Trauma Handbook 2007

8/8/2019 Trauma Handbook 2007

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TRAUMA

RESIDENTHANDBOOK

Elvis Presley Memorial Trauma Center Department of Surgery

Division of Trauma and Surgical Critical CareUniversity of Tennessee Health Science Center

Memphis, Tennessee


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These policies are intended to serve as

guidelines only. Individualcircumstances must be considered, and

there may be times when it is

appropriate or desirable to deviate from

these guidelines. They should not be

considered to be accepted protocol or

policy, nor are they intended to replace

clinical judgment or to dictate care of individual patients. These educational

guidelines will be reviewed and updated

routinely.


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ContentsGENERAL P OLICIES

Trauma Service Policies 4Conferences and Clinics 10Service Assignments and Transfer 11Universal Precautions in the Trauma Rooms 12Criteria for Triage to Trauma Rooms 13Routine Trauma Labs 14Consults 15

HEAD /S PINE Cervical Spine Clearance 16Spinal Cord Injury with Deficit 17Dermatomes 18Sensory Levels 19Classification of Spinal Cord Injury 20

NECK Blunt Cerebrovascular Injury 22Penetrating Neck Injuries 23

CHEST Blunt Aortic Injury 24Emergent Thoracotomy 25Hemothorax 26

ABDOMEN /P ELVIS Hemodynamically Unstable Blunt Abdominal Trauma 27Hemodynamically Stable Blunt Abdominal Trauma 28Antibiotics for Penetrating Abdominal Trauma 29Anterior Abdominal Stab Wounds 30Blunt Liver Injury 31Blunt Splenic Injury 32Pancreatic Injury 33Organ Injury Scales 34Management of Pelvic Fractures 37Tile Classification of Pelvic Fractures 38

VASCULAR Ligate vs. Repair 39Neurovascular Injuries 40

EXTREMITIES Fracture/Dislocations 41Muscles and Nerves 42Mangled Extremity Severity Score 43

S URGICAL CRITICAL CARE Diagnosis & Empiric Therapy of VAP 44Risk Factors & Prophylaxis for DVT 47Herbal Supplements 48Ventilator Weaning 52Management of Hypertension 53Pharmacologic Agents 54Alcohol Withdrawal 55Sedation 56Stress Ulcer Prophylaxis 58ICP Management 59


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Trauma Service Policies

Welcome to the Trauma Service. To ensure optimal patient care as well as a

productive educational experience, the following guidelines have been formulated by

the Trauma staff. These policies cover the roles and goals for each resident and

medical student rotating on the Service, the responsibilities of each member of the

Trauma Team, specific policies regarding patient care, and other issues essential to

the efficient running of the Trauma Service.

General Policies

1. A complete and accurate trauma history and physical is required for all trauma

admissions. There are no exceptions.

2. A complete daily Trauma Service note in SOAP format addressing all problems

and containing all laboratories and other studies obtained is required on each

patient on the Trauma Service.

3. The trauma team is expected to respond to all Shock/Trauma room admissions.

Dismissal from the trauma room is at the discretion of the senior trauma resident.


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Resident/Medical Student Roles

The PGY-5 on the Trauma Service is the chief resident of the Trauma Service. This

resident is responsible for the Trauma Service. This includes running daily work

rounds and the Trauma Clinic. Morning rounds will include a review of the previous

nights work-ups to include radiology studies. This resident is responsible for the

coordination of care with consulting services. In order to comply with the work hour

restrictions, all residents are excused after turnover rounds following their night on

call.

Aside from the PGY-5 Trauma Resident, there is also a PGY-3/4 Trauma Resident, a

PGY-2 Trauma Resident, two PGY-1 Trauma Residents, and rotating medical

students. There are also two Surgical Critical Care fellows and at least one NursePractitioner. The daily responsibilities of the resident are as follows:

PGY-5 Trauma Resident

1. Initial response to all patients triaged to the Shock/Trauma Room.

2. Management of resuscitation in the Shock/Trauma Room.

3. Daily management of trauma patients.

4. Primary operative responsibility for trauma patients.5. Overseeing junior residents daily activities.

6. Detailed turnover rounds to the other chiefs when they assume call.

7. Trauma Conference coordination.

PGY-3/4 Trauma Resident

1. Daily management of TICU patients.

2. Assisting with resuscitation in the Shock/Trauma Room.

3. Detailed turnover rounds to the other TICU residents when they assume call.

4. Performing bedside procedures on TICU patients in conjunction with the Trauma

attending and/or fellow.

PGY-2 Trauma Resident

1. Management of patients in CCA.


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2. Assisting with resuscitation in the Shock/Trauma Room.

3. Emergency room consultations .

PGY-1 Trauma Residents

1. Management of patients on the 4 th floor ICUs in conjunction with the fellow and the

Nurse Practioner.

2. Assisting in Shock/Trauma Room resuscitations and recording the history and physical

exam.

3. Management of patients on the floors in conjunction with the chief.

4. Coordination of discharge planning with the case managers.

Medical Students Daily Responsibilities

1. Assisting in care of Shock/Trauma Room patients as dictated by the chief, fellow, and

attending.2. Assisting in care in CCA as dictated by the CCA Resident.

Surgical Critical Care fellows

1. Assist with management of Shock/Trauma patients.

2. Assist the operating surgeon (if appropriate).

3. Assist the ICU residents in critical care management.

4. Assist the Nurse Practitioner with management of Trauma Step-down patients.5. Assist the CCA resident as appropriate.

6. Serve as continuity liason between Trauma service and attendings.

Nurse Practitioners

1. Management of CCA patients in conjunction with the CCA resident.

2. Management of Trauma Step-down patients in conjunction with the fellow.

3. Assist the floor resident with patient management and discharge planning.


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Rotation Goals

PGY-11. Learn initial management of trauma patients to include ATLS.

2. Learn resuscitation techniques, goals and end points.

3. Use appropriate diagnostic modalities commonly employed in the evaluation of trauma

patients.

4. Become proficient in various procedures to include diagnostic peritoneal lavage, closed-

tube thoracostomy, central line placement, placement of pulmonary artery catheter and

interpretation of the values, tracheostomy, and feeding tube placement.

5. Learn post-injury patient care and facilitate timely and appropriate patient discharge.

6. Learn the basics of surgical critical care in conjunction with the fellow and attending.

PGY-21. Learn initial management and resuscitation of major trauma patients in conjunction with

the Chief Trauma Resident.

2. Assist in surgical intervention in trauma patients.

3. Learn how to evaluate surgical patients in the ER.

PGY-3/41. Obtain proficiency in evaluation and management of all trauma patients.

2. Become proficient in various procedures to include bedside fiberoptic bronchoscopy,bronchoalveolar lavage, arterial cannulation.

3. Become proficient in operative management of patients with significant trauma.

4. Become proficient in the care of critically injured ICU patients.

5. Become proficient with various vasoactive agents in management of critically injured

patients.

PGY-5

1. Obtain proficiency in evaluation and management (including operative management) of all trauma patients.

2. Assume the leadership role on the Trauma Service.


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Surgical Critical Care fellows

1. Develop proficiency in the diagnosis and management of critically ill patients, to include

appropriate interventions and procedures.

2. Create, design, implement, and analyze research projects.

3. Expand and develop the ability to teach associates, residents in training, and other

critical care personnel.

4. Learn to administer and manage a critical care unit with particular emphasis on

allocation and utilization or resources and on ethical principles in the delivery of healthcare.


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Rounding Schedule For 2005-2006

Main Call Attending

Responsible for daily rounds and procedures in the TICU, GICU, and

Shock/Trauma admissions

Second Call Attending

Responsible for daily rounds and procedures on the floor, Trauma Step-down,

and patients in CCA. This attending will also staff the Trauma Clinic on

Tuesday and Thursday.

Teaching Rounds

Tuesdays at 8:00 a.m. All members of the Trauma Service (fellows, residents

and students) are expected to attend.


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Conferences and Clinics

The Trauma Service is expected to attend these and all other applicable general surgical

conferences:

Attending Teaching Rounds* ALL Trauma team members are expected to be present *

Tuesday, 8:00 a.m., TICU

Trauma ConferenceThursday, 7:30 a.m.

Radiology Conference Room

2 nd Floor Chandler

Week 1: Trauma/Critical Care

Week 2: Orthopedics

Week 3: Neurosurgery (Ground floor Adams)

Week 4: Trauma M & M (fellows responsible for case selection)

Week 5: Case presentations

Trauma Clinic (4 th floor MedPlex)

Tuesday, 9:00 a.m. 12:00 p.m.

Thursday, 9:00 a.m. 12:00 p.m.


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Service Assignments and Interservice Transfer Guidelines

To facilitate patient care and to eliminate potential misunderstandings between various

services caring for trauma patients, the following guidelines have been established

regarding admission to and transfer of trauma patients between services.

1. Patients with multiple system injuries or hemodynamic instability will be admitted to theTrauma Service.

2. Patients with unisystem injury without a mechanism for potential multiple system injuries

may be admitted to the pertinent service if both attendings (Trauma and other service)

agree, and the Trauma Service may be consulted to provide the Critical Care services. In

general, patients may be admitted to the Trauma service for a 24 hour observation period

prior to transfer.

3. Patients with unisystem injuries with a mechanism for potential multiple system injuries

will be admitted to the Trauma Service if evaluation for occult injuries is ongoing. Reasons

to remain on the Trauma Service with unisystem injuries include hemodynamic or

respiratory instability, or occult injuries still in the process of being ruled out.

4. Patients with unisystem injury may be transferred to another service when the following

general criteria are met:

a. they are tolerating a diet and having bowel function;

b. they no longer need central venous access*;

c. they no longer require a Foley catheter*;

d. they are deemed ready by the Trauma attending and the other service.

Once a patient is transferred from the Trauma Service to another service, Trauma Service

followup will continue for at least three days post-transfer. Results of these visits will be

documented in the patient's medical record. exceptions may be made after agreement with all services


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Universal Precautions in the Trauma Rooms

All physicians, nurses, employees, students, and observers are required to wear all of

the following with all patients in trauma rooms:

1. Gloves

2. Gowns for procedures

3. Masks

4. Eye Coverings

5. Head covers

Non-compliance with Universal Precautions may result in disciplinary action. OSHA

standards require compliance.

The patients privacy will be respected under all circumstances. Therefore,

identifiable pictures and cell phone pictures are NOT allowed. However, pictures taken for

medical reasons are allowed.


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Criteria for Triage to Shock / Trauma Room

Physiological Alterations Trauma Score 13 Known GCS


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Routine Trauma Labs: Adult

The following laboratory tests should be ordered for all adult surgical trauma patients evaluated

in the trauma rooms:

CBC with differential Trauma BMP (to include total bilirubin, ALT, AST) P-amylase INR Lactate Arterial blood gas UA -- also UCG in female patients

Type and screen. Type and crossmatch only for any patient who receivesuncrossmatched blood (red tag) for resuscitation in Shock/Trauma, or any patient going

directly to the OR from Shock/Trauma.


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Plastic and Reconstructive surgery Oral and Maxillofacial surgery Otolaryngology

Plastic and Reconstructive surgery Orthopedic surgery

Orthopedic surgery (patients admitted on odd days) Neurosurgery (patients admitted on even days)

Obstetrics preferably notify prior to arrival

Consults

Facial fractures

Alternates weekly

Hand injuriesAlternates weekly

Spine injuriesAlternates daily

Pregnant patients


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Cervical Spine Clearance

Blunt neck trauma

Awake, alert, no distractinginjuries, asymptomatic,

NEUROLOGICALLY NORMAL

Altered mental status, ormultiple system injury, or

awake with cervical pain or tenderness, orclinical signs of spinal cord injury

No neck painAND

No tendernessto palpation

C-spine cleared(document on chart),

remove collar

AP, Lateral,Odontoid plain films

Adequate,normal films

Poorly visualized areaor abnormal

Leave collar on and consult Orthopedics (admission date an odd day)or Neurosurgery (admission date an even day) for evaluation

MRI of affectedarea

CT scan C-spine

Normal Abnormal


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Spinal Cord Injury with Neurologic Deficit

Penetrating Blunt

Bolus methylprednisolone(Solumedrol) 30 mg/kg over 15 min

(if within 8 hours from injury)

45 minute steroid free pause

Continuous infusion 5.4mg/kg/hr for 23-47 hours*23 hours if started 0-4 hours after injury47 hours if started 4-8 hours after injury

Obtain CT of affected area

Consultation:Orthopedics on odd admission date, Neurosurgery on even admission date

Strict log rollTake off backboard

Keep in cervical collar if cervicalinjury or altered sensorium

*In conjunctionwith Orthopedics/

Neurosurgery

Obtain MRI of affected area


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Dermatomes


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Sensory Levels


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Standard Neurological Classification of Spinal Cord InjuryMOTORKEY MUSCLES

R LC2C3

C4C5 Elbow flexorsC6 Wrist extensorsC7 Elbow extensorsC8 Finger flexors (distal phalanx of middle finger)T1 Finger abductors (little finger)T2T3 0 = total paralysisT4 1 = palpable or visible contraction T5 2 = active movement, T6 gravity eliminated T7 3 = active movement, T8 against gravity T9 4 = active movement,

T10 against some resistance T11 5 = active movement, T12 against full resistance L1 NT = Not testable L2 Hip flexorsL3 Knee extensors L4 Ankle dorsiflexorsL5 Long toe

extensorsS1 Ankle plantar

flexorsS2S3

S4-5 Voluntary anal contraction (Yes/No)

TOTALS + = MOTOR SCORE

maximum 50

50 100

NEUROLOGICAL R L COMPLETE OR INCOMPLETE?

LEVELS SENSORY Incomplete = Any sensory or motor functionin S4-S5

The most caudal MOTOR

segment with ASIA IMPAIRMENT SCALE

normal function

American Spinal Injury Association 1996


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SENSORY KEY SENSORY POINTS

LightTouch

PinPrick

R L R LC2 0 = absent C3 1 = impairedC4 2 = normalC5 NT = not testableC6C7C8T1T2T3T4T5T6T7T8T9T10T11T12L1L2L3L4L5S1S2S3S4-5 Any anal sensation (Yes/No)

+ = PIN PRICK SCORE Max: 112 TOTALS{

+ = LIGHT TOUCH SCORE Max: 112 Maximum 56 56 56 56

R L

SENSORY

MOTOR

ZONE OF PARTIALPRESERVATIONPartially innervated segments


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Blunt Cerebrovascular Injury

Appropriate mechanism with Unexplained neuro deficit (inconsistent with CT) Horners syndrome LeFort II or III (unilateral or bilateral) Cervical spine injury, including transverse process

fractures C-1 C-6 Neck soft tissue injury

4 vessel cerebral angiogram

Carotid injury Vertebral injury

Neurosurgeryconsult

Neurosurgeryconsult

Treatment** Treatment**

Heparin** if no contraindication(preferred for carotid & complexvertebral injuries)Start @ 1000 units/hour NO bolus

Aspirin Plavix**(ASA only if vertebral occludedwith back-fill)

Repeat angiogram in

14 days and/or 6weeks if necessary

Serial PTT, 1 st value 4hours after drip started

then q8hrsGoal is 1.5-2.0 x normal

**In conjunctionwith Neurosurgery

Conversion to Coumadin or antiplatelettherapy depending on pathology/clinicalcourse for at least 6 weeks, follow up inTrauma Clinic and with Neurosurgery

CT angiogram


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Penetrating Neck Injury

Hemodynamically unstableExpanding hematomaExcessive bleeding

Dysphonia*Dysphagia*Air leak from woundTracheal deviationRetropharyngeal air*

To OR

Platysma ViolationDO NOT PROBE WOUND!

Zone I Zone II Zone III

unstable stable unstable stable unstable stable

4 vessel cerebral angio, +/-arch angiogram, barium

swallow

Injury No Injury

TO OR Observe

To ORTo OR To OR

*May benefit fromdiagnostic test

such as plain lateralc-spine X-ray,barium swallow,bronchoscopy, or laryngoscopy


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Appropriate mechanism of injury includes high speed impact injuries (MVC, MCC, fall, decelerating bluntinjury).*BP & HR goals: systolic BP 120 mmHg, HR


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Hemothorax Management

No

Place Chest Tube

Dail Chest X-Ra s

CT Chest

Clot ResolvedRemove Tube

Clot Resolved

Repeat CT Chest in 48 hours

1) Residual clot > 500cc OR2) Residual clot occupies >1/3 of thoracic cavity OR3) Unchanged

VATS Place SecondChest Tube

Yes

No

TPA Contraindications1) Active bleeding OR2) CVA in past 30 days OR3) Intracranial hemmorhage OR4) Intracranial Neoplasm OR5) Coagulopathy OR6) Pregnancy OR7) Chest tube with air leak

Repeat CT Chest

Repeat TPA infusion x 3 days(check daily chest x-ray)

TPA Infusion Protocol1) Obtain HCT, PT, PTT prior to infusion (if abnormal consider not using rTPA)2) Mix 4mg of rTPA (Reteplase ) in 50cc sterile saline.3) Instill mixture into chest tube and flush tube with 50cc of sterile saline.4) Clamp chest tube for 4 hours (observe patient for 10 minutes for problemswith breathing).5) Mobilize patient.6) Check HCT, PT, PTT 1 hour after infusion (if significantly changed frombaseline, consider stopping infusion)

Candidate for TPA infusion er chest tube?

Infuse TPA per chest tube q 24 hours x 3 days(check daily Chest x-ray)

48 Hours

Clot Resolved

Re eat CT Chest

Remove Tube

Clot Resolved

Re eat CT Chest

Daily Chest X-Rays

Candidate for VATS?

Yes

No

Yes

No

Yes

No Yes

Yes

No

48 Hours

Clot Resolved

VATS Contraindications1) Coagulopathy2) Hemodynamic instability3) Inability to tolerate singlelung ventilation


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Blunt Abdominal Trauma

Hemod namicall unstable

Physical exam

F.A.S.T. DPL

Large amountof fluid in

abdomen

Scant/no fluidin abdomen

Grosslypositive*

Microscopicallypositive for

WBC*

Microscopicallypositive for

RBC*

To OR To ORTo OR

Continuesearch for

other sourcesof hemorrhage

*Criteria for positive DPL:Grossly positive - >10cc bloodRBC - >100,000 cellsWBC - >500 cells at least 1 hour after injury

Consider DPL if unstable


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Blunt Abdominal Trauma

Hemodynamically stable

Physical exam

Reliable, awake, alert,no distracting injuries

Unreliable, abnormalmental status,

distracting injuries

CT scan

Nontender

Observationeriod

Remainsnontender

Discharge 1

Tender

CT scan

Normal Abnormal 2

Admit for 23hour

observation

Admit,follow

protocols

Admit,treat other

injuries

1 If any doubt, admit the patient for at least 23 hours2 May require DPL or other evaluation depending on findings

Normal


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Antibiotics for Penetrating Abdominal

Trauma

Penetrating abdominalinjury requiring

laparoscopy/laparotomy

Ertapenem 1 gram IVprior to skin incision

No hollow organinjury

No further antibiotics

Hollow organinjury

No further dosing

*For patients with penicillin allergy, give ciprofloxacin 400 mg IV every12 hours (2 total doses for hollow organ injury, only the preop dose

for no hollow organ injury) and metronidazole 500 mg every 6 h (4total doses for hollow organ injury, only the preop dose for no hollow

organ injury)


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Anterior Abdominal Stab Wounds

Hemodynamically stable,nontender abdominal exam

Yes

To ORLocal woundexploration

Violation of anterior fascia

Definitely noviolation of

anterior fascia

Equivocalviolation of

anterior fascia

To OR for laparoscopy/laparotomy

To OR for laparoscopy/laparotomy

Discharge

For the cooperative patient,consider awake laparoscopy in

Shock / Trauma


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Nonoperative Management of Blunt Splenic Injury

Hemodynamic stability mandatory for nonoperative management

CT scan Pseudoaneurysm

Age 50 Age < 50Becomesunstable

ORGrade 3-5 Grade 1,2

ICU*

Largehemoperitoneum

Small, moderatehemoperitoneum

ICU*OR

Grade 1 Grade 2-5

Floor ICU*

F/U CT 24

Stable,improving

Floor

Worse

Angio-embolization

Stable Unexplainedblood loss

Consider splenectomy OR

*ICU-serial Hct q6h,

close observation

Quantitation of hemoperitoneum:Small perihepatic/splenicModerate small + paracolic gutter Large moderate + pelvis

Outpatient Management

Grade 1 2 Grade 3-5

CT if clinicallyindicated

CT in 1 monthHealed Not healed

Activity ad lib Light duty, repeat CT in 1month if indicated


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AAST Liver Injury Scale

Grade* Type of Injury Description of injuryHematoma Subcapsular, 3 Couinauds segments within a singlelobeV

Vascular Juxtahepatic venous injuries; ie, retrohepatic venacava/central major hepatic veinsVI Vascular Hepatic avulsion

*Advance one grade for multiple injuries up to grade III


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AAST Kidney Injury Scale

Grade* Type of Injury Description of injury

Contusion Microscopic or gross hematuria, urologic studiesnormalIHematoma Subcapsular, nonexpanding without parenchymal

lacerationHematoma Nonexpanding perirenal hematoma confirmed torenal retroperitoneumIILaceration 1.0 cm parenchymal depth of renal cortex withoutcollecting system rupture or urinary extravagation

IV Laceration Parenchymal laceration exteding through renalcortex, medulla, and collecting system

Laceration Completely shattered kidneyV

Vascular Main renal artery or vein injury with containedhemorrhage

VI Vascular Avulsion of renal hilum which devascularizeskidney

*Advance one grade for bilateral injuries up to grade III


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Pelvic Fracture Management

Initial assessment & A-P pelvic x-ray

Open

Exsanguinatinghemorrhage

BP~ 110

Algorithm for stable blunt

abdominaltrauma

Orthopedics

consult


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Tile Classification of Pelvic FracturesType A Stable fractures

A1 Fractures not involving ring; avulsion injuries

A2 Stable, minimal displacement; iliac wing, isolated ramiA3 Transverse fracture of sacrum

Type B Rotationally unstable, but vertically andposteriorly stable

B1 External rotation instability; open book injury

B2 Internal rotation instability; lateral compression injuryB3 Bilateral rotationally unstable injuryType C Rotationally, posteriorly, and vertically

unstable

C1Unilateral injury; ileal fracture, SI disruption, sacralfracture

C2 Bilateral injury; one side rotationally unstable, one sidevertically unstableC3 Bilateral injury; both sides completely unstable


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To Ligate or Not to Ligate

Injury Best Mode of Action

Infrarenal vena cava Repair Can ligate

Suprarenal vena cava Repair Cannot ligate - at least 50% mortality)

Internal jugular vein Repair Can ligate unilaterally

Brachiocephalic vein Repair Can ligate unilaterally

Subclavian vein and artery Repair Can ligate

Superior vena cava Repair Can ligate in life-threatening situations

Carotid artery Repair Can ligate in life-threatening situations

Mesenteric veins Ligate

Portal vein Repair

Can ligate if isolated injury, but at least 50%

mortality rate secondary to massive fluid

sequestration in splanchnic vascular bed and bowel

necrosis

Right renal vein Repair Cannot ligate - fewer collaterals than left renal vein

Popliteal vein Repair Cannot ligate

Femoral vein Repair Can ligate

Lobar bile duct Ligate

Celiac artery Ligate

Left gastric artery Ligate

Common/proper hepatic

arteries Ligate Especially if proximal to gastroduodenal branch

Right/left hepatic arteries Ligate Especially if portal vein is intact

Splenic artery Ligate Short gastric a. from left gastroepiploic

Iliac vein - comm/ext Ligate

Iliac artery - comm/ext Repair

Femoral/popliteal arteries Repair

Tibial arteries Repair Can ligate but need to ensure patency of other leg

arteries

Brachial artery Repair Can ligate if distal to profunda brachi branch since

the elbow has rich collateral blood flow

Radial/ulnar arteries Repair Can ligate but need to ensure patency of other artery

and palmar arch


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Neurovascular Injuries Associated with Fractures or Dislocations

Orthopedic Injury Neurovascular Injury

Anterior shoulder dislocation Axillary nerve, axillary arteryHumeral shaft fracture Radial nerveSupracondylar humeral

fractureBrachial artery

Distal radius fracturePerilunate dislocation

Median nerve

Posterior hip dislocation Sciatic nerveSupracondylar femur fracturePosterior knee dislocation

Popliteal artery

Tibial plateau fracture Popliteal artery, tibioperoneal

trunkProximal fibula fracture Peroneal nerve


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Fracture/dislocation of Extremity

Equal pulses,ABI .7

Pulse deficit, ABI< .7

Orthopedics consult,reduce injury

Orthopedics consult,reduce injury

Pulses still equal

Orthopedicsmanagement of

injury

Pulses equal Pulse deficit

Angiogram inoperating

room


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Chart of Muscle Groups and Nerve and Nerve Root Supply

Muscle Nerve Root Nerve

Cervical flexors C1 C4

Cervical extensors C1 C4

Trapezius Cranial nerve XI

Sternocleidomastoid Cranial nerve XI

Arm abduction

0 15 o , supraspinatus

15 to 90 o , deltoid

>90 o , trapezius & serratus

anterior

C4 C6

C5 C6

C5 C7

Suprascapular

Axillary

Long thoracic

Biceps C5 C6 Musculocutaneous

Forearm supination C5 C6 MusculocutaneousForearm pronation C6 C7 Median

Wrist flexors C7 C8, T1 Median

Wrist extensors C6 C8 Radial

Hand intrinsics C7 T1 Median and Ulnar

Hip flexion L1 L3 Femoral

Hip extension L4 S1 Sciatic

Thigh abduction L4 S2 Superior gluteal

Thigh adduction L2 L4 Obturator

Leg flexion L4 S2 Sciatic

Leg extension L2 L4 Femoral

Foot plantar flexion L5 S1Superficial peroneal and

tibial

Foot dorsiflexion L4 L5 Deep peroneal

Great toe extension L4 L5, S1 Deep peroneal

Foot inversion L4 L5 Deep peroneal

Foot eversion L5 S1 Superficial peroneal

Rectal spinchters S2 S4 Pudenal


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Mangled Extremity Severity Score

Skeletal / soft-tissue injury Low energy (stab; simple fracture; pistol gunshot wound) 1

Medium energy (open or multiple fractures, dislocation) 2

High energy (high speed RTA or rifle GSW) 3

Very high energy (high speed trauma + gross contamination) 4

Limb ischemiaPulse reduced or absent but perfusion normal 1*

Pulseless, paresthesias, diminished capillary refill 2*

Cool, paralyzed, insensate, numb 3*

Shock Systolic BP always > 90 mm 0

Transient hypotension 1

Persistent hypotension 2

Age (years)< 30 0

30-50 1

> 50 2

* Score doubled for ischemia > 6 hours

The MESS is the sum of scores from each category. Scores < 7 are associated with limbsalvage, Scores > 10 are associated with primary amputation. Outcome is variable for scores 7-10.


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Diagnosis of Ventilator Associated Pneumonia

Indications for bronchoscopy with bronchoalveolar lavage (FOB + BAL)

- Patient must have at least three of the following:

1. Fever (temperature > 100.5) or hypothermia (T < 96)2. Abnormal WBC (>10,000, 10% bands)

3. Purulent sputum

4. New or changing infiltrate on chest x-ray

BRONCHOSCOPY + BAL T ECHNIQUE

1. Routine suctioning with in-line catheter of the upper airway until clear.

2. Increase FiO 2 to 100%, change IMV rate if necessary.

3. Sedate patient as necessary. Pharmacologic paralysis is NOT necessary.

4. Advance bronchoscope into affected lung segment (as seen on CXR) or

LLL (if bilateral infiltrates). DO NOT USE SUCTION OR CONNECT

SUCTION LINE TO BRONCHOSCOPE.

5. Scope should be advanced to the smallest bronchial segment possible to

perform BAL.6. Use 100cc sterile nonbacteriostatic saline in 20cc aliquots. Inject 20cc

then immediately aspirate and pool the effluent for quantitative cultures.

7. Follow up with chest radiograph.

8. Proceed to VAP Pathway for treatment.


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Clinical Suspicion of VAP

Fiberoptic Bronchoscopy with BAL

7 days in ICU

Vancomycin 20mg/kg IV q12h * + Cefepime 2g IV q8h *

Empiric antibiotic therapy based on timing of ICU admission

No growth to date Insignificant(1-99,999 cfu/mL)

Significant( 100,000)

Streamline antibiotictherapy**

Discontinue antibiotictherapy**

Continue empiricantibiotic therapy

100,000 cfu/mL

Definitive antibiotic therapy(see Definitive Therapy Pathway for TICU )

Defined as the appearance of a new or changing infiltrate on chest radiograph and at least 2 of he following:Abnormal temperature (>38 oC or 10,000 cells/mm 3 or 10%mmature bands);Macroscopically purulent sputumIf severe beta-lactam allergy, change: Unasyn to Levofloxacin 750 mg IV Q24H, Cefepime to

Ciprofloxacin 400 mg IV Q8H; dosage adjustment may be necessary based on renal function

**Continue to monitor for changes in Final culture results

Final culture results

Preliminary culture results >24 hours

Trauma ICU Ventilator-Associated Pneumonia Clinical PathwayDiagnosis and Empiric Management


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* Adequate antibiotic therapy is antibiotic therapy with in vitro activity against thepathogen. Patients extubated or not eligible for repeat BAL should be treated for 7 fulldays (consider 10-14 days if Pseudomonas or not responding clinically)** Consider treatment for 10,000 cfu/mL in severely injured patients with Pseudomonasand/or Acinetobacter

Use final culture result. Continue antimicrobial therapy in patients with septic shock Pseudomonas requires a follow-up BAL regardless of being early or late VAP

Trauma ICU Ventilator-Associated Pneumonia Clinical PathwayDefinitive Therapy

VAP pathogen(s)


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Guideline for the Prevention of Venous Thromboembolism in Critically ill Patients Approved by Pharmacy and Therapeutics Committee May 2004

Evidence-based references Geerts WH, et al. Chest 2001; 119: 132S-175S.

Available at http://www.chestjournal.org/cgi/reprint/119/1_suppl/132S(accessed 5/14/04)

Rogers FB, et al. J Trauma 2002; 53(1):142-164. Also available at http://www.east.org/tpg/dvt.pdf (accessed 5/14/04)

Modified 5/14/04

No

Sequential compressiondevices (preferred) or A-V footpumps. Consider serial duplexultrasound in high-risk patients

N

[A] Consider Inferior Vena Cava (IVC) filter in:

High-risk trauma patients with significant bleeding risk or Patients with injury pattern rendering them immobile for prolonged period of time:

a) Severe Traumatic brain injuryb) Spinal cord injury with para- or quadriplegiac) Complex pelvic fracture with associated long bonefracture(s)d) Multiple long bone fractures

Unfractionated heparin 5,000 units sq every 8 hours plusSequential compression devices (preferred) or A-V foot

pumps

Enoxaparin 30mg sq every 12 hours plusSequential compression devices (preferred) or A-V foot

pumps

Unfractionated heparin 5,000units sq every 8 hours plus

Sequential compressiondevices (preferred) or A-V foot

Enoxaparin 30mg sq every 12 hours plus

Sequential compression devices(preferred) or A-V foot pumps

Yes

Operativeacetabulum

fracture?

> 24 h post-operativePre-operative

Yes

4

Contraindication to heparin pharmacotherapy? [A]examples include: Active hemorrhage

Recent hemorrhagic stroke INR > 1.6 PTT > 60 sec Platelet count < 50 x 10 9 cells/L

Traumatic brain injury with progression on headCT >24h post-injury (consult neurosurgery)

Hx of Heparin-induced Thrombocytopenia (HIT) Epidural catheter present (consult anesthesia)

2

Primary risk factor present? [A] Spinal cord injury Spinal column fractures Long bone fracture Pelvic fracture Sacral fracture

Acetabulum fracture Traumatic brain injury Laparotomy Age > 40 plus major surgery, cancer, history of VTE, or hypercoagulable state

3

No

Yes

Reevaluate all patients for continuation of venous thromboembolism prophylaxis upon ICU discharge

Baseline CBC, BMP, PTT, and PT/INR

*Note: May not be indicated in

burn patients unless other risk factors are present.

*

1


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Natural Products with Potential to Act as Blood Modifiers

Natural Products THOUGHT to have Blood Modifying EffectsHerb(other names)

Effect Ingredient(s)Responsible

Comments

Angelica root ( Angelicaarchangelica , root of theHoly Ghost)

AnticoagulantAntiplatelet

Coumarinconsitiuents

There is some evidence that therelated Angelica species can inhibitplatelet aggregation and lower prothrombin time when combinedwith warfarin.

The coumarin constituents of relatedAngelica species can inhibit humanplatelet aggregation in vitro. Therelated species, Angelica sinensis,can lower prothrombin time in rabbitswhen coadministered with warfarin.

Anise (Pimpinella anisum ,aniseed, sweet cumin)

Anticoagulant Coumarin constituents Anticoagulant effects have been seenwith excessive doses of anise. (Typicaldose is 0.5-1 gram of the dried leaf or 50-200 mL of the essential oil.)

Theoretically, excessive use of anisemight prolong coagulation, increasingPT/INR and test results, due tocoumarins contained in anise.

Asafoetida (Ferula assa-foetida , assant, devilsdung, fum, giant fennel)

Anticoagulant Coumarin constituents Anticoagulant effects have been notedin vivo.

Dong Quai ( Angelicasinensis , Chinese angelica,Danggui)


Coumarin constituents Dong quai can potentiate the therapeuticand adverse effects of warfarin andantiplatelet drugs.

Fish Oils (omega-3 fattyacids)

Antiplatelet Docosahexaenoic acid(DHA)

Eicosapentaenoic acid(EPA)

The antithrombin activity of fish oil is dueto prostacyclin synthesis, vasodilation,reduced platelet counts andadhesiveness, and prolonged bleedingtime.

Fucus (Fucus vesiculosis ,bladderwrack, kelp, blacktang, cutweed)

Anticoagulant Fucoidin The isolated fraction, fucoidin, has 40-50% of the blood anticoagulant activityof heparin, and fucus can increase therisk of bleeding.


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Natural Products with THEORETICAL Potential to Have Blood Modifying EffectsHerb (Other names) Effect Ingredient(s)

Responsible Comments

Agrimony ( Agrimoniaeupatoria , agromonia,cocklebur)

Coagulant Vitamin K constituent Excessive doses of agrimony couldinterfere with anticoagulant therapy.(Typical dose is 3 grams/day.)

Arnica montana , leopardsbane, wolfs bane, mountaintobacco)

Anticoagulant Coumarin constituents Arnica could potentiate the effects of anticoagulant and antiplatelet drugs.

Aspen (Populi cortex, Populi

folium )

Antiplatelet Salicin Salicin is a salicylate constituent.

However, in vitro studies providepreliminary data that suggest salicinmight not potentiate the effects of anticoagulant drugs.

Black cohosh (Cimicifugaracemosa , baneberry, blacksnakeroot, bugwort)

Antiplatelet Salicylate There is insufficient reliable informationto determine if there is enough salicylatepresent in black cohosh to havesignificant effects.

Bogbean (Menyanthestrifoliata , buckbean, marshtrefoil, water shamrock)

Bleeding risk Unidentifiedconstituent

Excessive doses of bogbean canincrease the risk of bleeding due to thehemolytic effects of an unknownconstituent. (Typical dose is 1-2 mL of the 1:1 liquid extract in 25% alcohol TIDor 1-3 grams of the dried leaf TID.)

Boldo (Peumus boldus ,

boldine)

Anticoagulant Coumarin constituents Excessive doses could increase the risk

of bleeding. (Typical dose is 60-200 mgof the dried leaf TID.)

Borage Seed Oil (Boragoofficinalis , burage,starflower)

Anticoagulant

Antiplatelet

Gamma linolenic acid Borage seed oil could prolong bleedingtime.

Bromelain ( Ananascomosus , bromelin)

Antiplatelet Enzyme constituent Bromelain could increase the risk of bleeding when used in combination withantiplatelets or anticoagulants.

Capsicum (Capsicumfrutescen , African pepper,cayenne, chili pepper)

Antiplatelet Capsaicinoidconstituents

Capsicum has led to increasedfibrinolytic activity and could prolongbleeding time.

Celery ( Apium graveolens ,smallage, Apii fructus)

Antiplatelet Apiogenin (coumarin) Celery could have anticoagulant effectsdue to the apiogenin constituent.

Clove (Syzygium

aromaticum , caryophyllus)

Antiplatelet Eugenol Clove contains a volatile oil that consists

primarily of eugenol.Danshen (Salviamiltiorrhiza , red sage, salviaroot)

Anticoagulant Protocatechualdehyde

3,4-dihydroxyphenyl-lactic acid

There is one case report of increasedinternational normalization ratio (INR)with concomitant use of danshen andwarfarin.

European Mistletoe(Viscum album , all-heal,devils fuge, drudenfuss)

Coagulant Lectin Studies show that lectin can haveagglutinating activity and could interferewith anticoagulant or coagulant therapy.

Fenugreek (Trigonellafoenum-graecum , birds foot,Greek hay)

Anticoagulant Coumarin constituents Fenugreek could potentiate the effects of anticoagulant and antiplatelet drugs.

Feverfew (Tanacetum parthenium , featherfew,midsummer daisy,

bachelors button)

Antiplatelet Crude extracts The crude extracts can inhibit plateletaggregation and the neutrophil andplatelet secretory activity. This could

potentiate the effects of anticoagulantand antiplatelet drugs.Ginseng, Panax (Asianginseng, Korean red,

jintsam)


Active constituents Panax ginseng could decrease theeffectiveness of warfarin and affectclotting time.

Goldenseal (Hydrastiscanadensis , yellow puccoon,eye balm)

Coagulant Berberine Goldenseal could inhibit theanticoagulant effects of heparin.

Horse Chestnut ( Aesculushippocastanum , escine,venostat)

Anticoagulant Aesculin (coumarin) Aesculin may increase bleeding time dueto antithrombin activity, which couldincrease the risk of bleeding when usedconcomitantly with anticoagulants or antiplatelets.


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odorata , coumarouna,torquin bean)

coumarin and theoretically potentiate therisk of bleeding associated withanticoagulant drugs or natural products.

Turmeric (Curcuma longa ,tumeric, Indian saffron)

Antiplatelet Curcumin Curcumin has anti-inflammatory activityand could potentiate the antiplateletactivity of other drugs or naturalproducts.

Wild Carrot (Daucus carota ,Queen Annes lace,beesnest plant)

Anticoagulant Coumarin constituents Large amounts of wild carrot couldpotentiate the risk of bleeding withanticoagulant drugs or natural products.

Wild Lettuce (Lactuca

virosa , green endive, lettuceopium)

Anticoagulant Coumarin constituents Large amounts of wild lettuce could

potentiate the risk of bleeding withanticoagulant drugs or natural products.

Willow Bark (Salix alba ,white willow, silberweide)

Antiplatelet Salicylate constituents Data suggests irreversible inhibition of thrombocytes is unlikely and there mightbe no increase interaction with bloodcoagulants.

Yarrow ( Achillea millefolium ,thousand-leaf, wound wort)

Coagulant Achilleine There is some evidence to suggest thatachilleine has decreased clotting time.

HERBS WITH ANTICOAGULANT/ANTIPLATELET POTENTIAL : Concomitant use of herbs that have coumarin constituents or affectplatelet aggregation could theoretically increase the risk of bleeding in some people. These herbs include anise, arnica, asafoetida,bogbean, boldo, capsicum, celery, chamomile, clove, danshen, fenugreek, feverfew, garlic, ginger, ginkgo, Panax ginseng, horsechestnut, horseradish, licorice, meadowsweet, prickly ash, onion, papain, passionflower, poplar, quassia, red clover, turmeric, wildcarrot, wild lettuce, willow, and others.


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Weaning from Mechanical Ventilation

Daily screening

Problem for which patient wasintubated is controlled

No

Continuemechanicalventilation

Yes

SaO 2 90%FiO 2 0.5PEEP 5 cm H 2O

Airway reflexes intactNo vasopressors or significant sedation

Yes

No

Therapist to measure RR/Vt

No RR/Vt < 105 breaths/min/L

Spontaneous breathing trial

RR > 35 breaths/min for more than 5 minutesSaO 2 < 90%

Yes

No

Extubate


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MANAGEMENT OF HYPERTENSIONDiagnosis of Hypertensive CrisisImmediate control to minimize end organ damage (CNS - hypertensive encephalopathy; cardiac- AMI, BAI, dissecting aortic aneurysm; renal ARF) is necessary.Otherwise BP should be lowered slowly and cautiously.

Management of HypertensionThere are many causes of hypertension in ICU patients, common causes include:

- underlying hypertension- agitation- pain- withdrawal

- cold, shivering- hypoxia, hypercarbia- increased ICP- transducer height etc.

Treat underlying causes prior to administration of antihypertensives

Common intravenous antihypertensive agents:

Drug Action Effect Dose Comments

Metoprolol-1 antagonist(min -2 antagonist)

Negative chronotropyNegative inotropy

IVP: 2.5 to 15 mg slow IVP every 6hours

Half-life 4 to 6 hoursOral:IV conversion 2.5:1No vasodilation

Labetalol-1 antagonist(mod -2 antagonist) -1 antagonist

Negative chronotropyNegative inotropyVasodilation

IVP: 5 to 20 mg slow IVP every 1 to4 hoursBolus: 5-20 mg IVPInfusion: 0.5 to 4 mg/min (Titrate)

Half-life 4 to 6 hoursMonitor closely inasthmatic patient (beta-2 antagonist)

Esmolol-1 antagonist(min -2 antagonist)

Negative chronotropyNegative inotropy

Bolus: 250-500 mcg/kg slow IVPInfusion: 25-100 mcg/kg/min(Titrate)

Half-life ~ 15 minNo vasodilation

Nitroglycerin Exogenous source of nitric oxideVenous vasodilation(min arterial dilation)

Infusion: 5 to 20 mcg/min (Titrate;max 400 mcg/min)

MethemoglobinemiaHeadache

Nitroprusside Exogenous source of

nitric oxide

Arterial and venous

vasodilation

Infusion: 0.1 to 10 mcg/kg/min

(Start low and Titrate)

Profound hypotensionCyanide toxicityReflex tachycardia

Hydralazine Direct arterial smoothmuscle relaxation Arterial dilationIVP: 5 to 20 mg slow IVP every 4to 6 hours

Intrapatient variabilityReflex tachycardia

Enalapril ACE Inhibition Vasodilation(arterial > venous)IVP: 0.625 to 1.25 slow IVP every6 hours

HyperkalemiaAcute renal failureAngioedema

Oral antihypertensives can be used in patients with stable hemodynamics. Otherwise use of IVantihypertensives is more easily titratable in ICU patients.Note on choice of antihypertensives: avoid -blockers in patients with increased adrenergic activity (pheochromocytoma, use of sympathomimetic drugs such as cocaine, amphetamine etc) avoid -blockers in patients with poor LV function, also check for other contraindications(bronchospasm) nimodipine produces cerebral vasodilation, effect noticeable in areas of brain with restrictedcirculation than healthy areas, usually used in patients with vasopasm after subarachnoidhemorrhage nitrates and nitroprusside can produce cerebral vasodilation and hence should be avoided inpatients with intracranial pathology prolonged nitroprusside administration can lead to acidosis and cyanide toxicity


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1Mechanically ventilated trauma

patient requiring sedation

2Patient w/TBI,

ICP, or requiringfrequent

neurologicexaminations?

6Pt expected to

require sedationfor 24 hours?

9Preferred Midazolam prnagitation 3 PLUS Morphinesulfate prn pain/agitation 2

Alternative - Propofol (generic)continuous infusion 1 PLUS

Morphine sulfate prnpain/agitation 2

Titrate to Riker SAS of 4

10Continued need

for sedation past24 hours?

12D/C Sedation Protocol, continue Morphine

sulfate prn pain (or morphine sulfatecontinuous infusion) 2

7Lorazepam prn agitation, THEN

Lorazepam continuous infusion if dosingrequirements are high 4

PLUSMorphine sulfate prn pain/agitation, THEN

Morphine sulfate continuous infusion if dosingrequirements are high 2

Titrate to Riker SAS of 4In refractory cases, may use

Propofol (generic) continuous infusion 1 PLUSMorphine sulfate prn pain/agitation 2

3Preferred - Propofol (Diprivan brand) continuous

infusion 1 PLUS Morphine sulfate prnpain/agitation 2 OR

Alternative - Fentanyl continuous infusion 2 Titrate to Riker SAS of 4

May consider use of neuromuscular blocker to

assist with ventilator compliance

4Patient w/TBI, ICP,

or requiringfrequent neurologic

examinations?

5Go to 12

8Pt requiring

sedation after 24 hours?

11Go to

12

YES

YES

YES

REASSESSPt every

shift & asneeded

REASSESSPt every

shift & asneeded

REASSESSPt every

shift & asneeded

NO

NO

NO

NO

NO

YES

YE


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ICU Pharmacologic AgentsATRACURIUM Half life: 20 minutes. Cleared in plasma via Hoffman reaction; therefore, suitable for

usage in renal failure. Titrate to 2/4 TOF. Dosage (continuous infusion): 0.1 mg/kg/h. Cost: $11.46/100 mg.

24-hour cost (70 kg patient): ~$19.00/day.

PANCURONIUM Half-life: 2 hours. May cause tachycardia. Titrate to 2/4 TOF. Dosage (continuous

infusion): 0.06-0.1 mg/kg/h. Cost: $1.79/10 mg. 24-hour cost: ~$28.00/day.

VECURONIUM Half-life: 1.5 hours. Clearance adversely affected by renal failure. Titrate to 2/4 TOF.

Dosage (continuous infusion): 0.01 mg/kg/h. Cost: $12.39/10 mg. 24-hour cost: ~$20.00/day.

MIDAZOLAM Short acting benzodiazepine. Duration of action: 2 hours. Excellent amnestic effect. Use

with caution in elderly; may cause hypotension/respiratory depression. Contraindicated in hepatic failure.

Dosage (continuous infusion): 2 mg/h. Cost: $9.48/5 mg. 24-hour cost: ~$90.00/day.

LORAZEPAM Intermediate acting benzodiazepine. Duration of action: 8-20 hours. May cause

paradoxical reactions in the elderly. Prolonged use can lead to prolonged sedation. Dosage (continuousinfusion): 1 mg/h. Cost: $15.89/40 mg. 24-hour cost: ~$8.00/day.

HALOPERIDOL Butyrophenone/antipsychotic. Does not cause sedation per se; does not cause

respiratory or cardiovascular depression. Mechanism of action is to cause affective dissociation. Does hav

limited anticholinergic effects; may cause dystonia/tardive dyskinesia. Should use Cogentin at regularly

scheduled intervals. Half-life: 18 hours. Dosage: 5-10 mg/dose. Titrate to affect up to 50 mg/dose. Cost:

$0.57/5 mg. Cost per dose: $0.57-5.70.

MORPHINE Opiate, the gold standard analgesic in the ICU setting. Has sedative as well as analgesic

properties. Metabolites accumulate in renal failure. Duration of action: 4-5 hours. Causes respiratorydepression, histamine release, and hypotension. Dosage (continuous infusion): 2-4 mg/h. Cost: $5.76/100

mg. 24-hour cost: $3.00-6.00/day.

FENTANYL Short acting opiate. Duration of action: 1-2 hours. Sedative and analgesic effects. Causes

respiratory depression. Does not have histamine release. Much more stable than morphine from

cardiovascular standpoint. Dosage (continuous infusion): 1-5 mcg/kg/min. Cost: $1.28/1000 mcg. 24-hour

cost: $12.80-64.00/day.

PROPOFOL Lipid soluble, ultra-short-acting anesthetic. Prepared in lipid carrier. Duration of action: 15

minutes. Easily titratable. Lowers ICP. Should not be used in patients with hypertriglyceridemia. Exhibits

three-compartment redistribution with prolonged use, leading to prolongation of action. Bolus doses may

cause hypotension. Rare fatal reactions noted in children. Dosage (continuous infusion): 20-200

mcg/kg/min. Cost: $49.95/1000 mg. 24-hour cost: $100.00-1,000.00/day. ALL PATIENTS RECEIVING

DIPRIVAN MUST HAVE DAILY SERUM LACTATE AND CPK CHECKED. IF EITHER RISES, STOP

DIPRIVAN IMMEDIATELTY.


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Alcohol Withdrawal Protocol

Patient with riskfactors for alcohol

withdrawalsyndrome

Obtain:

1. liver function panel, INR/PT

2. BMP, magnesium, phosphorus, albumin3. Blood glucose monitoringProvide:

1. Thiamine 100mg once daily IV/IM/PO2. Folic acid 1mg once daily PO/IV3. Multivitamin once daily or Cernevit 5ml inminimum 500ml IVF once daily4. Adequate hydration

High clinicalsuspicion for

withdrawal

Activewithdrawal

Lorazepam 2-4mg PO/IV/IMq 6 hrs x 4 doses, then 1-2mg PO/IV/IM q 6 hrs 2 8doses (3 day prophylaxiswean). Monitor vital signs

and status q 4-6 hrs.

Ethanol 5% in D5W atinitial rate of 50 ml/hr.

Titrate for symptoms of early withdrawal. Wean

over 3 days. Monitor vitalsigns and status q 4-6 hrs.

Transfer tomonitored

unit

Lorazepam 2-4mg IVevery 1 hr until lightly

sedated andsymptoms resolved.

Monitor vital signs andstatus every hour

Select desired therapy:Lorazepam (preferred) or ethanol

dripNote:ethanol is contraindicated in patientswith pancreatitis and liver disease


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Stress Ulcer ProphylaxisPatient Admitted toMICU/SICU/TICU

Evidence of activeGI bleed

MAJOR RISK FACTORS Severe Head TraumaBurns > 30% BSAPrior Organ TransplantRenal FailureRecent PUD (6 weeks)*Hypotension/Shock

> 48h Mech. VentilationOR

Coagulopathy

IV PROTON PUMP INHIBITORi.e. Pantoprazole 40 mg IV every

24 hours

IV H2 BLOCKERi.e.Ranitidine 50 mg IV every 8 hours

(For Cr Cl < 50) 50 mg IV daily

ORAL H2 BLOCKERi.e. Ranitidine 150mg PO BID

(For Cr Cl < 50) 75 mg PO BID

OROral Proton Pump Inhibitor

i.e. Pantoprazole 40 mg every24 hours

Treat active bleeding

References1. Cook DJ , Fuller HD, Guyatt GH et al.Risk factors for gastrointestinal bleeding in critically ill patients.N Engl J Med. 1994 Feb

10;330(6):377-81.2. Levy MJ, Seelig CB, Robinson NJ et al.Comparison of omeprazole and ranitidine for stress ulcer prophylaxis.Dig Dis Sci

1997Jun;42(6):1255-93. CookD, HeylandD,Griffith L,et al:Risk factors for clinically important UGIB in patients requiring mechanical ventilation. Crit

Care Med 1999;27:281228174. Jung R, MacLaren R. Proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients. Ann Pharmacother. 2002

Dec;36(12):1929-37*Endosco ic or radio ra hic evidence of e tic ulcer disease in recedin 6 weeks

No

No Prophylaxis IndicatedRe-evaluate need for

treatment

NoOn Transfer/Discharge

ORRisk Factors Resolved

Discontinue Therapy

No

Yes

This clinical practice guideline is a systematically developed algorithm intended to assist practitioner and patient decisionsabout appropriate health care for specific clinical circumstances. This guideline is not a fixed protocol that must be followed,but is intended for health care professionals and providers to consider. While it identifies and describes generallyrecommended courses of intervention, it is not presented as a substitute for the advice of a physician or other knowledgeablehealth care professional or provider. Individual patients may require different treatments from those specified in this particular guideline.

No

Yes

Yes

Yes

Tolerating TubeFeedings or PO

Patient with SRMD,PUD, or GERD*

*SRMD=Stress Related Mucosal DamagePUD=Peptic Ulcer DiseaseGERD=Gastroesophageal Reflux


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General Management Principles for Severe (GCS 3-8) andModerate (GCS 9-12) TBI

Use very short-acting sedatives if needed, for frequent neurological exams Especially important in first 24 hours

Sedation holiday for nursing neuro check unless otherwise ordered Convert field collar to Miami J until ligamentous injury can later be ruled out Insertion of intraparenchymal ICP monitor after coagulopathy (if present)

corrected (Normal PTT and INR < 1.2 desireable, 20 mm Hg x > 5 minutes): Notify NeurosurgeryFirst Tier Therapies: Ensure HOB elevated Ensure no compression from cervical collar and neck in neutral position Ensure ventriculostomy (if present) patent and functioning Sedation and analgesia with Diprivan Drip (discontinue if elevation of CPK or

lactate) or Fentanyl or Morphine Drip or Intermittent Dosage Maintain Hyperosmolar Euvolemia

A Catheter, Mannitol +/- Lasix, hypertonic saline boluses, serum Na andosmolarity every 6 hours

No hyperosmolar agents if osmolarity > 320 Goal serum Na 145-155 usually

Cerebral Perfusion Pressure Goals 50-70 mm Hg usually Neosynephrine preferred pressor if pressors needed Dopamine in low doses


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Trauma Handbook 2007

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