk falls:• adults: fall >20 feet (one story = 10 feet)• children aged <15 years: fall >10 feet or 2 -3 x child’s height;

11. High-risk motor vehicle collision:• extrication or intrusion intrusion: >12 inches to the occupant

site or >18 inches to any site• ejection (partial or complete) from automobile• death in same passenger compartment• vehicle telemetry data consistent with high risk of injury;

12. Auto versus pedestrian/bicyclist thrown, run over, or withsignificant (>20 mph) impact

13. Motorcycle collision >20 mph14. Or per Emergency Medicine Physician / Trauma Service

discretion


Equipment available: Ultrasound / dopplers / full 02 tank Uncrossmatched blood in room Limit number of staff in CT to 3 due to small space

Post-patient Arrival

Always send an ABG even if venous to get rapid HCT Vocalize ABC findings 1st Good neuro exam before intubating or going to the

Operating Room. Obtain info, if possible, before intubation (weight, allergies,

family contact) If blood administration – Rapid Infuser / warmer Hemorrhage? Blood Alert (massive transfusion) call Blood

Bank to request 4-2273 Examine under cervical collar 1 person call CT only when ready to leave resus area Initiate signing all verbal medication orders when in CT Notify bed center ASAP 3-9932 to request bed All ED Deaths need a note from the chief resident All OR Deaths need a dictated note from the senior resident

or attending

TRAUMA ALERT PROCESSCONTINUED FROM PREVIOUS PAGES

TRAUMA ALERT CONSIDERATIONS

Pre-Patient ArrivalPre-alert conference held?

Orders in?Prompt nurse/tech to obtain cooler with blood for transport if

anticipated as a possible need (Hypotensive, receivingblood, etc.

Clean hands pre-post gloving Eye shield, mask, lead shield, gown if within reach of

patient Pre-alert review responsibilities / priorities, including

probable drug needs Document time out on all invasive procedures unless true

life-threatening situation Minimize number of people in the room so that staff can

have unobstructed access to patient and supplies Chief and residents involved in care check in with nurse

recorder and assure your name and pic are recorded.


PEARLSTrauma Surgery Service Pearls

• All PEGS in patients on the TRAUMA SERVICE are to besewn into place at the time of placement WITHOUTEXCEPTION.

• It is expected that a chief or attending physically be presentto round on all Intensive Care Units with trauma servicepatients before noon. If the chief feels he/she will be unableto fulfill this expectation, the attending must be notifiedimmediately so that he may fulfill this importantresponsibility. The chief/attending is to check in with thenursing staff at the time of the visit and leave a clear planregarding discharge planning.

• Attending / Chief Floor rounds shall occur at 2 pm daily onweekdays, and immediately after ICU rounds on weekends.

• If a TLSO is ordered, it must be on before standing pt upright

• Indicators for Speech Evaluation:

- Altered mental status, > 1 point difference from baseline

- Trauma to mandible, oropharynx, or larynx

- Intubation > 72 hours

- Clinical suspicion of ongoing aspiration

• In general, morphine is to be avoided in patients on theTRAUMA Service. Use fentanyl for frail or hemodynamicallyunstable pts, use dilaudid in young pts with severe pain.

• Workup when cause of fall / injury / MVC is unclear:

Holter Monitor or 24hr review of telemetry / ICU alarmhistory

Assess for seizures (tongue soreness, incontinence)

Assess for recent changes in medications

Suicidality?

• Tertiary Survey – If pt A&O perform tertiary survey. If not,perform within 48 hrs when A&O. Full visual & joint mobilityassessment including UE & LE resistance strengthevaluation assessing for reports of pain. Documentcompletion and positive findings. Identify what hurts, whathas ecchymosis and image it. Planter flexion checks for painresponse (may indicate weight bearing concerns, jointimaging needs). Image areas of concern.

CONTINUED


• Operative Treatment of Abdominal Hemorrhage – “if youpack it, squirt it”

• Bleeding scalp lacerations – consider early whip stitchinstead of staples.

• Penetrating trauma initial assessment – roll early! Mark allwounds.

• Blood Alert – early activation of blood alert may improvesurvival.

• Interventional radiology / embolization may be an acceptabletreatment modality for hypotensive patients with hemorrhagefrom isolated severe pelvic fractures and negativeabdominal exam/FAST. Occasionally this will even occurbefore CT. If laparotomy precedes interventional radiology,temporary closure may be desirable.

• In general, injured patients belong on the Trauma Service,not the Medicine Services.

• Any bad ABG must be repeated or treated with intubation.

• In general, we admit most patients to trauma for the first24hrs with some exceptions such as isolated severe TBI.

• Psych must leave note in the chart that a sitter is no longerneeded.

• Yes, simultaneous craniotomy / thoracotomy / laparotomy /peripheral vascular repair are possible!

• Thoracic hemorrhage >1.5 liters must receive expeditiousoperative therapy.

• In general use of benzodiazepines in patients with naturalairways is discouraged, especially in the elderly. ConsiderHaldol for delirium instead.

• Consider removing one line or tube daily on patients whoare improving clinically.

• Incidental Findings: All incidental findings that possiblyrepresent neoplasm or metatastic disorders with potentialfor severe consequence require definitive consultation priorto discharge and notation in the discharge summary withoutexception.

PEARLSCONTINUED FROM PREVIOUS PAGE


TRAUMA SERVICE COMMUNICATIONS

JUNIOR RESIDENTS TO CONTACT CHIEF

• Saturations < 90 not responding to one intervention

• Arrhythmia with hypotension

• Lactic acidosis not corrected by 8 hours after admission

• Urine output less than 0.5 cc/kg/hr not responding to oneintervention

• Before any antibiotics are begun

• Before Swan-Ganz catheter is placed or bronchoscopy isperformed

• Before any consult other than Ortho, Face, Spine, orNeurosurgery is called.

• Increase in PEEP > 8, increase in mean airway pressure >15, increase in peak pressures > 30, increase in FIO2 greaterthan 50% for more than 30 minutes.

• Decrease in BP < 90 not responding to single intervention.

• Decrease in CI >1 L/M, and/or increase in LA > 2.5

• Significant change in abdominal exam.

• Significant change in lab tests (pancreatitis, drop in HCT of10% or more, elevation of creatinine > 1.5)

• Temp > 39.5

• Before any consult service cancels or performs a procedureor takes the patient to the OR

• Acute deterioration in neurologic status

• Updated DNR status (patient/family requests DNR/comfortmeasures only) CONTINUED


CHIEF TO CONTACT ATTENDING

Call Attending If:

• Significant family conflict

• Transfer to ICU

• All admissions and consults

• Any major conflict with Consult service

• Cardiac, respiratory arrest

• Any complication of procedure or consult procedure

• Death (if not DNR)

Text Attending If:

• Death if DNR

• On evidence of organ failure (CV, resp, renal, neuro)

• Missed injury

• Consult operation

• Before bronchoscopy, Swan-Ganz, or other major bedsideprocedure during daytime hours

• Patient leaving AMA

TRAUMA SERVICE COMMUNICATIONSCONTINUED FROM PREVIOUS PAGE


DISCHARGE PLANNING

DISCHARGE ORDERS

Trauma Service Clinic appointments should be with either Dr.Young, Calland or Tache-Leon. For Dr. Sawyer’s patients, hewill specifically request when a f/u apt with him is indicated.

Post-chest tube insertion: No flying for 4 weeks postdischarge date; follow up chest x-ray first.

Note follow-up plan for incidental findings:

Incidental Findings: All incidental findings that possiblyrepresent neoplasm or metatastic disorders with potential forsevere consequence require definitive consultation prior todischarge and notation in the discharge summary withoutexception.

For spleen & hepatic injuries —• No contact sports• No strenous exercise

The Transitional Care Hospital at the University of Virginiaprovides Long Term Acute Care (LTAC) services to medicallystable but complex patients. Patients who require this level ofcare are too ill for discharge to home, a nursing facility, or anacute care rehabilitation facility.

Transitional Care Hospital (LTAC) referrals for vent weaning:

• Discuss plans with RT, Request RT do a NegativeInspiratory Flow (NIF) and Vital Capacity (VC)

• Discuss the medical indications for LTAC referral withfamily

• Call Social Work

TRANSITIONAL CARE HOSPITAL


DISCHARGE SUMMARY GUIDELINES

Discharge summaries must be dictated before residents rotateoff service and within 7 days of discharge. Non-compliance istracked and reported.

Patient’s NameMedical Record NumberAdmission DateDischarge DateAccount NumberAttending PhysicianReferring Physician

PRIMARY DIAGNOSIS:1. Multiple Trauma2. List all injuries including lacerations, abrasions, and

contusions with the most significant injuries first3. Any relevant diagnostic imaging studies, laboratory and

surgical pathology findings, must be documented in theclinical notes to be applicable for coding purposes.Pneumothorax MUST be documentated as traumatic.

Injury Documentation Keys:1. List specific number of rib fractures2. Specify grade of all organ injuries3. Specify LOC duration for all head injuries. DOCUMENT if

patient did not return to their baseline mental status.4. Specify head injury ex: concussion, contusion, etc NOT CHI5. Note Hemoperitoneum if appropriate

PROCEDURES:1. List all procedures2. Specify “sharp, excisional debridement if tissue was

physically “clipped or cut” away, please dictate excisionaldebridement within the heading of “OP REPORT”.Excisional debridement should be documented whenperformed in the OR or at the bedside.

3. Specify “blood loss anemia” if reason for blood transfusions

CONTINUED


PAST MEDICAL HISTORY:1. List all co-morbid conditions including history of alcoholism

or substance abuse, as well as COPD, Diabetic etc.

PAST SURGICAL HISTORY:

HISTORY OF PRESENT ILLNESS:1. Primary reason for admission such as: rule out head injury,

or treatment of splenic lac. NOT: multi trauma

PHYSICAL EXAM:

RADIGRAPHIC STUDIES:

LABORATORY STUDIES:1. Specify lab values and if abnormal document hyper or hypoconditions by specify name.

HOSPITAL COURSE:

DISCHARGE CONDITION:

DISPOSITION:

DISCHARGE MEDICATIONS:1. If antibiotic list reason for, this is a potential “acquired”

condition in house, and could affect severity of illnesscoding.

FOLLOW UP APPOINTMENTS:Follow-up clinic appointments will be with Dr. Young, Dr.Calland or Dr. Tache Leon.

Dr. Sawyer does not have trauma follow-up appointmentsunless he requests to see the patient.

General Surgical attendings taking trauma call do not havetrauma follow-up in clinic.

DISCHARGE SUMMARY GUIDELINESCONTINUED FROM PREVIOUS PAGE


ABDOMINAL PENETRATING TRAUMAGUIDELINE

Trajectory likely (or possibly) through abdomen: from nipples/tip of scapula to inguinal ligaments:

ABCDE’sCXR

FAST ExamUnasyn 1.5 g + Tetanus

Previous GSW?

Unstable Stable

OR for Laparotomy1 /Thoracotomy2

Mark Wounds3

Flat plate X-Rays of allpossible trajectories4

Stab Wound GSW

Tender / tachycardic /nauseated:Laparotomy

Non-tender:Local wound explorationor laparoscopyLap. if violation of post.fascia / peritoneum

Tender / tachycardic ortrans-abdominal:

Laparotomy

Non-tender:CT Scan w / contrast +/-LaparoscopyLaparotomy if violation ofperitoneum

➤

1. Prep Chin to Knees, table-to-table, prep penis if urologic injurysuspected.

2. Resuscitative thoracotomy acceptable prior to laparotomy3. Closed paper clips: anterior wounds

Open paper clips: posterior wounds4. Bullets + Wounds: must = even number

Obtain pediatric surgery / OB consult for pregnant patients.The SAFEST place for the UNSTABLE patient is

in the Operating Room.

➤➤➤

TRAUMA PRACTICE GUIDELINES - ADULT


AIRWAY MANAGEMENT – EMERGENTCLINICAL PROTOCOL

PURPOSEThis document describes the expectations and roles ofphysicians and other credentialed providers, respiratorytherapists and registered nurses caring for adult patients withthe need for urgent or emergent airway management in theacute and critical care units and the Emergency Department.

PROTOCOL1. Identify the need for airway management.2. Initiate basic airway management by locally trained

healthcare personnel within the scope of jobresponsibilities; in life threatening situations acredentialed physician with advanced airway managementtraining may manage the airway prior to the arrival of theanesthesiologist.

3. Page 1311 for the anesthesiologist on-call AND call4-2012 to overhead page for respiratory therapy supervisor.

4. Page the respiratory therapist covering that unit/area if notalready present.

5. Upon arrival at the bedside, the anesthesiologist assumesleadership for directing the management of the patientairway. The anesthesiologist performs endotrachealintubation or, clinical situation permitting, the localphysician or other credentialed provider (or trainedrespiratory therapist in the STBICU: per Department ofRespiratory Therapy Policy 210) continues to manage theairway under the anesthesiologist’s supervision.

6. In the critical care units or the Emergency Department, acredentialed physician with advanced airway managementtraining and competency may assume responsibility formanaging the patient airway. In the STBICU, a trainedrespiratory therapist may initiate advanced airwaymanagement. In these situations, the physician or othercredentialed provider determines the need foranesthesiology consultation.

7. Anesthesiology will be called to the EmergencyDepartment as part of the trauma alert.


ARF PATIENTTRACHEOSTOMY PLANNING

PRACTICE GUIDELINES

EARLY EVALUATIONShould occur at day 5. If the following criteria are met,schedule tracheostomy for day 7:• Failure of CPAP trial, without explanation (sedation, head

injury)• FIO

2 > 50% to maintain saturation greater than 90% Does

not apply if patient presently on lung protective strategy• Severe head injury with GCS< 8T and no evidence of rapid

recovery. Patients undergoing treatment for ICH should notundergo tracheostomy.

SUBSEQUENT EVALUATION:Should occur after first week of ventilator support:Patient unlikely to wean by day 10 due to:• Mental status• Secretions• Pulmonary co-morbidities• Large intra-pulmonary shunt

All tracheostomies should be done by day 10Tracheostomies performed after this undergo performanceimprovement evaluation in all cases.

OTHER ISSUES: Complete clearance of spine should becompleted by day 3Peep < 8Percutaneous tracheostomy at bedside is first choiceEnteral access should always be considered in conjunctionwith tracheostomy.In general #4 Shiley trach should not be used in adult traumapatients.The cuff should be deflated on acute care patients.Consider pre-diet speech evaluation.

CONTINUED


CLINICAL PROTOCOLTRACHEOSTOMY PATIENTS IN ADULT ACUTE CARE

Purpose: This document describes the actions required byregistered nurses caring for adult patients with a tracheostomyin the acute care settingProtocol:Order entry must be completed by MD or RN or RT1. Set up patient’s room with the following equipment:

• Suction, oxygen flow meter, resuscitation bag and mask,air flow meter,

• Spare tracheostomy tube at bedside2. Oxygen/Humidity:

• Use humidification for all patients with tracheostomy.• Titrate oxygen (via trach collar) to maintain oxygen

saturation > to 93%.3. Assessment:

• Respiratory Therapy (RT) will assess the patient every 4hours for the first 24 hours after transfer from ICU, andthen,

• RT will assess at least - q 8 hours or as indicated bymedication regimen.

• Suction prn as indicated by assessment.• Notify MD for blood clots and/or moderate bleeding around

and/or through the tracheostomy.4. Tracheostomy cuff:

• The tracheostomy cuff should remain deflated for all acutecare patients.

• If special circumstances require cuff to remain inflated, MDshould place an order. Cuff pressure should be assessedand documented every shift by RT.

• If cuff inflation becomes necessary, notify RT for patientassessment.

5. Inner cannula care:• Replace disposable inner cannula daily or more frequently

if indicated.• Clean and replace non-disposable inner cannula every shift

or more frequently if indicated.CONTINUED


6. Suture Removal:• Suture removal is the responsibility of the physician/

service that performed the tracheostomy.• The RT may perform suture removal on day 7 if airway is

secure and sutures remain in place (ENT patientsexcluded).

7. Speaking Valve:• Speaking valve may be used as tolerated per procedure

18-9.2 in the Adult Acute Care Procedure Manual• Remove speaking valve at bedtime (HS) per

manufacturer’s guidelines and resume trach collar / T-piecewith humidification. HME (heat moisture exchange) is notrecommended.

• Supplemental O2 (not to exceed 6 LPM) may be delivered

through the speaking valve.• Notify RT to assess patient if oxygen requirements exceed

6LPM.8. Nocturnal care of tracheostomy patient:

• Resume trach collar / T-piece with humidification. HME isnot recommended.

9. Travel:• When leaving the nursing unit, the patient should travel

with a resuscitation bag and mask, spare tracheostomy(same size as the current tracheostomy,) obturator, ifavailable, empty 10mL syringe, pink saline bullet,appropriately sized suction catheter, and size 8 sterilegloves.

In general, patients on the TRAUMA Serviceshould not be decannulated until the patient

no longer requires acute care.

Clinical decision tools are general and cannot take into account allof the circumstances of a particular patient. Judgment regarding thepropriety of using any specc procedure or guideline with a particularpatient remains with that patient’s physician, nurse or other health careprofessional, taking into account the individual circumstancespresented by the patient.

Origin: Oxygen Therapy Workgroup Approved: Pt Care Committee 08/07

TRACHEOSTOMY PATIENTS IN ADULT ACUTE CARECONTINUED FROM PREVIOUS PAGE


VENTILATIONPARALYSIS TRIAL

PRACTICE GUIDELINE

1. Consider neuromuscular relaxants (NMRs) when P/F ratio< 100 mm Hg

2. Monitor the pressure waveform on the ventilator screen toascertain if the patient is making respiratory efforts or isdyssynchronous with the ventilator

3. The initial action is to increase the patient’s sedation

4. NMRs should be given only if the patient is dyssynchronouswith the ventilator, is having frequent oxygen desaturations,and is unresponsive to increasing sedation.


VENTILATION – PRONINGPRACTICE GUIDELINE

EXCLUSION CRITERIA

• Hemodynamically unstable (patient requires frequentinterventions to maintain SBP > 90 mm Hg)

• Unstable spine

• Elevated intracranial pressure

• Pregnancy

• Uncontrolled agitation

• Glaucoma / recent ophthalmic surgery

• Gross abdominal distension

COMPLICATIONS

• Inadvertent extubation or loss of IV lines

• Pressure sores • Corneal damage

REASONS TO ABORT PRONING

• Persistent (> 5 minutes) hemodynamic instability

• Persistent (> 5 minutes) decrease in O2 saturation(> 5% decrease from baseline)

PROCEDURE

• Ensure that the patient does not have an unstable spine

• Treat any agitation with increase in sedation

• Increase FiO2 to 100% for 5 minutes prior to turning

• Place cardiac electrodes on patient’s limbs or back

• Disconnect tube feeds and any nonessential lines/wiresduring the turning process

• Draw baseline ABG and record BP, HR and SaO2 before

turning

CONTINUED


VENTILATION – PRONINGCONTINUED FROM PREVIOUS PAGE

• Ensure that sufficient staff are present to assist in the turningprocess–always a minimum of 4 staff–the person most skilledin airway management should be assigned to manage thepatient’s head and endotracheal / tracheostomy tube

• The direction of the turn should always be TOWARD theventilator

• Once prone, elevate the patient’s head and dependent eye offthe bed using a foam pillow or other suitable device,supported at forehead and chin. Ensure that the patient’sdependent eye is closed and not in contact with any surface.

• Perform frequent checks of the patient’s skin, pressure points,and eyes.

• The patient’s head should be turned every 2 hours by liftingthe patient’s chest from the bed (requires 3 people–RRTshould always be present).

• The head of bed should be elevated (reverse Trendelenburg)to decrease head/facial edema. This position should bemaintained when patient returned to supine position.

RECOMMENDED SCHEDULE FOR TURNING

• Avoid turning the patient between the hours of 2100 and 0700

• Patient should be turned every 12 hours

• Patient should be turned into the prone position in the earlyevening and maintained in this position until after 0700 thenext day. Patient should then be turned supine in order tocheck skin and perform nursing care.

• If the patient’s oxygen saturation significantly deteriorateswhen supine, return to the prone position.

• A second attempt at turning the patient supine may be madein the afternoon–returning to the prone position overnight.


ARDS PATIENTS — VENTILATEDSTICU CRITERIA FOR TRANSPORT

PRACTICE GUIDELINES

POPULATION DEFINITION:• PaO

2 / FIO

2 ratio < 100 mm Hg

• Minute ventilation > 20 liters• PEEP > 18 cm H

2O

If patient meets above definitions, transport must meet thefollowing conditions:• Cranial CT for acute neurologic change• Abdominal CT for acute physiologic change• Thoracic angiography to rule out pulmonary embolism, or

other life-threatening condition• Other justification that bears in mind high-risk of transport

Patients should not be transported for:• Feeding tube placement• Spinal clearance, without neurologic deficits• Orthopedic workup without risk of SCI or spinal instability• Routine CT for non life-threatening issues

If transport still deemed necessary, 30 minute trial on travelventilator must be done in ICU:• Trial successful: O2 saturation > 90%, hemodynamics

unchanged• Trial failed: Sats < 90%, hemodynamic instability

Respiratory therapist will remain with the patient while off unit,including operating room.

These transports should be discussed with the unit chargenurse no later than 9AM on the day of transport, unlessemergent.


↓

BRAIN INJURY: INITIAL ASSESSMENT

Assess airway and neuro status

↓

Intubate if GCS < 10 or if airway compromise exists

Support using Resuscitation Guideline*

↓

↓

CONTINUED

↓

CXR, pelvic x-rayLarge bore IV access

Trauma labs (correct coagulopathy)**

↓

Penetrating Injury: thorough examination for other GSW***

Reference the additional brain injury guidelines(resuscitation and increased intracranial pressure)

Immediate head CTPenetrating Injry: Angiogram follows head CT if Zone III

TBI-RELATED TREATMENT GOALS:• INR < 1.2• PaCO2 35-40 mmHg• SBP > 90 mmHg

Goal PaCO2 if posturing orfixed, non-reactive pupils:25-30 mmHg↓

If Licox present: maintain Pbro2 > 20Call attending / fellow if sustained < 20


* Hyperventilation and Mannitol are only indicated if patient isposturing, and / or has dilated, asymmetric, or non-reactive pupils.

• 20% mannitol 0.25 - 1.0 g / Kg IVP• Hyperventilate to goal P

aCO

2 25-30 mmHg

** All patients with traumatic brain injury and actual orsuspected intracranial hemorrhage must receive RAPIDcorrection of the INR (with FFP) AND / OR correction ofplatelet dysfunction with platelet transfusion.

*** In general, maxillofacial hemorrhage from a GSW to theface is best treated through angiographic intervention. Inintubated patients, the nares and mouth may be packedwith kerlix to attain hemostasis prior to definitive care.

• Any acute cerebral hemorrhage should be admittedto NIMU or ICU for 1st 24 hrs.

• In general, all patients with intracranial blood in thesetting of traumatic brain injury should receive 7 or >days prophylaxis with Dilantin or Keppra.

BRAIN INJURY: INITIAL ASSESSMENTCONTINUED FROM PREVIOUS PAGE


BRAIN INJURY SEDATIONPRACTICE GUIDELINE

ICP PLACEMENTICP monitors will be placed at the discretion of the Neurosurgeryservice. In general, patients with GCS <9 and/or intracranial mass

lesions will require ICP placement.

SEDATION

ICP MONITOR IN PLACE↓

YES↓

Sedation (Midazolam) /Paincontrol (Fentanyl) should be

attained so that patient isunresponsive. If paralysis

needed, use Cisatracurium.0-1 twitch from train of four

should be present.↓

When mental status needs tobe evaluated, D/C paralytics

and switch to continuousPropofol infusion.

(See non-monitored guideline)

↓NO↓

Sedation/Pain Control(Fentanyl) and Propofol –

titrate to level where patientcan be easily ventilated

and cooperative with medicaltreatment.

↓Confirm with NSGY resident

time of exam, 30 minutesbefore scheduled neuro exam,

stop Propofol and↓

If patient cannot be controlledoff Propofol, call NSGY

resident immediately and ask ifthey wish to perform exam,if they are unavailable, try to

sedate with Fentanyl.Restart Propofol if necessary.

↓Neuro exam should be

performed on NSGY roundseach morning; therefore,confirm with NSGY that

Propofol can be stopped at6:30 AM.


INTRACRANIAL PRESSURE MANAGEMENT GUIDELINE

Yes No

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CONTINUED

Optimize positioning:• Head midline• HOB > 30 degrees

(reverse Trendelenberg ifspines not cleared)

o Patients with bonyclearance of C/T/L spinescan have HOB up withc-spine immobilization

o Determine optimal HOBfor patient(typically 30-70 degrees)

• Check neck collar andendotracheal tube securingdevice – remove jugularcompression to permit venous

Indications for ICP monitoring and consideration of otherneuromonitoring (Licox, cerebral blood flow, etc):

• GCS < 8 and mass lesion on head CT

• GCS < 8 plus posturing with negative head CT

• GCS < 8 with expectation of prolonged wait for exam(e.g. going to OR or angio, requires heavy sedationfor pulmonary management)

Monitor patient.Consider other causes ofdecreased LOC. Consider

withdrawing sedating medications.

GOAL OF TREATMENTIS TO

MINIMIZESECONDARY BRAIN INJURY:

• PaCO2 35-40 mm Hg(continuous EtCO2 monitoring)

• CPP > 6O mm Hg withSBP > 90 mm Hg

• Temp < 38.0°C

• Euvolemia or mild hypervolemia

• Na+normal or sightly high

➤

➤➤

Maintain CPP > 60 mm Hg *

* If pressor support needed after preload optimized:levophed = 1st linevasopressin = 2nd line


Sedation/analgesia with fentanyland midazolam OR propofol

If ventricular drain, check orders forCSF drainage intervention

Neuromuscular blockade

ICP > 20 mm Hg for > 5 min?

Contact neurosurgery to discuss20% mannitol 0.25 – 1.0 gm/kg IV

bolus OR hypertonic saline

Neurosurgery will consider:• Placement of EVD• Craniectomy• Pentobarbital

Consider gradualdecrease in therapyonce ICP< 20 mm Hgfor > 12 h.

Note: In certain patients,neurosurgery may set an ICPgoal of < 25 mm Hg.Post-craniectomy, the ICP goalmay be set at < 15 mm Hg.



Call NSGY


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➤➤

➤➤

➤➤

➤

➤

➤

No

No

No

No

➤

Yes

Yes

Yes

Yes

Yes

INTRACRANIAL PRESSURE MGT.GUIDELINECONTINUED FROM PREVIOUS PAGE


➤

* See Clinical Portal for dosing of hypertonic saline

https://www.healthsystem.virginia.edu/documentation/manuals/CPGuidelines/1.060_HypertonicSalineProtocol_AdultNeuro.pdf?CFID=26882574&CFTOKEN=14a7cb3273337eef-4E2F5982-C447-E4A2-1DCDEC862F648D3B&jsessionid=8430b6e7c6b34f7f8ce31e4c867672567102


ADULT GUIDELINES FOR CRANIOTOMY/CRANIECTOMY

INDICATIONS FOR SURGERYfrom the American Brain Trauma Foundation

Epidural Hematoma• Volume > 30 CM3 or• if GCS < 9, > 15 mm thick, or > 5 mm shift

Subdural Hematoma *• > 10 mm thickness or > 5 mm shift• Change in GCS > 2 points or anisocoria or ICP > 20

Intraparenchymal hemorrhage• Clinical deterioration referable to lesion• Refractory intracranial hypertension• Mass effect• In patients with GCS 6 – 8, if volume > 20 CM3, and 5

mm shift or cisternal compression• Volume > 50 CM3

* GCS < 9 = ICP Monitor

The complete Brain Trauma Foundation Guidelines areavailable at http://tbiguidelines.org.


BURN (MAJOR)RESPIRATORY MANAGEMENT

PRACTICE GUIDELINEINHALATION INJURYInhalation injury should be suspected if there is history ofentrapment in a closed space. The patient may present with ahoarse voice, new onset cough or shortness of breath, andmay also have carbonaceous sputum, singed nasal hairs andfacial edema. Diagnosis may be confirmed by bedsidebronchoscopy. Patients should be treated with vigorouspulmonary toilet and ambulation (as appropriate) to assist inairway clearance of particulate matter. Intubation and ventilatorsupport should be initiated if there is profound facial edema(anticipated or present) or difficult ventilation and/oroxygenation based on direct airway injury. Persistent debris inthe airway may need to be removed by serial endoscopicbronchopulmonary lavage. Evidence of carbon monoxidepoisoning may warrant hyperbaric oxygen therapy consult evenif the carbon monoxide has normalized in the bloodstream.

Identification:• All enclosed fires• Explosions• Patients with: carbonaceous sputum, increased carboxy-

hemoglobin levels (>5%), hypoxia, and/or facial and mouthburns

ABG and CXR: mandatory

Endotracheal Intubation:• Should be performed immediately by anesthesia (consider

paging Respiratory Therapy supervisor (1616) for bronchcart)

• If: any evidence of respiratory distress or upper airwayswelling (stridor, severe cough, hoarseness, voice change)

• Bronchoscopy for diagnosis and treatment in first24 hours

CONTINUED


Extubation Criteria:• Patient follows commands• Audible leak around a 7.0 or higher ET tube• Meet extubation criteria by Respiratory Therapy• No evidence of progression of airway disease

Ventilator Management: see protocols to follow

Tracheostomy Considerations:• Intubated >7 days without immediate expectation of extubation• Extubation failed twice• Major problem with secretions (suctioning required q2h, recurrent mucus plugging, etc.)• Unable to follow commands when ready for extubation

BURN (MAJOR) RESPIRATORY MANAGEMENTCONTINUED FROM PREVIOUS PAGE


CONTINUED

ADULT BURN FLUID RESUSCITATIONGUIDELINES

(All other applicable ICU protocols/guidelineswill be maintained)

ALL DEVIATIONS MUST BE APPROVEDBY ATTENDING PHYSICIAN

(ICU Attendings: Dr. Young, Dr. Sawyer, Dr. Lowson, and Dr.Calland should be notified and utilized as a primary resource in

the event of alternative Attending coverage)

Charge RN should be consulted in the event ofnursing-initiated call to Attending

The clock begins at time of injury, and not at arrival at thehospital.

INCLUSION CRITERIA: Burns > 20 % TBSA

Pre-Hospital• Administer routine wound care (removal of burning material,

gentle cleansing, and loose bandaging with clean, drymaterial. Topical agents should be avoided.)

• Initiate fluid resuscitation in the field if possible, but immediatefluid requirement should be low, so this is not imperative.

• Administer airway control and support dependent on localskill level and patient condition.

Referring Hospital• Initiate contact with UVA as soon as possible• Initiate IV therapy Large-bore (>18 ga.) peripheral IV in unburned skinCentral or femoral access if peripheral access unavailable


ADULT BURN FLUID RESUCITATION GUIDELINESCONTINUED FROM PREVIOUS PAGE

CONTINUED

Imperative that IV therapy with LR or NS be initiated priorto transfer. Even though the total burned BSA may not beknown, if estimated at >40%, fluid should be administeredat rate of 1liter per hour to prevent severe intravascularfluid deficits in the early post-burn period.

• Initiate airway control Immediately intubate any patient exhibiting airway

symptoms (stridor, hoarseness, severe cough, voicechange) or respiratory distress before swelling worsens

Emergency Department/Burn Center• Calculate and record prior fluid administration• Administer fluid to keep patient on track for fluid requirements

(see below)

INITIAL 24-48 HOURS:TIME OUT: PRIOR TO INITIAL WOUND CARE,THE FOLLOWING MUST BE ADDRESSED:• Adequate IV access• Evaluation of respiratory stability• Normothermia (maintain temp > 35°C)• Lab evaluation (assess for coagulopathy-INR < 2)• If escharotomies/fasciotomies are deemed emergent despite

alterations in the above items (other than chest for hemo-dynamic/respiratory instability) and decision conflict arisesamong the involved teams, Trauma and Plastic SurgeryAttendings should be consulted.

FLUIDS:Ringers Lactate 3ml x wt (kg) x % TBSA• 1/2 calculated amount over first 8 hours• second 1/2 over subsequent 16 hours&Hespan 40ml/hr (not to exceed 1 liter/24 hours)• In setting of hyperkalemia, consider alternating LR with

0.9% NS


CONTINUED


MAINTAIN URINE OUTPUT OF 0.5ml/kg/hr-1ml/kg/hr

HEART RATE GOAL < 130• Avoid beta blockers first 48 hours

FLUID TITRATION:• If calculated needs are met prior to 24 hour mark, utilize a

MIVF rate of 3ml/kg/hr• Hourly u/o < goal 2 consecutive hours => increase MIVF by

10%• Following 2 hours continued inadequate u/o => increase

MIVF by 10%• Continued inadequate u/o over the following 2 hours:

Initiate Dopamine at 3mcg/kg/minSwan-Ganz catheter or obtain stat echo if feasible

• Place Swan-Ganz (CCO) catheter under thesecircumstances: oliguria despite calculated resuscitation (>150% of

calculated needs or 6 cc/kg/%TBSA) and Dopamineinfusion hypotension severe respiratory failure (P/FiO2<100) pulmonary edema burns > 70% cardiac disease

• If excessive u/o (> 2ml/kg/hr), decrease MIVF by 10% in 2hour intervals until u/o is below 2ml/kg/hr but meeting 0.5-1ml/kg/hr

• NO Fluid boluses unless approved by core faculty

• NO diuretics during resuscitation



• If persistent acidosis – pH < 7.25 (> 12 hrs):Reassess fluid resuscitationConsider Swan-Ganz catheter

• MIVF (upon completion of initial 24 hour fluid resuscitation) isdetermined by the IV rate at the last hour of fluidresuscitation; continue to titrate as noted above to urineoutput

AIRWAY:• NO ETT should be electively changed within the initial 48hrs

for bronchoscopy unless Attending approval

LINE MANAGEMENT:• Transition femoral central access to subclavian through non-

burned skin• MAC/Swan may be inserted through burned skin in emergent

situations

LABS:• CBC/Chem/Coags: every 8 hrs• Lactate: every 24 hrs

(used as a guide to acid-base status, not a resuscitationendpoint)

• ABG: every 24 hrs

• Rhabdomyolysis: every 12 hrs (until 2 negative results)Positive and CK > 5000 Initiate NaHCO3 drip

(1:1 concentration with central access) (150meq:150ml)Maintain u/o 100ml/hrMannitol (12.5-25 gms) and/or increase MIVF rate for u/o

< 100ml/hr

CONTINUED


Positive and CK<5000Do not initiate NaHCO3 dripMaintain u/o 100mI/hrMannitol (12.5-25 gms) and/or increase MIVF rate for u/o

< 100ml/hrGI:Nutrition:• NGT and post-pyloric Dobhoff placed upon admission with

initiation of tube feeds• If unable to advance Dobhoff post-pyloric:

Begin trophic tube feeds (20ml/hr)Check residual from NGT every 4 hrs (residual > 250ml– hold TF)

• Obtain admission weight; daily weights• Obtain bladder pressure every 12 hrs• Administer soap suds enema with Zassi placement first

tanking after 24 hr mark (initiate Zassi bowel motility regimen)• Ensure order for daily vitamin regimen

Temperature:• maintain normal thermoregulation• insert rectal or esophageal temperature probe for continuous

monitoring

Hypothermia:Ranger fluid warmer; Rapid Infuser if neededHeated vent circuit Bair huggerRoom temp elevatedWarmed saline/water utilized for wound careMinimize large surface area exposure during

wound care

CONTINUED



48-72 Hours:Fluids:• D/C Hespan• Initiate 5% Albumin-40ml/hr• Continue MIVF Ringers Lactate• In setting of hypematremia, consider alternating LR with

0.45% NS or D5W• Maintain urine output 0.5 ml/kg/hr-1ml/kg/hr

After 72 hrs:• TF should be at goal• D/C Albumin drip• Reassess need for Dopamine gtt• Titrate MIVF to adequate u/o• Maintain urine output 0.5 ml/kg/hr-1ml/kg/hr

Complications:**In setting of acute renal failure and decreased pulmonary

compliance with ongoing high fluid resuscitation need,consider abdominal compartment syndrome (ACS) and/orcardiac failure. If severe respiratory failure ensues, considerCRRT for fluid management.

Abdominal Compartment Syndrome• Burn patients at increased risk:

inhalation injury, extensive FT burns to the torso, and large%TBSA

increased intra abdominal pressure (> 25mmHg)

oliguria---------------decreased pulmonary compliance



WORKUP AND TREATMENT OF BLUNT MYOCARDIAL INJURY

PRACTICE GUIDELINE

All patients with Blunt Thoracic Trauma who have:• Unexplained Sinus Tachycardia / Ectopy, or• Major chest wall contusion, or• Multiple rib fractures

Obtain 12 Lead EKG,TroponinsProvide hemodynamic support

EKGnow Normal?

Troponins< 0.05?

No further workup

Admit TelemetryRepeat 12 Lead EKG

in 24 hoursTroponin x3 (Q8 hours)

Echo (STAT iF hypotension)Cardiology Consultation

No

Troponin /EKG

Abnormal?Hemodynamic instability?

Myocardial Infarction?

No

STBICU / CCU Admission

No RoutineCare

Yes Yes

Yes


BLUNT THORACIC TRAUMAPRACTICE GUIDELINE

Retained Hemothorax:All patients with retained hemothorax should be aggressivelydrained with a combination LARGE CALIBER straight andRight-angle chest tubes as soon as such conditions areappreciated upon imaging tests. Consideration should begiven to early VATS (within 72 hours of injury) to avoid latefibrothorax and empyema.

Multiple rib fractures / flail segment:Non-ventilated patients with multiple rib fractures or flailsegments and respiratory compromise1 who are otherwisegood candidates for epidural analgesia should haveepidurals catheters placed by the acute pain service or on-callanesthesia team as soon as adequate bony spine clearanceis obtained.2

AORTIC TRANSECTION (ACTUAL OR SUSPECTED)PRACTICE GUIDELINE

Indications for implementation / utilization:

1. Widened mediastinum (in patient with high-riskmechanism)3

2. CT evidence of aortic injury (without extravasation)4

Procedure

Maintain SBP < 110 mm Hg and HR < 110 BPM5

Appropriate pharmacologic regimens:1. Gradual titration of benzodiazepines / narcotics (no

boluses!!)6

If inadequate response to gradual increasein sedation, then:

2. Labetolol gtt +/- nicardipine gtt as needed or, Esmolol gtt +/- nicardipine gtt as needed

1 Incentive Spirometry < 18 cc’s / kg IBW/sec2 See Epidural / Analgesia Guideline for Trauma Pts with Rib Fxs3 MVC > 30 MPH, Fall > 15 feet, Ped struck, MCC > 20 MPH4 If extravasation present, prepare for emergent thoracotomy.5 Use these parameters with caution in patients with severe closedhead injury and elderly patients with a medical history of poorlycontrolled hypertension.6 Patient s with actual (or potential for) severe injuries who are notintubated should NOT, in general, receive conscious sedation.


EPIDURAL / ANALGESIA GUIDELINES FOR TRAUMAPATIENTS WITH RIB FRACTURES

A) Timely / expeditious epidural analgesia is desirable forthe trauma patient with multiple rib fractures and thepotential for respiratory failure, and should be achievedwithin 12 - 18 hours after admission unless acontraindication to placement exists. For epiduralanalgesia, the patients MUST HAVE:

1) No major coagulopathy (INR < 1.3, platelets > 100,000)

2) Cleared cervical, thoracic, and lumbar spines, or, at least,minimal spinal trauma (e.g., <3 contiguous SP / TPfractures at least 5 CM away from the level of entry for theproposed epidural catheter).

3) Mental status clear enough to provide consent, OR adesignated medical power-of-attorney to provide consent,OR a written statement of medical necessity composedby a senior surgical resident or attending on the traumaservice.

4) An accurate detailed list of the pre-admission and currentmedications confirming no Plavix use in last 7 days, noEnoxaparin or Dalteparin administration in the last 18hours, an INR < 1.3.

For rib fractures above T-4, the reality is that epiduralanalgesia may not be that effective since it may be difficult toobtain and sustain the desired level of analgesia above thislevel. Alternate/additional methods for pain control will benecessary, and the APS Team can consult to provide those.

The Acute Pain Service Team is in-house 0700 to 1800. Afterthese hours, reliance is placed on the overnightanesthesiology team for most necessary patientmanagement issues. However, as they assume manyresponsibilities and are in many locations beyond theoperating room, it may not be feasible for them to placeepidurals simply upon the request of the Trauma Service.Though it remains the standard of care for such catheters to

CONTINUED

EPIDURAL/ ANALGESIA GUIDELINES FOR PATIENTS WITH RIB FRACUTRES


EPIDURAL/ ANALGESIA GUIDELINES FOR PATIENTS WITH RIB FRACUTRESCONTINUED FROM PREVIOUS PAGE

be placed as soon as there are adequate resources tofacilitate such action, arrangements will need to be workedout on a case-by-case basis depending upon the existingworkload of the in-house anesthesiology team.

Most of the APS attendings acknowledge that they serve as aback-up to the in-house overnight team and in certaincircumstances could be called in to facilitate epiduralplacement.

B) If epidural catheter placement is not feasible, second-line alternatives to epidural catheter placement include:

1) Threading an epidural catheter adjacent to anexisting chest tube, for the instillation of up to 20 mL0.25% bupivacaine every 6-8 hours. This techniquerequires that the patient be placed for 30 minutes sothat the volume will layer in the posterolateralparavertebral gutter AND that the chest tube beclamped for 30 minutes.

2) Paravertebral blocks and/or catheters may be placed,as the expertise of the Departmental staff increases

3) Separate intercostal nerve blocks can providetemporary benefit when only 4-5 levels are involved.


Precautions:

CT Scan NOT reliable in determining trajectory of low velocity(stab) wounds

ECHO / FAST 100% sensitive for pericardial / cardiac injuryEXCEPT if associated with adjacent pleural effusion

If unsure of trajectory through pericardium: OR for pericardialwindow

CHEST TRAUMA - PENETRATING CENTRAL WOUND

Recent / witnessed SBP < 90 Stablearrest or moribund

ED OR for CXR,thoracotomy Pericardial window, Consider:

thoracotomy, or - CTA of chest or sternotomy - STAT Echo or

- Pericardial window

Repeat CXR in 6 hrsif no Chest CT

➤

➤

NoYes and HR <40and/or wide

complex

Trajectory between nipples,sternal notch, xiphoidor transmediastinal *

Consider Chest tube,pericardiocentesis, ACLS,

or no therapy

➤ ➤

Tube Thoracostomy(as indicated by physical

exam / trajectory)

➤➤ ➤

* Consider / Perform Laparotomy iftrajectory uncertain or if trajectorypotentially passes belowdiaphragm

➤ ➤➤


DEEP VENOUS THROMBOSIS

Bilateral lower extremity duplex

➤➤ ➤

HIGH RISK:• Spinal cord injury• Severe head injury• Severe (multiple/complex) pelvic fracture• > 2 long bone fractures with bedrest > 5 days• Major Iliac, Femoral, or Popliteal Venous Injury

(e.g., penetrating trauma to groin)

MEDIUM RISK:• Trauma service

patients who arenot high risk

➤

Low molecular weight heparin, unlesscontraindicated* + SCD’s + IVC filter**

Low molecular weight heparin,unless contraindicated* + SCD’s

➤

➤ ➤

➤ ➤

➤ ➤

Positive duplex studybelow the knee? ***

Positive duplex study above knee?(pelvic,femoral or popliteal) ***

Progressive or symptomatic? Anticoagulation OK?

➤

➤ ➤Yes

No Yes

➤

No

Therapeutic Enoxaparinor Heparin infusion

(according to institutional

Coumadin for 3-6 mo orTherapeautic Enoxaparin

Target hep Ptt + INR

IVCF**

➤

Recheck duplex q 5 d

➤

* Enoxaparin is contraindicated inpatients with:

• Chronic renal insufficiency• Excessive bleeding risk• First 48-72 hrs after SCI or CHI

** All filters should be removeable ones inpatients < 65 years old

*** For + DVT assess leg daily for phlegmasia(neuro & vasc)

For dosing guidelines see Adult Medication References at back of manual.

Assess Risk


EXTREMITY TRAUMAPRACTICE GUIDELINE

Active hemorrhage, expanding hematoma, severe ischemia*

Reduce fracture / dislocation if present

Ischemia persists or active hemorrhage

Yes No

Intraoperative anteriogram Risk classificationVascular repair

+ orthopedic fixation

High LowABI < 0.9 ABI>0.9

Pulse deficit No pulse deficit

➤➤

➤ ➤➤ ➤

➤ ➤

➤ ➤

Normal Minimal Majorarterial arterialinjury injury

Observation Observation Operation± serial

arteriography

Arteriography Observation

➤ ➤➤➤ ➤➤

*Consider blood pressure cuff above site of hemorrhage.


HEMATURIAPRACTICE GUIDELINES

Unstable pts with grosshermaturia

Or significant (>50RBC’s per hpf)microscopicrequires GU work-up.

GU Work-up:

1. RUG for urethra

2. CT scan for kidney & ureter

3. Cystogram for bladder

Surgical Note:

Laparotomies with Urethraprepped into field and sterile foley

No significant pelvic fx.No blood at meatus.Normal rectal exam.

➤➤

Pelvic fracture withcomminution of anterior ring,blood at meatus, high-riding

prostate, gross hematuria

No work up


RHABDOMYOLYSISPRACTICE GUIDELINES

Check serum creatine kinase on patients with:

• Chest injury• Ischemic injury• Hyperpyrexia• Suspected rhabdomyolysis• Cranberry colored urine• Two or more long bone fractures• A long bone fracture and a pelvic fracture

Check CK q12 hrs

Add 100 meq Bicarb to 1 liter NS or LRMaintain urine output > 100 cc/hr

Keep urine ph > 6.5and

Re-check CK every 12-24 hours

➤➤

> 5,000

< 5,000➤

Repeat until twoconsecutive

negative results

** No need forbicarbonateinfusion **

➤

➤


NON-OPERATIVE MANAGEMENT OF SPLEENAND HEPATIC TRAUMAPRACTICE GUIDELINE

Day 1(0-24 hrs)

Day 2(24-48 hrs)

Day 3(48-72 hrs)

Day 4(72-96 hrs)

➤ ➤

See next page for footnotes 1-5

CBC q 8 hrs x 24hrsStrict bedrest2

Hold LMWH

CBC BID x 24hrsStrict bedrest2

Start LMWH and orderdiet if Hgb stable

OOB, DuplexCBC in pm

Discharge in PM ifHgb stable3 and no

change in abd. exam

Grade I or II1

(little or nointraperitoneal fluid)

Admit Floor

Grade III to V1

(intraperitoneal fluidpresent)

IR/embolization?4

OR if Unstable5

Admit STBICU

LA, CBC q 4 hrs x 24hrsStrict bedrest2

Hold LMWH

CBC q 8 hrs if Hgbstable

Transfer to floorif stable HgbStrict bedrest2

Start LMWH

Continue bedrest2

CBC BID x 24hrsVerify Type & Screen

OOB repeat CT *Duplex and CBC in pm

Discharge if Hgbstable3 when OOBand no changes inabdominal exam.


NON-OPERATIVE MANAGEMENT OF SPLEEN AND HEPATIC TRAUMACONTINUED FROM PREVIOUS PAGE

Footnotes from Non-opertaive Management of Spleen andHepatic Trauma Practice Guideline

1 Depending on trauma, attending interpretation of CT scan,duration of bed rest may be altered.

2 HOB can be up to 30 degrees during strict bedrest if spinesare clear.

3 Remember to check CBC after walking.

4 Embolization appropriate for normotensive patients withoutother serious traumatic injuries who have arterial blush,pseudoaneurysm, or large subcapsular hematoma.

5 Persistently hypotensive patients (SBP < 90 after 2Lcrystalloid or 1u PRBC’s) and a positive FAST or knownsplenic injury with hemoperitoneum on CT, should undergooperative therapy with splenectomy and/or packing of the liver+/- pringle.

* In general, only IV contrast is necessary for the repeat CT.However, consider enteral contrast if the patient is nottolerating enteral feeds.

No


SEVERE PELVIC FRACTURE ALGORITHMLC 2 / 3 AC 2 / 3 VS

Multi-Trauma pt w/ >2 cm ofpubic diastasis / displacement

Place Pelvic Binder*& perform FAST

AbdominalCT

PelvicBlush

Observe

FAST

- free fluid- abd. tenderness

Laparotomy

Repeat FAST**and / or DPL

(Discuss findings w/ attending)

Angiography

➤

➤

➤➤

➤

➤

➤

➤

➤

➤

* Do not remove binder for 1st 24 hrs, and thereafter, only afterclearance to do so by trauma Attending, consult orthopedics.

** Obtain experienced ultrasonographer

Equivocal

NoNoYes

Yes

UnstableVS➤

➤

NoYes


PULMONARY EMBOLISM WORKUP & TREATMENTPRACTICE GUIDELINE

Suspicion(oxygen desaturation that does not respond immediately tosimple measures, severe acute dyspnea, acute decrease inP/FIO2 ratio to < 200 with no evidence of hypoventilation)

CXR, ABG, Supplemental Oxygen

Treatable process(pneumothorax, mucous plug,

effusion)

➤➤

➤

Problem Sats < 90% Sats > 90%resolved with supp. O2 with O2 < 4/L

No treatable cause

Treat cause and reassess

➤

➤

➤

➤

➤

Heparinize if possible

CTALE Duplex

*For treatment of positive LE duplex, see DVT guideline.

➤➤

➤

Negative Positive

LE Duplex in IVC Filter5 Days* +

if inpatient Anticoagulation

➤ ➤

➤ ➤

Observe


RESUSCITATIONPRACTICE GUIDELINE

Concurrent Resuscitation: (ALL Patients)Stop bleeding, resuscitation with blood, blood products

and crystalloid to SBP >100, pulse <100↓

Assess perfusion↓

LA >2.5*↓

Infuse fluids to achieve clinically normal perfusionand repeat LA

↓LA >2.5

↓Place Swan-Ganz catheter and arterial line

Increase PCWP >12CI >3.5

SVO2 sat >65CPP >60

↓Preferred fluids:

bloodblood products

albumin or Hespancrystalloid (minimize glucose administration,

Check serum sodium and intervene on values <135)↓

If parameters not met Add:Dobutamine

(Milrinone should be used in patients with cardiac index < 3.0, orpatients with CI < 4 with elevated lactate. May cause hypotension)

Search for continued bleeding – FAST, consider ECHO

Goal LA <2.5

*Do not use LA as an endpoint in SCI pts.


NON-HYPOVOLEMICCARDIOVASCULAR FAILURE

PRACTICE GUIDELINE

PATIENTS TO BE TREATED• Fresh trauma patients (<48 hours PI), with no evidence of

hypovolemic shock (workup without evidence of ongoinghemorrhage)

• Evidence of shock (Base deficit < -5, LA >3.0, pH <7.30) and/or evidence of cardiovascular failure(BP<95 mm systolic, urine output <0.5 cc/kg/hour) withobjective evidence of normovolemia (normal or stablehematocrit, normal CVP, no evidence of bleeding)

PROCEDURE• Physical examinationRule out murmur, pneumothorax, mainstem intubation, etc. Look for missed injury Evaluate known injuries (increased compartment size,

etc.)Clinical evidence of perfusion

• Labs, studies Troponin, ABG 12-lead EKGCXRRepeat scans as needed to rule out ongoing hemorrhage

ALGORITHM• HemorrhageResuscitateOperation or angiography

• MI Swan-Ganz catheterCardiology consult Echocardiogram

• Primary vascular failure (neurogenic shock, sepsis??) Swan-Ganz catheter (oximetric if possible)Goal-directed therapy

CONTINUED


SITUATIONS• Low cardiac index , pump failureCardiac parameters Increase preload (PCWP) to 12 mm Hg taking into

account possible interference from ventilator If no response –

If hypotensive• The Trauma Attending must be informed before

pressors are begun in a fresh (<24 hours) TraumaPatient

• Neosynephrine or Levophed to increase MAP to >65mm Hg. If this is inadequate, consider Vasopressin at0.04 units

• Once accomplished – Milrinone or Dobutamine toaugment cardiac index to point where acidosis beginsto correct (at least 2.0, preferably 3.0)

If normotensive• Milrinone or Dobutamine as above

• Failure of therapy STAT echo to rule out tamponadeRepeat cavitary scans to insure that there is no bleedingConsider aortic balloon pump, or surgery as

recommended by Cardiology

NON-HYPOVOLEMIC CARDIOVASCULAR FAILURE GUIDELINECONTINUED FROM PREVIOUS PAGE


GENERAL SPINE CLEARANCE ALGORITHM

PATIENT EXAMINABLE?

*CTA Neck is indicated if a pt has any of the following: Fx through C1-C4;Extensive bruising or "seatbelt sign" on neck; Cerebral infarct; Acute anisocoria;GCS < 8 without explanatory findings on CT of the head; Neuro deficits, decline/ clinical picture not consistent with injury, petrous fx.

**If < 2 contiguous TP/SP fractures in the T or L spine and no severe adjacenttorso trauma (e.g. sternal fx/flail chest) spine consultation is not required andHOB should be raised to 30 degrees to optimize pulmonary status. Subsequenttertiary exam 12 – 24 hours later is required to clear patient for unrestrictedactivity in such cases.

GENERAL SPINE CLEARANCE INFORMATION:

NEURO DEFICITS? Obtain prompt Spine Consultation(e.g. paraplegia, tetraplegia, weakness/parasthesia consistent with SCI)

MSK Spine Service even months NSGY Service odd months

A TRANSFER? Check PACS referral folder under the OSH pt info foroutside images. If a trauma alert, place an outside read order underthe ED Trauma Alert pathway (in Epic) to have images read.

EXPEDITING READS: Reading Room CoordinatorsMSK: 2-2526 NSGY: 2-3432

CONTINUED

➤

Is the pt. GCS 15/Alert?

No,Seenextpage➤

No ➤

YesDoes the pt. have one or more of these?

1) intoxication2) midline cervical/thoracic/lumbar pain/tenderness,3) neurologic deficits,4) high risk mechanism, distracting injury (pt can’t

participate in exam)

Yes

➤

CT C-Spine, T & L recons of CT Torso *Plain Films of T&L spines if no CT Torso indicated

➤

Preliminary Reads POSITIVE(or suspicion for bony injury / malalignment)**?

Yes

➤

Spine Consultation(Complete consult request w/ date & time, clarify

activity orders in Epic)

No

➤

See page 68 for Cervical Spineand page 69 for

Thoracic and Lumbar Spines


GENERAL SPINE CLEARANCE ALGORITHMCONTINUED FROM PREVIOUS PAGE

PATIENT EXAMINABLE?

GCS 15, Alert, and NONE of the following:Intoxicated, midline cervical/thoracic/lumbar pain/tenderness,

neurologic deficits, high risk mechanism***, distracting injury(pt can participate in exam), no spine imaging is indicated.

➤

No Yes

➤

Image C and/or T&L if indicated:CT C-Spine/T & L Recons

(See note on previous page for CTANeck indications)

Upon Tertiary Exam / Clinical Exam of the Complete Spine:Signs/ Symptoms abnormal?**

Remove Collar(unless desired for pt. comfort)

document exam clearancedate & time, update activity orders,

including d/c old activity orders

Preliminary Reads POSITIVE or INDETERMINATE?

➤ ➤

No Yes

See page 68 forCervical Spine,

see page 69 forThoracic and Lumbar Spines

➤

• Falls - > 20 ft. (one story = 10 ft.)

• High-Risk Auto Crash

*** High Risk Mechanism:

- Intrusion: > 12 in. occupant site; >18 in. any site - Ejection (partial or complete) - Death in same passenger compartment - Vehicle telemetry data consistent with high risk of injury

• Motorcycle Crash > 20 mph

** midline tenderness, limited ROM,peripheral or central sensory /motor deficit

Spine Consultation(complete consult sheet with

date & time)MSK even months, NSGY odd mo.

If pt has < 2 contiguous TP/SP Fx inthe T / L spine and no severe

adjacent torso trauma (e.g., sternalfx / flail chest) spine consultation is

not required and HOB should beraised to 30 degrees to optimizepulmonary status. Subsequent

tertiary exam 12 – 24 hours later isrequired to clear patient for

unrestricted activity in such cases.

• Auto v. Pedestrian/Bicyclist Thrown, Run Over, or wtih Significant (>20 mph) Impact

➤


Cervical spine bony imagingfinal reads negative?

Yes

Patient Examinable?

Consider MRIif anticipating that patient

is un-examinablefor > 5 days

Pain, tenderness and/orperipheral sensory/motor signs/

symptoms

STOPthe cervical spine clearance

process, replace the patient’sC-collar, and obtain imaging.

(Flex / Ex or MRI) *

➤

➤

Yes


CERVICAL SPINE CLEARANCE —NEGATIVE BONY IMAGING

Cervical spine bony imagingPRELIMINARY reads negative?

No➤

➤

Ask the patient totouch chin to chest,

extend neck backward androtate from side to side.

Does the patient experiencepain or neurologic symptoms

during these maneuvers?

No➤

STOPthe cervical spine clearance

process, replace the patient’sC-collar, and obtain imaging.

(Flex / Ex or MRI)*

Remove collar,document exam clearance

date & time,update activity orders including

dc old activity orders

No ➤Yes

Retain Collar, Cervical Spine Precautions

Perform Tertiary Exam /Clinical Exam of C spine.

Remove the patient’s collarand palpate the C-spine.

➤

➤➤

➤

Yes

* Prerequisites for flexion / extension films: no neuro deficits,cooperative patient, and C spine can be visualized to C7 on plain film(avoid in obese pts, “short neck” pts, or muscular male pts)


THORACIC & LUMBAR SPINE CLEARANCE –

Notes/Precautions:

• Patients with negative imaging, but severe pain /tenderness in T / L spine should be evaluated for potentialdiscogenic disease or occult FX.

• Age indeterminate spine injury image interpretations shouldbe considered acute except in the clear absence of pain,tenderness and limitation of mobility.

• Patients with no bony abnormalities or malalignment onimaging who are awaiting ligamentous cervical spineclearances may be upright and OOB with collar.

• Spine clearance procedures must be documented in theclinical record (progress notes) and with orders.

• All patients with >48 hours flat bed rest due to spine injury/evaluation should be on Rotorest beds unlesscountermanded by spine consultant or otherwisecontraindicated.

• Respiratory complications and Decubitis ulcers are the twotop sources of morbidity in patients with spine cord injury:Spine clearance must be efficient and thoughtful.

• DO NOT BE A COWBOY when it comes to evaluations of thespine!!


Preliminary reads negative

➤

HOB to 30 degrees, update activity orders

➤Final reads negative

➤

Clinical exam of spine, advance orders


Are any TWO of the itemsbelow present?

Temperature >38.3 or <36 degrees?HR > 90 bpm

RR > 20 or PCO2 < 32 mm HgWBC > 12 OR < 4, or BANDS > 10%

Suspicion of Infection?

AND

Systolic Blood Pressure < 90 mm HgOR

Lactate >4 mmol / LiterOR

Evidence of Dysfunction in>1 organ system

WITHIN ONE HOUR OF DIAGNOSIS:

Call MET Team and Notify ICU

Draw lactate level

Draw blood cultures

If MAP < 65, place large bore IV’s or Central Line andadminister 1-3 liter Normal Saline over 30-60 minutes,

And begin pressors if SBP remains < 65

Administer broad spectrum antibiotics

Perform 12 lead ECG

Place foley / central line

➤➤

➤

➤

NO

NO

YES

Sepsis Alert/ Pathwaynot indicated

Sepsis Alert/ Pathwaynot indicated

SEPSIS ALERT


*Hyperglycemia without history of diabetes, Hypoglycemia, withoutdiabetes, in an immunocompromised patient increases suspicion ofinfection.

+Organ dysfunction can be defined as: respiratory failure, acuterenal failure, acute liver failure, coagulopathy, or thrombocytopenia.

Laboratories that will suggest organ dysfunction include: PaO2(mmHg)/FiO2 < 300, Creatinine > 2.0 mg/dl OR Creatinine Increase > 0.5 mg/dL,INR >1.5, PTT > 60 sec, Platelets < 100,000/uL.

Total bilirubin > 4 mg/dL £Systolic Blood Pressure < 90 mmHg or MeanArterial Pressure < 65 mmHg.

Reprint with permission from Annals of Emergency Medicine.38

(Forms submitted)

Table 1: Definitions for Inflammatory Response,Sepsis, Severe Sepsis and Septic Shock.

Variable DefinitionTemperature > 38.3°C or < 36°CWBC < 12,000 or < 4,000or > 10% BandsHeart Rate > 90 bpmRespiratory Rate > 20bpm*Hyperglycemia > 120mg/dlAltered level of consciousnessLactate > 2 mmol/LDecreased capillary refill

Systemic inflammatory response +a presumed or identified source ofinfection

Sepsis + > 1 Organ dysfunction+ orLactate > 4mmol/L

Severe Sepsis + hypotension£

(despite 20 – 40cc/kg crystalloid or colloidequivalent fluid challenge)

SystemicInflammatory > of theResponse following:

Sepsis

SevereSepsis

SepticShock

SEVERE SEPSIS AND SEPTIC SHOCKCONTINUED FROM PREVIOUS PAGE


UPDATES AND CHANGES TO THE 5TH EDITION OF THE TRAUMA MANUAL, JUNE 2011

REFERENCES

Cover New QR (Quick Response) code to direct your mobiledevice to the Trauma Manual on the Clinical Portal

7-8 Updated MD and NP contact information

9 Added additional transfer hospital and film room numbers

12 Chief needs to view outside images

13 & 66 Updated CTA Neck Criteria

15 New CT Algorithm for Pregnancy

16 Removed reference to geriatric consult service

17-18 Updated Trauma Alert Criteria

21 New PEARLS re: Rounding Expectations, TLSO uprights,Speech Evaluation, PEGS, and Morphine use

31 Clarification on decannulating patients

41 New Adult Guidelines for Craniotomy / Craniectomy

47 Updated Burn Resuscitation Guideline (Rhabdomyolysis)

50 Updated Blunt Myocardial Injury Guideline

51 New Blunt Thoracic Trauma Guideline

54 Updated Chest Trauma Algorithm

55 Updated Deep Venous Thrombosis Guideline

58 Updated Rhabdomyolysis Guideline (PreviouslyMyoglobinuria Guideline)

59-60 Updated Non-Operative Spleen / Hepatic Trauma Guideline

61 Updated Severe Pelvic Fracture Algorithm

68 Updated Cervical Spine Clearance Guideline

69 New Note regarding age-indeterminate spine findings

70-71 Updated Sepsis Alert Guideline

79-81 New References regarding PT / OT & LTAC Services

86 New High-Risk Agitation Guideline

88 Updated Sedation / Delirium Reference

117 Added Relative Contraindications to Factor VIIaAdministration to Pediatric Neurotrauma Guideline

126 Updated Medication Reference for Treatment ofRhabdomyolysis (Previously Myoglobin Positive)

127 Updated Medication Reference for Seizures Prophylaxis toprioritize Levetiracetam (Keppra)


REFERENCES

INJURY SCALES

LUNG INJURY SCALE

Grade* Injury Type Description of Injury ICD-9 AIS-90

I Contusion Unilateral, <1 lobe 861.12 3861.31

II Contusion Unilateral, single lobe 861.20 3861.30

Laceration Simple pneumothorax 860.0/1 3

III Contusion Unilateral, > 1 lobe 861.20 3861.30

Laceration Persistent (> 72 hrs) air leak 860.0/1 3-4from distal airway 860.4/5

862.0

Hematoma Nonexpanding intraparenchymal 861.30

IV Laceration Major (segmental or lobar) 862.21air leak 861.31 4-5

Hematoma Expanding intraparenchymal 901.40 3-5Vascular Primary branch intrapulmonary

vessel disruption

V Vascular Hilar vessel disruption 901.41 4901.42

VI Vascular Total uncontained transection of 901.41 4pulmonary hilum 901.42

*Advance one grade for bilateral injuries up to grade III.Hemothorax is scored under thoracic vascular injury scale.

CONTINUED


SPLEEN INJURY SCALE (1994 REVISION)


I Contusion Unilateral, <1 lobe 861.12 3

I Hematoma Subcapsular, <10% surface area 865.01 2865.11

Laceration Capsular tear, <1cm 865.02 2 parenchymal depth 865.12 2

II Hematoma Subcapsular, 10%-50% surface 865.01 2area intraparenchymal, 865.11<5 cm in diameter

Laceration Capsular tear, 1-3cm 865.02 3parenchymal depth that does not 865.12involve a trabecular vessel

III Hematoma Subcapsular, >50% surface areaor expanding; rupturedsubcapsular or parecymalhematoma; intraparenchymalhematoma > 5 cm or expanding

Laceration >3 cm parenchymal depth or 865.03 3involving trabecular vessels 865.13

IV Laceration Laceration involving segmentalor hilar vessels producing majordevascularization(>25% of spleen) 4

V Laceration Completely shattered spleen 865.04 5Vascular Hilar vascular injury with

devascularizes spleen 865.14 5

*Advance one grade for multiple injuries up to grade III.

CONTINUED


LIVER INJURY SCALE (1994 REVISION)


I Hematoma Subcapsular, <10% surface area 864.01 2864.11

Laceration Capsular tear, <1cm 864.02 2 parenchymal depth 864.12

II Hematoma Subcapsular, 10% to 50% 864.01 2surface area intraparenchymal 864.11<10 cm in diameter

Laceration Capsular tear 1-3 parenchymal 864.03 2depth, <10 cm in length 864.13

III Hematoma Subcapsular, >50% surface area 3of ruptured subcapsular orparenchymal hematoma;intraparenchymal hematoma> 10 cm or expanding

Laceration >3 cm parenchymal depth 864.04 3864.14

IV Laceration Parenchymal disruption involving 864.04 425% to 75% hepatic lobe or 864.141-3 Couinaud’s segments

V Laceration Parenchymal disruption involving 5>75% of hepatic lobe or >3Couinaud’s segments within asingle lobe

Vascular Juxtahepatic venous injuries; 5ie, retrohepatic vena cava/centralmajor hepatic veins

VI Vascular Hepatic avulsion 6

*Advance one grade for multiple injuries up to grade III

CONTINUED

INJURY SCALESCONTINUED FROM PREVIOUS PAGE


KIDNEY INJURY SCALE TABLE 19


I Contusion Microscopic or gross hematuria, 866.01 2urologic studies normal 866.11 2Hematoma Subcapsular,nonexpanding withoutparenchymal laceration

II Hematoma Nonexpanding perirenal 866.01 2hematma confirmed to renal 866.11retroperitoneum

Laceration <1.0 cm parenchymal depth of 866.02 2renal cortex without urinary 866.12extravagation

III Laceration <1.0 cm parenchymal depth of 866.02 3renal cortex without collectingsystem rupture or urinaryextravagation

Laceration Parenchymal laceration 866.12 4extending through renal cortex,medulla, and collecting system

IV Vascular Main renal artery or vein injury 4with contained hemorrhage

V Laceration Completely shattered kidney 866.03 5

Vascular Avulsion of renal hilum whichdevascularizes kidney 866.13 5

*Advance one grade for bilateral injuries up to grade III


CONTINUED


HEART INJURY SCALE

Grade* Description of Injury ICD-9 AIS-90I Blunt cardiac injury with minor ECG 861.01 3

abnormality(nonspecific ST or T wave changes,premature arterial or ventricular contraction orpersistent sinus tachycardia)

Blunt or penetrating pericardial wound withoutcardiac injury, cardiac tamponade, or cardiacherniation

II Blunt cardiac injury with heart block (right or left 861.01 3bundle branch, left anterior fascicular, oratrioventricular) or ischemic changes (STdepression or T wave inversion) withoutcardiac failure

Penetrating tangential myocardial wound up to, 861.12 3but not extending through endocardium,without tamponade

III Blunt cardiac injury with sustained (>6 beats/min) 861.01 3-4or multilocal ventricular contractions

Blunt or penetrating cardiac injury with septal 861.01 3-4rupture, pulmonary or tricuspid valvularincompetence, papillary muscle dysfunction,or distal coronary arterial occlusion withoutcardiac failure

Blunt pericardial laceration with cardiac herniation

Blunt cardiac injury with cardiac failure

IV Penetrating tangential myocardial wound up to, 861.01 3-4but extending through, endocardium, with 861.12 3tamponade

Blunt or penetrating cardiac injury with septal 861.12 3rupture, pulmonary or tricuspid valvularincompetence, papillary muscle dysfunction,or distal coronary arterial occlusion producingcardiac failure

Blunt or penetrating cardiac injury with aorticmitral valve incompetence

Blunt or penetrating cardiac injury of the rightventricle, right atrium, or left atrium


CONTINUED


HEART INJURY SCALE (CONT.)

Grade* Description of Injury ICD-9AIS-90IV Blunt or penetrating cardiac injury with proximal

(cont.) coronary arterial occlusion

Blunt or penetrating left ventricular perforation

Stellate wound with < 50% tissue loss of the right861.03 5ventricle, right atrium, or of left atrium

V Blunt avulsion of the heart; penetrating wound 861.03producing > 50% tissue loss of a chamber 861.13 5

861.03 5

VI 861.13 6

*Advance one grade for multiple wounds to a single chamber ormultiple chamber involvement. From Moore et al. [3]; with permission.

DIAPHRAGM INJURY SCALE

Grade* Description of Injury ICD-9 AIS-90I Contusion 862.0 2

II Laceration <2cm 862.1 3

III Laceration 2-10cm 862.1 3

IV Laceration >10 cm with tissue loss < 25 cm2 862.1 3

V Laceration with tissue loss > 25 cm2 862.1 3

*Advance one grade for bilateral injuries up to grade III.



ACUTE PHYSICAL AND OCCUPATIONAL THERAPY

• PT Goal in the Acute Care setting is to restore functionalmobility of the patient to achieve discharge to home or to thenext level of care.

• OT Goal in the Acute Care setting is to restore ADL skills ofthe pt to achieve discharge to home or to the next level ofcare.

ROLES1. Evaluate pts to make recommendations re: next level of

care/discharge setting2. Evaluate pts and collaborate with nursing in terms of

mobility/self-care/positioning needs3. Evaluate and treat those pts with deficits requiring the skills

of a physical therapist or occupational therapist

INAPPROPRIATE REFERRALS• Get patient out of bed• Patient is bored/not motivated• Check O2 Sat. while walking• Long standing mobility deficits• Improve endurance• OT for a pt w/ no desire to be more independent/hasn’t been for yrs

APPROPRIATE REFERRALS1. Pts with new musculoskeletal condition which affects

function e.g. joint replacement, burn pt, multi trauma, hip fx2. A pt for whom nursing has noticed a persistent balance

problem of unknown origin when walking3. A medically complex patient with a decline in functional

status who might need post-acute rehab4. Pts with a new neurological deficit. e.g. brain injury, stroke,

SCI, GB, MS5. Patient must be hemodynamically stable and able to

participate in therapy

• Spending time on inappropriate referrals (including ordersfor patients not yet medically stable) takes time away frompatients who require PT or OT.

• Complete info needs to be in chart - spine clearance, weightbearing status, precautions

PT/OT Office - 924-8732

• Post-op ambulation• From SNF, back to SNF• Force pt to get OOB• Passive range of motion• Non-responsive pts• Lots of lines/bags to carry when walking


WHAT IS AN LTAC?LTACHs are licensed as acute care or specialty hospitals andthey are certified by Medicare as long-term care hospitals.LTACHs must maintain a 25-day average length of stay andbe accredited by JCAHO. Patients must meet acute careadmission and continued stay criteria.

• LTACHs provide acute services for patients who aremedically complex and require a long hospitalization

• LTACHs offer specialized care for a variety of conditionsincluding, but not limited to:

• Ventilator dependent and weaning difficulty• Pressure wounds / wound care complications• Cardiac diseases• Neuromuscular / neurovascular diseases• Multi-system organ failure• Gastrointestinal diseases• Post-op complications• Pulmonary disease• Acute renal failure including dialysis• Infectious diseases requiring long-term IV therapy

UNIVERSITY OF VIRGINIATRANSITIONAL CARE HOSPITAL

CONTINUED


Patients who are admitted to a long-term acute care (LTAC)hospital typically:

• Require acute care services as determined by a physician• Are not candidates for treatment at a lower level of care• Require physician management of multiple acute

complexities

Patients that meet LTAC admission criteria usually have oneor more of the following needs:

• Mechanical ventilation for respiratory failure• Stabilization of underlying disease and ventilator weaning• Pulmonary hygiene• Tracheostomy with respiratory insufficiency• Exacerbation of COPD• Infectious disease with two or more co-morbidities• Primary cardiac and /or peripheral vascular disease with

co-morbidities• Wound management requiring interdisciplinary team care• High level orthopedic conditions• Low-tolerance rehabilitation, 1-3 hours daily• Other primary medically complex condition or illness• Malnutrition requiring feeding tube or TPN, and speech

therapy intervention with swallowing techniques

Long Term Acute Care Services include:

• Multi-specialty medical and surgical consultationsavailable

• Diagnostic services available• Respiratory therapy services on-site 24/ 7• Continuous cardiac monitoring• Weekly interdisciplinary team review• Medical / Surgical services with nurse staffing the same as

short-term acute care• Wound management• Daily physician rounds

UNIVERSITY OF VIRGINIA LTAC CRITERIA

TRANSITIONAL CARE HOSPITAL (LTAC)CONTINUED FROM PREVIOUS PAGE


ASSIGNMENT OF PALLIATIVE CARE CODETO PATIENT MEDICAL RECORD

From the UVA Department of Coding Services

Definition: Palliative care is comfort care provided to patientsin the final stages of an illness who are no longer receivingcurative and/or aggressive treatment.

Purpose: UVA Health System defines guidelines for codingand documentation for patients that are provided palliativecare within the inpatient setting.

Background for Palliative Care: The code for palliative care,V66.7, became effective October 1, 1996. Code V66.7 can beused for any terminally ill patient receiving end-of-life palliativecare. Code V66.7 may be assigned as an additional code toidentify patients who receive palliative in any health caresetting, including a hospital. The code is never assigned asthe principal diagnosis.

Physician Documentation: The physician documentation inthe medical record must substantiate that palliative care is theprimary goal of treatment rather than cure in a person withadvanced disease that is life limiting and refractory to diseasemodifying treatment. Terms such as comfort care, end-of-lifecare, and hospice care, are synonymous with palliative careand are phrases that facilitate assignment of the V66.7palliative care code. Palliative care provided within theinpatient setting must be documented clearly within the:• Admission note• Consult Note (consult Palliative Care “only” is insufficient by

itself)• Discharge Summary• Physician orders• Progress note

Coding for Palliative Care: Specific ICD-9-CM guidelinesmust be followed, and the palliative care code will beassigned with the secondary ICD-9-CM code V66.7. Aseparate primary diagnosis must be documented.

CONTINUED


For example, if a patient has been receiving curative care andis transferred to another service for “Hospice” or “PalliativeCare”, the admission order or note by the receiving serviceshould document that the patient is transferred for palliativecare. Medical record documentation requirements must befollowed to substantiate that palliative care was provided, andto justify the assignment of an ICD-9-CM code V66.7 as asecondary diagnosis for the inpatient encounter.

REFERENCESAmerican Hospital Association Coding Clinic. First Quarter1998, PAGES 11-12

Submitted by:Paula Hathorn CCS, CPC, Coding and Compliance ManagerJonathon Truwit MD, Senior Associate Dean for Clinical Affairs

ASSIGNMENT OF PALLIATIVE CARE CODECONTINUED FROM PREVIOUS PAGE


ORGAN DONATION

Do not discuss organ donation with family.

If next of kin initiates discussion about donation, immediatelynotify LifeNet.

Contact LifeNet (1-866-543-3638) whenever there is a patientwho is:

• Intubated with a GCS < 4 or

• Brain death testing is discussed or

• Intent to discuss terminal withdrawal of support (vent /pharmacological) or

• Grave prognosis (no hope of meaningful recovery /non-survivable injury) or

• Family initiates discussion of donation

LifeNet Health will be on-site to work with you on appropriateEnd-of-Life options for the family.

All deaths are to be call into LifeNet Health within 1 hour(60 minutes)

If the Organ Procurement Coordinator deems that the patientdoes meet criteria for donation, a Lifenet representative willinitiate the request for organ donation to the next of kin onlyafter the physician discusses the patient prognosis with thefamily. If the next of kin is not interested in discussingdonation, further contact will only be at their request.

See Medical Center Policy 0098.

Catastrophic Brain Injury Guidelines

Purpose: to offer management guidelines for theneurologically devastated patient when the Organ DonationProtocol is activated by established clinical triggers. Theseguidelines are to preserve organ function in the event thatorgan donation becomes an option.

Organ donation should not be mentioned to the family beforethe physician along with the patient care team discusses thepatient’s prognosis with them.

CONTINUED


These suggestions must only be instituted when theAttending Physician has given permission to use all or partof these suggested clinical interventions.

Maintain SBP>100 (MAP>60)1. Consider invasive hemodynamic monitoring2. Adequate hydration: Ensure adequate hydration to maintain

euvolemia3. Vasopressor support: If hypotensive post adequate

rehydration, use Neosynephrine as the first pressor ofchoice up 2mcb/kg/min, followed by dopamine

Maintain Urine Output >0.5ml/kg/hr<400ml/hr(consider DI if >400ml/hrx2hrs)1. Treat DI with Vasopressin drip 1-2.5 units/hr, if

UO still >400/hr2. If UO falls below 0.5ml/kg/hr, assess fluid status—may

need rehydration or BP support

Maintain PO2> 100 and pH 7.35-7.45Adequate ventilation maintained by:1. Peep 5.0-8.02. Aggressive pulmonary hygiene if not contraindicated by

patient’s condition (sx and turn every 2 hrs)3. Respiratory treatments to prevent bronchospasm

HypothermiaMaintain core body temperature between 36C and 73.5C

Labs1. Basic metabolic panel, Magnesium, phosphage, heme8,

ABG’sa. Maintain Hgb>8g/dL and Hct>30%b. If PT>18, given 2 units FFPc. Replete electrolytes as neededd. Monitor glucose and treat with insulin drip if needed

(keep 80-200)2. Bloodbank sample for ABO typing

Source: Organ Donation Breakthrough Collaborativehttp://www.organdonationnow.org/

ORGAN DONATIONCONTINUED FROM PREVIOUS PAGE


DISCHARGE AGAINST MEDICAL ADVICECHECKLIST

Please check all that are completed.

I. Nurse and physician assess the patient Ask why do they want to leave? How can we meet their request? Strive to alleviate patient concerns

II. Physician components1. Notification of chief resident2. Attending physician notified by chief resident3. Determine capacity to make medical decisions or

necessity for medical TDO4. Documentation AMA form completed Decision making status addressed in progress notes Brief summary in progress notes of patient

communications, include severity of condition andpotential consequences for leaving AMA

Discharge plans designed to ensure the safestpossible dischargeA. Discharge instructions, inform patient of clinical

signs/symptoms that would prompt a return to theemergency department/PCP visit

B. Arrange for clinic visits, home care as indicatedC. Provide prescriptions

Dictate discharge summary


CLINICAL PRACTICE GUIDELINESEDATION GUIDELINE:

ADULT CRITICAL CARE UNITS1. Treat pain first with an analgesic.

2. If delirium is suspected (confused and/or disorderedthinking), try non pharmacological interventions. If neededfor patient comfort/safety consider the use ofantipsychotics.

3. PRN/bolus dosing by IV or enteral route is the preferredmethod for managing sedation. PRN/bolus dose 1 - 2times prior to considering the use of a sedation infusion.

4. Use of sedation infusions should be restricted to thefollowing: neuromuscular blockade, altered intracranialdynamics, status epilepticus, acute medical or surgicalinterventions, ventilator dys-syncrony adversely affectinggas exchange, management of ETOH or other drugwithdrawal, hypothermia protocol in use, open chest orabdomen, and invasive cardiac life support devices.

5. Choose a sedation target in collaboration with the healthcare team using the Richmond Agitation-Sedation Scale(RASS). RASS desired target level is determined daily bythe health care team and documented on computer criticalcare flow sheet. Variances from the desired target levelshould be addressed by the health care team, andrationale noted on the flow sheet. When actively titratinginfusions document sedation level Q1 hour until desiredRASS level achieved. When RASS level is stable, documentwith each nursing systems assessment.

6. Sedation infusions are to be interrupted at the unit-determined time (unless a criterion for sedation infusionuse precludes a sedation interruption)

7. The decision to interrupt an analgesic infusion is separateand discussed on team rounds.

8. Select and record reason(s) for not attempting a dailysedation interruption on computer screen.

9. Chemically paralyzed patients should have the paralyticturned off before weaning any sedative or analgesic.

Guidelines are general and cannot take into account all of the circumstances ofa particular pt. Judgment regarding the propriety of using a specific procedureor guideline with a particular pt remains with that pt’s MD, RN, or other healthcare professional, taking into account the circumstances presented by the pt.

Approved: Critical Care Subcommittee 1/2009; Patient Care Committee 3/2009


ADULT CRITICAL CARE SEDATION GUIDELINECONTINUED FROM PREVIOUS PAGE

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RICHMOND AGITATION-SEDATION SCALE (RASS)

Score Term Description+4 Combative Overtly combative or violent; immediate

danger to staff+3 Very agitated Pulls or removes tube(s) or catheter(s)

or has aggressive behavior towardsstaff

+2 Agitated Frequent non-purposeful movement orpatient ventilator dyssynchrony

+1 Restless Anxious or apprehensive butmovements not aggressive or vigorous

0 Alert and Calm

-1 Drowsy Not fully alert, but has sustained (morethan 10 seconds) awakening, with eyecontact, to voice

-2 Light Sedation Briefly (less than 10 seconds) awakenswith eye contact to voice

-3 Moderate Any movement (but no eyeSedation contact) to voice

-4 Deep No response to voice, but anySedation movement to physical stimulation

-5 Unarousable No response to voice or physicalstimulation

PROCEDURE1. Observe patient. Is patient alert and calm (score 0)?

• Does patient have behavior that is consistent withrestlessness or agitation (score +1 to +4 using thecriteria listed above, under Description)?

2. If patient is not alert, in a loud speaking voice statepatient’s name and direct patient to open eyes and look atspeaker. Repeat once if necessary. Can prompt patient tocontinue looking at speaker.• Patient has eye opening and eye contact, which is

sustained for more than 10 seconds (score -1).• Patient has eye opening and eye contact, but this is not

sustained for 10 seconds (score -2).• Patient has any movement in response to voice, but no

eye contact (score -3). CONTINUED



3. If patient does not respond to voice, physically stimulatepatient by shaking shoulder and then rubbing sternum ifthere is no response to shaking shoulder.• Pt has any movement to physical stimulation (score -4).• Pt has no response to voice or physical stimulation

(score -5).

Bedside nurse responsibilitiesDocument the sedation scale, infusion changes, and boluseson the CCFS, along with rationales.Long-Term Mechanical VentilationAssure that the sedation goals are being addressed daily perhealth care team plan.


Identify Patients at High-Risk for Delirium(Consider CAM-ICU Screening)

• Elderly• Underlying dementia• Previous history of delirium• Dehydration• Existence of co-morbidities• Critically ill

General Considerations

• Perform sedation interruption daily.• Appropriately address and treat pain.• Collaborate with health care team (to include LIP, nurse,

and pharmacist) to evaluate for deliriogenic medicationsand adjust as appropriate. (Avoid Benzos!)

• Utilize patient’s Care Partners to assist in non-pharmacologic interventions.

• Initiate fall precaution strategies as needed.• Sleep hygiene - minimal lighting at night, brighter

lighting during day, control excess noise (extremelyimportant intervention)

• Provide patient and family education regarding delirium• Attempt consistency in staff• Provide alternative stimuli: television during day with

news/weather or non-verbal music• Treat underlying metabolic derangements and infections

Medical Center guideline is available on the Clinical Portal

https://www.healthsystem.virginia.edu/documentation/manuals/CPGuidelines/2.055%20Delirium%20Recognition%20and%20Treatment%20Guidelines-Adult%20ICU.pdf?cfid=26882574&cftoken=14a7cb3273337eef-4e2f5982-c447-e4a2-1dcdec862f648d3b&jsessionid=9030dc97735b576a2d5486d2f7a756d13320


Initiate Appropriate Analgesia

• Consider Epidural if Multiple Rib Fractures, patientAwake, and Spine Clearance Possible

• Consider Tylenol, NSAIDS (caution: NSAIDS may causeor exacerbate renal failure if low GFR)

• Consider PCA (Avoid morphine in renal failure. ConsiderFentanyl if hemodynamic instability or elderly)

o Initial Settings

Dilaudid 0.2 - 0.4 mg Q8 min

Fentanyl: 15-25 mcg Q6 min

• If adequate Analgesia not Appropriate / Possible withPCA or Epidural:

o Consider Fentanyl drip: 25-75 mcg / hr if Elderly,Severe CHI, or Hemodynamic Instability

o Consider Dilaudid drip: 0.4 to 2 mg / hr to minimizeneed for benzodiazepine gtts

TRAUMA: PAIN AND SEDATION GUIDELINES

Titrate to achieveanalgesia withoutsedation

CONTINUED

Patient in Pain

➤}


NeedsSedation?

Titrate Narcotic Drip to Effect• Consider weaning with enteral

narcotics or by switching to PCA• Consider adding Haldol

2.5 - 5 mg IV q3 hrs PRN

Intermittent SedativeConsider Ativan 1-2 mg Q1h PRNConsider Haldol 2.5 - 5 mg q2 h PRN

(Especially if need for sedation secondary to delirium)

Need forSedative Drip?

Severe ClosedHead Injury?

VentilatorDysynchrony?

Ativan Drip Titrate toEffect*

Propofol (for < 24 hours)**

}

TRAUMA: PAIN AND SEDATION GUIDELINESCONTINUED FROM PREVIOUS PAGE

➤

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DailyInterruption

* Turn off drip daily and reassess need for continuousbenzodiazepine

** Especially useful for short term sedation such as in earlyCHI, short-term vent weaning.

*** Utilize CAM ICU assessment to evaluate for delirium

➤


University of Virginia Health System

LEVEL ITRAUMA CENTER

PEDIATRIC GUIDELINES

Final Editing by:

Julie Haizlip, MDAssistant Professor of PediatricsDivision of Pediatric Critical Care

Bradley Rodgers, MDProfessor of Surgery and Clinical PediatricsDivision Head, Division of Pediatric Surgery

Eugene McGahren, MDProfessor of Surgery and Pediatrics


PEDIATRIC TRAUMA PROTOCOLS

TABLE OF CONTENTS PAGE

Sedation Service 96

Brain Injury 97

Guidelines for the Management of IntercranialHypertension in Children with Closed Head Injury 98

I. Standard Therapy for All Children 98-99

II. Sequential Treatment of Elevation in IntracranialPressure (ICP > 20 mmHg All Ages) 100-102

III. Severe, Abrupt Elevation in ICP and/orManifestation of Impending Herniation 103

IV. Sequential Treatment of Decreased MAPDecreased CPP 103-104

Sequential Treatment for ICP >20 mmHg (All Ages) 105

Second Tier Treamtnet for ICP > 20 mmHg (All Ages) 106

Severe, Abrupt Elevation ICP and/or Manifestationof Impending Herniation 107

Treatment of Decreased MAP → Decreased CCP 108

Sequential Treatment for ICP >20 mmHg (All Ages) 109

Severe TBI Standard Therapy Checklist 110-111

Clinical Pathway Evaluation of the PediatricCervical Spine 112-113

Near Drowning/Submersion Injury 114-115

Non-accidental Trauma (Abusive Injury) 116-117

Hemostasis in Pediatric Neurotrauma 118-119


PEDIATRIC TRAUMA

The following guidelines were created by consensus in thePediatric Trauma Sub-Committee. The Pediatric Trauma Sub-Committee is a multi-disciplinary group that includesrepresentation from Pediatric Surgery, Pediatric EmergencyMedicine, Pediatric Critical Care, Pediatric Neurosurgery,Orthopedics, and the University of Virginia TraumaCommittee.

These guidelines were approved for patients < 18 who areunder the care of the pediatric surgeons.

MAJOR CONTRIBUTIONS BY:

John Jane, Jr, MDAssociate Professor of Neurosurgery and Pediatrics

Mark Abel, MDLillian T. Pratt Professor and Chair of Orthopedic Surgery

Professor of Pediatrics

Bartholomew J. Kane, MDAssistant Professor of Surgery and Pediatrics



SEDATION SERVICE

PIC# 1662 Peds Sedation Nurse Coordinator(Call this first!)

PIC# 1813 Peds Sedation AttendingHours: Monday – Friday 0700 – 1700

The pediatric sedation service is staffed by a pediatric intensivist anda pediatric sedation nurse. Its purpose is to provide moderate to deepsedation to pediatric patients to facilitate diagnostic and therapeuticprocedures. With the exception of Doug Willson, MD, pediatricsedation providers are not qualified to provide general anesthesia orinhalational anesthesia.

• Patient MUST be NPO for solids/ full liquids for 6 hours prior toprocedure (may have clear liquids until 2 hours prior to procedure)

• Peds Sedation does not electively intubate, and so cannot sedateanyone who requires oral contrast (this is equivalent to a fullstomach). Children who require sedation but have not been NPOmay be electively intubated and sedated by anesthesia for urgentprocedures.

• If you are scheduling a radiology procedure – put in order andrequest “with Peds Sedation” and radiology scheduling willcoordinate with Pediatric Sedation. If it is urgent, you can also callthe Peds Sedation nurse to help facilitate.

• Burns

Acute burns require that the patient have been NPO for the 6hours prior to the burn - if acute debridement is necessary, theywill require anesthesia.

Burns often require daily dressing changes and will need NPOorders prior to sedation every day.

After the first debridement, Peds Sedation will coordinate timesfor subsequent dressing changes.



BRAIN INJURY

Guidelines for the Management of Intracranial Hypertensionin Children with Closed Head Injury

Please note: These are meant to be guidelines.No criteria, protocol or guideline can anticipate every clinicalcircumstance nor are these meant to substitute for clinicaljudgment.

COMMUNICATION AND RESPONSIBILITIESThe PICU team will be responsible for ongoing monitoring,and for safe and expedient transport to CT scan or otherimaging procedures. The PICU Resident and Fellow, theTrauma Service Resident (Pediatric Surgery) andNeurosurgery Service Resident will be responsible foradministration of these guidelines. Deviation from theseguidelines or rapid or unexpected escalation of therapy willrequire notification of the Chief Resident and/or AttendingPhysician from each of the involved services with appropriatedocumentation entered into the patient’s chart. The TraumaChief Resident and Attending, Neurosurgery Chief Residentand Attending, and PICU Attending must be available at alltimes for consultation regarding the management of thesepatients.

INDICATIONS FOR ICP MONITORINGPediatric patients with closed head injury who meet one ormore of the following criteria will have ICP monitoring devicesplaced by Neurosurgery.1

1. Patients with admission (E.D. or PICU) GCS < 82. Patients with GCS > 8 but who require operative or other

interventions that compromise evaluation of the child’sneurological status.

3. Patients with GCS > 8 who require intubation and sedationfor accompanying traumatic injuries and are, thus, unableto be adequately evaluated neurologically.

CONTINUED



Guidelines for Management of Intracranial Hypertension inChildren with Closed Head Injury

Goals of therapy by age*:

Age MAP2,3 ICP1 CPP< 2 years > 55 mm Hg < 20 mmHg > 45 mmHg2-5 years > 60 mm Hg < 20 mmHg > 50 mmHg>5 years > 65 mm Hg < 20 mmHg > 55 mmHgAdolescents/ > 70 mm Hg < 20 mmHg > 70 mmHgAdults

*Correction of elevated ICP should occur before correctionof MAP/CPP

I. Standard Therapy for All Children: 1. Head elevated to 30°, neutral position or reverse

Trendelenburg position if Thoracic/Lumbar spine notcleared.

2. All patients should have an arterial line and a centralvenous line capable of monitoring central venous pressure(CVP).

3. Avoid obstruction of neck veins-> inspect cervical collar forproper fit; avoid circumferential endotracheal tube ties.

4. Minimal stimulation → low light, minimal noise, room doorclosed.

5. After fluid resuscitation, IV fluids at full maintenance usingLactated Ringers or Normal Saline solution. Any additionalIV fluids should be administered in bolus form and titratedto effect.

6. Monitor serum sodium at least every 6 hours →hyponatremia must be avoided. Sodium falling by morethan 3 mEq/L in 6 hours needs to be investigated andaddressed immediately.

7. Analgesia with an initial fentanyl infusion at 1-2 mcg/kg/hr,titrated to effect. Avoid oversedation. Additional analgesia(fentanyl 1-2 mcg/kg bolus) should be given for painfulprocedures (laceration repair, central line placement, ICPmonitor placement, etc.)

CONTINUED

BRAIN INJURYCONTINUED FROM PREVIOUS PAGE



8. Sedation with midazolam at 0.05-0.1 mg/kg/doseq1-2 hours prn, a midazolam infusion at 0.05-0.1 mg/kg hrmay be started if prn doses are inadequate. Avoidoversedation. Agitation may be a sign of elevated ICP,hypoxia, or inadequate analgesia and should beinvestigated. Due to the risk of propofol infusionsyndrome, propofol should not be used for long-termsedation in pediatric patients.

9. Controlled ventilation to maintain PaCO2 between 35 and40 mmHg1.

10. FiO2 should be adjusted to maintain O2 saturation > 92%.High levels of PEEP should be avoided.

11. Colloid infusions as indicated: may consider PRBC’s forHCT < 30, FFP for INR > 1.3, platelet infusions for plateletcount < 100K if intracranial bleeding (SDH, SAH,intraparenchymal hematomas) is present. ConsiderActivated Factor VII if initial administration of FFP does notimprove coagulopathy.

12. Temperature control (< 37° C, rectal temp.). Temperatures> 37° C must be brought down within 1 hour. Temperaturecontrol may require acetaminophen, a cooling blanket,fans, decreased ventilator humidifier temperature, and iceto groins and axillae.

13. Consider the initiation of prophylactic anticonvulsantmedication (Phosphenytoin preferred), especially inchildren < 2 years old with intraparenchymal hemorrhageson admission CT scan.1 Anticonvulsant medication shouldbe strongly considered for patients requiring prolongedneuromuscular blockade.

14. Initiate prophylactic antibiotics (cefazolin or otherStaphylococcal sp. coverage) while ICP monitor is inplace.

15. Initiate stress ulcer prophylaxis (famotidine or equivalent)16. Severe, abrupt or recalcitrant elevations of ICP should

prompt Neurosurgical evaluation and consideration ofrepeat CT scan.


CONTINUED



II. Sequential Treatment of Elevation in IntracranialPressure (ICP > 20 mmHg, all ages)

1. Severe, abrupt or recalcitrant elevations of ICP at any pointin these guidelines should prompt Neurosurgicalevaluation and consideration of repeat CT scan.

2. If there is reason to believe the child is experiencing pain, afentanyl bolus of 1-2 mcg/kg can be given and the infusionadjusted upward by 1-2 mcg/kg/hr. If there is a responsebut it is inadequate, the bolus should be repeated.

3. Sedation should be deepened with an initial bolus(midazolam 0.05-0.1 mg/Kg) and infusion increasedproportionately. If there is a response but it is inadequate,the sedation bolus should be repeated. Agitation may be asign of hypoxia or inadequate analgesia and should beinvestigated.

4. If elevations of ICP are associated with suctioning,consider lidocaine 1mg/kg IV q2 prn. Followingconsultation with the PICU Fellow or Attending, mayconsider barbiturates (thiopental or pentobarbital) prior tosuctioning if the patient is hemodynamically stable. Monitorclosely for hypotension and be prepared to intervene.

5. If ICP elevation is not responsive to additional sedationand analgesia and an External Ventricular Drain (EVD) ispresent, consider additional CSF drainage. TheNeurosurgical service must be notified prior to EVDmanipulation. CSF drainage should be replaced cc:cc withnormal saline IV.

6. Occult seizures must be considered in cases of refractoryor rising ICP. Consider emergent bedside EEG andNeurology consultation. Consider initiation of antiepilepticmedications (Phosphenytoin or Phenobarbital).

7. If ICP elevation is not responsive to the above measures,give Mannitol 0.25 – 0.5 grams/Kg IV over 10-20 minutes. Aworking foley should be in place, urine output must beclosely monitored and euvolemia should be maintained.Serum osmolarity should be monitored every 4 hours andshould be maintained< 320 mOsm/L unless mannitol is used in conjunction with3% saline (see #8).

CONTINUED




8. Consider initiation of 3% Saline infusion at 0.1 mL/kg/hr.May increase infusion every 6 hours to a maximum of 1mL/kg/hr to maintain ICP < 20 mmHg,1,4 the lowesteffective infusion rate should be used. Serum sodiumshould be monitored at least every 4 hours. Serumsodium should not be allowed to increase > 2 mEq/L in a4 hour period (15 mEq/L/24 hours) and should notdecrease by more than 1-2 mEq/L in a 4 hour period (10mEq/L/24 hours). Serum osmolarity should be maintained< 360 mOsm/L whether or not mannitol is used.

9. If ICP elevation is not responsive to the above measures,initiate paralysis with non-depolarizing neuromuscularblockade (NMB) either intermittently (e.g., pancuronium0.2 mg/kg) or as a continuous infusion (suggestvecuronium at 0.1 mg/kg/hr, titrated to effect). Paralysisshould be monitored using nerve stimulator and NMBagent repeated/adjusted when 3/4 twitches return on train-of-four monitor. If not already initiated, anticonvulsantmedication (Phenytoin or Phenobarbital) and continuousEEG monitoring should be strongly considered with theinitiation of neuromuscular blockade.

10. If ICP refractory to the above measures and it has been atleast 24 hours since the time of injury, may consider mildhyperventilation (PaCO2 30-35) until ICP can be controlledby other measures.1 Normocarbia should be re-established as soon as other measures become effective.

11. Should these measures fail, depending on the timing andseverity of ICP elevation, more aggressive measuresshould be considered in consultation with the Traumateam, Neurosurgery and the PICU Attending:a. Higher and/or repeated doses of mannitol

(0.5-1 gm/kg IV)b. If an External Ventricular Drain (EVD) is present,

consider additional CSF drainage.c. Decompressive craniectomy


CONTINUED



i. Can be considered immediately following injury insevere cases of elevated ICP.

ii. Should be strongly considered for refractory elevationof ICP in patients with some or all of the followingcriteria1:1. Diffuse cerebral swelling on CT2. Within 48 hours of injury3. Secondary clinical deterioration4. Evolving cerebral herniation

iii. Some patients may be candidates fordecompressive craniectomy earlier in their clinicalcourse. Therefore, close consultation withNeurosurgery is essential in any patient with rising orpersistently elevated ICP at any stage in theseguidelines.

iv. If decompressive craniectomy is not performed,consider EVD placement if not already done.

d. Barbiturate anesthesia–monitor closely for hypotensionand be prepared to intervene (IV fluids, vasoactivemedications).i. Must have continuous EEG monitoring.ii. Pentobarbital

1. Loading dose: 1-2 mg/kg IV aliquots until ICPcontrolled or burst suppression on EEG.

2. Maintenance: 1 mg/kg/hr, titrated to effect (ICP < 20mmHg or burst suppression).

e. Moderate hypothermia to 32-34° F.1i. May be established using cooling blanket, fans,

decreased ventilator humidifier temperature, and iceto groins and axillae.

ii. Neuromuscular blockade (NMB) must be maintainedto prevent shivering → consider NMB infusion.

iii. If hypothermia cannot be limited to 24 hours,consider daily blood cultures.

CONTINUED




III. Severe, abrupt elevation in ICP and/or manifestation ofimpending herniation (unequal pupils, pupillary dilatationor loss of reactivity)

1. Trauma Service, Neurosurgery and PICU Attendings will becalled immediately.

2. Ventilation will be immediately taken over with handventilation to achieve hypocarbia (PaCO2 < 30 mmHg) untilICP can be controlled by other measures.

3. Mannitol 0.5 - 1 grams/kg will be administered as quicklyas possible.

4. Thiopental 1-3 mg/kg IV or Pentobarbital 1-3 mg/kg IV →monitor for hypotension and be prepared to intervene.

5. Severe, abrupt or recalcitrant elevations of ICP shouldprompt Neurosurgical evaluation and consideration ofrepeat CT scan.

IV. Sequential Treatment of Decreased MAP causingDecreased CPP.

1. CPP = MAP − ICP → Correction of elevated ICP shouldoccur before correction of decreasedMAP/CPP.

2. If ICP is not elevated, low MAP/CPP should be treated ifthere are other clinical indications (poor perfusion,decreased urine output etc).

Age MAP2,3 ICP1 CPP< 2 years > 55 mm Hg < 20 mmHg > 45 mmHg2-5 years > 60 mm Hg < 20 mmHg > 50 mmHg>5 years > 65 mm Hg < 20 mmHg > 55 mmHgAdolescents/ > 70 mm Hg < 20 mmHg > 70 mmHgAdults

3. Fluid bolus of 10-20 cc/kg of Lactated Ringers or NormalSaline solution. If there is a response but it is inadequate,the fluid bolus should be repeated.



CONTINUED


4. Colloid infusions as indicated: PRBC’s for HCT < 30, FFPfor INR > 1.3, platelet infusions for platelet count < 100K ifintracranial bleeding (SDH, SAH, intraparenchymalhematomas) is present. May also consider 1 gram/kg of5% or 25% albumin for volume expansion.

5. Examine patient/review studies for occult sites ofbleeding and address with the Trauma Service andNeurosurgery.

6. As needed, adjust medications that can affect bloodpressure including narcotics, benzodiazepines,neuromuscular blocking agents, barbiturates.

7. Initiate vasoacitve medications such as dopamine,vasopressin, or phenylephrine.

REFERENCESAdelson PD, Bratton SL, Carney NA, et al: Guidelines for the

Acute Medical Management of Severe Traumatic BrainInjury in Infants, Children, and Adolescents. Critical CareMedicine 2003; 31(6).

Jones PA, Andrews PJD, Easton VJ, Minns RA: Traumaticbrain injury in childhood: Intensive care time series dataand outcome. British Journal of Neurosurgery 2003;17(1): 29-39.

Report of the second task force on blood pressure control inchildren–1987-from the


CONTINUED



SEQUENTIAL TREATMENT FOR ICP > 20 MMHG(ALL AGES)

PAIN CONTROLFentanyl 1-2 mcg/kg bolus

Consider infusion at 1-2 mcg/kg/hour

SEDATIONMidazolam 0.05-0.1 mg/kg bolus

Consider infusion at 0.05-0.1 mg/kg/hour

OSMOLAR THERAPY3% Saline infusion at 0.1 mL/kg/hr

Monitor sodium level q2h until infusion and value stable

CSF DRAINAGEThrough EVD (if present)

***Consult with Neurosurgery***

CONSIDER SEIZURESConsider EEG

Consider anti-epileptic medications

ADDITIONAL OSMOLAR THERAPYMannitol 0.25 – 0.5 gram/kg

Monitor serum osmolality now and in 4-6 hours

NEUROMUSCULAR BLOCKADEPancuronium 0.2 mg/kg prn OR Vecuronium 0.1 mg/kg prn

Consider continuous EEG monitoring &/orprophylactic anti-epileptic medications

HYPERVENTILATIONMild hyperverntilation to PCO2 30-35 until ICP controlled by

other measures

GO TO SECOND TIER TREATMENTS


CONTINUED



SECOND TIER TREATMENT FOR ICP > 20 MMHG(ALL AGES)*

* See Text of Guidelines for details* Severe, abrupt or recalcitrant elevations of ICP at any point in

these guidelines should prompt Neurosurgical evaluationand consideration of repeat CT scan.

ICP remains > 20 mmHgdespite First Tier Therapies

Additional consultation withPICU AttendingNeurosurgery

Trauma Surgery

Mannitol 0.5-1 gm/kg IV

Decompressive Craniectomy

Barbiturate ModerateAnesthesia Hypothemia

Need continuous EEG 32-34 degrees CPrepare for hypotension


CONTINUED



SEVERE, ABRUPT ELEVATION IN ICP AND/ORMANIFESTATION OF IMPENDING HERNIATION*

* See Text of Guidelines for details* Severe, abrupt elevations of ICP at any point in these

guidelines should prompt Neurosurgical evaluation andconsideration of repeat CT scan

Immediately Notify:PICU AttendingNeurosurgery

Trauma Surgery

Hand Ventialte toPaC02 < 30 mmHg

until other measuresbecome effective

Mannitol 0.5 - 1 gm/kg IV

Thiopental 1-3 mg/kg IV orPentobarbital 1-3 mg/kg IV

Be prepared for hypotension

Consider repeatHead CT Scan


CONTINUED



TREATMENT OF DECREASED MAP →→→→→DECREASED CPP *

Treat elevated ICPbefore treating

decreased MAP/CPP

20 cc/kg bolus ofLR or NS

Examine patient/reviewradiology studies for occult

volume loss or bleeding

Consider Colloid infusionsPRBC’s for HCT < 30

FFP for INR > 1.3Platelets for < 100 if bleeding

Adjust medications thataffect blood pressure:

benzodiazepines, narcoticsparalytics, barbiturates

Initiate vasoactive medicationsfollowing consultation withPICU Attending, Trauma

Surgery and Neurosurgery


CONTINUED



SEQUENTIAL TREATMENT FOR ICP >20 MMHG(ALL AGES)

Pain ControlFentanyl 1-2 mcg/kg bolus

Consider infusion at 1-2 mcg/kg/hour.Titrate up if necessary.

SedationMidazolam 0.05-0.1 mg/kg bolus

Consider infusion at 0.05-0.1 mg/kg/hour.Titrate up if necessary.

Osmolar Therapy3% Saline infusion at 0.1-0.2 mL/kg/hr

(reduce maintenance fluid rate). Titrate. Monitor sodium levelq2h until infusion and value >145 & stable

CSF DrainageThrough EVD (if present)

***Consult with Neurosurgery***

Consider SeizuresConsider EEG

Consider anti-epileptic medications

Neuromuscular BlockadePancuronium 0.2 mg/kg prn OR Vecuronium 0.1 mg/kg prn

Consider continuous EEG monitoring &/or prophylacticanti-epileptic medications

Additional Osmolar TherapyMannitol 0.25 – 0.5 gram/kg

Monitor serum osmolality now and in 4-6 hours

HyperventilationMild hyperventilation to PCO2 30-35 until

ICP controlled by other measures

GO TO SECOND TIER TREATMENTS


CONTINUED



SEVERE TBISTANDARD THERAPY CHECKLIST

Nursing• Head to 30° or reverse Trendelenberg• Maintain Core Body Temperature < 37° C• Inspect cervical collar for proper fit, change to Aspen Collar• Minimal stimulation (light, noise)• Earplugs if no otorhea• Goal ICP < 20 mmHg, Goal CPP 50 – 70

(To Be Determined by PICU attending or fellow & NSGY)

Monitoring• Arterial Line• Central Venous Line with CVP Monitoring• Serum sodium checked every 6 hours (minimum)

Goal Na > 145.• Serum Sodium checked every 2 hours if receiving 3% NS

(or other hypertonic saline)• Blood glucose monitoring every 6 hours (minimum).

Goal glucose 80-150. Avoid hypoglycemia• Hourly blood glucose monitoring if on insulin infusion

(until stable)• Serum osmolality every 6 hours and prn if receiving mannitol• Train of Four Monitoring every 4 hours if on neuromuscular

blockade• Daily holiday from neuromuscular blockade unless clinically

contraindicated

Respiratory Support• Adjust FiO2 to maintain oxygen saturations >92% - minimize

PEEP• Maintain PaCO2 between 35-40 mmHg on Arterial Blood

Gas

CONTINUED




Fluids/ Meds• Maintenance IV fluids with 0.9%NS once resuscitation

complete (NO dextrose containing fluids)• Adequate analgesia (fentanyl preferred)• Adequate sedation (midazolam preferred)• Neuromuscular blockade if indicated (vecuronium or

pancuronium preferred)• Support BP with vasopressors if indicated (norepinephrine

or phenylephrine preferred)• DISCUSS with PICU Attending or Fellow• Colloid infusions as indicated (PRBCs, FFP, Platelets)• Maintain normal hematologic parameters (HGB > 8, INR d”

1.2, Platelets e” 100 )• Consider prophylactic anticonvulsant medication for high

risk patients (Keppra preferred)• [depressed skull fracture, post-impact seizure,

neuromuscular blockade, epidural]• Appropriate antibiotic prophylaxis for ICP monitor (cefazolin

preferred, vancomycin if allergic)• Stress ulcer prophylaxis (famotidine or equivalent)• Consider lidocaine 1 mg/kg IV prior to suctioning (maximum

7 doses per day)• DVT prophylaxis if post-pubertal

Other• Severe abrupt or recalcitrant elevations of ICP (>20 mmHg

for > 5 mins) should prompt Neurosurgical evaluation andconsideration of repeat CT scan. (assure adequatesedation, etc.)




C-SPINE INJURY CONCERNAGE < 17 YO

Normal &Meets NEXUS

Criteria

*Traction Study (should not be used if ligamentous injuryseen on post 72h MRI !)• initial lateral radiograph is taken to eval for C0-C1-C2

subluxation• initial wt applied should be stratified according to age and wt

o For ped pts with adult habitus, adult protocol may be usedo For infants and children, wt used should be % of totalbody wt

• Initial and incremental wt should be 5% of total body wt• Ultimate wt should not exceed 1/3 total body wt• The 5% value is a conservative extrapolation from adult

population (initial wt = 10 lbs)• Upright C-spine with and without collar prior to full clearance

Obtunded or Intubated

➤

➤➤

➤

Age > 9 yo?

Awake & Alert

YES

YES

NO

➤

Age > 3 yo andCooperative and

No Dev Delay

High RiskMechanism

or Pain on exam

Age < 3 yo ORUncooperative

OR Devel Delay

GettingHeadCT?

Meets Nexus Criteria:1. Absence of midlinetenderness2. No evidence of intoxication3. Normal level of alertness4. Normal neurologic exam5. Absence of painful,distracting injury

C-Spine Clear

➤

➤ ➤

NONO

YES

➤➤

YES

C-Spine Clear

AP, Lateral Cspine± swimmer’s. Odontoidonly if age > 9 yo (ifodontoid is sufficient,get CT occiput-C2)

NO

➤

➤

➤

➤➤

➤

➤ ➤

Abnormal,or painon exam

➤

CONTINUED



Normal

NormalAbnormal

Alert?

Obtunded?

Meets Nexus Criteria?

MRI w/in 48 to 72hrs

SpineConsult

C-SpineClear

Normal

Abnormal,or MRInot done

within48-72 hrs

Upright CspineLat with

then without collar

AP/Lat CspineNo odontoid view

Must see C7 on T1CT Occ to C2

YES

➤ ➤

➤➤ ➤ ➤

C-spine CT(Occiput to T1

with saggital andcoronal recons)

(If getting Head CTdo at same time)

➤

➤➤

➤➤➤

➤➤

➤

NO

➤➤

YESNO

➤

➤

➤

➤

➤➤

C-SpineClear

Normal

➤

Abnormal

Abnormal

➤

➤ ➤

➤

Approved By Ped Trauma Committee Revised 4/06

PEDIATRIC TRAUMA ALERT OR CONSULTCONTINUED FROM PREVIOUS PAGE



NEAR-DROWNING/SUBMERSION INJURYPRACTICE GUIDELINE

1. Provide 100% FiO22. Possible Traumatic Mechanism?

a. Immobilize C-spineb. Consider abuse in bathtub drownings

3. Airway / BreathingA. Clear airway of debrisB. Intubate if

1. undergoing CPR2. Respiratory failure (PaCO2 >45)3. unable to maintain PaO2 >60 mmHg on 100% FiO24. altered LOC with dimished airway reflexes5. worsening ABG’s

C. Consider Cuffed ETT (will likely progress to ARDS)D. If doesn’t require intubation and alert but w/ resp

distress – consider CPAP/BiPAP4. Circulation

A. CPR if necessary (especially if hypothermic)B. Consider ECMO if evidence of icy water submersion

5. RewarmingA. Warmed IV fluidsB. Warmed oxygen (including thru vent circuit)C. Bladder lavage through foley with 40 degree fluidD. DPL can be performed for warm peritoneal lavageE. Thoracotomy with warm mediastinal lavage and open

heart massageF. ECMO cannulation (thoracic preferable to femoral for

rewarming but hypothermic atrium is prone todysrhythmias)

G. Do not abandon resuscitation until temp > 30degrees6. Lab Investigation

A. ABGB. ElectrolytesC. DIC PanelD. ETOH/ Tox screen if indicated



7. RadiologyA. CXRB. If possible trauma

1. Lateral C-spine2. Head CT3. Skeletal survey (if concern for abuse)

8. AntibioticsA. Indicated if drowning was in grossly contaminated waterB. Fever and Elevated WBC count may occur following near

drowning in absence of infectionC. At risk for septic shock associated with Strep Pneumo in

1st 24 hours

NEAR-DROWNING/SUMBERSION INJURYCONTINUED FROM PREVIOUS PAGE



NON-ACCIDENTAL TRAUMA (ABUSIVE INJURY)PRACTICE GUIDELINE

Injuries that are concerning for non-accidental trauma

SHAKEN BABY• Subdural hematomas• Retinal hemorrhages• May have c-spine injury

BRUISING• In infants (“If you don’t cruise, you don’t bruise”)• Bruising in patterns (ie. brush, hand, belt)

FRACTURES• Skull fractures in infants or in children without significant

mechanism• Rib fractures in infants–especially posterior• “Bucket handle” fractures• Spiral fractures (however can be benign Toddler’s fracture)• Multiple fractures in different stages of healing

BURNS IN CONCERNING DISTRIBUTIONS• Bathtub scalds – buttocks, plantar surface of feet, stocking/

glove distribution• Cigarette burns

INCONSISTENT HISTORY• Changing history• History isn’t consistent with development (if you have

questions about what is developmentally possible–ask apediatrician!)

• History doesn’t explain injury Falling off a bed/ sofa onto carpeted floor doesn’t cause a

skull fracture 2 month old infants don’t “roll” off anything

CONTINUED



ABDOMINAL INJURY WITHOUT APPROPRIATE MECHANISM• Small bowel hematomas• Pancreatic injury

PROCEDURES• Appropriate medical care and stabilization• Fill out DOCTOR’S SCAN form (available from HUC’s) – this

documents injuries for CPS• Take pictures of visible injuries when possible• Take a careful history determine who has been caring for child ask for specifics of how injury occurredDOCUMENT EVERYTHING. Use direct quotes when

appropriate.• Get Social Work involved• Notify Child Protective Services (CPS) for the appropriate city/

county Albemarle County – 972-4010Charlottesville – 970-3400 State Hotline 1-800-552-7096

• Tell the family of your concern and that you have notified CPS• Ancillary studiesOphthalmology consult – specifically required for Shaken

Baby Skeletal survey IF there are subdural hematomas, check coags - correct

if abnormal

NON-ACCIDENTAL TRAUMA (ABUSIVE INJURY)CONTINUED FROM PREVIOUS PAGE



HEMOSTASIS IN PEDIATRIC NEUROTRAUMA REQUIRINGURGENT PROCEDURAL INTERVENTION

PRACTICE GUIDELINE

PURPOSE

1. To define appropriate goals for hemostasis in pediatricpatients with neurotrauma requiring urgent proceduralintervention.

2. To outline therapeutic interventions to achieve goalhemostasis.

Please note: these are meant to be guidelines. No criteria, protocolor guideline can anticipate every clinical circumstance nor are thesemeant to substitute for clinical judgment.

IMPLEMENTATION / PROCEDURE

Definitions

1. Standard Risk Procedures: Applies to minor surgicalprocedure such as placement, maintenance, and removalof an intraparenchymal intracranial pressure monitor or anexternal ventricular drainage (EVD) device.

2. Higher Risk Procedures: Applies to major surgicalprocedure such as decompressive craniectomy, orevacuation of a subdural or epidural hemotoma.

Hemostatic Goals

1. Standard Risk Procedures:

a. INR < 1.5

b. Platelet count > 70,000

c. PTT < 3 seconds above the appropriate upper limit ofnormal for age and gestation.

2. Higher Procedures:

a. INR < 1.2

b. Platelet count > 100,000

c. PTT < 3 seconds above the appropriate upper limit ofnormal for age and gestation.

CONTINUED



Interventions to Achieve Hemostatic Goals for Intervention

1. To achieve goal INR and or PTT:

a. Supplement fibrinogen if the value is less than 100 mg/dl using cryoprecipitate 0.2 units/kg

b. Administer Fresh Frozen Plasma (FFP) 30 mL/kg

c. Repeat coagulatin testing and platelet number. If goalsnot met, then supplement platelets using 10 mlplatelets per kg and

d. Administer recombinent Factor VII (rFVIIa) 90 mcb/kg.(hour 0) NOTE rFVIIa should only be given when it isknown with the highest confidence that everything andeveryone is available to initiate the procedure in nomore than 30 minutes.

e. Once rFVIIa is given, there is no benefit to recheckingINR or PTT during the duration of action of rFVIIa (2hours). However, figbinogen and platelet levels shouldbe monitored every 3 hours. Supplement fibrinogen withcryoprecipitate, and low platelets, as above.

f. Repeat rFVIIa dosing every 2 hrs for a total of 3 doses tomaintain perioperative hemostasis. (Hours 2,4,6)

2. To achieve goal platelet count:

1. If patient is requiring FFP transfusion and patient hasplatelet count < 100,000 transfuse with 10mL/kg.(Based on assumption that ongoing plateletconsumption may result in further drop in plateletcount).

b. Repeat Platelet count 30 minutes after transfusion. Ifplatelet count is > 70,000 at time of appropriate INRcorrection, this number is sufficient to proceed withsurgery.

c. Notify blood bank to have additional platelets (10 mL/kg)available if needed during procedure.

Relative Contraindications to Factor VIIa Administration

PEDIATRIC TRAUMA ALERT OR CONSULTCONTINUED FROM PREVIOUS PAGE


1. Multiple trauma including vascular injury2. History within 30 days of new onset arterial or venous thrombosis3. History within 30 days of myocardial infarction


ADULT MEDICATION REFERENCES

STBICU David Volles weekdays Pager 39246E Julie Kesley weekdays Pager 2440Pharm eve-nights Phone 4-5255

ANALGESICSFentanylIV injection 25-50mcg slow IVP q1hr prn adequate analgesia

IV infusion 2500mcg/50ml; Start at 50mcg/hr titrated toadequate analgesia

IV PCA 2500mcg/50ml; 25mcg PCA dose, 6 min lockout delay,hourly limit of 250mcg

MorphineIV injection 2mg slow IVP q2hr prn adequate analgesia

IV infusion 100mg/100ml D5W; Start at 1mg/hr titrated toadequate analgesia

IV PCA 100mg/100ml D5W; 1-2 mg PCA dose, q 6-8 minlockout delay, hourly limit of 12mg

HydromorphoneIV injection: 0.4-0.6 mg q 2 hr PRN

PCA: 10 mg (50 m) 0.2-0.6 mg q 6-8 min

Oxycodone+acetaminophen 5/325mg (Percocet)Pain Score As needed:

1-4 One tablet PO (5/325mg) every 4 hrs

5-6 Two tablets PO (10/650mg) every 4 hrs

(PO tablet, 5/325mg, Percocet)

(PO/enteral tube liquid, 5/325mg per 5ml, 10/650mg/10ml,Roxicet)

Oxycodone 5mg (PO tablets)Pain Score As needed:5-10 Two tablets (10mg) every 4 hrs

CONTINUED


Hydrocodone+acetaminophen 5/325mg PO tablet (Vicodin)Pain Score As needed:1-4 One tablet PO (5/325mg) every 4 hours5-6 Two tablets PO (10/650mg) every 4 hours

Lidocaine PatchOn pain site 12 hrs on (10:00 AM), 12 hrs off (22:00 PM)

Methadone (Chief approval: consider pain consult)Long-term pain management.

5 to 10 mg po every 8 hours starting dose. Will peak in 3 days.Taper 10% qod.

NON-STEROIDAL ANTI-INFLAMMATORYAGENTS*

* Avoid NSAIDs in patients with any renal insufficiency or inpatients with history or risk of bleeding (GI bleeds, lowplatlets, spleen, liver lac and anticoaguant use).

Ketorolac (Toradol)30mg IVP now followed by 15mg q6hr prn (May not use

ketorolac longer than 3 days; convert to oral NSAID orother agent)

Ibuprofen (Motrin, Advil)400-800mg PO, q6-8hr prn(Not to exceed 3200mg / day)

SEDATIVESMidazolamIV injection 2-4mg slow IVP q1 hr as needed for sedation

IV infusion (duration <48h) 100mg/100ml; Start at 2mg/hr andtitrate for sedation

Lorazepam (duration >48h)IV injection 1-2 slow IVP q1hr as needed for sedation

IV infusion 40mg/40ml; Start at 1mg/hr and titrate for sedation

Propofol (head injury and/or <24h)ED/Radiology phase where need for immediate control fordiagnostic purposes. PROPOFOL INFUSION (preferable overbolusing due to hypotension risk) 25mcg/kg/minute based on

CONTINUED

ADULT MEDICATION REFERENCESCONTINUED FROM PREVIOUS PAGE


estimated weight for the intubated patient. If ineffective forsedation after 5 minutes and no hypotension or other cardiaceffect, titrate in increments of 5 mcg/kg/minute every 5minutes until sedated. Observe closely for cardiaccomplications including mean BP < 70.

To initiate unit IV infusion 1000 mg/100ml; Start at 25mcg/kg/min and titrate for sedation

Dexmedetomidine dripFor 2nd line treatment after failure of other 1st line sedatives.(also for severe withdrawal agitation) 200 mcg/50ml @ 0.2-1.5 mcg/kg/hr. Adverse Events: Bradycardia, hypotension

NUTRITION PATHWAYLactobacillus2 capsules qhs.For patients on broad spectrum antibiotics, tube feeding.

ANTIPSYCHOTICS FOR DELIRIUMHaloperidol (Haldol)2-10mg IV q8-6hr as needed for ICU psychosis

Quetiapine (Seroquel)25mg PO qHS – q12hr; may titrate up to 300-400mg/day individed doses as needed

ALCOHOL DETOXIFICATIONCIWA on presentation if score > 8CIWA via orders in computer

Chlordiazepoxide scheduled or symptom triggered based onCIWA order set

50mg PO now and then q6hr x 4 doses followed by 25mg POq6hr x 8 doses

25 – 100mg PO q1hr as needed for CIWA >8

LorazepamScheduled or symptom triggered based on CIWA order set

CONTINUED



2mg PO or IV now and then q6hr x 4 doses followed by 1mgq6hr x 8 doses

1-2mg PO or IV q1hr as needed for CIWA score > 8

RALLY PACK:Thiamine100mg IV now followed by 100mg PO q12hr x 3 days or100mg IV qday x 3day

Folic Acid1mg PO or IV q12hr x 3 days

MagnesiumMagnesium sulfate 2g/50ml D5W over 60 min qday x3 days

Magnesium oxide 420mg q12hr x 3 days

Multivitamins with minerals1 tablet/liquid PO qday or 10ml MVI in maintenance IV qday

Clonidine0.1 – 0.2 mg q12hr x 3-4 weeks for withdrawal symptoms

Quetiapine50mg PO qday – q12hr; may titrate up to300-400mg/day individed doses. Consider higher night dose. Titrate down 25-50mg qod

ANTIHYPERTENSIVES ANDHEART RATE CONTROL

MetoprololIV 2.5 – 5mg slow IVP q6hr initial doses; up to 10mg q4hrfor tachycardia)PO 12.5 q12hr initial dose (Up to 50mg q8hr or 100mg q12hras tolerated)

DiltiazemIV 0.25mg/kg (15-20mg is typical) slow IVP as needed for rate

CONTINUED


control


Continuous infusion at 5 - 10mg/hr not to exceed 15mg/hrtitrated for rate control

PO 30 – 60mg q6hr or SR formulation once daily

DigoxinIV load with 0.5 - 1mg total given in divided doses (0.25 x 2doses followed by 0.125mg x 2)

IV/PO maintenance dose is 0.125mg – 0.25mg qday

LabatelolIV 10 - 20mg slow IVP q1hr as needed for blood pressurecontrol

PO 100mg oral q12hr initial dose, up to 200-400mg q12hr

HydralazineIV 10 – 20mg slow IVP q4-6 hr as needed for blood pressurecontrol

ClonidinePO 0.1 – 0.2mg q8-q12 hr initial doses; up to a maximumdose of 0.6mg q6hr

Patch 0.1mg patch q7 days initial dose; up to 0.3 - 0.6mgpatch q7days

ANTIFUNGALSFluconazole400mg IV, qday to 800mg qday* if resistant fungal speciessuspected

Amphotericin0.5 – 0.7 mg/kg qday over 4-6hrs, Pre-medications and salinehydration

AnidulafunginFor resistant fungal species. 200 mg IV load followed by 100mg IV q24h (for candidemia, intra-abdominal abscess)

CONTINUED



ANTIMICROBIALS** Requires adjustment for renal dysfunction

(CrCl < 50ml/min); ask pharmacistGRAM NEGATIVECefepime 2grams IV, q12h* (Higher doses for meningitis:Cefepime 2grams, q8h)

Ciprofloxacin 400mg IV, q12h, or 750mg PO, 1 12hr*(400 mg q8h for pneumonia)

Meropenem 1gram IV, q8h*

Piperacillin-tazobactam 3.375gram IV, q6h*

(Pseudomonas Zosyn 4.5gram IV, q6h)

GRAM POSITIVEVancomycin 1gram IV, q12h or 15mg/kg, q12h*

Linezolid 600mg IV/PO, q12h (weak MAO inhibitor, avoid usewith SSRI drugs)

ANAEROBESClindamycin 600mg IV, q6h

Metronidazole 500mg IV, q12 - 8h

C. DIFFICILEMetronidazole 500mg PO, q8h or Vancomycin 125 mg po

q 6 hrBOWEL MOTILITY

Docusate sodium capsule/liquid100mg, PO daily – q12hr

Milk of magnesia conc10mL, PO, qod, if no bowel movement(May schedule qhs if no result)

Bisacodyl suppository10mg, #1 PR, qod, if no bowel movement

Fleet’s phosphate enema#1 PR, qod if no bowel movement

Senokot#1 tab qHS if no bowel movement CONTINUED



DVT / PE*PROPHYLAXISEnoxaparin (Moderate to high risk patient including orthoand spinal cord injury)30mg BID

*Consider 40mg s.c. once daily (18:00) in preparation forpossible epidural catheter placement. Remember that anepidural catheter may not be placed within 18 hours ofenoxaparin & unfractionated heparin dosing or within 6 hoursof heparin dosing.

Consider venous foot pump if platelets less than 30K.

Heparin (Low risk patients)Rarely appropriate for Trauma Service5000units s.c. q8hr + Intermittent Pneumatic compressiondevice (IPC)

TREATMENTHeparinLoad with 80 units/kg and initiate infusion at 16 units/kg/hr i.v.titrated to therapeutic aPTT (64 – 101 per Institutional HeparinDosing Nomogram. Heparin Drip: 25,000 units in 250ml NS

Coumadin5mg PO, once daily to start and titrated to INR 2 – 3

ELECTROLYTESPotassiumIV (peripheral line) 10 meq in 100ml Sterile Water over 1hr

IV (central line) 20 meq in 50ml Sterile Water over 1hr

PO 20 – 40 meq (powder, liquid, SR capsule) as needed for K< 3.6

MagnesiumIV 2-4g in 100ml D5W over 1hr

PO Magnesium Oxide 400mg (#2- 4) as needed forMag < 1.8

CONTINUED



PhosphorousIV 30 meq in 100ml D5W over 2 hr

PO Sodium Phosphate (Neutra-Phos Powder) 2 packetsas needed for Phos<2.2

EYE CARELacrilube ointment to both eyes as needed every 4 hr

GI PROPHYLAXISFamotidine20 – 40mg, IV/PO q12hr

LansoprazoleLiquid suspension 30mg, NGT or feeding tube q 24hr unlesshigh risk for GI bleed the q 12hr

Esomeprazole40mg, PO qday

Esomeprazole IV40mg slow IVP qday – q12hr

Continuous infusion for GI bleed80mg in NS 50ml over 15 min, followed by continuousinfusion 80mg/250 NS at 8mg/hr X 72 hours (After 72 hourschange to PO or to prophylaxis dose listed)

GLUCOSE MANAGEMENTInsulin infusion per STBICU unit guidelineInsulin 250 units in 250ml NS titrated per STBICU guideline(Continuous infusion)

NAUSEAOndansetron4 mg IV q8hr prn

CONTINUED



TREATMENT OF HYPERKALEMIAGlucose and InsulinD50W 50ml IVP and 10 units regular insulin IVP

Calcium Gluconate1g slow IVP over 2 minutes

Sodium Bicarbonate1meq/kg slow IVP (1-2 amps, 50-100meq)

Sodium polystyrene sulfonate (Kayexalate)15-60g PO or by enema, q3-4 hrs(Higher doses for enema, 50g)

TREATMENT OF RHABDOMYOLYSIS(CK >5,000)

Sodium Bicarbonate100 meq sodium bicarbonate in sterile water 1000ml IV,begin at 50 ml/hr and titrate to keep urine pH > 6.5, untilCK < 5000

NEUROMUSCULAR BLOCKERCisatracuriumIV bolus 0.1mg/kg IV push

IV infusion 200mg/200ml D5W; Start at 3 mcg/kg/min andtitrate for paralysis

ORAL CAREChlorhexadine 0.12% (Peridex mouth wash) 15ml swish andspit as needed

Oral candidiasis preventionNystatin 500,000 units Swish and Swallow or NG q6hr

PRESSORS/ INOTROPESDopamine(Emergency peripheral line 200mg/250ml D5W),

2-20mcg/kg/minCentral line preferred 400mg/250ccNS,

2-20mcg/kg/minCONTINUED



Dobutamine – 500mg/250ml NS, 2-20 mcg/kg/min

Norepinepherine – 8mg/250ml NS, 1-30 mcg/min

Phenylepherine – 20mg/250cc NS, 10 – 100 mcg/min

Vasopressin – 100 units/NS 100ml, 0.02 – 0.04 units/min

SPINAL CORD INJURY, ACUTEMethylprednisolone bolus (30mg/kg ) followed by an infusion

at 5.4 mg per kg per hour for 23 hours.

SEIZURES PROPHYLAXISLevetiracetam (Keppra)500 mg-1gm q 12hrs po or IVPB

PhenytoinIV load with 20mg/kg (usual doses of 1000mg given as an

infusion over 60 minutes)IV/PO maintenance dose of 200mg q12hr titrated in 100mg/

day increments to level of 10-20mg/L(IV and suspension products are NOT sustained release and

must be divided q8-q12hr)(The 100mg phenytoin capsule is a SR product and may be

given once daily up to 400mg/day)

SPLENECTOMYVACCINESWithin first 7 days or day prior to discharge.

Pneumococcal polyvalent 23 vaccine0.5ml s.c. x 1

Meningococal vaccine0.5ml s.c. x 1

Haemophilis influenza (Haemoph B Conjugate)0.5ml I.M. x 1

PLATLET COUNT > 1MILLIONAspirin325mg PO qday


CONTINUED


TRAUMATIC BRAIN INJURY3% saline – Hyponatremia3% Sodium Chloride (“hot salt”) 500ml

Start at 15-20ml/hr; Follow serum sodium very closely, repeatas needed for hyponatremia

Do not correct sodium too rapidly

MannitolIV 1g/kg (usual doses of 100g) as the 20% solution 500mlover 30-60 minutes q4-6hr as needed(The 25% mannitol solution is 25g/100ml and the 20%solution is 20g/100ml)


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UVa Trauma Pearls