Trauma Center Pocket Manual

8/17/2019 Trauma Center Pocket Manual

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University of Virginia Health System

LEVEL ITRAUMA CENTER

TRAUMA HANDBOOK

Final Editing by:

Jeffrey S. Young, MDDirector, Trauma Center

Professor of SurgerySenior Associate Chief Medical Officer for Quality

James Forrest Calland, MD Assistant Professor of Surgery

Associate Chief Medical Officer, Acute Care

http://tinyurl.com/uvatraumamanual

November 2012


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2 11/12 UVA TRAUMA HANDBOOK

This handbook is also available online via the

Clinical Portal: http://www.healthsystem.virginia.edu/clinician-portal/index.cfmh

Trauma Intranet: http://www.healthsystem.virginia.edu/pub/trauma-center/intranet and as an EPIC link in the Trauma

Admission Order Set.

Additional educational information can be found atwww.clinicalbraintraining.com or at Clinical Brain Trainingon iTunes.


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UVA TRAUMA HANDBOOK 11/12 3

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 evaluated

during a period of intellectual reflection, and not in the ED at 2AM.The clinician should use these guidelines to provide safe andeffective care to injured patients.”

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

Jeffrey S. Young, M.D.Professor of SurgerySenior Associate Chief MedicalOfficer for Quality

Guidelines are general and cannot take into account all of the circumstances of a particular patient. Judgment regardingthe propriety of using any specific procedure or guideline witha particular patient remains with that patient’s physician, nurseor other health care professional, taking into account theindividual circumstances presented by the patient.

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

Produced by the Trauma Program.Project Lead: Kathy Butler

Project Assistant: Shannon Lohr All rights reserved.

Sixth Edition

November 2012


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Mission Statement

The Trauma Center at the University of Virginia seeks to provide and support the highest standard of healing and compassionate care to the injured people of Virginia and itssurrounding regions – uninfluenced by the lifestyle,socioeconomic status, race, gender or political beliefs of

patients we serve.

Vision Statement

The Trauma Center at the University of Virginia seeks a world free of preventable morbidity and mortality from injury. Wefurther seek to become the premiere organization in supportingits state, populace, and patient population to reduce the burdenof injury through excellence in patient care, research,education, and participation in planning and advocacy.

Values

Team members of the Trauma Center at the University of Virginia believe in and adhere to the following values:

1) Patient and family centered care:

a. We will always put the needs of the patient and families

FIRST.

b. We will always create systems of care that maximize

transparency, safety, and participation.

c. The only patient and family need that will be emphasized

higher than satisfaction and comfort shall be SAFETY.

d. We agree to the need to standardize our care as much as

possible to reduce the incidence and impact of variation.

e. We shall scrutinize our outcomes, near misses, and

accidents to ensure that we are doing all we can to

promote superlative processes and outcomes.

f. We shall maintain a culture that simultaneously recognizes

our potential for excellence AND the possibility of catastrophic failure of our care systemsCONTINUED


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2) Stewardship:

a. We will use limited and precious resources responsibly to

ensure sustainability through effective and transparent

budgeting and resource allocation.

b. When facing conflict in the use of system resources, our

primary allegiance is to the patient.

c. We will do everything within our power to ensure that

patients needing expert care have access to our services at

all times.

3) Scholarship and Collegiality

a. Expertise shall take precedence over rank in high risk

clinical scenarios.

b. We shall support all of our academicians in their pursuits to

create new knowledge through academic publication,

participation, and attainment of external funding.

c. We shall be always be inclusive and respectful so as toensure creation and sustainment of effective teams.

CONTINUED FROM PREVIOUS PAGE


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5TH EDITION CHANGES

Pelvic Fracture

Trauma Nurse Practitioners

Mild TBI

Moderate-Severe Traumatic Brain Injury

Coagulopathy Neurotrauma Guideline

Deep Vein Thrombosis

Mangled Extremity Guideline

Cardiovascular Evaluation-Perioperative

Cardiovascular Evaluation

Spinal Cord Inujury Management

Syncope

MET Team

Disclaimer: this list is not comprehensive


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2012-13 CHIEFS & FELLOWS

PAGER PAGER

GENERAL SURGERY VASCULAR & TCV

6623 Flohr, Tanya R. 3870 Adams, Joshua

4422 Hennessy, Sara 6895 Carrot, Phil

4882 Hranjec, Tjasa 3396 Griffiths, Eric

6582 Nagju, Alykhan 4627 Tesche, Leora

2880 Parker, Anna

TRANSPLANT

6234 Kane, Bart

2866 Ladie, Danielle

2006 Rasmussen, Danielle

4TH YEARS

4853 LaPar, Damien 4061 Turza, Kristin4705 Riccio, Lin 3158 Walters, Dustin4705 Shada, Amber

3RD YEARS

2995 DeGeorge, Brent 4088 Politano, Amani6552 Judge, Joshua 6635 Rosenberger, Rosa6554 McLeod, Matthew 2878 Umapathi, Bindu

2ND YEARS6954 Davis, John 4038 Mehta, Gaurav6994 Dietch, Zachary 6442 Wagner, Cynthia2146 Edwards, Brandy 4715 Willis, Rhett

6178 Hanna, Kasandra 4782 Yount, Kenan4063 Hu, Yinin

1ST YEARS4429 Charles, Eric 3334 Olenczak, Bryce4833 Coster, Jenalee 3970 Poiro, Nathan4985 Day, Matthew 4028 Rueb, George3591 Downs, Emily 3826 Shaheen, Basil3600 Elmer, Donald 3844 Shah, Puja6884 Eymard, Corey 4068 Smith-Harrison, Luriel2264 Gilsdorf. Daniel 3165 Wheeler, Karen6203 Johnston, Lily 4420 Wong, Scott3152 McEarchern, Rachel 4532 Zee, Rebecca3185 McPhillips, Kristin

RESEARCH6939 Stone, Matthew (Kron) 2276 Guidry, Christopher (Sawyer)4992 Davies, Stephen (Sawyer) 2685 Newhook, Timothy (Bauer)6966 Lindberg, James M. (Bauer) 2744 Pope, Nicholas (Ailawadi)

3767 Gillen, Jacob (Lau) 6988 Salerno, Elise P. (Slingluff)6587 Petroze, Robin (Calland) 6963 Johnston, W Forrest (Ailawadi)


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CONTINUED

CONTACT DIRECTORY

Phone Pager

TRAUMA ALERT GROUP MEMBERS

9162 Adult Trauma Alert Intern

1294 Trauma Alert 2nd yr

531-3494 1560 Trauma Chief

1459 Trauma Alert Backup Chief

1311 Anesthesia Resident

9248 Anesthesia PACU Resident

1564 Trauma Attending

1450 Trauma LIP – Acute Care

1294 Trauma Resident – ICU

1297 Trauma Consult – Day

1824 Pediatric Trauma Chief

1356 Peds Trauma Intern

1707 Peds Trauma Attending

531-5703 ED: 2nd yr (consults)

3-6341, 3-6317 ED: Attendings

1391 Chaplain

1576 NSGY Resident 2

1822 Nursing Supervisor

1371 OR Charge Nurse

1616 Respiratory Therapy-Adult

1716 1684 (RT Back-ups)

1742 Respiratory Therapy-Pediatric1989 Radiology Portable

4-2120 1384 Social Worker-ED

1908 Back up Trauma Attending

CONTACT DIRECTORY

284-2845 3462 Trauma Center Director, Jeff Young, MD

2-3549 Administrative Assistant, Amy Bunts

242-9458 4425 Assoc. Trauma Direc tor, For res t Cal land, MD

2-4278 Administrative Assistant, Cynthia Carrigan

465-5152 3404 Trauma At tending: Rob Sawyer, MD

227-1278 6151 Trauma At tending: Carlos Tache Leon, MD

825-2503 6356 Trauma At tending: Zequan Yang, MD

3994 Trauma At tending: Michael D. Williams

284-1923 3868 Trauma Center Manager: Kathy Butler, RN

202-841-5535


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CONTINUED

CONTACTSCONTINUED FROM PREVIOUS PAGE

Phone Pager

9558 IRPA (in-house rescue physician)

9520 Floor Attending

Trauma Service Nurse Practiti oners

962-1974 4334 Deborah Baker, ACNP

813-731-9736 Heather Passerini, ACNP-BC

882-1375 6744 Gabriele Ford, FNP-C

465-8083 4735 Sherry Child, ACNP-BC

865-8064 6822 Matt Robertson, ACNP-BC465-8943 2333 Kwame Boateng, ACNP-BC

531-5839 ED Charge Nurse 2-0201

531-0701, 02 ED Attending #1, #2

4-9295 ED Registration Fax

4-1201 ED “back” Fax

4-0351 STBICU Fax

4-5227 (1) LAB

4-2273 Blood Bank

3-9218 Bed Center RN

3142 Neuro CNS

2-1794 Translator

RADIOLOGY3-9296 CT

1234 CT Tech

1404 Head CT Resident–ED Board

Body CT Resident–ED Board

4-9338 Diagnostic Work Area

4-9400 (3,2) Image Management

9416, After hours 1329

1844 IR Resident (Request on-call IR Nurse also)

3-9535, 06 IR Department

2-3155 MRI

2-2526 4701 MSK Reading Room Coordinator (even months)

2-3432 1492 Neuro Reading Room Coordinator (odd months)

2-3988 Body CT Reading Room Coordinator


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CONSULTS

1415 Acute Pain Service

1251 Orthopedics ED

1609 ENT

4-8738 3819 Geriontology NP M-F 08-5:00

1518 Plastics- Consult ER

1800 Plastics Intern

6811 Psych Nurse - Brenda Barrett

1288 TCV night1847 Thoracic Chief

1847 Thoracic Day Consult

1253 Urology

1378 Vascular Day Consult

1818 Vascular Chief

TRANSFER HOSPITALS

Hospital Main Phone Film Room

Augusta 800-932-0262 540-932-4483

Culpeper 800-232-4264 540-829-4144 or 4145

Lynchburg 877-635-4651 434-200-4139

Martha Jeff. 434-654-7000 434-654-7104

Roanoke 540-981-7000 540-981-7126

Rockingham 800-543-2201 540-433-4380 or 4386

Danville 434-799-2100

Lewis Gale 540-776-4035

QUALITY CONCERNS

284-1923 3868 Kathy Butler, RN

Please share adult or pediatric trauma concerns with the trauma

center manager promptly (within 72hrs) by phone or pager.

TRAUMA REGISTRY REPORT REQUESTS

3-4858 Michelle Pomphrey RN

4-1770 Sera Downing

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

CONTACTSCONTINUED FROM PREVIOUS PAGE


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TABLE OF CONTENTS PAGE

TRAUMA ALERT PROCESS 14-17

TRAUMA ALERT CRITERIA 18-20

Trauma Alert Considerations 21

PEARLS 22-24

Trauma Service Communications 25-26

Trauma Service NP’s 27

Discharge Planning 28

Discharge Summary Guidelines 29-30

TRAUMA PRACTICE GUIDELINES – ADULT (Alphabet ical)

Abdominal Penetrating Trauma 31

Airway Management – Emergent 32

Blood Alert 33-35

Tranexamic Acid 35

Brain Injury –

Mild TBI 36

Moderate to Severe TBI 37

Brain Injury Sedation 38

Guidelines for Craniotomy / Craniectomy 39

Coagulothopy in Neurotrauma 40

Burn –

Major, Respiratory Management 41-42

Adult Burn Fluid Resusci tation Guidelines 43-48

Cardio-Evaluation-Perioperative 49-50

Cardiovascular Failure, Non-Hypovolemic 50-51

Chest Trauma Aortic Transection (Actual or suspected) 53

Blunt Myocardial Injury 54

Blunt Thoracic Trauma 55

Epidural Protocol 56-57

Penetrating Central 58

Deep Venous Thrombosis 59-60

Extremity Trauma – Penetrating or Blunt 61

Mangled Extremity Guideline 62

Free Fluid-No Solid Organ Injury 63

Hematuria 64

Pelvic Fracture Algorithm 65

Pregnancy CT Algorithm 66

Pulmonary Embolism Workup & Treatment 67

Resuscitation 68

Rhabdomyolysis 69

CONTINUED


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Syncope 70

Spine Clearance Algorithm 71-74

Spinal Cord Injury Mgmt 75-76

Spleen and Hepatic Trauma, Non-operative Management 77-78

REFERENCES 79

ARF Tracheostomy Planning 80

Tracheostomy Patients In Adult Acute Care 81-82

Ventilator Paralysis Trial 83

Ventilation – Proning 84-85

ARDS Patients - Ventilated STBICU 86

Against Medical Advice Discharge 87

Injury Scales

Lung 88

Spleen 89

Liver 90

Kidney 91

Heart 92-93

Diaphragm 93

LTAC 94-95

MET Team 96

Organ Donation 97-98

Pain and Sedation 99-100

Palitative Care 101-102

Physical and Occupational Therapy 103

TABLE OF CONTENTSCONTINUED FROM PREVIOUS PAGE

CONTINUED

PAGE


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TABLE OF CONTENTSCONTINUED FROM PREVIOUS PAGE

PEDIATRIC GUIDELINES 104-130

Sedation Service 107

Brain Injury

Guidelines for the Management of Intracranial 108

Hypertension in Children with Closed Head Injury

I. Standard Therapy for All Children 109-110

II. Sequential Treatment of Elevation in ICP 111-112III. Severe, Abrupt Elevation in ICP and/or 113

IV. Sequential Treatment of Decreased MAP / CPP 114-115

Sequential Treatment for ICP >20 mmHg (All Ages) 116

Second Tier Treament for ICP > 20 mmHg (All Ages) 117

Severe, Abrupt Elevation ICP and/or Manifestation 118

of Impending Herniation

Treatment of Decreased MAP → Decreased CCP 119

Sequential Treatment for ICP >20 mmHg (All Ages) 120

Severe TBI Standard Therapy Checklist 121-122

Clinical Pathway Evaluation of the Pediatric

Cervical Spine 123-124

Near Drowning/Submersion Injury 125-126

Non-accidental Trauma (Abusive Injury) 127-128

Hemostasis in Pediatric Neurotrauma 129-130

MEDICATION REFERENCES 131-140


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TRAUMA ALERT PROCESS

In general, the adult trauma service shall be theevaluating and admitting service for all patients 16years of age and older with multi-system injury.

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

responsibilities, and contingency planning• 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• Adequately resuscitate patient before leaving the ED• CXR, pelvis x-ray and trauma labs (if patient hemodynamically stable, pelvis may be withheld if patient A&Ox4 and non-tender)

INDICATIONS FOR IMMEDIATELY SECURING AIRWAY• Inability to follow commands• Inability to protect airway• Inability to safely complete workup• Hypotension/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• King Airway: If oxygenating well, good O2 Sats- leave King in

place until after CTCONTINUED


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CONTINUED

TRAUMA ALERT PROCESSCONTINUED FROM PREVIOUS PAGE

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

splints)

• Consider resuscitative thoracotomy if:

witnessed arrest (blunt)-

-Patient must have had palpable pulse or CLEARLY measurable PulseOx at lease once on hospital grounds

recent arrest (penetrating)-

-Patient should have had RECENT signs of life

-Survival may be as high as 18% in those with the recent arrest

after thoracic stab wounds

` -May withhold thoracotomy if Wide Complex PEA at


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CONTINUED

• 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 the head CT

• CT Thorax Significant thoracic injuries on CXR Rapid deceleration mechanism (see #11 Gamma criteria) 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 hypotensionmechanism (see #11 Gamma criteria)(if any of above criteria are not met, likelihood of

intraabdominal injury is


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• 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 Situations where the good of the patient would be served

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 with significant risk for respiratorycompromise because of their injuries OR BECAUSE of their baseline medical fraility.

• Any trauma patient with 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 elderly patients)• Any of these patients who cannot be admitted to the STBICU

must 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


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CONTINUED

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

1. Airway obstruction or respiratory compromise includingintubated patients who have been transferred from another facility with ongoing respiratory compromise or facial burns/singed facial hair with dyspnea.

2. Confirmed hypotension

a) SBP < 90 on 2 consecutive measurements

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

c) Absence 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 Attendingpresence. Patient has NO Alpha Alert Criteria and one or more of the following:

1. Severe single system injury (including penetrating head

trauma)

2. Respiratory

a) Intubated at scene or < 2 hours prior to arrival at UVA with

NO ongoing respiratory compromise or King Airway

b) Mechanically assisted ventilation and NOT intubated

c) Facial Burns or singed facial hair with altered phonation

TRAUMA ALERT CRITERIA

*Any conflict with other teams during an alert must becommunicated immediately to the attending on-call orDr.’s Young, Calland


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TRAUMA ALERT CRITERIACONTINUED FROM PREVIOUS PAGE

CONTINUED

5. MSK

a) Two or more proximal long-bone fractures

b) Amputation proximal to wrist or ankle

c) Crushed, degloved, or mangled extremity

d) Greater than 2cm diastasis, sig. crushed pelvis or widening of SI joint

6. Stab wounds to neck, chest, or abdomen

7. Burns: Adults > 40%, Pediatric > 25% TBSA

8. Concomitant thermal / multi-system injury

9. Or per Emergency Medicine Physician / Trauma Service

discretion

*Any patient may be upgraded to alpha status according to EITHEREmergency Medicine OR Trauma Service discretion.

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 with

known or suspected history of injury (including GLF)

3. Cardiovascular

a) Cardiac Arrest – blunt mechanism

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

GAMMA ALERT - Surgical Chief presence within 30 minutes of activation; Patient has NO Alpha or Beta Alert Criteria andhas one or more of the following:

1. Trauma service consults should be initiated as gamma alert

minimally and as a higher alert if meeting the criteria

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

3. Severe pain in chest, abdomen, neck, or back

4. Significant solid organ injury

5. Pelvic fractures

6. 2 or more organ systems/body areas significantly injured


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•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;

•Auto versus pedestrian/bicyclist thrown, run over, or with

significant (>20 mph) impact

•Motorcycle collision >20 mph

11. High energy mechanism:

•High-risk falls:•adults: fall >20 feet (one story = 10 feet)

•children aged 10 feet or 2 -3 x child’s height;

9.Time-sensitive extremity injury

10. Early Pregnancy with abdominal pain / signs of abdominaltrauma

7. Operative therapy anticipated / planned by subspecialty service

8. Moderately injured with severe medical co-morbidities

TRAUMA ALERT CRITERIACONTINUED FROM PREVIOUS PAGE

12. Trauma transfers unless meeting alpha/beta criteria


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Trauma Surgery Service Pearls

• 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

-Medical conditions (myasthenia gravis, Parkinson’s...)

• All advance directive/DNR discussions should be carried out

with an attending present or with immediate attendingnotification after such conversations have occurred

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

•King Airway: If oxygenating well, good Sats leave in place untilafter CT.

• Blood Alert – early activation of massive transfusion processmay improve survival. Remember calcium, bicarbonate andwarming patient. Call 4-2012 to activate. All patients receivingblood in the ED for hemmorrhage/hypotension in the EDshould ALSO receive Trenexemic acid if within 3 hours of injury

•Do not bolus propofol

•Key physical exam findings should be demonstrated duringbedside sign-out

•Do not copy forward the previous day’s note unless you can becertain that the outdated portions have been deleted

• ALL trauma patients shall have a .tricutransfer note completedin EPIC prior to transitioning to the acute care (ward / floor)service.

• Collaborative notes should be completed during rounds oneach patient-either on a sticky note, or on the white board

CONTINUED

• SPECIFIC necessity to maintain central venous and urinary catheters must be documented DAILY in the progress notes.

• All central venous catheters and arterial lines from outside hospitals

(or that were placed in the trauma bay under questionable aseptic technique) must be replaced within 48 hours of admission by A FRESH STICK — they may no longer rewired!!


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PEARLSCONTINUED FROM PREVIOUS PAGE

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

• Simultaneous craniotomy / thoracotomy / laparotomy ispossible

•Opthathmology consult is needed for orbital wall fracture,

obvious injury to eye, pain on exam, visual changes (changesin visual acuty, double vision, floaters)

•If initial chest CT positive for aspiration, bronch pt.

•Bedside report is expected for the night resident prior to A.M.

rounds to sign-out the service

•Patients with radiographic evidence of severe pancreatic injuryrequire imaging (ERCP, or cholecystopancreatography, or MRCP) to assess ductal integrity

•Attending should be notified of all planned DNR discussionsbefore they occur and afterwards if such occur in impromptufashion

•Institutional clinical guidelines Sepsis, sedation, and elimination

of life/sustaining measures can be accessed on the UVA clinicalportal: http://www.healthsystem.virginia.edu/docs/manuals/guidelines/cpgguidelines

• In general, we admit most patients to trauma for the first 24hrswith some exceptions such as isolated severe TBI.

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

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

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

• Consider removing one line or tube daily on patients who areimproving clinically.

• Thoracic hemorrhage >1.5 liters must receive expeditiousoperative therapy.


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TRAUMA SERVICE COMMUNICATIONS

JUNIOR RESIDENTS/NPs TO CONTACT CHIEF IF:

•MET team activation

• Saturations < 90 not responding to one intervention

• Arrhythmia with hypotension

• Lactic acidosis not corrected by 8 hours after admission

• Urine output 8, increase in mean airway pressure > 15,increase in peak pressures > 30, increase in FIO2 greater than 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 of 10% 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/comfort

measures only)CONTINUED


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CHIEF TO CONTACT ATTENDING TO:

Call Attending If:

• MET team activation

• Significant family conflict

• Any conflict with other teams during an alert must becommunicated immediately to the attending on-call or Dr.’s Young/Calland

• 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:

• MET team activation

• 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

Discuss: all floor changes with the attending who is roundingin the ICU on the weekends


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Trauma Service Nurse Practitioners

• Medical management of patients on acute caretrauma in collaboration with trauma chief andattending

• Daily physical assessment of all patients on acutetrauma

• Daily notes

• Collaborating with case managers and SW toidentify and achieve individualized discharge plan

• Ordering and follow up on indicated imaging

• Daily review and update of orders

• Timely discharge

• Communicating with all consulting services

• Communicating daily plan with patient and families

• Responding to trauma alerts

• Documentation including daily notes, dischargesummary.

• Providing communication and updates to patient’sPCP

• Responding to patient phone calls.


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DISCHARGE PLANNING

DISCHARGE ORDERS

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

Post-chest tube insertion: No flying for 4 weeks post discharge

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 for severe 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 of care are too ill for discharge to home, a nursing facility, or anacute care rehabilitation facility.

Transitional Care Hospital (LTAC) referrals for ventweaning:

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

• Discuss the medical indications for LTAC referral with family

• Call Social Work

TRANSITIONAL CARE HOSPITAL


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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 Number

Admission DateDischarge Date

Account Number Attending 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 fractures

2. 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”. Excisionaldebridement should be documented when performed in theOR or at the bedside.

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

CONTINUED


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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, Dr. Tache Leon.

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

Dr. Williams and Dr. Yang will see trauma follow-up.

DISCHARGE SUMMARY GUIDELINESCONTINUED FROM PREVIOUS PAGE


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ABDOMINAL PENETRATING TRAUMAGUIDELINE

Trajectory likely (or possibly) through abdomen: from nipples/tipof 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 / tachycard ic or trans-abdominal:

Laparotomy

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

➤

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 fo r the UNSTABLE patient isin the Operating Room.

➤

➤ ➤

TRAUMA PRACTICE GUIDELINES - ADULT


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AIRWAY MANAGEMENT – EMERGENT

10. Significant bleeding around a trache (soaking of a 4x4 pad, or constant flow) should be treated as an emergency with notification of the senior resident and stat CTA of neck and chest). Life threatening bleeding (hypotension, arterial hemorrhage) should initiate immediate thoracic surgery consult and transfer to OR.

PURPOSEThis document describes the expectations and roles of physicians and

other credentialed providers, respiratory therapists and registered

nurses caring for adult patients with the need for urgent or emergent

airway management in the acute 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 job responsibilities; in life threatening

situations a credentialed physician with advanced airway

management training may manage the airway prior to the arrival of

the anesthesiologist.

3. Page 1311 for the anesthesiologist on-call AND call

4-2012 to overhead page for respiratory therapy supervisor.

4. Page the respiratory therapist if not already present.

5. If a crichothyroidotomy is a possibility (facial injuries, history of

difficult intubation, unfavorable anatomy) equipment for surgical

airway should be at the bedside BEFORE the intubation is

attempted. At the least a knife, betadine, and a 6.0 endotracheal

tube should be at the bedside.

6. Upon arrival at the bedside, the anesthesiologist assumes

leadership for directing the management of the patient airway. The

anesthesiologist performs endotracheal intubation or, clinical

situation permitting, the local physician or other credentialedprovider (or trained respiratory therapist in the STBICU: per

Department of Respiratory Therapy Policy 210) continues to

manage the airway under the anesthesiologist’s supervision.7. In the critical care units or the Emergency Department, a

credentialed physician with advanced airway management training

and competency may assume responsibility for managing the

patient airway. In the STBICU, a trained respiratory therapist may

initiate advanced airway management. In these situations, the

physician or other credentialed provider determines the need for

anesthesiology consultation.

8. Anesthesiology will be called to the ED as part of the trauma alert.

9. Obturator / King Airways should be converted to difinitive airways immediately if problems with oxygenation or ventilation. Otherwise, they may be converted when patient arrives in OR or ICU


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Continued

TRANSFUSION MEDICINE SERVICES

BLOOD ALERTMASSIVE TRANSFUSION PROTOCOL

Phase I:

A. Indications

1. Trauma patient with suspected or known clinical massivehemorrhage. (The patient is likely to bleed to death inthe next 15 minutes)

B. Activation

1. The BLOOD ALERT wil l be act ivated by the traumaattending, or trauma chief resident, or anesthia attendingcalling the Blood Bank.

2. a. The blood bank staff will complete the top portion of the Blood

Alert form located in the front of the Windowprocedure book.

b. Call 4-2012 (emergency operator) and request“Blood Alert Activation” and provide the patient location.When the Blood Alert is activated, the trauma surgeons,trauma coordinator, OR charge nurse, transportationservices, blood bank bench on call and the blood bankmanager are paged with a text message indicating ablood alert and the delivery location of the blood products.The Blood alert will be cancelled in the same manner itis activated (the physician will request cancellation andthe Blood Bank staff will call 4-2012 to initiate “Blood

Alert cancelled” text message distributed to the pager group.

3. Make 4 copies of the Blood Alert Activation form. Send one copy with each of the coolers.


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Phase II:

Upon notification, immediately thaw 6 AB plasma and prepare4-6 uncrossmatched O neg red cell units and place in a cooler.(If patient has a current Blood Bank sample, type specific bloodmay be issued.)

#1 Initial Issue four - six uncrossmatched O neg red cellunits with Blood Alert Form (or type specific if patient has acurrent BB sample.) Thaw six AB plasma. Prepare and issueone dose

#2 15 minutes, or immediately after the 1st group ispicked up. Prepare six more O neg uncrossmatched red cellunits, or six type specific red cells if sample has been receivedand typed. Issue when transportation arrives. Issue six ABplasma. Thaw six ABO compatible plasma Prepare and issueone dose. Thaw cryo pool if ordered

#3 15 minutes, or immediately after the 2nd group ispicked up.Prepare six type specific red cell units. Issue whentransportation arrives. Issue six ABO compatible plasma. Thawsix more ABO compatible plasma. Prepare and issue onedose

#4 15 minutes, or immediately after the 3rd group ispicked up. Prepare six type specific red cell units. Issue whentransportation arrives. Issue six ABO type compatible

plasma.Thaw six more ABO compatible plasma. Prepare andissue 1 Dose. Every other dose

#5 Alert cancelled? Page activating physician todetermine if the blood alert needs to continue or be cancelled.

#6. The Blood Bank will continue to set up a cooler every15 minutes until the protocol is cancelled by the activatingphysician or the patient expires.

Transportation staff will come to the Blood Bank to retrieve anew cooler and a copy of the Blood Alert activation formapproximately every 15 minutes. They will return a cooler andthe form every time products are picked up. Transportationstaff may also relay any ongoing needs and deliver a Type &Crossmatch specimen when available.

A trauma team member should place orders for 30 red cells, 30plasma, and 3 platelets after the blood alert is cancelled.

Continued


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Products and coolers will be returned after the protocol is cancelled by the unit staff. Note: Patients with active Blood Bank specimens will receive type specific red cellsand plasma. The patient care team should secure a properly labeled Blood Bank sample as early in the procedure as possible and deliver it directly to the Blood Bank.Prompt blood typing is essential to maintaining the availability of universal donor

plasma (AB) and universal red cells (O neg) which are on limited supply.Reference:

AABB Technical Manual, 17th edition, 2011, pp 748-751, 458


Inclusion Criteria:

References:

The Use of Tranexamic Acid for Adult Trauma Patients

OR

• There is no evidence to support additional doses of tranexamic acidDosing:

· All adult (>16 yo) trauma patients presenting tothe Emergency Department (ED) within 3 hoursof injury who:

o Exhibit ongoing signs of significanthemorrhage (SBP < 90 mmHg and/or HR> 110 bpm) that receive TRANSFUSIONIN THE TRAUMA BAY (especially thosethat require activation of the Blood Alert).

o Are considered to be at risk of significanthemorrhage

Table 1. Dosing, Reconstitu tion, and Administ ration

Treatment

Dose

Reconstitution

Infusion

Rate

Duration

Loading Dose 1 gm 1 gm in 100 ml NS 600 ml/hr 10 minutes

Maintenance

Dose

1 gm 1 gm in 250 ml NS 31.3 ml/hr 8 hours

1. CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant

hemorrhage (CRASH-2): a randomized, placebo- controlled trial. Lancet, 2010; 376 (9734): 23 – 32.

2. CRASH-2 protocol. http://www.crash2.lshtm.ac.uk/.


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MILD TBI

LOC?Neurological SX?

(headache,

impulsivityconfused)

Obtain PMRConsult*

NoStandard

Care

Obtain Speech andOT Consults*

Arrange OutpatientFollow Up According

to Consult Recs

* May have to occur as outpatient consult if dischargecan otherwise occur between 3 PM Friday and 0600

Yes➤

➤

➤

➤

(Ongoing symptoms or loss of consciousness at time of injury)


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Moderate

to

Severe

TBI

(GCS

<

9)

Treatment Goals INR 75100

ICP 60 and 92%

Maintain adequate preload (CVP 812) Maintain preload (CVP 812 mmHg)

SBP > 90 mmHg Place ICP Monitor

HOB 30 degrees Maintain Serum Sodium @ 150165

Assess for

need

to

remove

Ccollar

Head

Midline

* Place monitor within 2

hours of admission

** Vaso + Levo (or

Phenylephrine) are

first line therapy

*** chk Na +/ sOSM q4

hours, stop HTS if Na >

165, no mannitol if

sOSM > 320

Sedation and analgesia +/ paralysis

ICP > 20 mmHg (>5min)*

Mannitol (0.250.5g / kg) or HTS bolus***

Consider repeat Head CT

ICP still > 20 mmHg?

ICP still > 20 mmHg? No

ICP still > 20 mmHg?

Consider ventriculostomy / CSF Drainage

ICP still > 20 mmHg? No

Yes

Notify Trauma

Attending STAT and

Contact NSGY for

decompression /

operative

intervention Optimize medical MGMT

No

ABTF Indication(s) for surgical

decom ression resent?

Yes

No

No

Yes

Yes

Yes


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BRAIN INJURY SEDATIONPRACTICE GUIDELINE

ICP PLACEMENTICP monitors will be placed at the discretion of the Neurosurgery

service. In general, patients with GCS


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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.


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Pt taking ASA

or Plavix?

Pt taking Coumadin?

Consider 10cc/kg FFP

Administer 2u Thawed FFP STAT

Administer 1-2u pooled PLT STAT

Head Injury with GCS


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BURN (MAJOR)RESPIRATORY MANAGEMENT

PRACTICE GUIDELINE

INHALATION INJURYInhalation injury should be suspected if there is history of entrapment in a closed space. The patient may present with ahoarse voice, new onset cough or shortness of breath, and mayalso have carbonaceous sputum, singed nasal hairs and facialedema. Diagnosis may be confirmed by bedside bronchoscopy.

Patients should be treated with vigorous pulmonary toilet andambulation (as appropriate) to assist in airway clearance of particulate matter. Intubation and ventilator support should beinitiated if there is profound facial edema (anticipated or present) or difficult ventilation and/or oxygenation based ondirect airway injury. Persistent debris in the airway may need tobe removed by serial endoscopic bronchopulmonary lavage.Evidence of carbon monoxide poisoning may warranthyperbaric oxygen therapy consult even if the carbon monoxidehas 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 bronch cart)• If: any evidence of respiratory distress or upper airway

swelling (stridor, severe cough, hoarseness, voice change)• Bronchoscopy for diagnosis and treatment in first

24 hours

CONTINUED


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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

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


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ADULT BURN FLUID RESUSCITATIONGUIDELINES

(All other applicable ICU protoco ls/guidelineswill be maintained)

ALL DEVIATIONS MUST BE APPROVEDBY ATTENDING PHYSICIAN

(ICU Attendings: Dr. Young, Dr. Sawyer, Dr. Lowson, Dr. Yang,Dr. Williams and Dr. Calland should be notified and utilized as aprimary resource in the event of alternative Attending coverage)

Charge RN should be consulted in the event of nursing-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, dry

material. Topical agents should be avoided.)• Initiate fluid resuscitation in the field if possible, but immediate

fluid requirement should be low, so this is not imperative.

• Administer airway control and support dependent on local skilllevel and patient condition.

Referring Hospital

• Initiate contact with UVA as soon as possible

• Initiate IV therapy

Large-bore (>18 ga.) peripheral IV in unburned skin

Central or femoral access if peripheral access unavailable

CONTINUED


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ADULT BURN FLUID RESUCITATION GUIDELINESCONTINUED FROM PREVIOUS PAGE

• Imperative that IV therapy with LR or NS be initiated prior

to transfer. Even though the total burned BSA may not be

known, if estimated at >40%, fluid should be administered

at rate of 1liter per hour to prevent severe intravascular

fluid deficits in the early post-burn period.

• Initiate airway control

• Immediately intubate any patient exhibiting airway

symptoms (stridor, hoarseness, severe cough, voice

change) 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 despitealterations in the above items (other than chest for hemodynamic/

respiratory instability) and decision conflict arises

among the involved teams, Trauma and Plastic Surgery

Attendings 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


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• If persistent acidosis – pH < 7.25 (> 12 hrs):

Reassess fluid resuscitation

Consider Swan-Ganz catheter

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

AIRWAY:

• NO ETT should be electively changed within the initial 48hrsfor 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 emergentsituations

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)

Positi ve and CK > 5000

Initiate NaHCO3 drip(1:1 concentration with central access) (150meq:150ml)

Maintain u/o 100ml/hr

Mannitol (12.5-25 gms) and/or increase MIVF rate for u/o< 100ml/hr

CONTINUED


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Positi ve and CK 250ml

– hold TF)

• Obtain admission weight; daily weights

• Obtain bladder pressure every 12 hrs

• Administer soap suds enema with Zassi placement firsttanking 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 continuousmonitoring

Hypothermia:

Ranger fluid warmer; Rapid Infuser if needed

Heated vent circuit

Bair hugger

Room temp elevated

Warmed saline/water utilized for wound care

Minimize large surface area exposure duringwound care

CONTINUED



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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 pulmonarycompliance with ongoing high fluid resuscitation need,

consider abdominal compartment syndrome (ACS) and/or cardiac failure. If severe respiratory failure ensues, consider CRRT for fluid management.

Abdominal Compartment Syndrome

Burn patients are at increased risk of:

• inhalation injury

• extensive FT burns to the torso

• large %TBSA


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Need for

emergency

noncardiacsurgery?

Activecardiac

conditions?

Low risksurgery?

Good functional

capacity withoutsymptoms?

Operating Rm

Perioperativesurveillance &

postop risk

stratification &risk mgmt

Evalutate & treatper ACC/AHA

guidelines**

Consider

operating Rm

Proceed withsurgery

Proceed with

plannedsurgery

Vascularsurgery

Intermediaterisk surgery

Vascularsurgery

Intermediate

risk surgery

Consider

testing if it willchange

management

Proceed with planned surgery with HRcontrol (ClassIIa LOEB) or consider

noninvasive testing (Class IIB) if it willchange management

Proceed with

planned surgery

3 clinicalrisk factors

1-2 clinical

risk factors

*MET level

greater than or

equal to 4

Unknown or no

clinical risk

factors

Cardiovascular Evaluation-Perioperative

(If previous percutaneous coronary intervention see next page)

Yes?

Yes?

Yes?

Yes?

http://www.anesthesia-analgesia.org/

content/106/3/685.short

**


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Drug-elutingstent

365 days

Bare-mentalstent

>30-45 days


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NON-HYPOVOLEMICCARDIOVASCULAR FAILURE

PRACTICE GUIDELINE

PATIENTS TO BE TREATED• Fresh trauma patients (3.0, pH


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SITUATIONS• Low cardiac index , pump failure Cardiac 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 (65mm Hg. If this is inadequate, consider Vasopressin at0.04 units

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

If normotensive-• Milrinone or Dobutamine as above

• Failure of therapy STAT echo to rule out tamponade

Repeat cavitary scans to insure that there is no bleeding Consider aortic balloon pump, or surgery as recommended

by Cardiology

NON-HYPOVOLEMIC CARDIOVASCULAR FAILURE GUIDELINECONTINUED FROM PREVIOUS PAGE


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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 increase in sedation, then:

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

1 MVC > 30 MPH, Fall > 15 feet, Ped struck, MCC > 20 MPH2 If extravasation present, prepare for emergent thoracotomy.3 Use these parameters with caution in patients with severe closedhead injury and elderly patients with a medical history of poorlycontrolled hypertension.4 Patient s with actual (or potential for) severe injuries who are notintubated should NOT, in general, receive conscious sedation.


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WORKUP AND TREATMENT OF BLUNT MYOCARDIAL INJURY

PRACTICE GUIDELINE

Al l patients with Blunt Thorac ic 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 hours

Troponin x3 (Q8 hours)

Echo (STAT iF hypotension)Cardiology Consultation

No

Troponin /EKG

Abnormal?

Hemodynamic instability?Myocardial Infarction?

No No Routine

Care

Yes Yes

Yes

STBICU / CCU Admission

First line intrope for cardiogenicshock due to blunt myocardial is

Dobutamine

➤

➤

➤

➤

➤

➤

➤

➤

➤

➤

➤


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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 are

appreciated upon imaging tests. Consideration should be givento early VATS (within 72 hours of injury) to avoid late fibrothoraxand empyema.

Multiple rib fr actures / flail segment:Non-ventilated patients with multiple rib fractures or flailsegments and respiratory compromise1 who are otherwise goodcandidates for epidural analgesia should have epiduralscatheters placed by the acute pain service or on-call anesthesiateam as soon as adequate bony spine clearance is obtained.2

In the setting of displaced rib fractures and chest deformityconsider early rib fixation.

1 Incentive Spirometry < 18 cc’s / kg IBW/sec2

See Epidural / Analgesia Guideline for Trauma Pts with Rib Fxs


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EPIDURAL / ANALGESIA GUIDELINES FOR TRAUMAPATIENTS WITH RIB FRACTURES

A) Timely / exped it ious epidural analges ia i s desi rab le for the trauma patient with mult iple rib fractures and thepotential for respiratory failure, and should be achievedwithin 12 - 18 hours after admission unless acontraindication to placement exists. For epidural

analgesia, the pati ents MUST HAVE:

1) No major coagulopathy (INR < 1.4, platelets > 100,000)

2) Cleared cervical, thoracic, and lumbar spines, or, at least,minimal spinal trauma (e.g.,


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EPIDURAL/ ANALGESIA GUIDELINES FOR PATIENTS WITH RIBFRACUTRES


such catheters to be placed as soon as there are adequateresources to facilitate such action, arrangements will need to beworked out on a case-by-case basis depending upon theexisting workload 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 an existingchest tube, for the instillation of up to 20 mL 0.25%bupivacaine every 6-8 hours. This technique requiresthat the patient be placed for 30 minutes so that thevolume will layer in the posterolateral paravertebralgutter AND that the chest tube be clamped for 30minutes.

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.


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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


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Patients with high risk for intra-cranial or epidural bleedingfrom head or spinal cord injuries shall receive 5,000uunfractionated heparin TID approximately 24 hours after aSTABLE neurologic exam AND / OR stable cross-sectionalimaging.

If such patients develop thromboembolic complications (e.g.,DVT or PE) they should ALL receive IVC Filters.

Patients undergoing the following procedures do NOT requirethat their heparin / lovenox be stopped for the OR:

1) Ankle ORIF (not PILON)2) ORIF lisfranc3) Pinning metatarsals4) Pinning of hip fractures5) Distal femir ORIF (not femoral nailing)

Superfic ial Venous Thrombosis

•Cephalic and saphenous vein thrombosis are NOT deep veinthrombosis should be followed with ultrasound and NOTanticoagulation

For dosing guidelines see Adult Medication References at back of manual



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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 Low ABI < 0.9 ABI>0.9

Pulse deficit No pulse deficit

➤

➤

➤ ➤

➤ ➤

➤ ➤

➤ ➤

Normal Minimal Major arterial arterialinjury injury

Observation Observation Operation± serial

arteriography

Arteriography Observation

➤ ➤ ➤

➤ ➤➤

*Consider blood pressure cuff above site of hemorrhage.


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Mangled Extremity Algorithm*

*Upper Extremity under construction

ABI


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No Work up

Unstable pelvic fracture* w/gross hermaturia? Orsignificant (>50RBC’s per hpf) microscopic?

GU Work-up:1. RUG for urethra2. CT scan for kidney and ureter

3. 3.Cystogram for bladder

Yes

Surgical Note:

Laparotomies with Urethra prepped into field and sterile foley

*Pelvic fracture: comminuition of anterior ring, blood at meatus, high riding

prostate, gross hematuria

No

HematuriaPractice Guidelines


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CT

Trauma Attending to

bedside, repeat FAST,consider DPL

No

Stable

VS?

Blush

?

Equivocal

FAST?

Pelvic plain film

Consider need forbinder

Perform FAST

Routine ICU

care, Remove

binder in

consult withOrtho

No

Yes

Yes

ABCDE’s

Severe

Pelvic

FX?

Usualcare

Lap +/‐

Exfix in OR

thenpost‐op

Angio

Fast

Neg.?

No

AngioYes

No, clearly negative

Yes

No

Pelvic FractureHemodynamically unstable patient with high risk mechanism

and/or lateral or anterior compression II‐III or vertical sheer

injuries

Yes


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CT ALGORITHM FOR PREGNANCY

Avoid CT through pelvis to avoid

radiation exposure to

cranial vault / fetal brain.

Consider CT options for lower radiation

dosing (consult with radiologist),

Or alternative to CT imaging of pelvis:

e.g., IVP / cystogram for imaging of GU

system, or MRI of pelvis.

No

Yes

Obtain routine trauma

imaging.

Consider obtaining

pre-imaging Beta-HCG

if not otherwise

contraindicated by

patient status.

Known pregnancy?

or

Fetus visible on plain film/Torso

Scout Images on CT?

➤

➤

Is pt hemodynamically

unstable and / or have abdominal

tenderness and / or a

known pelvis fx?

Obtain routine trauma

imaging.

Consider obtaining

pre-imaging Beta-HCG

if not otherwise

contraindicated by

patient status.

➤

Yes

No

➤


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CXR. ABG, Supplemental Oxygen

Treatable process(pneumothorax,

mucous plug,

Treat cause and

reassess

Saturated 4L oz?

Heparinize if possible

Yes No

CTA LE Duplex

Yes

No

PositiveIVC filter +

anticoagulatuon

No

LE Duplex in 5 Days

If inpatient

If patient persistently hemodynamically unstable, Cardiac surgery should be consulted foremergent pulmonary emboloectomy

*For treatment of positive LE duplex, see DVT guideline

Problem

resolved?

Yes

PE Suspicion includes:(oxygen desaturation that does not respond immediately to simplemeasures, severe acute dyspnea, acute decrease in P/FIO2 ratio to


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RESUSCITATIONPRACTICE GUIDELINE

Concurrent Resuscitation: (ALL Patients)

Stop bleeding, resuscitation with blood, blood productsand crystalloid to SBP >100, pulse 2.5**

↓Evaluate for hemorrhage/missed injury

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


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RHABDOMYOLYSISPRACTICE GUIDELINES

Check serum creatine kinase on patients wit h:

• 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 li ter NS or LRMaintain urine output > 100 cc/hr

Keep urine ph > 6.5*and

Re-check CK & urine PH every 12hours after goal has been achieved

➤

➤ > 5,000

< 5,000

➤

Repeat until twoconsecutive

negative results

** No need for bicarbonateinfusion **

➤ ➤

*Check urine PH as often as necessary to achieve this goal


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Reason for Fall / MVC Unclear

(i.e. injury could be intentional or due to syncope?)

Perform Hx, PE, 12lead EKG

Obtain appropriate

consults as indicated by

findings of testing

Consider cardiology consultation, tilt table test, and other

outpatient diagnostic tests

No

Yes

Initial evaluation suggestive of specific

anatomic/physiologic problem?

(Possible arrhythmia,

Aortic

stenosis,

PE,

neurologic

sx, family HX syncope / sudden death)

Unexplained Syncope

Alarm Hx, ECHO or

other Tests

Positive?

Admit to telemetry or ICU

AND perform testing as indicated:

(e.g., ECHO, EEG, as indicated by

Hx / Physical Exam)

Review alarm history q1224h !!

DO NOT OBTAIN CAROTID DUPLEX !!

Yes

Age > 60?

Known / suspected

CVD?

Signs / Sx of CHF?

Abnormal ECG?

Initial evaluation diagnostic /

suggestive of orthostatic hypotension/

benign cause

or

possible

suicidality?

(As determined by medication history,

autonomic dysfxn or single vehicle

collision vs. stationary object, and / or

Toxicology screen)

No

Holter Monitor or 24hr review of telemetry / ICU alarm history

Assess for seizure s (tongue soreness, incontinence )

Assess for recent changes in medications

Suicidality?

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


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CONTINUED

• 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

• Auto v. Pedest rian/B icyc list Thrown, Run Over, or wt ih Signif icant (>20 mph) Impact

SPINE CLEARANCE ALGORITHM

➤

Remove collar (unlessdesired for pt.) comfort

document exam clearancedate & time, update activity

orders, including d/c oldactivity orders

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 for outsideimages. If a trauma alert, place an outside read order under the ED Trauma

Alert pathway (in Epic) to have images read.

EXPEDITING READS: Call the appropriate Reading Room Coordinator by

0800 for needs.MSK:2-2526 (even months) NSGY: 2-3432 (odd months)

Follow up Spine Studies-Uprights, MRIs, etc.- order as pr iority 2

Yes

See Next Page

PATIENT EXAMINABLE?

GCS 15, Alert, and NONE of the following:Intoxicated, midline cervical/thoracic/lumbar pain/tenderness,neurologic deficits, high ri sk mechanism***, distracting injury

(pt can participate in exam), no spine imaging is indicated.

No➤


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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)***

Spine Consultation

(Complete consult request w/ date & time,

clarify activity orders in Epic)

See next page for Cervical,Thoracic and Lumbar Spines

Negative Bony Imaging

**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 thehead; 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

adjacent torso trauma (e.g. sternal fx/flail chest) spine consultation isnot required and HOB should be raised to 30 degrees to optimizepulmonary status. Subsequent tertiary exam 12 – 24 hours later isrequired to clear patient for unrestricted activity in such cases.

➤Yes

➤No

Imaging Indicated:

SPINE CLEARANCE ALGORITHMCONTINUED FROM PREVIOUS PAGE

Patient Not Examinable*

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

neurologic deficits,distracting injury (pt can participate in exam)

Positive C Spine Imaging needs a spine consult!

CONTINUED


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Yes

Consider MRIif anticipating that patient

is un-examinablefor > 5 days

Pain, tenderness and/or peripheral sensory/motor signs/

symptoms

STOPthe cervical spine clearance

process, replace the patient’s C-collar, and obtain imaging. (Flex /

Ex or MRI) *

➤

➤Yes

SPINE CLEARANCE AL GORITHMCONTINUED FROM PREVIOUS PAGE

CERVICAL SPINE CLEARANCE —NEGATIVE BONY IMAGING

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

Perform Tertiary Exam /Clinical Exam of C spine.

Remove the patient’s collar and 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)

PATIENT EXAMINABLE?GCS 15, Alert, and NONE of the following:

Intoxicated, midline cervical/thoracic/lumbar pain/tenderness,neurologic deficits,distracting injury

(pt can participate in exam)

Preliminary Cervical spine bony imaging readsnegative (No new, old or undetermined findings)?

CONTINUED


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THORACIC & LUMBAR SPINE CLEARANCE –NEGATIVE BONY IMAGING

SPINE CLEARANCE A LGORITHMCONTINUED FROM PREVIOUS PAGE

(No new, old or undetermined findings)Preliminary reads negative

➤

HOB to 30 degrees, update activity ordersincluding dc old orders

➤

PATIENT EXAMINABLE?

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

neurologic deficits,distracting injury(pt can participate in exam)

Yes No➤

Examined patient before advancingpositioning. Patients with negativeimaging, but severe pain/tendernessin T/L spine should be evaluated for potential discogenic disease or occultFX.

• Age indeterminate spine injury image interpretations should beconsidered acute except in the clear absence of pain, tenderness andlimitation of mobility.

• Patients with no bony abnormalities or malalignment on imaging who areawaiting ligamentous cervical spine clearances may be upright and OOBwith collar.

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

• All patients with >48 hours flat bed rest due to spine injury/evaluationshould be on Rotorest beds unless countermanded by spine consultantor otherwise contraindicated.

• Respiratory complications and Decubitis ulcers are the two top sourcesof morbidity in patients with spine cord injury: Spine clearance must beefficient and thoughtful.

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

Final read needed toadvance position


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Traumatic Spinal Cord Injury: Early Acute Management

Based mainly on Consortium for Spinal Cord MedicineClinical Practice Guidelines: Early Acute Management in Adults with Spinal Cord Injury

1) Resuscitationa) Monitor and treat symptomatic bradycardia (from

unopposed vagal innervation to heart).i) If problematic, hyperventilate prior to orotracheal

care.ii) If still problematic, consider use of IV atropine

prior to orotracheal care or turning.b) Monitor and regulate temperature (patients are at risk

for poikilothermia).i) Consider warm IV fluids and/or a patient-warming

device.2) Neuroprotection:

a) No clinical evidence exists to definitively recommendany neuroprotective agent, including steroids.

b) Stop methylprednisolone immediately in those whoseprior neurological symptoms have resolved.

3) Diagnostic Assessmentsa) Image the entire spine, and get an MRI for the known

or suspected area(s) of SCI.4) Associated Injuries

a) Screen for thoracic and intra-abdominal injury in allpatients with SCI.

b) Consider placing an NG tube to low intermittentsuction for abdominal decompression.

5) Anesthetic Concerns: Avoid succinylcholine after the first48 hours post-SCI.

6) Secondary Preventiona) Order a pressure-reduction mattress or a mattress

overlay.b) Use a pressure-reducing cushion when the patient is

sitting out of bed.c) Reposition/turn at least q2 hours (right sideàbackàleft

side).e) Respiratory Management:

i) Get baseline Vital Capacity, FEV1, and ABGinitially and at intervals until stable.

d) DVT/PE Prophylaxis:i) Begin Lovenox 30 mg subcu BID plus SCDs once

primary hemostasis is evident.

CONTINUED


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ii) In patients with expiratory muscle weakness (SCIinvolving T6-T12 myotomes) treat retained secretionswith manual assisted coughing (relative contraindicationis IVC filter), aggressive pulmonary hygiene, mechanicalinsufflation-exsufflation (“Cofflator”), etc.

f) Place a Foley catheter at admission and keep in place untilhemodynamically stable and 24-hour urine output isconsistently 72 hours, and begin anticoagulants as soon as feasible.

iii) Get baseline lower extremity ultrasound to rule out DVT

e) Respiratory Management:



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Clinical Practice Guideline

Non-operative Management of Blunt

Splenic and Hepatic trauma

Day 3

(48-72 hours)

Day 4(72-96 hours)

Grade III – VIR Embolization?

4

OR if Unstable5

Admit Floor

Day 1

(0-24 hours)

Grade I or II No intra-peritoneal fluid

Admit STBICU

CBC q8 X 24h

Strict Bedrest2 + Hold LMWH

Lactate, CBC q8 X 24h

Strict Bedrest2 + Hold LMWH

CBC in AM & assess abd

exam

If Hb Stable and no change

in abd exam and > 24 hoursafter injury:

Give diet and allow OOB

THEN, recheck Hb3

andconsider discharge 6 hours

after OOB

CBC q12 X 24h

If hb stable, transfer to floor

and start clear liquids

Continue strict bedrest2

Start LMWH if Hb stable

Day 2

(24-48

hours)

CBC q12 X 24

Advance diet

Continue bedrest2

Verify type and screen

CBC

OOB, Repeat CT*

Duplex and CBC in AM

Discharge in PM if Hb

stable, tolerating po’s and

no change in abdominal

examGIVE VACCINES!

If

embolized

1. Duration of bed rest may be altered depending on trauma

attending interpretation of CT scan as low risk for bleeding.2. Bed can be broken and HOB can be up to 30 degrees during

strict bedrest if spines are clear.

3. Remember to check CBC after walking.

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

5. Persistently hypotensive patients (SBP < 90 after 2L

crystalloid or 1u PRBC’s) and a positive FAST or knownsplenic injury with hemoperitoneum on CT, should undergooperative therapy with splenectomy and/or packing of theliver +/- pringle. Use GIA for liver resection, if needed.

6. In general, only IV contrast is necessary for the repeat CT.However, consider enteral contrast if the patient is nottoleratin enteralfeeds.

8/17/2019 Trauma Center Pocket Man

Trauma Center Pocket Manual

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