Trauma Service Manual

Miami Valley Hospital Level 1 Trauma Center

Dayton, Ohio

Revision Date November 5, 2008

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INTRODUCTION

The Trauma Service Manual was prepared for the physicians and staff working with the Trauma Program at Miami Valley Hospital (MVH) in Dayton, Ohio. MVH is the only Level I Trauma Center in the greater Dayton area, reflecting the hospital's commitment to be The Region’s Leader. Continuing support of the hospital administration for the Trauma Service has encouraged the development of a service dedicated to comprehensive, cost-effective, high-quality care and recognition by the American College of Surgeons as among the best trauma centers in the country. MVH was first verified as a Level I Trauma Center in September 1992, and has recently completed its sixth re-verification. This manual is purposefully brief. It is not meant to replace the general trauma patient care literature, such as the Advanced Trauma Life Support Course, but to aid those on the MVH Trauma Service in “reflecting the national literature locally.” The reader will notice that only the chapters on Initial Assessment and Secondary Assessment have been presented with any detail. This was done because of the obvious importance of these areas, but also to provide a framework for subsequent chapters. Current thinking in trauma care, and our local capabilities, are constantly changing and improving. Therefore, this manual will be dynamic. Frequent updates are necessary to keep abreast of the Trauma Service at Miami Valley Hospital. Your suggestions for additions, deletions and improvements are always invited. This manual is dedicated to the health care providers of the Trauma Team.

Mary C. McCarthy, MD FACS Director of Trauma Services Miami Valley Hospital Dayton, Ohio

MIAMI VALLEY HOSPITAL TRAUMA SERVICE

RESIDENT ORIENTATION HANDBOOK

Signature: Printed Name: PGY Date of Trauma Service Orientation Remove this page from handbook and return to the Trauma Program office.

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Table of Contents (hold “Ctrl” key and click on symbol to return to Table of Contents)

I. Trauma Alert Notification System

A. Levels of Evaluation B. Trauma Categories C. Definitions of Alert System Activation D. Trauma Resuscitation Roles

II. Evaluation of the Multiply Injured Patient

A. Initial Assessment Trauma Lab Panels B. Secondary Assessment Zones of the Neck Penetrating Injury to the Neck Blunt Abdominal Protocol Boundaries of the Flank Penetrating Injuries to the Torso

III. Trauma Service Guidelines

A. Trauma B. Shock Guidelines for Emergency Issue of Blood Products Massive Hemorrhage Protocol C. Burns D. Direct to OR Trauma Resuscitation Patient Triage Criteria Procedure for Direct to the OR E.. DVT Prophylaxis and IVC Filter Placement for

Trauma Patients

F. Intensive Care Unit (ICU) Potassium Replacement in Trauma Paralytic Agents Change Nasal ETT to Oral ETT Suspected Ventilator Associated Pneumonia Classification of Pressure Ulcers by Grade Nutritional Support in Trauma Canadian Clinical Practice Guidelines Ventilator Treatment and Weaning Protocol Flowchart for Management of Narcotic Withdrawal Flowchart for Benzodiazepine Withdrawal Flowchart for Alcohol Screening Flowchart for Alcohol Detoxification G. Spinal Cord Injuries H. Soft Tissue I. X-Ray Flexion/Extension C-Spine Policy/Procedure J. Pelvis TPOD Guidelines for Use

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K. Obstetrical L. Consultations M. Motor-Vehicle License N. Trauma Unit Care Guidelines O. Hypothermia Resuscitation Care Guidelines P. Pain Management: Approaches in Trauma Guidelines for Intravenous Patient-Controlled

Analgesia

Pain Treatment Recommendations Q. Emergency Thoracotomy Guidelines R. Head Injury Raney Clip Gun Guidelines for the Management of Severe Head

Injury

Reversal of Anti-Coagulation Guidelines for CT Scanning in Patients with Head

Trauma

Ranchos Los Amigos Scale Glasgow Coma Scale S. Spine T. Ocular and Orbital Trauma U. Abdomen Abdominal Compartment Syndrome Pre-Operative/Post-Operative Considerations AAST Grades of Organ Injury Non-Operative Splenic Trauma Management V. Chest Chest Injury Guidelines Thoracic Aortic Trauma Guidelines Criteria for Positive CXR in Patients with Potential

Aortic Injury

W. Evaluation and Management of the Injured Child

Pediatric Trauma Score X. Organ Donation Clinical Criteria for Brain Death Clinical Care Guidelines for Potential Organ

Donors

IV. Geriatric Medication Management Beer’s List Medications to Avoid in Elderly Patients with

Specific Concomitant Diseases

Criteria for Potentially Inappropriate Medication Use in Older Adults: Considering

Diagnosis or Conditions

Criteria for Potentially Inappropriate Medication Use in Older Adults: Independent of

Diagnosis or Conditions

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V. Acute Care Surgery Service Resident and Other Schedules Day Time Duties Night Time Duties Trauma Service Handoff Report Procedure Communication Attending Schedule Trauma Attending Contact Information Contacting the Research Department Resident Meeting Schedule Mini Disaster Plan Patient and Family Interactions When Issues Occur After Hours ICM Guidelines What Happens When Patients Don’t Get What

They Want

Breaking Bad News Recommended Manner of Breaking Bad News Dealing With Anger Patient Satisfaction Guidelines for Jehovah’s Witness

APPENDIX 1 – Trauma Phone Book

I. TRAUMA ALERT NOTIFICATION SYSTEM Purpose: Provide notification to the Trauma Team members of all major trauma victims arriving. Rationale: The goal of the trauma stand-by/alert beeper system is to assure the presence of the trauma team in the Emergency Trauma Center and to expedite the care of injured patients. Notes If the patient's condition worsens at any time during transport or during evaluation in the Emergency Center, their status should be upgraded immediately to Category I. The beeper system will be tested daily at 9:00 am. The Emergency Medicine Attending Physician will be medical control for CareFlight and other EMS units. On all Category I patients, the senior resident will contact the attending prior to patient arrival. A. LEVELS OF EVALUATION Trauma Alert: The entire system is activated to provide for a full notification of the trauma team. Personnel on Beeper System Trauma Director CT Scan Assistant Trauma Director Medical Imaging Trauma Attendings Clinical Pharmacy Trauma Chief Resident ETC Nurse Manager Trauma Residents/Interns Surgery Medical Student Trauma Advanced Practice Nurses Pastoral Care Physician Assistants Administrative Officer Orthopedic Resident On-Call CareFlight Medical Control Trauma Program Manager CareFlight Communications Burn Unit Director ETC X-ray Blood Bank Anesthesia on-call CompuNet Clinical Labs ICU Shift Manager OR Front Desk Surgical Associate Program Director Respiratory Therapy Information Systems Manager of PACU Telephone Office ED Attending Manager of Respiratory Care Ortho Trauma Advanced Practice Nurse

Alerts should be called for all appropriate patients even if there is a current Trauma Alert patient being evaluated in the Emergency Department. This ensures notification of all individuals on the system.

It is expected that these trauma alerts will be initiated 15-20% more often than the ultimate care would require. All trauma patient care will be evaluated for appropriateness of the trauma alert, call, cancellation of the trauma alert, or the lack of a trauma alert call when indicated.

The first RN or physician in the Emergency & Trauma Center aware of a Category I or major trauma patient will activate the appropriate trauma notification level.

The individual who activates the trauma notification system will then be responsible to notify the Emergency & Trauma Center personnel of major trauma:

Patient's primary nurse ETC Physician Health Unit Coordinator ETC Registration ETC Phlebotomist

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The RN or physician who activated the trauma alert may cancel the trauma alert. Trauma Alerts may be canceled for a variety of reasons: patient not being transported to Miami Valley Hospital or a change in the patient condition.

Trauma Service Consult: This is obtained for patients who do not need full resources of the resuscitation team but who are felt to need Trauma Service admission, close follow-up or surgical intervention in the Emergency Department. A PGY-2 or 3 may provide the initial response. The in-house senior resident should see the patient promptly and staff the patient with the Chief Trauma resident and the trauma attending. Emergency Department Evaluations: These patients are those who will not require the Trauma Service for resuscitation, care, or admission. These patients are typified by single system injuries, extremity injuries, and stable vital signs. There is no notification of the trauma team unless the patient's condition on evaluation requires upgrade to a Trauma Service Consult or Trauma Alert. All inter hospital transfers should be Consults or Alerts. B. TRAUMA CATEGORIES 1. Category I Trauma: Trauma Alert required. This level of activation provides for response of the Trauma Team, Senior Resident and Attending.

A - Compromised/uncontrolled airway, intubated Severe maxillofacial injuries

B - Inability to oxygenate/ventilate Unstable chest injuries to include:

o Flail chest o Hemo/pneumothorax o Known or suspected pericardial tamponade o Known or suspected ruptured diaphragm

C - Clinical signs of shock, hypotension BP < 90 mmHg Major vascular injury, uncontrolled hemorrhage, interhospital transports receiving blood

D - Coma or neuro deficit (GCS < 8, posturing or lateralizing signs) Traumatic paralysis

E - Everything else: Combined Major System Injury Gunshot wounds of neck, chest, abdomen Open pelvic fractures/major traumatic amputation Second or third trimester pregnancy AND significant trauma High voltage electrical injuries Emergency physician discretion

2. Category II Trauma: May require a Trauma Alert. This level of trauma activation is conducted by the Trauma Team and Senior Resident. At minimum, a Trauma Service Consult should be obtained for all Category II patients that require admission or observation. Injury Classifications

Moderate injury (hemodynamically stable) Stable blunt injury Two or more proximal long bone fractures Burn with trauma Major soft tissue injuries with stabilized bleeding Multiple rib fractures without flail segment Blunt abdominal injury without hypotension

Altered level of consciousness

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Two organ systems injured 3. Category III Trauma: Trauma Alert not required. Initially evaluated by the Emergency Department physicians and subsequent disposition determined.

No hypovolemia or hypotension No neurological injuries No abdominal injuries Minor/moderate soft-tissue injuries Chest injuries not producing respiratory distress

C. DEFINITIONS OF ALERT SYSTEM ACTIVATIONS:

1. Trauma Alert Standby Activate when: a. Ground transfer of a known or suspected Category I trauma patient is to arrive in > 5 min b. CareFlight is dispatched to a trauma scene. c. CareFlight is dispatched to a referring facility for the transfer of a Category I or major trauma. 2. CareFlight Liftoff Activate when: a. CareFlight lifts off from the scene with a Category I or major trauma patient. CareFlight liftoff notification will be communicated by the pilot to CareFlight dispatch.

b. The CareFlight dispatcher (ETCDISP) will activate the trauma alert system and communicate: liftoff

Category I status of the patient ETA to Miami Valley Hospital In Trauma Arrest the rhythm will be identified as: “V-fib, EMD (PEA)” or “Asystole”

c. CareFlight liftoff on an interhospital transfer with a Category I or major trauma patient. d. The addendum "Category I" will be added when leaving the scene if appropriate to provide early trauma attending notification. The in-house senior resident should call the Trauma Attending as soon as notification of a Category I trauma patient is received.

3. Trauma Alert Activate when:

a. Ground transfer with a known or suspected major trauma patient is to arrive in < 5 min. b. CareFlight transfer or scene response of any trauma patient. The CareFlight RNs may participate in the decision to call or cancel a Trauma Alert/standby based on notification criteria and trauma category.

QUIET D. TRAUMA RESUSCITATION ROOM ROLES SENIOR RESIDENT (TEAM LEADER) RESPIRATORY THERAPIST PGY 2-3 / Midlevel Provider MONITOR O2SATURATION ECG, B/P CUFF ETC PRIMARY NURSE PGY-1 / Midlevel Provider ETC SECONDARY NURSE ETC TECHNICIAN EMERGENCY ATTENDING TRAUMA ATTENDING SURGEON PHLEBOTOMIST TRAUMA TEAM ONLY PAST THIS POINT (full protective gear required) RECORDER ANESTHESIOLOGIST OR NURSE HEALTH UNIT COORDINATOR ETC REGISTRATION CLERK ECG TECHNICIAN MEDICAL STUDENT CHAPLAIN

Roles and Responsibilities

SENIOR RESIDENT (TEAM LEADER) • Verbalize leadership role • Receive historical information • Direct/supervise management of the patient • Discretion regarding needed interventions • Perform and verbalize complete primary and secondary surveys to facilitate completion of the Trauma Flow

Sheet and H & P • Establish or delegate airway • Define the order of therapy and priority of injuries • Direct/coordinate diagnostic studies and interventions • Consult with Trauma Attending within 15 minutes of patient arrival • Maintains communication with primary nurse • Discuss medical findings and plan with family • Responsible for contacting and conveying information to consultants ETC PRIMARY NURSE • Calls Trauma Alert • Prepares anticipated equipment and paperwork • I.D.'s self as primary nurse • Receives orders: confirms or delegates • Takes patient vitals • Responsible for patient temperature (monitoring and intervening)

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• After team leader performs initial survey, performs primary and secondary surveys with reassessment as necessary

• Start peripheral IV • Places NG/OG tube after Team Leader approval • Intervenes as necessary • Acts or assigns liaison for family • Coordinates patient transport • Delegates non-assigned tasks to other nursing team members • Releases other team members • Accountable for final nursing documentation on the Trauma Flow Sheet • Completes ETC billing sheet • Confirms trauma room ready for next patient PGY-1/Midlevel Provider • Right side of patient • Obtain central venous access under Senior Resident direction • Perform right sided procedures (right chest tube insertion, ABG, draw blood, rectal exam, Foley insertion) • Complete trauma admission H&P/orders • Assist with DPL • Cleanse/suture laceration sites • Cover open wounds with dressing • Other procedures as assigned by Team Leader RESPIRATORY THERAPIST • Acts as support for securing patient's airway • Provides ventilatory support/management during resuscitation and transfer • Assists physician with airway procedures • Arranges for ventilator set-up prior to transfer • Accompany patient during diagnostic procedures or transfer • Initiates EtCO2 monitoring EMERGENCY MEDICINE ATTENDING • Pre-hospital radio communications • Assists in determination of Direct-to-OR, in conjunction with Trauma Attending or Senior Resident • Initiates/cancels trauma alert as warranted • Patient report to Team Leader upon arrival • Supervises resuscitation until patient staffed by the Trauma Attending • Participates in resuscitation until Team Leader and EM Attending agree he/she no longer needed • Communicate with family as needed • Assist in airway control at request of the Team Leader • Give direction to Emergency Medicine resident

RADIOLOGY TECHNOLOGIST • Prepares for x-rays • Places cassette on bed prior to patient arrival • Performs x-rays and processes films • Verifies orders from Team Leader for special films • Ensures penetrating injuries are marked

10PGY-2, 3/Midlevel Provider

• Left side of patient • Achieve central venous access left side • Perform left sided procedures at direction of Team Leader (left chest tube insertion, DPL, thoracotomy) • Mark penetrating injuries ETC SECONDARY NURSE/ED TECHNICIAN • Initiates cardiac monitoring and transport monitor • Initiates pulse oximetry • Removes clothing, covers patient with warm blanket • Attaches oxygen until RT arrives • Anticipates procedures • Prepares equipment required (DPL, CT, thoracotomy, cricothyroidotomy, central line insertion) • Set up/start peripheral IV fluids • Obtains and administers medications and IV solutions (not applicable if ED Technician) • Obtains ice for ABG • Clothing and valuable disposition • Assists with patient transfer • Brings warmed blankets to cover patient • Other duties as assigned • Turns up room temperature prior to patient arrival PHLEBOTOMIST • Obtains patient blood sample • Take blood to lab, waits for results, report results back to Trauma Room • Obtain urine from Foley and take to lab RECORDER • Documents initial assessment on Trauma Flow Sheet • LISTENS for information to document from team • Documents verbal assessment from Team Leader • Monitors personal protective equipment for caregivers • Controls crowd • Confirms receiving x-ray/lab, blood bank orders • Communicates with support services and HUC's • Assures lab work is ordered priority • Receives reports of labs and radiology and communicates to patient caregivers OR NURSE • Report in to recorder • May respond to trauma for potential case • Liaison between trauma room and OR • May assist secondary RN ETC REGISTRATION CLERK • Attempts to identify patient • Assigns registration number • Completes registration process

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TRAUMA ATTENDING SURGEON • Alerted through TA system • Present within 15 minutes of patient arrival for Category I resuscitation • Participates in all major therapeutic decisions • Promptly available for patient evaluation • Involved in major resuscitations in identification and prioritization of injuries • Present at any general surgical operative procedures • Contacts second call attending and additional resident staff if needed • Participates in determining and communicating with consultants • Assists in determination of Direct-to-OR ICU NURSE • May respond to ETC if available • Assess potential ICU needs ANESTHESIOLOGIST (CRNA) • Airway support • Identify operating room needs and priorities HUC • Notifies front desk • Present in resuscitation room the first 5-10 minutes • Obtains lab, x-ray orders from recorder • Notifies unit to receive patient • Relays information regarding patient (lab results, availability of CT scanner, etc.) to the recorder • Marks orders and order numbers on ETC sheet MEDICAL STUDENT • Observation role on Category I patients • May participate at direction of Team Leader in resuscitation of non-Category I patients CHAPLAIN • Provides pastoral care and counseling • Accompanies family in Trauma Room These guidelines are adopted for the resuscitation of severely or multiply-injured patients. The protocol will be modified based upon the number of injured patients, the availability of team members, and the severity of injuries.

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II. Evaluation of the Multiply-Injured Patient

PRIMARY SURVEY OF THE MULTIPLY INJURED PATIENT

Trauma Team History Assess Airway

Spontaneous Potential Respiratory Respiratory compromise Patient arrives Respirations Compromise/hypoxia with hypoxia present intubated Chin lift Suction Jaw Thrust Airway open No change

Secure airway

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Orotracheal Nasotracheal Surgical Intubation intubation airway

Auscultate chest

Protect and maintain airway

Auscultate both lung fields

Assess:

Respiratory rate Respiratory rhythm Respiratory symmetry

Inspect chest Percuss Palpate Auscultate

A. INITIAL ASSESSMENT

1. Upon arrival in the hospital, the injured patient should be met by the Trauma Team. This team should include a senior resident, a middle level resident (PGY 2 or 3), a PGY 1 or midlevel provider, an experienced trauma nursing team, a respiratory therapist, and a radiology technician. For Category I traumas, the chief (PGY4 or 5) responds immediately and the attending must be present within 15 minutes of patient arrival.

2. A complete history of the mechanism of injury and prehospital care should be obtained. All preceding

events should be taken into account to create a high index of suspicion for potential injuries. The primary survey consists of an evaluation of the airway, breathing, circulation and disability (neurologic function). The patient is then classified according to severity of injury into one of the three following categories: (1) life threatening injury with interruption of vital physiologic function, (2) serious injury likely to require close observation or definitive surgical care, or (3) minor injury that may require extended observation or outpatient follow-up.

3. Management of the airway takes precedence over all other activity. Hypoxia may be caused by mechanical problems or lack of oxygen exchange at the alveolar-arterial interface. Hypoxia may be clinically manifested by an uncooperative, anxious, combative, and/or restless patient. These findings should not be attributed to alcohol or drug abuse. Patients who present to the hospital with spontaneous respirations should be continuously reassessed. The airway should be protected and maintained.

4. The upper airway should be assessed for patency. Initial attempts to establish a patient's airway include

the chin lift or jaw thrust maneuver and suctioning to remove foreign debris. The cervical spine should be stabilized in the neutral position to prevent further injury. Excessive movement of the cervical spine can convert a fracture with no neurologic damage into a fracture-dislocation with neurologic injury. Patients who have an upper or lower airway obstruction manifested by poor air exchange, slow or rapid respirations or depressed central nervous system should be rapidly intubated. Oral endotracheal intubation with inline stabilization of the head and neck or nasotracheal intubation in a spontaneously breathing patient should be performed.

5. Spinal stabilization and immobilization must be maintained until a cervical fracture has been ruled out.

(One must remember that a normal lateral cervical spine film does not rule out a cervical spine injury.) 6. Prior to attempted intubation the patient should be assessed for laryngeal injury, edema of the glottis, or

severe oropharyngeal hemorrhage associated with facial trauma. A laryngeal mask airway may provide temporary support in difficult cases. Inability to intubate the trachea is the only indication for a surgical airway. A surgical cricothyroidotomy is the preferred choice. (Surgical cricothyroidotomy is not recommended for children under 12 years of age. Needle cricothyrotomy with jet insufflation may be temporizing). If a fractured larynx is identified, a tracheostomy may be indicated. An emergency tracheostomy may be difficult to perform and is best done in the operating room.

7. Patients who arrive at the hospital already intubated must be evaluated for proper tube placement on

arrival. The tube may have been inserted into a mainstem bronchus or dislodged en route to the hospital. Placement can be checked quickly by listening for bilateral equal breath sounds and by listening over the stomach for improper placement. The tube must be repositioned if mainstem bronchus intubation has occurred and breath sounds then reassessed. End tidal CO2 should be monitored continuously, especially in head-injured patients.

8. Once the tube is in place, regardless of the method selected, both lung fields must be auscultated in the

mid-axillary lines to be certain the right mainstem bronchus has not been cannulated or a pneumothorax has not developed. A chest radiograph should be obtained to confirm proper tube placement. Right mainstem intubation may be confused with left diaphragmatic rupture on CXR. Assess tube position first.

9. The chest should be exposed to assess adequate ventilatory exchange. The team should note the rate,

rhythm, and symmetry of chest wall movement. One should look for distended neck veins, open wounds, lacerations, bruising and abrasions that may indicated underlying injury. Adequate oxygenation and ventilation must be assured. Despite clear bilateral breath sounds, patients should be frequently reassessed. Oxygen should be administered to maintain a PaO2 greater than 80 torr (O2 saturation >92%). Arterial blood gases should be obtained to evaluate oxygenation, ventilation and base deficit.

10. Simultaneously the chest must be assessed for mechanical factors that compromise the ventilatory process. Loss of chest wall stability, as seen in flail chest, mechanical compression due to a tension pneumothorax, an open pneumothorax, a massive hemothorax, or encroachment of the chest cavity as seen with herniation of visceral contents secondary to a ruptured hemidiaphragm should be carefully

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considered. Many patients vomit and aspirate prior to arrival, thereby impairing adequate ventilation. Bronchoscopy may be indicated. Other less common entities that compromise breathing and ventilation are exaggerated Trendelenburg position, inflated military antishock trousers (MAST) and chest wall restriction secondary to circumferential bums. The patient’s chest should be palpable for subcutaneous emphysema.

11. All life threatening injuries must be quickly treated. Rapid decompression by needle thoracentesis or

chest tube insertion is essential in the patient with a tension pneumothorax. Evacuation of blood from the chest and re-expansion of the lung by closed tube thoracostomy controls most parenchymal bleeding. A sucking chest wound should be quickly sealed using a three-corner flap dressing followed by closed tube thoracostomy. A large flail segment is best treated by intubation and positive pressure breathing. The primary goal of mechanical ventilation is to achieve adequate cellular oxygenation. Chest films should be obtained as indicated but should not delay life saving procedures.

12. Hemorrhage is one of the early causes of post-injury death. Rapid assessment of the injured patient's

hemodynamic status is essential. The key components to circulatory assessment are heart rate, skin color and temperature and state of consciousness. The presence of a femoral (BP ≥ 70 mmHg) or carotid (BP ≥ 60 mmHg) pulse signifies coordinated cardiac action with at least 50 percent of residual blood volume. Rapid thready pulses are a sign of hypovolemia. An irregular heart rate is usually a warning sign of cardiac decompensation. The patient's skin color should be evaluated; the ashen, gray skin of the face and pale skin of the extremities are ominous signs of hypovolemia. When blood volume is lost, cerebral perfusion is impaired, and unconsciousness may result. Circulatory collapse in the trauma patient most commonly occurs as a result of hypovolemia secondary to hemorrhage. Compensatory mechanisms will frequently mask the magnitude of bleeding. A blood loss of 30 to 35 percent of the total blood volume can occur before significant changes are noted in the blood pressure.

13. The patient must be rapidly assessed for external, exsanguinating hemorrhage during the primary

survey. Direct pressure to the wound is applied to control rapid ongoing blood loss. Tourniquets should be used only if bleeding cannot be controlled by other means.

14. The severely injured patient who arrives with a normal blood pressure should be rapidly evaluated for

occult injuries. Two large bore (16 gauge or greater) peripheral intravenous lines should be established and Ringer's lactate solution infused. Blood should be obtained for a complete blood cell count (CBC), type and cross-match, and other routine trauma laboratory studies.

15. Three interrelated physiologic functions must be assessed in hypotensive patients, as follows: (1) the

heart, (2) the blood and extracellular fluid volume, and (3) the arterial and venous resistance. Pump failure may occur as the result of primary cardiac disease, myocardial contusion, or mechanical problems such as cardiac tamponade. Volume deficits are most commonly associated with hemorrhage but may result from crush injuries, third spacing or redistribution. Cardiac output may be diminished because of inadequate venous return as seen with tension pneumothorax or cardiac tamponade. Vascular resistance may be altered by injury to the spinal cord, drugs, and sepsis. Regardless of the mechanism, circulatory collapse results in the low flow state and inadequately perfused cells. Normal aerobic metabolism is converted to anaerobic metabolism and, if untreated, leads to metabolic acidosis and eventual cell death.

16. Four types of shock are commonly recognized, as follows: (1) Hypovolemic (e.g. hemorrhagic), (2)

neurogenic, (3) cardiogenic and (4) septic. Although hemorrhagic shock is the most common type seen in the trauma patient, it is possible for more than one source to contribute to the patient's hypotension. Compensatory mechanisms may preclude a measurable fall in systolic pressure until the patient has lost up to 30 percent of blood volume, therefore, specific attention should be directed to the heart rate, respiratory rate, skin perfusion and pulse pressure. A narrowed pulse pressure is one of the earliest signs of hypovolemia. The heart rate is a sensitive, but non-specific, indicator but may be normally high in

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children or artificially low in the elderly. Older patients have a limited cardiac response to catecholamine stimulation and/or may be taking medication such as beta-blockers. They rarely get tachycardic even in severe shock. The more common signs of hypovolemic shock, such as diaphoresis, cool clammy skin, decreased venous pressures, decreased urine output, thirst and an altered state of consciousness are easily recognized. Neurogenic shock symptoms are much different than those of hypovolemic shock. The patient will have a motor and sensory deficit associated with dry skin, normal or slow heart rate, normal mentation and normal urine output. The initial treatment of neurogenic shock is 2 liters of fluid, just as for hypovolemic shock, but if the patient does not respond, Neo-Synephrine or Dopamine should be considered. A source of blood loss MUST be excluded before using pressors.

17. Cardiogenic shock caused by myocardial infarction or arrhythmias is often determined by history and

should be monitored by ECG. Myocardial dysfunction may occur from tension pneumothorax, myocardial contusion, cardiac tamponade, and air embolus from the patient's associated injuries or severe metabolic acidosis (pH < 7.2). Be suspicious in patients who passed out prior to the crash.

18. Blunt cardiac injury is not uncommon in rapid deceleration trauma to the thorax. Patients with blunt

thoracic trauma should have an ECG, and if abnormal, 24 hours of ECG monitoring to detect dysrhythmias. Any patient suspected of having cardiogenic shock should have a pulmonary artery catheter placed. Enzymes are unnecessary unless an MI is suspected.

19. Hypovolemic shock is initially treated by the administration of crystalloid solutions given through

established large bore peripheral intravenous lines. Central line catheters should be avoided if possible during the initial resuscitation. However, if other access cannot be obtained or the patient is profoundly hypotensive and very large bore access is needed, central lines may be required. Complications from the central venous route are more frequent, especially in the flailing, uncooperative trauma patient. If the patient does not respond to the first 2 L of fluid, and hemorrhagic shock is suspected, blood administration is indicated. Owing to the emphasis on component therapy, packed red cells will be provided by the blood bank. Initially, thawed plasma and platelets should be given to correct deficiencies, or in the case of massive hemorrhage, empirically replaced. FFP will be available in 30 minutes. In urgent cases, type-specific blood can be given. In the emergent life-threatening case, it may be necessary to use a universal donor such as 0- in women of reproductive age (< 50 years), or O+ in males if there is evidence of hemodynamic instability. This is termed “emergency release blood.” On the other hand, if the individual can be managed just as safely without blood administration, then that should be the goal.

20. As part of the primary survey, a brief neurologic examination is performed and baseline observations

recorded. The Glasgow Coma Score (GCS) is used to quantify the extent of neurologic injury. Patients with a coma score of less than 9 are classified as having severe injuries; 9 to 12, moderate injuries; and 13 to 15, minor injuries. Lateralizing neurologic signs are generally related to an elevated ICP or focal lesion which may be caused by a subdural or epidural bleed.

21. The diagnosis of a neurologic injury is best made on clinical evaluation. There are many diagnostic

studies available, but the injured patient may not be stable enough to allow a time consuming work-up. The computed tomography (CT) scan is the single most useful study to obtain and, with proper planning, can frequently be performed without causing delay in the initial management of the trauma patient.

22. Increased intracranial pressure is a common sequelae of blunt head injury. Evidence points to more

favorable outcomes if the intracranial pressure can be quickly reduced. The ICP monitor should be placed within 2 hours of patient arrival. Hypoxia results in insufficient substrate delivery to the injured brain. The principal metabolic requirements of the brain are oxygen and glucose, both used at extremely high rates. Elevated intracranial pressure is often accompanied by hypertension, temperature elevation, and bradycardia, but it may be masked in patients who are hypovolemic. Hypotension cannot be

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attributed to bleeding in the head unless the patient is an infant and the sutures have not closed or unless there is evidence of an open skull fracture with measurable external blood loss. Reduction of intracranial pressure can be rapidly accomplished by the use of diuretics such as mannitol. Caution must be exercised and their administration withheld in the hypovolemic patient. The hypovolemic, hypotensive head injured patient should be resuscitated in the usual manner, with rapid assessment for the source of blood loss. The patient should not be hyperventilated; they should remain normocapnic (normal pCO2).

23. The trauma patient should be completely undressed to facilitate thorough examination and assessment.

The patient must be assessed anteriorly, laterally and posteriorly. All injuries must be identified. Roll the patient in the trauma room, stabilizing the spine. Look at both sides before removing patient from the board. Care should be taken to avoid hypothermia. The Trauma Room thermostat should be placed on maximum prior to arrival of the patient.

24. Simultaneously, as the primary survey progresses, other procedures are performed. Oxygen is

administered, two large bore peripheral intravenous lines are established, and Ringer's lactate solution is given. Blood is drawn for an arterial blood gas, CBC, type and cross-match, and other studies as indicated. A nasogastric tube should be placed in the stomach, and the contents evacuated. (nasogastric tube placement is contraindicated if a cribriform plate fracture is suspected, in which case an orogastric tube should be placed). A Foley catheter should be inserted unless there is evidence of blood at the meatus or unless there is a scrotal hematoma, perineal hemorrhage or a high riding prostate on rectal exam.

Trauma Lab Panels –

Trauma Panel

Level Lab Test to be Ordered

Category 1 CBC, BMP, Liver Panel, Amylase, UA, ETOH, UDS, Coags, and ABG, T&C

Category 2 CBC, BMP,UA, ETOH, and UDS, T&S Category 3 CBC, UA, ETOH, Draw & Hold

Note: These are basic trauma lab panels that correspond with the category of the trauma patient. If the patient has complicating medical illnesses, the physician should order additional, appropriate labs to evaluate those conditions.

25. When the primary survey has been completed and the initial resuscitation and stabilization begun, the patient's overall condition must be re-evaluated. Priorities must be assessed, and the patient taken immediately to the operating room if indicated. It is essential that a single physician, the trauma surgeon, assume the leadership of the resuscitation and coordinate all the consultative activities.

B. SECONDARY ASSESSMENT

1. The secondary survey does not begin until the primary survey (i.e., airway, breathing, and circulation assessment) has been completed and until the resuscitation phase and management of all life-threatening conditions have been initiated. The secondary survey consists of a complete head-to-toe physical examination. Following the secondary survey, the patient is again re-evaluated and priorities of care and diagnostic evaluation assessed.

2. The in-depth evaluation employs the look, listen and feel techniques, which assesses each body region.

All body regions must be inspected, percussed, palpated, and auscultated. Vital signs are frequently monitored, i.e., blood pressure, pulse, respiration and temperature.

a. Head/Face (1) Airway obstruction is the most serious problem to recognize and correct when assessing the head and face. Airway obstruction usually originates from uncontrolled secretions, bleeding, swelling or mechanical causes associated with severe maxillofacial injuries. Scalp lacerations can produce significant blood loss that is sufficient to cause hypotension. The scalp must be palpated carefully to identify all lacerations, potential fractures and changes in integrity. The examiner should carefully look through the hair to identify all penetrating wounds. Palpation of all the bony prominences of the face will identify most obvious or suspected fractures, whereas others require special roentgenographic views to be identified. Bleeding associated with nasal fractures may require anterior or posterior packing to achieve adequate hemostasis. After airway control, maxillofacial bleeding may be controlled with pharyngeal/oral packing with a Kerlix. Malocclusion may be the only finding present in mandibular fractures. Look for evidence of open maxilla and mandible fractures by examining teeth and gingiva, and assessing for mobility. Loose or broken teeth may obstruct the airway, and any injury to the tongue may cause airway obstruction by bleeding or swelling. All injuries should be documented. Definitive treatment of maxillofacial injuries is often delayed until the initial injuries are stabilized.

(2) Ocular injuries must be assessed with the recognition that visual disturbances may occur as a direct result of trauma to the eye or because of a brain injury. Assessment of pupillary function is important; a difference in pupil diameters of more than 1 mm is abnormal. Look for and remove contact lenses. Alert patients should be asked to read print with each eye. Mydriatic solutions should not be used.

(3) The ears should be inspected for injury and hemotympanum. The presence of ecchymosis over the mastoid process (Battle's sign), periorbital ecchymosis (raccoon eyes), hemotympanum and CSF otorrhea and/or rhinorrhea may be present in patients with a basilar skull fracture. Frequently the diagnosis of basilar skull fracture is by clinical signs alone, since these fractures may not be visualized by routine head CT.

b. Neck The cervical region contains a greater variety and concentration of anatomic structures than any other area of the body relative to its size. The airway, vessels, thoracic duct, pharynx, esophagus, spinal cord, spinal column, thyroid gland, parathyroid glands, lower cranial nerves, brachial plexus, muscle, and soft tissue are all at risk for injury. The neck should be visually inspected to identify potential injury, lacerations, abrasions, and penetrating wounds. The examiner should note any deviation of the trachea, distention of the neck veins, palpable injury to the larynx, and subcutaneous emphysema. Injury to the airway is suspected in patients who have subcutaneous emphysema, hemoptysis, and difficulty with phonation or stridor. One MUST remove the cervical collar temporarily to adequately examine the neck, taking care to keep the head and neck immobilized.

(1) Blunt Injuries Laryngeal trauma may be manifested by a fracture of the thyroid cartilage, subluxation of the arytenoid cartilage, or dislocation of the cricothyroid joint. Laryngeal trauma can occur from a direct blow to the neck or a strangulation/hanging mechanism. Symptoms include hoarseness, and treatment may include endotracheal intubation before the patient develops edema and total airway obstruction.

Patients who sustain blunt trauma, are unconscious, or complain of neck pain must have their neck immobilized in a neutral position until a fracture has been ruled out. The cervical vertebral column should be palpated carefully with the neck stabilized. Any irregularities, step-off or pain on palpation

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should be considered to be an injury until further diagnostic procedures can either identify the extent of injury or rule out injury. Patients with suspected C-spine injuries should undergo CT of the neck. Do not waste time with plain films—these are not sensitive for injury. Subsequent evaluation of neck pain with mobilization of the neck may be done in a sober, alert patient with a normal neck CT and no distracting injuries (see spine clearance guidelines).

(2) Penetrating Injuries The zones of the neck (see diagram for anatomical landmarks) associated with penetrating neck trauma must be evaluated to assist in diagnosis and in planning operative intervention. Unstable patients with indications for surgery, such as shock, expanding hematomas or uncontrollable bleeding, are taken directly to the operating room (OR). Additional diagnostic studies such as arteriography, endoscopy, contrast radiography and computed tomography (CT) may be obtained in the stable patient if the diagnosis is in question or if information is sought to plan an operative procedure.

Zone I Patients who have Zone I injuries may have damage to major arterial structures in the root of the neck or upper mediastinum, making choice of operative incision more challenging. These patients, when stable, benefit from

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preoperative arteriography to identify the site of injury. Also, bronchoscopy, esophagram or esophagography helps to identify the site of injury of these structures to better plan the best operative incision. Zone II Patients with penetrating injuries that penetrate the platysma muscle in Zone II who are hemodynamically stable may be evaluated by exploration vs. angiography + panendoscopy. Injuries with entrance wounds in Zone II may still involve other zones of the neck, depending on the trajectory of the bullet.

Zone III Penetrating injuries in Zone III may be very difficult to manage if the internal carotid artery is injured. Keep in mind that penetrating injuries to the face may involve Zone III vascular structures. In stable patients, arteriography is both diagnostic, but also therapeutic in many cases (e.g., embolization of the external carotid artery and branches). Rather than panendoscopy, head CT may be useful to further evaluate Zone III injuries.

PENETRATING INJURY TO THE NECK

c. Thorax

Injuries to the thorax account for approximately 25% of the deaths attributable to trauma. Fifteen percent require operative intervention, 85% require only chest tube decompression or observation. Hypoxia may occur as a result of diminished blood volume, failure to ventilate the lungs, direct pulmonary injury, or changes in the pressure relationship in the pleural space that leads to displacement of mediastinal structures or collapse of the lung. During the secondary survey the chest is re-evaluated and any resuscitative procedures previously performed are again assessed. The chest wall is carefully inspected for evidence of external trauma, i.e., abrasions, contusions, crepitus and frank instability.

Penetrating Neck Wound -Airway control -Chest x-ray -AP & lat. Neck x-ray

Unstable or Zone II injury with hard signs

Immediate Exploration

All Negative Observation

All Negative

Any Positive

Zone III

- Aortic & great vessel angiography

- Esophagoscopy and/or Barium Swallow

- Tracheobronchoscopy

Zone II

Zone I

Selective Management - Angiography - Pharyngoesophagoscopy

vs. Barium Swallow - Tracheobronchoscopy

Selective Management - Angiography - Pharyngoesophagoscopy - Tracheobronchoscopy

Any Positive

All Negative

Any Positive

Appropriate method of Exploration

Observation

Neck Exploration

Observation

Appropriate method of Exploration or Embolization

Stable

(1) Blunt Chest Injury Blunt chest trauma is likely to produce such injuries as flail chest, hemothorax, pneumothorax, pulmonary contusion, blunt myocardial injury, traumatic aortic disruption, ruptured diaphragm, rib fractures, tracheobronchial injuries, and on rare occasion, traumatic asphyxia. Compression,

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deceleration, shearing and barometric forces are the usual mechanisms of injury seen with blunt trauma.

(a) Flail Chest Flail chest occurs when a segment of the chest wall loses its continuity with the rest of the rib cage as a result of multiple rib fractures. The definition of a flail segment is two or more rib fractures in contiguous ribs. Keep in mind that one can also have a flail sternum if there is a disruption of the chondral attachments of the ribs to the sternum. The chest wall instability causes paradoxical motion of the flail segment in contrast to the rest of the chest wall. Hypoxia associated with this condition is primarily a result of the underlying lung injury rather than of the chest wall defect. The associated pain and loss of compliance resulting from pulmonary injury may be the cause of hypoxia. Crepitus on palpation and the presence of asymmetrical movement with inspiratory and expiratory effort are the classic findings with this condition. Chest films may initially underestimate the extent of lung injury and may fail to demonstrate costochondral separations. Arterial blood gases help to assess the degree of hypoxia. Treatment of flail chest is directed at correcting the underlying hypoxia by providing adequate ventilation and humidified oxygen.

(b) Hemothorax (HTX) Hemothorax is commonly associated with a lacerated lung or injury to the internal mammary artery or intercostal vessels. It may be accompanied by a pneumothorax, and bleeding generally ceases after re-expansion of the lung. Massive HTX is associated with hypovolemia and requires aggressive resuscitation. Treatment of HTX is accomplished by inserting a large (36F or higher) chest tube and quantifying the amount and rate of bleeding. A thoracotomy is indicated if blood loss exceeds 1500 ml or if the hourly rate is in excess of 200 cc/hr for 3-4 hours. In the case of massive blood loss, the use of the Autotransfuser on the chest drainage system is essential. Blood evacuated can then be re-infused into the patient, thus saving blood bank resources, and minimizing risk to patient.

(c) Pneumothorax (PTX) A pneumothorax occurs when air enters the pleural space, thereby causing collapse of the ipsilateral lung. The source of the air is usually an injury to the lung parenchyma. A ventilation- perfusion defect occurs when the blood passes the non-ventilated segment of lung. Treatment of a simple PTX is accomplished by inserting a chest tube.

A tension PTX is a PTX which has led to mediastinal shift towards the opposite side. This is a life-threatening emergency and should be diagnosed clinically, NEVER radiographically. Immediate treatment involves needle decompression until tube thoracostomy can be performed.

(d) Pulmonary Contusion Pulmonary contusion is the most common potentially lethal injury seen in chest trauma. It may be associated with acute respiratory distress syndrome, which occurs over time rather than instantaneously. Vigorous pulmonary support beginning as early as possible provides optimal care. Care must be taken not to over-resuscitate the patient with lung injury as it can lead to pulmonary edema and worsening hypoxia. Pulmonary contusion can occur in children without the presence of rib fractures due to the flexibility of their ribs.

(e) Blunt Cardiac Injury Blunt cardiac injury (BCI), formerly known as myocardial contusion, is a difficult diagnosis and probably occurs more frequently than recognized. It ranges from a mild contusion of the myocardium to cardiac rupture. The mechanism is usually a compression of the sternum which squeezes the heart between the sternum and spine. ECG changes are variable but may be the

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most reliable indicator of this condition. Most commonly sinus tachycardia is seen, but this is nonspecific. Other dysrhythmias include premature ventricular contractions, atrial fibrillation, bundle branch block (especially incomplete right bundle), and less frequently, ST segment changes. The most life threatening dysrhythmias are ventricular tachycardia and fibrillation. Two-dimensional echocardiography can be a useful adjunctive study that may be obtained if the ECG is abnormal or if there is strong clinical evidence of blunt cardiac injury. Patients suspected of having BCI should be admitted to a monitored bed and observed. Cardiac tamponade may be seen with BCI, but is more common with penetrating injury.

(f) Thoracic aortic disruption [see Thoracic Aortic Trauma Evaluation] Aortic rupture is one of the most common causes of sudden death following rapid deceleration injuries. The aorta is usually torn at the ligamentum arteriosum just distal to the left subclavian artery at a point of relative fixation and mobility. Although the wall is torn, the hematoma is contained by the adventitia in those who survive. Knowledge of the mechanism of injury should make one suspect this injury. The most reliable finding on CXR has been a widened mediastinum (greater than 8 cm on an AP film), but this is not specific. An aggressive diagnostic work-up is imperative. Spiral CT is useful for screening and may be diagnostic. Definitive care requires stenting or operative repair. If the patient has other significant injuries, care should be prioritized and delay in aortic repair with BP control (systolic < 120 mmHg) may be appropriate. An esmolol drip is the usual drug of choice, but perfusion must be balanced against the needs of other tissues (such as the brain).

(g) Diaphragm Rupture A ruptured diaphragm is a less frequent injury and may be difficult to recognize. When present, it may cause pressure changes in the chest cavity and contribute to hypoxia by compressing the lung. Auscultation might reveal bowel sounds in the chest, but these are often absent with small tears. Chest films fail to demonstrate approximately 30% of these injuries. A previously placed nasogastric tube may be seen above the diaphragm on chest films. Peritoneal lavage and CT scans are notoriously poor in identifying this injury. The ruptured diaphragm requires operative intervention. Demonstration of herniated abdominal contents on CXR is indication for laparotomy and repair.

(h) Rib Fractures Fractured ribs are the most common thoracic cage injury and may compromise the patient's ability to handle tracheobronchial secretions adequately due to pain. This can lead to atelectasis and pneumonia, especially in patients with pre-existing pulmonary disease. Routine chest film may not demonstrate rib fractures, but the diagnosis may be made by physical exam alone. Analgesia is an important component of treatment. This may involve local injection, epidural anesthesia, or oral analgesics such as Percocet and NSAIDS. Patient instruction in pulmonary toilet is essential. Patients with more than 3 fractures should have a followup CXR in 24 hours.

(i) Tracheobronchial Injuries Tracheobronchial injuries are uncommon and involve the larynx, trachea, and major bronchi. These injuries are seen with both penetrating and blunt trauma. They may cause partial or complete airway obstruction and often are the cause of sudden death. Patients with major bronchial injuries present with a history of hemoptysis, subcutaneous emphysema, tension pneumothorax, or a persistent air leak after thoracostomy. Management of these injuries is individualized.

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(j) Traumatic Asphyxia Traumatic asphyxia is a rare injury caused by compression of the chest that results in obstruction of venous return in the SVC, which in turn leads to extravasation of blood into the soft tissue. The patient has a violaceous discoloration of the upper chest, neck, arms, and face (distribution of the SVC). Bulging eyes and subconjunctival hemorrhages may be present. A head CT scan should be performed since intracerebral hemorrhage may result from venous stasis, which causes focal neurologic problems ranging from agitation to death. Soft tissue changes resolve spontaneously, but attention must be directed to evaluating for significant intrathoracic injuries.

(2) Penetrating Chest Trauma Penetrating chest trauma may cause tension PTX, cardiac tamponade, open "sucking" chest wounds, esophageal trauma and abdominal injuries. Anatomic landmarks are helpful in predicting potential problems. One cannot assume a bullet travels in a straight line. The missile trajectory is unpredictable (e.g. ricochet, tumble, fragment, or embolization). Abdominal injuries should be suspected when a bullet wound is located below the nipple anteriorly, or tip of scapula posteriorly.

(a) Transmediastinal Gunshot Wounds Any gunshot wound that enters the chest and transverses the mediastinum warrants further evaluation. Any penetrating injury in the "box" outlined by the clavicles superiorly, the midclavicular lines laterally, and the xiphoid process inferiorly could potentially injure mediastinal structures. Mediastinal injuries can also occur with penetrating wounds outside the "box." Evaluation can include FAST to exclude pericardial effusion, CT scan of the chest, pericardiotomy (subxiphoid window), arch aortogram, esophagoscopy or esophagram, and tracheobronchoscopy.

(b) Tension Pneumothorax Tension pneumothorax is a life threatening injury that mandates clinical rather than radiologic diagnosis. This condition may be confused with cardiac tamponade; some of the signs, such as distended neck veins and cyanosis, are similar. The absence of breath sounds and tympany on percussion on the ipsilateral side are diagnostic of this condition. Rapid needle decompression should be accomplished in the second intercostal space in the midclavicular line.

(c) Cardiac Tamponade Cardiac tamponade is more frequent with penetrating trauma but must also be considered in blunt trauma. This is a life-threatening injury that warrants immediate intervention. FAST may be helpful in identifying fluid in the pericardium. Pericardiocentesis should only be done as a life saving and temporizing procedure; thoracotomy/median sternotomy is the means for definitive treatment.

(d) Open Wounds Open "sucking" chest wounds occur when penetrating wounds allow air to escape from the pleural space. If the wound is greater than two-thirds the diameter of the trachea, air will pass through the defect with each respiratory effort, taking the path of least resistance. This is a potentially life-threatening injury and leads to ineffective ventilation and ultimately hypoxia. Treatment involves a 3 corner occlusive dressing and a thoracostomy tube away from the chest wall wound.

(e) Esophageal Injury Unrecognized esophageal injury is potentially lethal. It is more common with penetrating trauma. It should be suspected in patients with a left HTX or PTX without rib fracture. Other signs and symptoms include pain, shock disproportional to the injury, particulate matter in the chest tube drainage, or mediastinal air. Contrast radiography and/or endoscopy confirm the diagnosis,

which demands prompt operative drainage and repair. Right vs. left thoracotomy depends on the level of the injury.

d. Abdomen

Assessing abdominal trauma can be one of the most challenging tasks for the trauma surgeon. Unresponsive and uncooperative patients, lack of physical findings, and delayed symptom onset add to the challenge. Physical examination can be misleading 10 to 15% of the time even in an alert, cooperative patient. The two major concerns in the evaluation of abdominal injuries are uncontrollable bleeding and peritoneal contamination secondary to perforation of a hollow viscus.

The abdomen is divided into the 3 following major areas: (1) peritoneal cavity, (2) retroperitoneal space, and (3) intrathoracic portion. Each of these areas requires special consideration for prompt injury recognition. The history and knowledge of the mechanism of injury are important. Many injuries within the peritoneal cavity cause enough irritation to be easily recognized. An exception is the presence of blood, which may or may not produce tenderness on physical examination. The degree to which it causes peritoneal irritation is unpredictable, and hence, a patient may have significant blood loss and a relatively benign abdominal exam. It is not important to identify the specific organ injured, but rather to recognize the need and proper timing for operative intervention. Retroperitoneal injuries present more of a challenge because the lack of peritoneal irritation may allow the patient to be relatively asymptomatic in the early post-injury period. Intraabdominal injuries are suspected with penetrating injuries below the nipples anteriorly and tip of scapula posteriorly.

(1) Abdominal trauma is divided into blunt and penetrating, each requiring a different approach. Patients with hemodynamic instability or evidence of an acute surgical abdomen, which suggests visceral injury, should be taken to the OR as quickly as possible following initial attempts at stabilization. Patients who sustain blunt trauma may require a variety of diagnostic procedures in the absence of obvious indication for celiotomy. These studies may include conventional radiography, laboratory determinations, DPL, CT scan, sonography, urologic survey, arteriography, and a variety of special procedures. In blunt trauma, screening radiography usually consists of a chest film and anterior-posterior (AP) view of the pelvis. On rare occasions, they may demonstrate air under the diaphragm, which suggests a visceral perforation or perirenal air which suggests a retroperitoneal hollow viscus injury.

Laboratory determinations play a relatively minor role in the evaluation of patients with abdominal trauma. The "major" trauma panel is a CBC, CMP, amylase, U/A, PT, PTT, ETOH, UDS and ABG. The "minor" panel is a CBC, ETOH, UDS and a U/A. UCG's are obtained in all female patients. All patients with an abnormally elevated amylase level should be admitted to the hospital for observation. A urinalysis is valuable in determining whether additional urologic studies are warranted.

The diagnostic peritoneal lavage (DPL) is a useful adjunctive procedure. It is the most sensitive test, probably too sensitive. It is extremely accurate in predicting injuries within the peritoneal cavity but less sensitive with retroperitoneal and diaphragmatic injuries. A positive lavage for blunt trauma is >100,000 RBC/ml or >500 WBC/ml or enteric contents in the lavage fluid. DPL is particularly useful as a screening study in an unstable patient or in a patient with an altered state of consciousness. In patients with penetrating trauma, >50,000 red blood cells may be considered positive. The presence of bile, bacteria or an amylase greater than serum is also indicative of intra-abdominal visceral injury.

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Focused abdominal sonography for trauma (FAST exam) is also a valuable adjunct in rapid abdominal assessment and may additionally provide information regarding pericardial or pleural fluid or pneumothorax. However, > 600 cc of blood is required to give a positive abdominal FAST exam.

The CT scan is the definitive diagnostic study for assessing abdominal injuries in stable, cooperative patients. The scan also provides a good assessment of the retroperitoneal area, which is an advantage over the DPL. It is also specific in that it identifies the organ injured.

Indications for DPL, FAST, or CT include the following:

(a) Unreliable or equivocal results of physical examination (e.g., altered mental status, intoxication or pain perception associated with neurologic or musculoskeletal trauma) in a hemodynamically stable patient.

(b) Hypotension of uncertain etiology. (c) Urgent or emergent need for general anesthesia and surgery for associated injuries

precluding a "safe period" of observation (i.e., 24 hours). (d) Associated major injuries (i.e., bilateral femoral fracture, multiple lower rib fractures,

major pelvic fracture) suggesting a significant acceleration/deceleration mechanism.

BLUNT ABDOMINAL PROTOCOL

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Yes OR Surgical Abdomen Or Direct to OR candidate

NO Positive Negative Stable Unstable Indeterminate Unstable Stable CT Scan OR CT/Observe

FAST

Circulatory Status

Circulatory Status Circulatory Status

Stable Unstable DPL CT Scan Positive Negative Look for OR other sources

Special procedures, such as oral contrast studies, arteriography, magnetic resonance imaging, laparoscopy and isotope scans also have their place in evaluation of the trauma patient. Arteriography may be useful to assess a potential renal artery injury or to embolize pelvic vessels to control hemorrhage associated with pelvic fractures. CT cystography may be performed in suspected

urologic injury as evidenced by flank injury or hematuria. A urethrogram is obtained prior to inserting a Foley catheter in those patients suspected of urethral injury.

Gunshot Wounds

Patients with gunshot wounds present different problems to the trauma team. Eighty to 90% of the patients who have penetration of the peritoneum by a missile sustain visceral injury. Therefore, an aggressive approach is recommended, and essentially all patients with gunshot wounds to the lower chest, abdomen, flank, and back are taken to the operating room. Rarely, isolated tangential hepatic injuries may be observed. Patients who sustain stab wounds are managed selectively. If there is no indication for celiotomy, the anterior abdominal wound is locally explored surgically. If the end of the tract is clearly seen and does not penetrate the fascia, the wound is irrigated and closed. However, if the end of the tract is not seen or if the fascia is violated, a DPL is recommended. For stab wounds of the back, triple contrast CT scans may be beneficial. [See the Penetrating Torso Injury protocol]

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PENETRATING INJURY TO THE TORSO Penetrating Injury to

Abdomen, Flank or Back

Gunshot Wound Stab Wound

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+

Outpatient Follow-up

DPL or Laparoscopy

Triple Contrast CT Scan

-

Repeat CXR*

-

Celiotomy

+

Option: Laparoscopy on Left side to Rule out Diaphragmatic injury

Abdomen Flank Back

Wound Exploration

Below

+-

Costal Margin

Lower Chest

Admission and

Observation *May reveal new fluid accumulation, indication of diaphragmatic injury Anterior Chest Wound: Peritoneal lavage or laparoscopy followed by observation if negative. Do not locally explore wounds over the chest. Anterior Abdominal Wound: Local exploration with discharge of the patient if the fascia is not violated and followed by lavage or laparoscopy if the end of the tract is not seen, or if it enters the peritoneal cavity. If lavage is negative, the patient is admitted and observed for 24 hours. Flank Chest Wound: Peritoneal lavage or laparoscopy followed by adjunctive studies as indicated if lavage is negative. If all studies are negative, the patient is admitted and observed for 24 hours. Flank Abdominal Wounds: Local exploration followed by lavage or laparoscopy if the end of the tract is not seen. Adjunctive studies are performed as indicated; and if negative, the patient is admitted and observed for 24 hours.

Back Abdominal Wounds: Local exploration with discharge of the patient if negative. Physical examination followed by adjunctive studies as indicated. CT with triple contrast--oral, intravenous and rectal [if indicated]--may be useful for patients with high risk injuries. Gunshot Wounds: Any patient with a penetrating injury between the level of the nipples and pubic symphysis should undergo exploratory laparotomy. Posterior penetrating injuries should be similarly managed. Patients with tangential wounds violating the fascia should undergo laparotomy. Rare exceptions for tangential hepatic injuries may occur (Feliciano). Extremities Extremity injuries are addressed in the secondary survey and have a lower priority of care. More than 1/2 of hospitalized trauma patients will have such an injury, and some may be life-threatening, especially if accompanied by uncontrollable bleeding. Limb threatening injuries must be identified in the early evaluation period and treated aggressively. The extremities are examined by paying close attention to the color, adequacy of perfusion, deformities (e.g. angulation or shortening), swelling, bruising and open wounds. Clinically, fractures are either closed or open. Any obvious or suspected fracture near a wound should be assumed to be an open fracture. Open fractures are classified by the size and complexity of the wound, degree of contamination, and the configuration of the fracture as seen on extremity films. Certain extremity injuries may be life-threatening because of associated injuries (e.g. crush injuries to the abdomen and pelvis; major pelvic fractures) or due to traumatic amputations of the arm, forearm, thigh, or leg. Vascular injuries proximal to the knee or elbow with or without dislocation, fractures with vascular or nerve injury, and major open fractures are all potentially limb threatening injuries. Bleeding associated with major closed fractures may produce enough blood loss to cause hypovolemic shock (e.g. femur or pelvis). Bleeding associated with a femoral fracture is generally controlled with a traction splint. The trauma team must be familiar with the various splints and their proper application. Massive bleeding may occur with certain types of pelvic fractures. If blood loss intraperitoneally has been excluded and the pelvic fracture is felt to be the source, arteriogram with embolization is indicated. The T-POD and pelvic fixation are other modalities that may help control bleeding from pelvic fractures. The late signs and symptoms of a compartment syndrome are pain, decreased sensation, tense swelling, and weakness or paralysis of the involved extremity. Compartmental pressure measurements may help diagnose a suspected compartment syndrome earlier. The syndrome usually develops over a period of time and is associated with crush injuries, fractures, and electrical injuries. MAST may cause a compartment syndrome, particularly if left inflated for prolonged periods of time. Under ideal circumstances, amputated extremities may be replanted. The evaluating physician should consult the replant surgeon to determine whether the patient is a candidate for replantation. If the patient qualifies, the amputated part should be carefully preserved and rapidly transported with the patient to the replantation center. Early recognition of vascular injuries is important. "Hard signs" of vascular injury are: pulsatile bleeding, expanding hematoma, a bruit or thrill, and the 6 P's (pulselessness, pallor, pain, paresthesia, paralysis, poikilothermia). "Soft signs" include: diminished pulses, history of moderate hemorrhage, a non-expanding hematoma, and peripheral nerve deficit. Hard signs are indication for surgical exploration, soft signs may indicate excluding injury with angiography.

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Central Nervous System (CNS) A thorough neurologic evaluation completes the head-to-toe survey. Careful examination that looks for lacerations, CSF leaks, and the presence of fractures, and an assessment of neurologic function using the Glasgow Coma Scale are important. The patient's head should be kept in the neutral position until injury has been ruled out. Cervical injuries are suspected in unconscious patients who demonstrate flaccid areflexia accompanied by diminished rectal tone, diaphragmatic breathing, ability to flex but not extend the elbow, pain above but not below the clavicle, hypotension, bradycardia without hypovolemia and priapism. The conscious patient may complain of local tenderness and a step-off deformity may be palpated. Examination for motor strength and weakness and sensory function and assessment of autonomic dysfunction are important. The physical examination delineates the precise location of injury, but appropriate films demonstrate the extent of injury and allow for proper planning and management. The CT scan is extremely valuable in assessing vertebral injuries and should be used liberally. Fluid administration should be monitored carefully. Continued reassessment of neurologic function allows the physician to note changes from the baseline that may necessitate re-establishment of priorities. Refer to the Spine Clearance Protocol under patient care guidelines. The Trauma Patient The trauma patient should be continuously monitored and re-evaluated to identify any changes in the condition that may warrant a change in management priorities. As initial life-threatening injuries are managed, other equally serious problems may become apparent. Less severe injuries or underlying medical problems may need attention. The patient's pertinent past medical history must be obtained. If a patient needs to be transferred to another facility (e.g. pediatric patient), little time should be spent obtaining diagnostic tests. Only those studies that will expedite resuscitation and stabilization should be obtained. Time is of the essence and the quicker the patient arrives at the appropriate definitive care center, the better the chances are for a successful outcome. III. TRAUMA SERVICE GUIDELINES

A. TRAUMA 1. The Trauma Service is staffed by 12 hour shifts with 1 hour for changeover in AM and 30 min in

PM. AM Changeover is at 0600; PM changeover is at 1830. The TR Attending should be in-house Wednesdays 0630-0930 to cover the service with the Emergency Medicine residents during grand rounds and resident conference, September – May.

2. A Trauma Alert response is conducted by three residents: a chief (PGY 4 or 5), a middle level resident (PGY 2 or 3) and a PGY 1 and/or midlevel providers.

3. The decision to reroute the ETC for trauma should only be done after all available resources have been exhausted. This includes the backup chief resident and trauma attending and any other available attendings. This decision requires involvement of top level administration and should not be made lightly as the closest level I facilities are in Cincinnati and Columbus.

4. The Trauma Service should respond to all trauma alerts. If the team is in the operating room then they should obtain coverage prior to going to the operating room to insure that a prompt response by the trauma team is obtained.

5. In general, do not transfer trauma patients to other hospitals, especially if unstable or it you do not think it is safe to move them.

6. Remember to admit patients under “observation status” or 23-hour admit when following abdominal pain or after angiography. Insurance companies will not pay for a regular 1 day admission for these patients.

7. All Category I patients should be admitted to the Trauma Service. All category II patients should, as a minimum, have a trauma service consultation. Patients in category III may require Trauma Service consultation at the discretion of the emergency room physician.

8. Trauma attendings should be contacted for all category I patients (see phone/beeper preference list) as soon as a category I designation is made. Attendings should be called within

15 minutes of patient arrival on all other alerts and consults. Category I alerts occurring at changeover should be responded to by the attending on-call when the category I is first paged.

9. All trauma patients requiring admission to the ICU must be admitted to the Trauma Service. 10. Target time to have patients to CT for scan, without extenuating circumstances, is 20 minutes. 11. Remember to keep the patient’s family well informed; chaplains are available and respond to

Trauma Alerts. 12. NO information other than condition is to be given over the telephone to outside callers unless you

are certain of their identity and release of information is approved by the patient (HIPAA guidelines).

13. Try to admit all non-acute emergencies to the floor as soon as possible. Do not keep ICU destined patients in the ER for prolonged periods; take to ICU. Time to definitive care areas should be less than 2 hours. Keep all unstable patients in the emergency room until surgery is ready for them.

14. Be aware of the need for organ donors. Call Life Connection of Ohio at 223-8223. 15. Should documentation for forensic reasons be required, please obtain the ER or OR camera and take

pictures of wounds prior to altering them. Do not cut through knife or bullet holes in clothing if you can avoid it – this is important forensic evidence.

16. Report suspected child abuse, elder abuse, or domestic violence by notifying social services. This is the law in Ohio. Social services are in-house (x 2251) or on call 24 hours a day.

17. If additional assistance is needed in the Emergency Department, Operating Room or ICU, the Senior Resident should contact, in order: a. Trauma Attending first call b. Trauma Attending second call c. Chief resident on call d. WSP attending on call e. Surgery program site directors Additional staff backup needed will be obtained by the administrative staff on call. Problems with case scheduling or sequencing in the operating room should be directed to the Trauma call attending. (Refer to Mini-Disaster Plan.)

18. A patient's family physician should be notified within 24 hours when a patient is admitted to the Trauma Service, and a copy of the discharge summary sent to him/her at discharge. Scripting: “Your patient, (name), has been admitted to MVH and is under the care of the Trauma Service. We are notifying you of his/her admission.”

19. Daytime follow-up cases: First option is the admitting attending. TC attending is 2nd option if the patient is within 24 hours of admission. After 24 hours ICU attending does ICU cases and the TR attending does the floor cases.

20. Brief documentation of indications and outcome of ETC open thoracotomies should be documented on a progress note and dictated on work type 89.

21. If the patient is declared dead immediately after initial exam and rhythm verification, family and coroner notification will be the responsibility of the Emergency Department attending, who is involved in the patient's care. If, however, there are further resuscitative attempts made in the case, the responsibility for coroner (call 225-4156 to report a death to the coroner) and family notification lies with the trauma team residents, under the supervision of the trauma attending. Of course, either discipline can offer to assist the other with these tasks as a collegial courtesy to facilitate patient care, especially if one or the other service is very busy. Verify who is calling the coroner at the time the death is called.

22. Look for medical causes of MVC in patients > 40 years old (e.g., arrhythmia, MI, TIA, etc.) 23. Removed foreign bodies that could be related to possible criminal litigation should be placed in a

properly identified container and sealed. Security should then be notified to come and pick up the evidence. A receipt will be given by the Security Officer that is to be placed on the patient's chart.

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(Foreign bodies related to criminal litigation might be guns, bullets, or knives.) Bullets removed in the OR should be marked in some way by the doctor removing them; so that they are easily recognizable should the case be prosecuted. Mark on the end of the bullet, not the sides, as the sides have rifling necessary for ballistics investigation.

24. Level I requirements: a. There must be a PGY-4, PGY-5, or attending in-house at all times. b. A mid-level resident (PGY-2 or 3) should be the first responder to critical patients in the ICU.

25. ETC Physicians are directed to call the Trauma Service when patients return within 30 days of discharge. This will allow Trauma Service the opportunity to re-evaluate the patient. We will readmit them to the Trauma Service within 30 days if admission is needed.

26. Know the Trauma Resuscitation Roles and Responsibilities. 27. The chief may delegate an uncontrolled airway to emergency medicine or anesthesia in order to

allow the chief to complete patient evaluation and identification and triage of injuries. 28. Review the Direct to OR policies before you get one! Make sure these patients have trauma H&P's

completed. 29. Allow the EMS squads or CF personnel 15 seconds of uninterrupted time at patient's arrival to allow

for report. The chief should be the person receiving report and asking questions. Pay attention to them!

30. All trauma patients are to be completely undressed and thoroughly examined prior to sending to X-ray or releasing to a specialty service. Write or dictate a note whenever you are consulted.

31. NG tubes should be inserted in all trauma cases going to surgery except potential vascular wounds of the neck or suspected cribriform plate or basilar skull fractures. After insertion, the stomach contents should be evacuated. Place on suction or dependent drainage.

32. Potential vascular wounds or wounds communicating with the thoracic cavity should never be probed or explored in the emergency room.

33. Record neurovascular findings on extremity injuries. 34. Don't give paralyzing agents until you've done your neuro exam. 35. Listen over the wound on gunshot wounds and stab wounds for bruits. 36. Patients with hematuria or suspected GU injury should have a urethrogram, cystogram and/or CT

performed as indicated. If a significant pelvic fracture is suspected in a male, a urethrogram should be done before the Foley is placed.

37. Patients with significant blunt trauma to the chest and abdomen and old people who live alone and have a major fall or any significant trauma or anticoagulation usually need to be admitted to the hospital for observation.

38. Familiarize yourself with the equipment in the resuscitation room and where it is kept. 39. Do not remove penetrating objects from patient's vital areas in the ETC. 40. Routine trauma X-rays in multiple blunt trauma patients are AP CXR and pelvis. Additional films

are ordered individually. 41. Mark wounds in patients with penetrating trauma prior to obtaining an X-ray or CT with an open

paper clip. AP and Lateral films are required for localization of foreign bodies (Including bullets).Do not document wounds as "entry" and "exit". Note dimensions and specific findings (e.g., powder burns)

42. Stab wounds should not be closed. Recent slash wounds which can be irrigated and debrided may be repaired.

43. If a patient with penetrating trauma requires emergent thoracotomy DO NOT include the entry wound in your incision if you can avoid it.

44. Any patient discharged from the ETC should receive a follow-up appointment to the clinic. 45. Patients who sign out AMA should still be given prescriptions and clinic follow up. 46. Triage of abdominal + head injuries:

Abdomen (gross blood, hypotension) → OR rather than head CT Head (Severe injury or lateralizing signs) → Head CT if patient is hemodynamically stable

47. Patients in CT should be monitored by a physician or trauma nurse/PA and ETC RN and should have an ECG, BP monitor and a pulse oximeter and/or EtCO2. Seriously injured patients should be monitored by a PGY-2 or higher.

48. Indications for CTA of neck: Coma unexplained by CT findings Lateralizing neurological deficits LeFort II or III facial fractures Severe epistaxis Horner’s syndrome Skull base fractures involving the foramen lacerum (carotid canal) Significant neck soft tissue injury/neck seat belt sign History of strangulation or near hanging GCS < 8 Cervical spine fractures or subluxations

49. All trauma admissions must be seen by an attending prior to discharge. 50. There are trauma resuscitation carts in CT-3 and special procedures if a patient crashes. 51. When a patient is freed from a long backboard, the CID's (head restraints) should be removed at the

same time the body straps are removed. Immobilization of the head with the body loose creates potential for further injury to the C-spine.

52. Post Splenectomy WBC a. After the fifth postoperative day, patients with sepsis consistently demonstrated a WBC higher

than 15 X 103 μL and a RBC/WBC lower than 20 Day 5 = sepsis b. Patients without sepsis consistently had a WBC lower than 15 x 103 μL and a RBC/WBC higher

than 20. 53. “Trauma Pouch" contains (responsibility of ED nurses):

Etomidate Succinylcholine (in refrigerator) Midazolam Ancef Flumazenil Rocuronium (in refrigerator) Cefoxitin Morphine Sulfate Naloxone Fentanyl

54. Incidentaloma letter a. Complete this letter (available from the Trauma Program Secretary) b. Copy and give to the Trauma Secretary to mail to the patient’s physician. c. Give original to the patient and review it with them. d. Write a note in the chart documenting this.

Date ____________

Re: _____________________________________ (Patient Name)

Dear _______________________________________________:

During your hospitalization on the Trauma Service at Miami Valley Hospital we found an abnormality on your diagnostic tests.

This abnormality is _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

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To further evaluate this abnormality, you should

Obtain further x-ray studies ___ _____________________________________

Follow-up with your family doctor ___ ________________________________

Follow-up with a specialist, Dr. _____________________________________ Phone No. ___________________________

Within _____Days _____Weeks _____Months

If applicable, a copy of the report on your diagnostic test is attached.

Sincerely, Miami Valley Hospital Trauma Program 937-208-6268 cc: Family Physician ________________________________________ Trauma Clinic Inpatient Chart

55. Unidentified Patients DNA—Do Not Acknowledge patient NI—No Information about the patient is given out (location, condition, etc.) Anonymous Patients

UN(Number 1-75), M or F followed by a 4 letter color (mint, rust, pear, etc.) e.g. UNTWENTYSEVEN, MTEAL

56. Pharmacology a. Levaquin may be associated with severe confusion, especially in elderly patients. b. Propofol infusion syndrome is characterized by severe metabolic acidosis, hyperkalemia, lipemia, rhabdomyolysis, hepatomegaly, and cardiac and renal failure. Although the syndrome most often occurs in patients receiving prolonged, high-dose infusions (>5 mg/kg/hour for > 48 hours), it also has been reported following large-dose, short-term infusions during surgical anesthesia. Alternative sedatives should be considered if prolonged sedation is needed, maintenance of sedation requires increasing doses, or infusion administration is accompanied by the onset of metabolic acidosis. However, abrupt discontinuation of propofol use should be avoided because of the risk for rapid awakening and associated anxiety, agitation, and resistance to mechanical ventilation. Rather, infusions should be adjusted to maintain a light level of sedation through the weaning process or during evaluation of sedation level. Propofol emulsion contains 100 mg/mL of soybean oil and 12 mg/mL of egg lecithin, its use is contraindicated in patients with allergies to eggs, egg products, soybeans, or soy products.

B. SHOCK

1. If a patient does not respond to 2 liters of Ringer's Lactate or responds and then becomes hypotensive again, consider blood administration. Be sure to rule out other causes of hypotension, i.e., myocardial, spinal shock, etc. Each liter of fluid should be sequentially numbered by the ETC RN, starting with the first liter of pre-hospital fluid as #1; this will be continued to the first definitive care area. Keep an eye on fluids. Salt-water drowning is a cause of significant morbidity!

2. If possible, give cross-matched blood (30-40 min availability). If time does not permit, give ABO group and Rh type specific blood (15 min availability [low risk]) and, in an emergency, give 0 negative (< 5 min, immediate availability). If 0 negative is not available or scarce, 0 positive may be given to males and women beyond childbearing age > age 50 (O negative or O positive blood is termed “emergency release”). Platelets are available in 15 minutes; FFP in 30 minutes. “Thawed plasma” is type-specific and more quickly available (10 minutes). Warm all blood and fluids in major trauma patients using the Level I warmer/pressure infusor as needed.

3. If the patient is unresponsive to therapy, take to the OR STAT. Do not waste time with lab and x-rays.

4. Place at least one IV in an upper extremity in all abdominal injuries. The peripheral route should be attempted first. Percutaneous femoral IV lines are acceptable (must be removed in 24 hours due to high risk of DVT). Emergency subclavian and internal jugular punctures have a high complication rate when performed in ETC for Trauma resuscitation.

5. "Trauma Kits" (8.5 Fr) Introducers are available. Do not use triple lumen catheters for resuscitation. 6. Do not administer IV fluids through an injured extremity. 7. Never use vasopressors unless directed by the senior surgical resident or attending.

Guidelines for Emergency Issue of Blood Products Tests Available

Requirements Tests Performed Time (upon receipt of specimen)

Type and Screen

Correctly labeled specimen Red armband correctly applied to patient

ABO/Rh Antibody Screen

5 minutes 30 minutes

Type and Crossmatch

Correctly labeled specimen Red armband correctly applied to patient

ABO/Rh Antibody Screen RC compatibility testing (specify # units required)

30-40 minutes

Draw and Hold

Correctly labeled specimen Red armband correctly applied to patient

A DRAW AND HOLD should be ordered when transfusion is possible pending medical evaluation. The BTS specimen is drawn, correctly labeled, and patient arm banded at the time of initial laboratory specimen collection. No tests are performed until the BTS is notified.

Same as above orders NOTE: PRECOLLECTED SPECIMENS MAY NOT BE LABELED AND USED FOR BLOOD TRANSFUSION

PRODUCTS AVAILABLE LOCATION: PROCESSING TIME: Red Blood cells (RBC) MVH Type and crossmatch or emergency release required Platelets (PLT), random donor CBC, must be pooled Type needed, 30 minute delivery to MVH, 15

minute processing in BTS Platelets (PLT), apheresis CBC, must be pooled Type needed, 30 minute delivery to MVH, 10

minute processing in BTS Fresh frozen plasma, (FFP) MVH, must be thawed Type needed, 30 minute thawing process in BTS

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Thawed Plasma MVH, type A and O available

Type needed (5 minutes), AB is universal donor (not always available)

Cryoprecipitate (CRYO) MVH, must be thawed Type needed, 15 minute thawing time, 15 minute pooling time in BTS

Factor IX CBC, must be reconstituted

30 minute delivery, 30 minute processing in BTS

Factor VII Pharmacy Dose - 100 mg/kg for coagulopathy, 50 mg/kg for Coumadin reversal

RH immune globulin (RhoGAM) MVH Type and screen required, 5 minute processing in BTS

BTS = Blood Transfusion Service CBC = Community Blood Center PROTOCOL PURPOSE PRODUCTS PREPARED EMERGENCY RELEASE

To be used when a patient requires transfusion before a specimen can be collected and compatibility procedures completed. To be used when type-specific blood is required before compatibility procedures have been completed (specimen in BTS) To be used when compatibility testing has been completed, but routine blood issue procedures must be bypassed.

Emergency Trauma Center; OR: 4 units O NEGATIVE RBC unless otherwise notified. The BTS will deliver the blood to the ETC. The BTS will deliver first request of RBC to OR. Throughout hospital: specify number of units required up to 4 units at a time. The BTS will NOT deliver blood to other departments unless the conditions are extreme. Same as above.

DIRECT TO OR To be used when a patient is being transported to MVH, bypassing the ETC, and there is a potential for a massive hemorrhage. The primary purpose for the Direct to OR protocol is to have RBC available IN THE OR when a potentially hemorrhaging patient is received. ORDERING THE MASSIVE HEMORRHAGE PROTOCOL IS NOT APPROPRIATE BEFORE A PATIENT IS RECEIVED.

4 units O NEGATIVE RBC delivered by BTS staff to the or front desk before a patient is received. The BTS may be notified by trauma paging system or by phone.

MASSIVE HEMORRHAGE

To be used in situations where greater than 10 units of RBC and other products are required for transfusion in a short period of time (less than 1 hour)

The following products are processed immediately: 10 units O POSITIVE RBC transported by BTS 4 units of FFP thawed

DO NOT USE THE MASSIVE HEMORRHAGE PROTOCOL UNTIL THE PATIENT IS EVALUATED. DO NOT USE THE MASSIVE HEMORRHAGE PROTOCOL UNLESS YOU ARE WILLING TO TRANSFUSE GROUP O POSITIVE, UNCROSSMATCHED BLOOD.

2 sets* of platelets ordered from the CBC (*1 set=10 random platelets or 1 apheresis platelet) The following are maintained until otherwise notified: 10 units RBC (type-specific when possible) 2 FFP thawed 1 set of platelets (not pooled)

An Emergency Release Form must be signed by a responsible physician (preferably the ordering physician). A specimen must be sent to the Blood Transfusion Service (BTS) as soon as one can be collected. All RBC products will be transported in approved coolers for blood storage. Products must remain in the cooler or placed in approved BTS refrigerators until transfusion.

A. Overall transfusion goals Blood/Fluid resuscitation (administration of blood/fluids and serial laboratory assay) must continue until the following goals are reached: • Lactate < 2.5 mmol/L or • Base deficit < 2 mEq/L • Within 24 hrs of admission The type of fluid administered should be adjusted to maintain the following standards: • Hemoglobin > 7 g/dL and < 10 g/dL for the first 24 hours or not yet euvolemic • INR < 1.5 and/or PT < 16 sec and/or APTT < 30 sec and/or fibrinogen > 100 g/L • Platelets > 50,000 /mm3 It is understood that the choice and timing of fluids administered and laboratory measurements must be adjusted to match the clinical situation, and that greater latitude in meeting these targets is appropriate early in resuscitation when clinical information may be limited or lacking. B. Transfusion guideline for RBC The following transfusion guideline covers all RBC transfusions and must be adhered to unless the clinical situation justifies deviations: In patients hemodynamically unstable as defined by: • SBP < 90 mmHg or • SBP is only maintained > 90 mmHg with massive fluids or vasopressor support ⇒ RBC should be administered as determined by “clinical necessity” In patients hemodynamically stable as defined by: • No SBP < 90 mmHg for 1 hour and • No resuscitation (or use of vasopressor support)(exception: use of low dose vasopressor support for

neurogenic shock) ⇒ Hemoglobin < 7g/dL: RBC administered at physician discretion ⇒ Hemoglobin 7-9 g/dL: RBC should only be administered if evidence of hypoperfusion is present ⇒ Hemoglobin > 9g/dL: No RBC transfusions 37

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Evidence of Hypoperfusion is o Continued slow bleeding with downward trend in hemoglobin o Decreased urine output (U/O) o Heart rate >120 beats/min with adequate analgesia o Cardiac Index (C.I.) < 3 L/m2 with low wedge pressure (PCWP) or central venous pressure (CVP) o Low SaO2 due to altitude, Acute Lung Injury (ALI) o Coronary or other organ ischemia syndromes

C. Transfusion guideline for other blood products The following transfusion guideline covers all plasma, cryoprecipitate and platelet transfusion In patients hemodynamically unstable as defined by: • SBP < 90 mmHg • SBP is only maintained > 90 mmHg with massive fluids or vasopressor support ⇒ Blood products should be administered as determined by “clinical necessity”

In patients hemodynamically stable as defined by: • No SBP < 90 mmHg for 1 hour and • No resuscitation (or use of vasopressor support)(exception: use of low dose vasopressor support for

neurogenic shock)

With bleeding: o INR > 1.5 or PT > 15 sec plasma at the discretion of the physician o Fibrinogen < 100 g/L cryoprecipitate at the discretion of the physician o Platelets < 50,000/mm3 platelets at the discretion of the physician

Without bleeding, but still in the perioperative period:

o INR > 2 plasma at the discretion of the physician o Platelets < 50,000/mm3 platelets at the discretion of the physician o Fibrinogen < 100 g/l cryoprecipitate at the discretion of the physician

Without bleeding in the ICU: o No blood product transfusion unless clinical situation justifies deviations

D. Guideline for use of high molecular weight colloids

The following guideline covers the use of colloids/plasma expanders and Dextran (or equivalent) and must be adhered to unless the clinical situation justifies deviations. • Use of colloids/plasma expanders must be limited to no more than 1,000 mL within 24 hours • Use of Dextran (and equivalent) is not recommended in the first 48 hours (unless vascular patient)

Massive Hemorrhage Protocol Action Steps 1. Establish large-bore access, and level 1 rapid infuser line for the infusion of products and blood (preferably

2 lines). 2. Call Blood Bank to activate protocol. (Call to terminate protocol is also required.) 3. Send blood sample for type and cross with first set of q30 minute lab studies. 4. At step 3 in shipment chart notify pharmacy of anticipated need for Factor 7. Ancillary Medications, Testing, Termination 1. Check blood gas, Chem-7 and CBC q30 minutes by I-stat method. 2. Order and/or have available calcium, magnesium, DDAVP, insulin drip as needed.

3. Get coagulation studies (PT, PTT, platelet count) every hour. Get all these tests plus a D-dimer and fibrinogen level prior to giving Novo-seven, and one hour afterward.

4. Novo-seven is to be given only on direct order of the Anesthesiologist or Attending Trauma Surgeon. The Novo-seven order sheet is available in EPIC.

5. Novo-seven is a refrigerated product. Store unmixed vials in refrigerator at all times. Mix without agitation to avoid foaming. Prompt return of unopened vials to the Pharmacy is a priority action in the resuscitation protocol.

Expected Shipments (shipment 1A is ‘emergency release’) Shipment PRBC’S Plasma Platelets Cryo Factor Seven

1A 5 4*** 1B 5 4*** Order 2 5 4*** 6 10 Give Factor 7 3 5 4 4 5 4 6 10 5 5 4 6 5 4 6 10 7 5 4 8 5 4 6 10

*** Early delivery of Plasma depends upon the availability of a blood type or AB plasma

C. BURNS

1. Burn patients with multiple trauma will be evaluated by both services involved and will be initially admitted to the Trauma Service. Subsequent transfer will depend upon which service will assume the majority of the patient's care.

2. Lines may be placed through eschar, but should be changed every 3 days. 3. On patients with "road rash," the burn nurses may be consulted for wound care.

D. DIRECT TO OR TRAUMA RESUSCITATION Purpose: Current research has found that certain patient types taken directly to the OR for resuscitation of traumatic injuries that patients suffered less and that morbidity and mortality were reduced. Efficiency is improved by avoiding losses of momentum, time, information, equipment, and personnel which frequently occur when a patient is moved from one treatment environment to another.

PATIENT TRIAGE CRITERIA • Hypotension: BP < 80 mmHg systolic despite Advanced Life Support • Penetrating thoracoabdominal trauma • Blunt abdominal trauma • Open pelvic fracture • Proximal traumatic amputations • Trauma arrest with sinus rhythm (PEA) — CareFlight only • Other indications as determined by the Trauma Attending or the senior surgical resident on-call.

PROCEDURE FOR DIRECT TO THE OR

A. Initiation of Direct to OR trauma resuscitation 1. Identification of Patient

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a. Medical Control will identify criteria for potential Direct to OR and call senior surgical resident in house (7204).

b. The patient will be designated as a Direct to OR by the trauma attending or the senior surgical resident in house.

c. The patient may be designated prior to arrival or upon arrival to the institution regardless of arriving by ambulance or helicopter. The senior surgical resident in-house will meet the patient on the 7th floor or ETC and make a final triage decision.

d. A patient may be identified as a Direct to OR as they come off of the helipad and without being received by an attending emergency physician. In this case, the attending physician of record will be the trauma attending physician. The attending emergency physician should be contacted. Call the OR to notify them of change in status (3111).

e. The patient triage criteria will be utilized for the designation process.

2. Notification for Direct to OR trauma resuscitation It is imperative that proper notification of all appropriate areas/individuals occur for Direct to OR trauma resuscitation to be successful. a. Patient arriving in the ETC and going Direct to the OR for trauma resuscitation.

(1) The surgeon responsible for the decision designates an individual to notify the OR by telephone that a Direct to OR is coming.

(2) The emergency department will generate, over the trauma alert beeper system, that there is a " Direct to OR " patient with an ETA. Example: "Direct to OR Trauma now" or "Trauma Alert/Direct to OR, GSW abdomen, BP 60/p mmHg, arrives by squad, ETA 5 minutes."

b. Patient arriving by helicopter and is a Direct to OR from the helipad. (1) If a decision is made as the patient enters the hospital off the helipad, the Primary Flight

Nurse should designate an individual such as security to call the OR at 3111 and tell them there is a Direct to OR coming from the helipad. That individual should then notify the ETC shift manager at 3359 that the patient is a Direct to OR. The shift manager would then initiate a Direct to OR over the trauma alert beeper system. Example: "Direct to OR - CareFlight, blunt trauma BP 60/0 mmHg, ETA on helipad now."

c. The disciplines who normally respond to Trauma Alerts in the ETC would then respond to the Trauma Alert in the OR.

d. As with other back-to-back flights, CareFlight may request an ETC RN to respond to the helipad for report and the ETC RN would transport the patient to the OR and assure OR and ETC notification if the decision is made for Direct to OR.

B. Responsibilities

1. Physicians a. Emergency Medicine/Medical Control-facilitate the timely communication of clinical

information to the chief resident so Direct to OR decision may be made as soon as possible. b. Senior Resident in house will make the decision for Direct to OR based upon the patient triage

criteria listed above. Will direct the trauma resuscitation in the surgical suite. Will utilize additional surgical residents as surgical assistants or in resuscitation roles and responsibilities.

c. Trauma Attending-will respond to the OR upon notification of Direct to OR over the Trauma Alert beeper system,

d. Anesthesia-function as in current role in the surgical suite. 2. Nursing

a. Surgical Services circulating and scrub nurses will prepare for surgical procedure as within their normal roles.

b. ETC RN will respond to trauma cases and perform role similar to roles of trauma resuscitation. Will assist in fluid resuscitation as well as other resuscitation procedures. Will facilitate the initial resuscitation documentation on the Trauma Flow Sheet although routine documentation

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c. May require the response of a second RN to facilitate with resuscitation component. If a second RN is required, the Administrative Officer will determine where the second RN will come from. The Administrative Officer will do this in conjunction with the ICU and PACU managers.

d. Administrative Officer (Trauma Program Manager Monday-Friday) will be notified of Direct to OR with activation of the Trauma Alert Beeper System. The Administrative Officer will respond to the front desk of the OR and notify Admitting, assure the availability of a HUC and that there are adequate personnel available for the resuscitation.

e. Health Unit Coordinator (HUC) — will assist in initiation of requisitions for tests and communications with ancillary services.

C. Ancillary Services

1. Admitting-will be notified of a Direct to OR by the Administrative Officer. The registration process will occur via the main admitting office. The patient will be registered as soon as possible and will utilize the unknown patient naming system if there is no name available on the patient. Early registration will facilitate testing.

2. Respiratory Therapy will respond to the resuscitation and assist the anesthesiologist as needed. If the respiratory therapist is not needed, they may leave until needed for postoperative traveling.

3. Medical Imaging will use their in-house personnel emergently and then use their on-call OR portable techs. X-rays could be kept to a minimum in the OR resuscitation process. Definitive films should be obtained after leaving the OR.

4. Laboratory-when blood bank receives a page for Direct to OR they will immediately bring 4 units of uncrossmatched 0 negative blood. The OR Attendant will transport the patient's blood specimen to the lab for Trauma labs, priority labs, and type and crossmatching for 6 units unless otherwise specified. Pre-printed paperwork with trauma lab requisitions is available in the OR.

5. ECG would be called if needed. 6. Pastoral Care- Would direct family to the Surgical Services waiting area.

D. Traveling

When the patient is ready to leave the OR and requires further definitive tests (i.e. CT scan or arteriogram) they will be accompanied by at least one RN and one surgical resident. Based upon the patient's condition more may need to be present. The RN will be either an RN from the PACU or the ICU because of their credentialing in critical care and recovering patients from anesthesia. The determination of who will travel will be made in conjunction with the Administrative Officer and the managers of the ICU and PACU.

E. DVT PROPHYLAXIS AND IVC FILTER PLACEMENT FOR TRAUMA PATIENTS Calculate DVT risk score on admission – use DVT prophylaxis based on total score (see below). Risk Assessment Scoring Tool Injury-Related Factors Score (total all risk factors) Major trauma > 2 body systems 5 Complex lower extremity fracture 5 Pelvic fracture 5 Bilateral tib-fib fractures 5 Tib-fib fracture with prolonged immobilization 5 Acute spinal cord injury+/- paraplegia or quadriplegia 5 AIS score >2 for head 3 Repair or ligation of major vascular injury 3 Burn > 20% TBSA 3

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Coma (GCS < 8) 2 AIS score > 2 for chest 2 AIS score > 2 for abdomen 2 Femur fracture 2 TLS fracture(s) with immobilization > 5 days 1 Iatrogenic factors Femoral line for > 24 hours 2 OR time 45 minutes 2 Immobilization > 2 days 2 Central venous access including PICC lines 2 Immobilization cast 2 4 or more transfusions in the first 24 hours 1 Underlying condition/risk factor History of DVT 3 Hypercoagulable state 3 Malignancy 2 Acute MI, CHF, Sepsis, COPD, Varicose veins 1 Estrogen or LOCP 1 Varicose Veins 1 Chronic venous stasis 1 Obesity 1 Pregnancy/post partum 1 Age > 75 years 3 61-74 years 2 41-60 years 1

LOW Total risk factor 0-1

MODERATE Total risk factors 2

HIGH Total risk factors 3-4

HIGHEST Total risk factors > 5

Early Ambulation IPC IPC & Lovenox IPC & Lovenox

If early ambulation not possible – IPC

Lovenox

If contraindication for Lovenox

consider IVC filter

Consider IVC filter

Lovenox after spine injury or surgery may be considered after 48 hours

(must be authorized by spine surgeon).

Lovenox may be used after 48 hours in Traumatic Brain Injury (must be authorized by NS) or non-

operative liver or spleen injuries (must be authorized by Trauma Attending).

* IPC = Intermittent Pneumatic Compression (SCD’s or foot pumps)

A. Elastic (TED) stockings and SCD's or AVI foot pumps are the primary methods for prophylaxis. Pharmacologic methods (low molecular weight heparin) should be used as an adjunct when proximal DVT risk exceeds 5%. Unfractionated heparin has been shown to be of less effectiveness in high risk trauma patients. There is a possibility of HIT with both unfractionated heparins and LMWH. The risk is approximately 5-8%.

• Long term prophylaxis (> 2 weeks) may utilize Coumadin (2.0 mg. initial dosing). Prophylaxis INR: 1.5 to 2.0 (ideal range < 2). Pro times should be checked weekly as an outpatient for monitoring. Duration of risk in major ortho and neuro injuries may last up to 12 weeks post-trauma.

• Calf DVT (tibial or soleal vein) has low risk (0.2%) of clinical PE and should not change prophylaxis or treatment regimen; 20% of calf DVT may progress to popliteal vein propagation,

therefore follow up ultrasound (7-10 days) recommended for surveillance. SCD’s may be left in place in below knee DVT.

• Trauma Patient Discharge - Trauma patients with ANY pelvic or lower extremity fracture, who demonstrate limited mobility at time of discharge, will have DVT prophylaxis continued for a minimum of 4 weeks after discharge

Lovenox or low dose Coumadin can be used. Low dose Coumadin with INR 1.5 is acceptable The Trauma Clinic Nurse must be notified of patients discharged on low dose Coumadin by

leaving a voicemail at ext. 5332. Head injured patients who fall into this population should have strong consideration given to

IVC filter placement rather than Lovenox or low dose Coumadin.

Established proximal DVT should be treated a minimum of 4-6 months. If patients are fully ambulatory, a scan at 4 months may be performed to evaluate for resolution of clot and therefore need for continuing treatment.

F. ICU

1. Elderly patients sustaining major trauma should be taken to the ICU and have a REFOX catheter placed as early as possible in resuscitation. All patients > age 70 with significant trauma should be admitted to ICU for observation.

2. All CVL's placed in the ICU should be blue Arrow lines. Guidewire change is done on day 7 with tip culture. Repeat weekly as long as tip remains negative and the site is not inflamed.

3. All invasive procedures should be performed with full sterile preparation: gown, gloves, hat and mask. The bed should be draped when pulmonary artery catheters are placed.

4. Nutritional support should be started within 24 hours after admission if the patient is fully resuscitated (no base deficit). Intestinal feeding tubes can be placed in surgery (Room 1) or after admission to the ICU using fluoro beds or Corgard system. Patients on high dose norepinephrine should receive TPN, not intestinal feedings (danger of gut ischemia).

5. DVT prophylaxis should be started upon admission to the ICU (see protocol). 6. Stress ulcer prophylaxis should be initiated on all ICU patients (Pepcid, Prevacid, etc.). 7. Consult the Rehab service on admission for all head and spinal cord injury patients. 8. Complete standardized admission orders and trauma H/P on all patients. 9. C. Difficile Colitis: Metronidazole is the preferred initial treatment 500 mg p.o. or IV qid for 10-14

days. If infection is recurrent or there is no response, treat with Vancomycin 125 mg p.o. qid for 10-14 days.

10. POTASSIUM REPLACEMENT IN TRAUMA

(ICU patients only)

< 2.0 CRITICAL 40 mEq KCI In 100 ml D5W over 60 minutes and notify MD of value2.1-3.0 40 mEq KCI In 100 ml D5W over 60 minutes 3.1-3.5 30 mEq KCI In 100 ml D5W over 60 minutes 3.6-4.0 20 mEq KCI In 50 ml D5W over 60 minutes > 5.0 D/C all KCI in IV's and notify MD of value

4.0 to 5.0 Is the desired potassium range. If replacement is required, recheck serum potassium 30 minutes after infusion completed. Repeat potassium administration if level is still low after rechecking. Once potassium is 4.0-4.9, recheck in six hours. 11. Sitter services will be utilized for the following reasons:

Suicidal patients/homicidal Patients requiring seclusion

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Level 4 head Injury patients 12. Paralytic Agents

Drug

Adult Intubation

Dose (Use IBW*)

Continuous infusion for mechanical ventilation

(Use IBW *)

Onset

Duration

Half-Life

Comments

Short Acting Succinylcholine 200 mg/10 ml vial

0.6-1 mg/kg

NA

0.5-1.5

min.

4-8 min.

1 min.

Hyperkalemia, bradycardia, hypotension, arrhythmias, malignant hyperthermia, histamine-release, use caution in thermal injury (↑↑K+)

Intermediate Acting Benzyl isoquinolinium

Agents

Atracurium

100 mg/10 ml vial

0.3-0.5 mg/kg

5-15

mcg/kg/min

2-3 min.

20-45 min.

20

min.

Moderate histamine-release. Minimal hepatic/renal clearance. Preferred agent for continuous paralysis agent in the ICU.

Cisatracurium

20 mg/10 ml vial

0.1 - 0.2 mg/kg

0.5-10

mcg/kg/min

2-3 min.

40-60 min.

22-29 min.

Minimal histamine release. Minimal hepatic/renal clearance

Amino steroidal Agents Rocuronium

50 mg/5 ml vial 0.6-1.2 mg/kg

NA 1-1.5 min.

31-67 min.

60-70 min.

Not for continuous infusion. Minimal histamine release.

Vecuronium

10 mg vial

(reconstitute with 10 ml to yield 1 mg/ml)

0.08-0.1 mg/kg

0.8-1.7

mcg/kg/min

2-3 min.

20-40 min.

51-80 min.

Prolonged blockade in patients with renal or hepatic dysfunction, alternative to atracurium if tolerance develops. Minimal histamine release.

13. Percutaneous Tracheostomy in the ICU

Relative contraindications: obese patients, unstable C-Spines, Halos Attending must be scrubbed and assisting in the neck Senior Resident or Attending (someone capable of handling the airway easily) at the head doing the bronchoscopy Video bronchoscope only Nurses have a setup list which can be requested.

44

Trauma/ICU: Change Nasal ETT to Oral ETT

Trauma Team decision to change

NETT to OETT with Anesthesia

NETT – Nasal ETT OETT – Oral ETT

45

YES, Airway Problems Anticipated

NO Airway Problems Anticipated

Trauma Chief or Attending to contact

Anesthesia Main Float at ext. 8576

Trauma Chief or Attending contacts Surgery at

ext.3111 to add ETT change to waiting list

ICU patient to OR for ETT

change...Surgical Team available

Patient transferred back to ICU

Anesthesia Evaluation &

Documentation

Reintubation/ETT change completed in

ICU

Obtain specimen with the Combi cath using the mini-BAL technique* and send for gram stain and quantitative culture. Do NOT send routine sputum cultures, or send >1 specimen in 48hrs.

Start empiric antimicrobial therapy**

BAL results ≥ 1 x 10(4) CFU/ml BAL results < 1 x 10(4) CFU/ml

Continue empiric antibiotics Discontinue empiric antibiotics

At day three of antibiotics Narrow spectrum based on culture and sensitivity results

If signs and symptoms of infection persist, consider other sources

SUSPECTED VENTILATOR ASSOCIATED PNEUMONIA

Evaluate need for continued antibiotic therapy at 7 days

*Mini BAL Technique

To be performed by Respiratory Therapist Aseptic precautions: cap, mask, glove Insert 13F Combi cath until resistance is met Pull set back 3-4 cm Advance inner catheter expelling plug Inject 20ml saline; draw 1-3ml of specimen Remove the set and transport to laboratory, label “BAL specimen” Quantitative Culture: threshold of infection ≥ 104 cfu/ml In addition to quantitative culture, a gram stain should be obtained A gram stain showing > 25 epithelial cells/HPF is considered contaminated

** Empiric Antimicrobial therapy

• Post trauma day ≤ 2d Ceftriaxone • Post trauma day >2d Zosyn/Tobramycin – Note dose of Zosyn for empiric treatment of nosocomial

pneumonia is Zosyn 4.5 gm IV Q 6 hr. Or Zosyn/Aztreonam (age >55 years, diabetic, renal insufficiency)

• If PTD > 7 days consider Zyvox for MRSA coverage.

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14. Classification of Pressure Ulcers by Grade

Grade 1 Non-blanchable erythema of intact skin. Discoloration, warmth, induration, or hardness of skin may also be used as indicators, particularly in people with darker skin.

Grade 2 Partial-thickness skin loss, involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister.

Grade 3 Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.

Grade 4 Extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures, with or without full-thickness skin loss.

NUTRITIONAL SUPPORT IN TRAUMA Nutritional support should be started within 24 hours of admission on all patients (once the patient is fully resuscitated).

1. Requirements a. Total calories 25-30 kcal/by body weight/day. Harrison-Benedict equation

(Males) BEE = 66 + (13.7 x wt [kg]) + (5 x ht [cm]) – (6.8 x age [yr]) (Females) BEE = 655 + (9.6 x wt [kg]) + (1.7 x ht [cm]) – (4.7 x age [yr])

b. Protein 1-2 g/kg/d c. Non-protein calories (NPC)

(1) Ratio 80-120 NPC/g N2 in hi-stress 110-130 NPC/g N2 moderate

(2) Carbohydrate 75-100 g/d. Excess leads to fatty liver, ↑CO2 production, hyperosmolarity, hyperglycemia

(3) Lipid 1-1.5 g/kg/day 2. Enteral Feeding

a. If the patient is fully resuscitated (normal lactate and base deficit), enteral nutrition may be initiated. Cor-pac intestinal feeding tubes can be placed in the OR (available in Room 1) or fluoroscopically or endoscopically in the ICU. Tubes should be placed in the duodenum and advanced as far distally as possible. (1) Blind technique – Give 20 mg Reglan I.V., Wait 20 minutes, insert feeding tube, inject 500-

1000 ml air, put patient in right lateral decubitus position x 2 hours, check KUB. (2) The Corgard System using the GPS is available in the ICU.

b. Feedings may be begun with full-strength Traumacal® in most patients, but in patients with recent laparotomy, major pelvic fracture, or spinal cord injury, it may be advisable to start with peptide formulas. Once they have improved GI function (+BM), they can be progressed to intact feedings. Patients with high injury severity scores (ISS > 15) may benefit from magic formulas with supplemental Omega-3 fatty acids and increased branched chain amino acids.

3. TPN

The standard order forms for TPN are appropriate for most trauma patients and TPN should be used to supplement patients who are not yet tolerating full enteral caloric intake.

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4. Assessment a. Indirect calorimetry is routinely performed on post-trauma day #3 in the Intensive Care Unit,

which is at the peak of hypermetabolism. Subsequent adjustments in caloric needs should be reassessed as metabolic status changes.

b. Nitrogen balance = Nin – Nout Nin = protein intake x 0.16 Nout = UUN 24 hour + 3-6 (injury, stress, losses)

c. Visceral proteins: albumin, transferrin, retinol binding protein, thyroxine binding globulin prealbumin.

Peiltzman, AB, Rhodes, M, Schwab, CW, Yealy, DM, Fabian, TC: Nutrition/metabolism in the trauma patient. The Trauma Manual. Philadelphia: Lippincott Williams * Wilkins, pp. 420-427, 2002.

Canadian Clinical Practice Guidelines Summary of Topics and Recommendations 1. Enteral Nutrition

vs. Parenteral Nutrition

Does enteral nutrition compared to parenteral nutrition result in better outcomes in the critically ill adult patient?

When considering nutritional support for critically ill patients, we strongly recommend the use of enteral nutrition over parenteral nutrition.

2. Early vs. delayed nutrient intake

Does early enteral nutrition compared to late enteral nutrition result in better outcomes in the critically ill adult patient?

We recommend early enteral nutrition (within 24-48 hours following admission to ICU) in critically ill patients.

3.1 Dose on EN: Use of indirect calorimetry vs. predictive equation for EN

Does the use of indirect calorimetry vs. a predictive equation for determining energy needs result in better outcomes in the critically ill adult patient?

There are insufficient data to make a recommendation on the use of indirect calorimetry vs. predictive equations for determining energy needs for enteral nutrition in critically ill patients.

3.2 Dose of EN: Achieving target dose of EN

Does achieving target dose of enteral nutrition result in better outcomes in the critically ill adult patient?

When initiating enteral nutrition in head injured patients, strategies to optimize delivery of nutrients (starting at target rate, higher threshold of gastric residual volumes and use of small bowel feedings) should be considered.

4.1

Composition of EN: Immune enhancing diets: Diets supplemented with arginine and other select nutrients

Compared to standard enteral feeds, do diets supplemented with arginine and other select nutrients result in improved clinical outcomes in the critically ill adult patient?

We recommend that diets supplemented with arginine and other select nutrients not be used for critically ill patients.

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4.2

Composition of EN: Immune enhancing diets: fish oils

Does the use of an enteral formula with fish oils, borage oils, and antioxidants result in improved clinical outcomes in the critically ill adult patient?

We recommend the use of enteral formula with fish oils, borage oils and antioxidants in patients with acute respiratory distress syndrome (ARDS).

4.3

Composition of EN: Immune enhancing

Compared to standard care, does glutamine-supplemented EN result in improved clinical outcomes in the critically ill adult patient?

Enteral glutamine should be considered in burn and trauma patients.

5.1 Strategies to optimize delivery and minimize risks of EN: feeding protocols

Does the use of a feeding protocol result in better outcomes in the critically ill adult patient.

If a feeding protocol is to be used, based on 1 level 2 study, a protocol that incorporates prokinetics (Erythromycin 250 mg qid) at initiation and tolerates a higher gastric residual volume (250 mls) should be considered as a strategy to optimize delivery of enteral nutrition in critically ill adult patients.

5.2 Strategies to optimize delivery and minimize risks of EN: Motility agents

Compared to standard practice (placebo), does the routine use of motility agents result in better clinical outcomes in the critically ill adult patient?

Critically ill patients who experience feed intolerance (high gastric residuals, emesis), the use of erythromycin as a motility agent should be considered.

5.3 Strategies to optimize delivery and minimize risks of EN: Small bowel feeding

Does enteral feeding via the small bowel compared to gastric feeding result in better outcomes in the critically ill adult patient?

We recommend the routine use of small bowel feedings.

VENTILATOR TREATMENT AND WEANING PROTOCOL

1. Patients requiring mechanical ventilation (by any mode) will be ventilated to achieve the following parameters:

a. Decreasing PEEP and FiO2 as early as possible given oxygenation guidelines below. b. Limiting ventilation volumes to no greater than 6 + 2 ml/kg predicted body weight as much

as possible. c. Limiting peak pressures to < 30 cm H2O whenever possible. d. Avoiding the use of muscle relaxants, except when specifically indicated. e. Attempting to wean on an ongoing basis, at least once daily when weaning criteria are met.

2. Mechanical ventilation protocol Requirement for ventilation treatment will be assessed each day between 0600 and 1000. If any procedure/test, or other extenuating circumstance prevents assessment for these criteria between 0600 and 1000, then the assessment may be delayed for up to six hours.

Patients requiring mechanical ventilation will be ventilated according to the following within 24 hours after meeting trial inclusion:

a. Vt set at 6mL/kg +/- 2 ml/kg predicted body weight (PBW) calculated as follows: For males: PBW (kg) = 50 + 2.3 [height (inches) – 60] = 50 + .91 (height (cm) – 152.4)

49

50

For females: PBW (kg) = 45.5 + 2.3 [height (inches) – 60] = 45.5 +.91 (height (cm) – 152.4) (Calculator available in epocrates)

b. PaO2 55-80 mm Hg or SpO2 88%-95%. Percent O2/PEEP ration to be = 5 +/-1. (i.e. patient with FiO2 50%and PEEP 12 cm H2O and PEEP must be <35 cm H2O if using a ventilator mode with PEEP).

c. Keep pH 7.25-7.45 using respiratory rate (RR) < 35 and PaCO2 > 25. HCO3 – infusion may be given at the discretion of the bedside physician. If pH less than or equal to 7.15 then Vt may be increased by 1 mL/kg tachieve pH>7.15 and target plateau pressures (see below) may be exceeded.

d. Keep plateau pressures (PP) less than or equal to 30 cm H2O if necessary by reducing Vt to no less than 4 mL/kg. If Vt<6 mL/kg and PP <25 then increase Vt until PP= 25-30 or Vt=6 mL/kg.

3. Commencement of Weaning Weaning readiness will be assessed each day between 0600 and 1000. If a patient procedure, test, or other extenuating circumstance prevents assessment for these criteria between 0600 and 1000, then the assessment and initiation of subsequent weaning procedures may be delayed for up to six hours. The patient is ready for a spontaneous breathing trial if all of the following apply:

• FiO2<0.40. • Ventilator support at minimal levels (PEEP or CPAP < 10 cm H2O, if using a ventilator mode

with PEEP). • No neuromuscular blockade. • Without anatomical lesions that preclude the ability to ventilate (e.g., spinal cord lesions, flail

chest, abdominal hypertension). • Patient exhibiting inspiratory efforts. If no efforts are evident at baseline, ventilator mandatory

rate will be decreased to 50% of baseline level for up to 5 minutes to detect inspiratory efforts. • Systolic arterial pressure > 90 mm Hg without vasopressor support (< 5 mcg/kg/min dopamine

or dobutamine will not be considered a vasopressor). 4. Spontaneous Breathing Trial Initiate a trial of 30-120 minutes of spontaneous breathing with FiO2< 0.5 using any of the following approaches:

• T-piece or tracheostomy mask • Pressure support < 10 cm H2O without mandatory ventilation • CPAP < 10 cm H2O without mandatory ventilation

Monitor for intolerance using the following. If the patient meets any of the 3 criteria, they are considered intolerant of weaning and must be placed back on ventilatory support to be re-evaluated the next morning at the latest. Repeated earlier trials are acceptable.

a. Sp2O < 90% or Pa2O < 60 mmHg. b. Respiratory rate > 35/min. c. Respiratory distress (defined as marked use of accessory muscles or paradoxical breathing).

5. Decision to Remove Ventilatory Support For intubated patients, if no intolerance criteria for spontaneous breathing are met for at least 30 minutes, the clinical team should discontinue assisted breathing. However, the spontaneous breathing trial can continue for up to 120 minutes if tolerance remains in question. If any of the criteria 1-3 above are met during unassisted breathing, then the ventilator settings that were in use before the attempt to wean will be restored and adjusted for comfort and the patient will be reassessed for weaning the following day. Unassisted breathing is defined as tracheostomy collar, t-piece, extubated on room air or oxygen. Any amount of pressure support or tidal volume support regardless of method of delivery (e.g. non-invasive mask ventilation or endotracheal intubation) will be considered to be assisted ventilation. 6. Readiness for Extubation The following criteria should be assessed to determine readiness for extubation:

• Does not require suctioning more than every 4 hours.

• Good spontaneous cough. • Lack of upper airway obstruction, as evidenced by a leak around the endotracheal tube with the

cuff deflated.

FLOWCHART FOR MANAGEMENT OF NARCOTIC WITHDRAWAL

1. Assessment Findings for Patients at Risk

for Withdrawal: a. History of abuse or dependence b. High Index of Suspicion: positive urine drug

screen (UDS), track marks

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2. If not already done, obtain: a. UDS b. Behavioral Assessment Tram (BAT) consult (Ext 6387) for:

i. Withdrawal management recommendations ii. Community referrals iii. If pregnant or with severe cardiovascular or respiratory disease,

consultation with a certified addictionologist is recommended.

3. Acute withdrawal from narcotics is not life threatening. Treatment is aimed at managing the symptoms as they occur. (I)

Narcotic withdrawal symptoms: • Dilated pupils • Excessive sweating • Yawning • Sneezing • Anxiety • Twitching and kicking movements, muscle cramps • Tremors • Gooseflesh • Fever and chills alternating with flushing • Overall weakness and muscle aches • Anorexia, nausea, and vomiting • Diarrhea abdominal cramping

4. Guidelines for Managing Narcotic Withdrawal Symptoms: Medication suggestions: Catapres TTS® 1, 2 or 3 patch (clonidine) – apply the patch to counteract sympathetic hyperactivity associate with narcotic withdrawal. The side of the patch depends on amount of narcotic used, age and blood pressure. The patch is changed every 7-10 days. (Caution – use of the patch can cause orthostatic hypotension) Paregoric® 5-10ml po four times daily as needed for diarrhea and/or other early significant withdrawal symptoms. Continue only for the first 2 days of symptomatic withdrawal. Dicyclomine (Bentyl®) 10-20 mg po four times daily as needed for abdominal cramping Methocarbamol (Robaxin®) 750-1500 mg po four times daily as needed for muscle aches Lorazepam (Ativan®) 1-2 mg po/IM/IV every four hours as need for anxiety Trimethobenzamide (Tigan®) 250 mg po 3 or 4 times daily as needed for nausea and vomiting

(I)

SAMPLE A 43 year old African American female admitted to the hospital with pneumonia. Within hours of admission, the patient specifically request Vicodin® for complaints of leg pain do to an old injury. History and physical reveals that the patient was prescribed pain medication in January 1996 following a car accident. She has been using Vicodin since that time and reports that she is currently taking 8-10 tablets each day. Within 24 hours of admission, the patient complains of abdominal cramping, nausea, and muscle aches. Further history reveals she has also used Darvon® for leg pain in addition to the Vicodin. Her current use of the Darvon ranges from 10-12 capsules each day. The nurse caring for her notes that she is increasingly anxious, diaphoretic, and her pupils are dilated. Her blood pressure is stable at 140/80 and pulse is 94 beats per minute. Use the guidelines to assist in her management. ANSWER: Catapres TTS-2 patch – apply one patch and leave on 7-10 days. Paregoric 5-10ml po now and up to four times daily as needed. Continue only for the first two days of symptomatic withdrawal Dicyclomine 10-20mg po now and up to 4 times daily as need for abdominal cramping Methocarbamol 750-1500mg now and up to 4 times daily as needed for muscle aches Lorazepam 1 mg po now and every 4 hours as needed for anxiety.

FLOWCHART FOR BENZODIAZEPINE WITHDRAWAL

(I)

(II)

52

2. If not already done, obtain: a. MVH UDS b. Behavioral Assessment Team (BAT)

consult (ext. 6287) for: 1. Detoxification recommendations 2. Community referrals

3. Symptoms of acute withdrawal from benzodiazepines (I)

Benzodiazepine Withdrawal Symptoms: Inability to concentrate Insomnia Nervousness, anxiety, agitation Diarrhea Muscle aches Memory loss Seizures

4. Guidelines for managing benzodiazepine withdrawal: a. Determine amount of substance used b. Select a long acting agent to assist in

the management of withdrawal (diazepam, lorazepam, or chlordiazepoxide are good alternatives*)

c. Estimate an equivalent amount of the chosen agent from the CNS Depressant Conversion table (II)

d. Administer the agent in divided doses throughout the day

e. Decrease or taper the dose by approximately 10% per day

f. For breakthrough symptoms, include an order for dosing on an “as needed” basis, as well (see SAMPLE below)

*whenever possible, choose a benzodiazepine other than the substance used by the patient

CNS DEPRESSANTS CONVERSION TABLE

SAMPLE: A 34-year old while female was admitted after a motor vehicle accident. Her injuries included right rib fractures, an ulna fracture, a femur fracture, and multiple facial lacerations. Later that evening, the nurse caring for her mentions that she is extremely anxious, agitated and is trying to get out of bed. Her UDS was positive for benzodiazepines. Upon obtaining her history, you discover that she takes 4mg of Xanax® (alprazolam) per day and has done so for the past 12 months. The drug was originally prescribed at a dose of 0.5 mg three times daily for anxiety. Use the guidelines for Benzodiazepine Withdrawal to assist in her management. ANSWER: 4mg alprazolam is approximately equivalent to 40mg diazepam (using 0.5mg alprazolam = 5mg

The following substances and respective dosages are approximate equivalents of 5mg of diazepam (half-life 36 hrs): Substance Trade name Dose (mg) half life (hrs) Chlordiazepoxide Librium 25 8-28 Phenobarbital Solfoton 30 53-140 Lorazepam Ativan 1 10-20 Alprazolam Xanax 0.25-0.5 12-15 Triazolam Halcion 0.5 1.7-3 Temazepam Restoril 15 10 Oxazepam Serax 30 5-15 Flurazepam Dalmane 15 40-114 Clorazepate Tranxene 3.75 30-200

1. Assessment Findings for Patients at Risk for Withdrawal: a. History of abuse or dependence b. High index of suspicion: positive urine drug screen (UDS) for benzodiazepines

Flowchart for Alcohol Screening and brief intervention for the Trauma Service Patient (ASBI)

53

BAL >= 80mg/dl (.08mg/ml)

Within the last 3 months, have you had more than X drinks in 1 day? (X=5 for men; X=4 for women) POSITIVE if answer is YES

NO=no further intervention

Meets criteria for Alcohol Detoxification Protocol BAT consult x 6387

Follow Alcohol Detoxification Guidelines (p. 95 Red Book)

Automatic referral to Turning Point per standing order.

Referral to Turning Point/Outpatient Psych Staff for Brief Evaluation AND Intervention

ALL Trauma consult admissions with no BAL drawn→Turning Point to screen with binge drinking question

-On the spot counseling-feedback and information on current situation -Enhancing motivation -Educational Brochure -Referral to AA -Referral to Dr. Simkari -Outpatient follow-up -Referral to Turning Point

ALL Trauma Alert Patient admissions- BAL Screen to be done with Trauma labs

FLOWCHART FOR ALCOHOL DETOXIFICATION XXIII. (I) XXIV. (III)

1. Assessment findings for patients at risk for alcohol withdrawal:

a. History of abuse, dependence or delirium tremens (DTs) b. High index of suspicion: blood alcohol level (BAL), elevated

liver enzymes, elevated mean corpuscular volume (MCV) c. Positive physical findings: jaundice, hepatomegaly, DTs,

seizures d. 2 or more positive answers to CAGE questions (I)

CAGE Questionnaire: a. Cut down on your drinking?

(I)

b. Annoyed by criticism of your drinking?

c. Guilty feeling about your drinking

2. If not already done< obtain: a. BAL b. Urine Drug Screen (UDS) c. Serum magnesium (Mg) level d. Chem 20 e. CBC f. Behavioral Assessment Team (BAT) ext. 6387

consult for: 1. Alcohol detoxification recommendations 2. Community referrals

(III) Mg Level 1.1-1.3mg/dl: Slow Mag 2 tablets po TID x 3days

Slow Mag 2 tablets po TID x 3 days If can’t take oral: magnesium oxide 400mg tablet crushed per enteral tube BID x 3 days

OR Magnesium sulfate 1 gram IM/IV x 1 dose

1.0mg/dl: Magnesium sulfate IM/IV x 1 dose <1.0mg/dl: Magnesium sulfate 4 grams/250 ml IV x 1 dose (infuse over 4 hours) Follow up Mg level

(II) CIWA-Ar Assessment Evaluates on a Likert scale the following 10 dimensions: maximum score = 67

Points 1. Nausea/Vomiting (N/V) 0-7 2. Tremors 0-7 3. Sweats 0-7 4. Anxiety 0-7 5. Agitation 0-7 6. Tactile Disturbances 0-7 7. Auditory Disturbances 0-7 8. Visual Disturbances 0-7 9. Headache 0-7 10. Orientation 0-4

3. For symptomatic alcohol withdrawal: a. Initiate CIWA-Ar assessment and reassess every

1-4 hours as indicated by patient condition. CIWA scores rise as alcohol withdrawal progresses (II)

b. Initiate the following medication: Thiamine 100mg po/IM/IV QD x 3 days MVI po/IV QD x 3 days Folic acid 1mg po/IM/IV QD x 3days Mg supplementation if needed (III)

c. The use of benzodiazepines to provide safe detoxification is generally considered with CIWA-Ar scores approaching 10 or greater.

(iv) 4. Sedation for a given CIWA-Ar Score (administer every 1-4 hours as indicated by patient condition): 0-6: No medication 7-10: 5-10mg Diazepam po/IV OR 1-2 mg Lorazepam po/IM/IV 11-15: 10-15mg Diazepam po/IV OR 2-3 mg Lorazepam po/IM/IV 16-20: 15-20 mg Diazepam po/IM/IV Over 20: 20mg Diazepam po/ir IV OR 4 mg Lorazepam po/IM/IV iv

5. If the patient is psychotic or combative add: Haloperidol 2-4 mg po/IM/IV Q 1-2 hours as needed (not to exceed 20mg over 24 hours) For doses above 10mg over 24 hours, add Benztropine (CongentinR) 2mg po/IM BID

(IV) For Patients presenting with CIWA-Ar Scores in excess of 20, consider “loading” as follows until lightly sedated: Lorazapam 1-5mg IM/IV (2mg/min) Q15

OR Diazepam 5-10 mg IV (5mg/min) Q 1 hour

54

G.SPINAL CORD INJURY

a. DO • Be suspicious. Ask every trauma patient about neck and back pain. • Record the patient's ability to move extremities and motor strength. • CT of the appropriate area of the spine should be obtained with great care. • Inquire about difficulty with voiding and check for urinary retention. Do a rectal exam.

Check perineal sensation. • All blunt trauma patients with impaired mental status or distracting injuries should have T

and L spines at some point. Log roll until obtained. • For blunt spinal cord injury, Methylprednisolone steroid therapy should be initiated as soon

as possible (within 8 hours of injury). The initial bolus dose is 30 mg/kg intravenously over 15 minutes, followed by 5.4 mg/kg/hour IV infusion for 24 or 48 hours (24 hours if bolus ≤ 3 hours of injury, 48 hours if the bolus 3 - 8 hours after injury). Call the pharmacy for "Spinal Cord Protocol" with the patient's weight and time of injury.

• Steroid therapy is not indicated or appropriate for penetrating cord injury. • Consult Enterostomal Therapy for skin care recommendations early in patient's care. • Order a STAT MRI and make the appropriate contact for consultation in patients with

neurologic deficits but negative CT. • Progression of neurologic deficits is an EMERGENCY.

a. DON’T

• Do not allow the patient to be moved unnecessarily. Be sure that all moves are done with four or five people to help in transfer.

• Do not overload the patient with IV fluids in an attempt to treat spinal shock. Use Neo-Synephrine or Dopamine. Monitor CVP or PCWP.

H. SOFT TISSUE 1. Fresh wounds should be irrigated with sterile saline. Iodine preparations may be used to wash

surrounding areas, but generally are not used in open wounds. 2. Do not shave eyebrows. 3. Do not use Xylocaine with Epinephrine in fingers, toes, or structures with compromised vascular

supply. 4. Always wear a mask when suturing. 5. Guidelines for antitetanus treatment of patient with open wounds.

Guide to tetanus prophylaxis in routine wound management among adults aged 19-64 years: Characteristic Clean, minor wound All other Wounds1 History of absorbed tetanus toxoid (doses)

Tdap or Td2 TIG Tdap or Td2 TIG

Unknown or < 3 Yes No Yes Yes > 3 No3 No No4 No

1Such as, but not limited to, wounds contaminated with dirt, feces, soil, and saliva: and wounds resulting from missiles, crushing, burns, and frostbite.

2Tdap is preferred to Td for adults who have never received Tdap. Tdap is preferred to TT for adults who received Tdap previously or when Tdap is not available. If TT and TIG are both used, Tetanus Toxoid Absorbed rather than tetanus toxoid for booster use only (fluid vaccine) should be used.

3Yes, if > 10 years since the last tetanus toxoid-containing vaccine dose.

55

4Yes, if > 5 years since the last tetanus-toxoid containing vaccine dose.

Td=tetanus and diphtheria toxoids, adult type; This reimmunization with d is NEW TIG=tetanus immune globulin

6. Sutures should be removed: Scalp: 7 days Face: 3-5 days (and Steri-Strip) Extremities: 10-21 days (depending upon mobility of site) Trunk: 7 days

I. X-RAY

1. Never send patient who is unstable to X-ray unaccompanied. 2. Be alert to pregnancy before sending females to x-ray. Ask about possible pregnancy and last

menstrual period. 3. Significant head injuries such as motor vehicle crashes, falling timber and all obtunded and

unconscious patients should have cervical spine CT scans performed when going for head CT. 4. X-ray fracture sites plus distal and proximal joints on all orthopedic injuries. If a hip injury is

suspected, order an AP of the pelvis, too. 5. Err on the side of ordering too many x-rays rather than too few in MVC and unconscious patients. 6. Order comparative extremity films on the uninvolved side in pediatric patients if there is a question

on the initial film. 7. Just because you can walk on it doesn't mean it's not broken. 8. The number of x-rays done in the trauma room should be inversely proportional to how sick the

patient is. 9. Lower extremity angiography in OR

-non contrast film of area -control vessel proximally -inject 20-30 ml of full strength contrast media -repeat x-ray at end of injection in upper thigh -two second delay at knee -five seconds in calf Exam result is limited to flow or no flow. Not reliable for AVF, false aneurysms, intimal injuries. Vasospasm is often present and findings maybe nonspecific. Go to angiography and repeat the exam if warranted.

10. Metformin and CT Scans Post procedure recommendations -The patient should be well hydrated to mitigate contrast nephrotoxicity. -Metformin should be stopped, and then withheld for 48 hours after the contrast administration. -Renal function should be closely monitored. -Metformin should not be restarted until after renal function has been re-evaluated and found to be normal.

11. Justification for Emergency MRI Emergency MRI at Miami Valley Hospital is available 24 hours a day. There are two levels of emergency studies: Level 1 and Level 2. a. Level 1 emergencies will be accommodated within a one hour response time. The technician will

be available to put the patient on the MRI exam table within one hour of approval of the exam. During the day, these exams will bump previously scheduled patients out of their time slots. After hours, the on call technician will have to be called in to do the study.

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57

Level One C-Spine/T Spine

• Any case of spinal cord compression. This does not include simple radiculopathy. Progression of neurologic deficits

Lumbar Spine • Cauda equina syndrome, where bowel and/or bladder function is lost. • Inability to move lower extremities, whether due to abcess, hematoma or large

recurrent disc. • Simple radiculopathy does not constitute an emergency. CT can be done for disc

pathology emergently in the virgin back. Brain MRI/MRA

• Acute 3rd nerve palsy where an aneurysm is suspected. • All other indications for emergency cerebral imaging can be handled by CT.

Thoracic Aorta • The evaluation of dissecting aortic aneurysms.

b. Level 2 emergencies will be done at 6:00 am the following morning by the technician on call if there are no open slots the next day. Level 2

Brain and Orbits All other cases which do not fall under the above guidelines, in which the Clinician has asked that the study be done STAT.

Spine • As above. Intractable back or neck pain, etc.

For requests obtained during the day, the MRI radiologist will decide what level the request falls under, and therefore the priority it has in being done. After hours, the general radiologist on call will make this decision. Physician to physician contact is needed to change this priority. Miami Valley Hospital Medical Imaging Department Flexion/Extension C-Spine Policy/Procedure Purpose: To determine correct procedure to follow for a flexion-extension c-spine ordered on patients.

Negative cervical spine radiography does not exclude ligamentous disruption or cervical instability. Stress views are required to confirm integrity of the spine in a certain subgroup of patients.

Policy: All technologists in Medical Imaging, including Special Procedure technologists, that receive a request to do a flexion-extension cervical spine exam on a patient, should perform the procedure if the following checklist is completed: Order in chart to remove hard collar (no order required to remove soft collar). (If there is not

an order to remove the hard collar, please call the Trauma Nurse, wireless phone# 6822 to obtain a verbal order per Dr. Mary McCarthy.)

Patient is alert, oriented and neurologically intact with pain at rest, with movement or during a physical exam.

There are two classes of patients that require these views: A. Protocol group 1 Patients: Neurologically intact, alert and oriented patients with neck pain

either at rest, with movement, or during physical exam. Protocol Group 2 Patients: Obtunded or comatose patients where physical exam is limited.

(Prolonged immobilization with cervical collars in this group of patients causes significant problems with hygiene, skin maceration, and decubitus ulcers as well as problems with incomplete immobilization. Early removal of collars will improve patient management, especially in patients requiring tracheotomy or surgical procedures.)

Procedure Protocol Group 1 Patients Perform the exam ONLY if the following criteria are present A. Order must be in patient’s chart to remove the hard collar and to perform flexion/extension

cervical spine views. (Technologists may remove soft collars without an order as these are for patient comfort only.)

*It is common for the patient to remain in the hard collar without a physician present for Group 1 Patients.

B. Patients must be neurologically intact, alert and oriented: a. Patient knows name, place and follows commands b. Patient is able to move all four extremities (i.e., clench fists, wiggle toes).

C. Patient must have bony clearance of the cervical spine from CT scan. (Bony clearance does not necessarily mean a negative CT scan. For example: A patient may have a fracture deemed to be stable by CT or a subluxation likely not related to trauma and can still have flexion/extension views obtained to further evaluate the cervical spine.)

D. Procedure must be performed with the patient in the ERECT position. The weight of the head is required to appropriately flex and extend the neck to properly evaluate the cervical ligamentous.

a. Technologist will remove hard collar from the patient. b. Patient should flex or extend only to their ability. c. Perform flexion and extension radiographs. (True lateral film is not necessary.) d. Technologist to replace hard collar upon completion of the exam.

Protocol Group 2 Patients Perform the exam Only if the following criteria are met A. Flexion/extension views in these patients require fluoroscopy, which is scheduled in

Medical Imaging through Special Procedures as a first shift weekday or Saturday a.m. exam.

B. A Radiologist and Trauma Team Physician, PA or Trauma Nurse should be in attendance. C. Patient must have a bony clearance of the cervical spine from CT scan. (Bony clearance

does not necessarily mean a negative CT scan. For example: a patient may have a fracture deemed to be stable by CT or a subluxation likely not related to trauma and can still have flexion/extension views obtained to further evaluate the cervical spine.)

D. With a physician maintaining in-line cervical stabilization, the patient is moved up on the backboard or table until the shoulders are just above the end of the board or table.

E. Under C-arm fluoroscopy, the cervical spine is taken through a full range of motion, starting with extension then proceeding to flexion. Permanent films are taken at the full extent of both flexion and extension.

F. Soft restraints may be fixed tightly to each wrist for arm traction. G. Bilateral 45-degree oblique images are obtained as needed to adequately visualize the

cervico-thoracic junction.

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J. PELVIS Trauma Pelvic Orthotic Device (TPOD) Guidelines for Usage – http://www.t-pod.com/instructions.html

Indications: Initial emergency stabilization of pelvic fractures to help prevent blood loss during initial resuscitation and aid in pain control. The TPOD is a temporizing measure until definitive treatment can be accomplished.

The Device: 2 parts – fabric wrap and plastic/Velcro “power unit” (the pulley). Stocked: TPOD is stocked in the ETC Central Supply area. Application: TPOD should be placed by an orthopedic or trauma surgeon. Wrap fabric around the supine patient (tag

inside). The orthopedic or trauma surgeon should manually reduce and hold pelvic reduction in place. Fit the TPOD around the pelvis at the level of the greater trochanters (ideally the fabric should cover the buttocks) and then CUT the excess on both sides in the front to leave a gap of approximately 6-8 inches of exposed abdomen. Apply the Velcro components of the “power unit” so that they straddle the exposed abdomen and then set the tension of the “power unit” (pulley) to maintain the same level of reduction as with manual support or until pain relief – vital sign improvement. In male patients, make certain that the genitalia are elevated out of the groin. Person applying the TPOD should write on the devise, the date and time in which it was applied.

Radiographic Studies

The TPOD is radiolucent. If the groin must be accessed for angio or other purpose, the TPOD can be cut to accomplish that while still maintaining stabilization of the pelvis.

Duration of Placement/ Skin Integrity

This device is s temporizing measure. The orthopedic service ideally does not want to keep the device in place for > 12 hours. In those cases where the TPOD is on longer than 12 hours, skin integrity should be evaluated daily or more frequently if compromised skin integrity. Pelvic stabilization should be maintained during skin assessment and reapplication.

Nursing If the TPOD becomes dislodged:

Monitor pulse and BP q 15 min Contact the orthopedic resident or trauma resident

K. OBSTETRICAL

1. All major obstetrical trauma > 20 weeks is considered Category I. 2. ETC will notify Berry 2 (Labor and Delivery) Shift Manager of pregnant trauma admission(s) to the

ETC at ext. 2408. 3. Berry 2 Shift Manager will NOTIFY:

a. Chief OB resident to respond to ETC b. Appropriate Berry 2 nurse(s) to prepare for ETC response c. Berry staff to bring all necessary obstetrical equipment to the ETC (if needed) d. Nurse responding to ETC will notify NICU to respond to ETC with resuscitation equipment if

needed. 4. All major obstetrical trauma patients will be evaluated by the in-house obstetrical team. As soon as

practical, the private obstetrician will be notified. 5. If patient has significant trauma, she should be admitted to ICU with OB monitoring. If cleared by

trauma, the patient may be admitted to Berry to the OB service. L. CONSULTATIONS

1. An extremity injury which may need replantation should be referred to Hand Call (distal to elbow) or the Ortho Service as appropriate.

2. Major traumatic amputations should be seen by the Ortho Service. 3. Spinal fractures are referred to the Neurosurgeon or Orthopedic Surgeon on Spine Call. Spine

injuries at each level (C-, T-, and L-) should be referred to the first or second call, ensuring that the surgeon who will care for that patient takes care of that injury level. (see spine call guidelines on PHP site)

4. A maxillofacial trauma call schedule (Oral Surgery and Plastic Surgery) is available. Isolated soft tissue trauma will be handled by the Plastic Surgeon on call. Scalp reimplants should be performed by a plastic surgeon with microvascular experience.

5. Ophthalmology also has a trauma call schedule. Trauma and surgical cases seen by the residents in the ETC at MVH are treated as resident cases with the senior ophthalmology resident acting as the primary surgeon. If the first year ophthalmology resident is on call, they will call the senior ophthalmology resident to come and perform the surgery with the attending on call.

6. Consult the Hand Service for suspected navicular fractures. (Any patient with tenderness in the snuffbox.) Consider CT Scan

7. Compartment Syndromes: Be suspicious — you don't need an absent pulse or numbness. Check the pressure. Call the ortho tech if a compartment pressure monitor is needed.

8. Consultants called to the ER should complete a written/dictated note. This protects you — make sure it is done. Document the recommendations of the neurosurgeon on the Trauma H/P in the space provided. This is essential documentation for Level I verification.

9. Alert patients or family may request specialist consultation of their choice, even if that physician is not on call.

10. An avulsed tooth should be replaced within 30 minutes, therefore call dental resident on call or oral surgery promptly. Jars of "Save a Tooth" are available in the ETC for storage of avulsed teeth prior to reinsertion.

11. Consideration for consultation of thoracic surgery: 1) positive arch CT protocol or angiogram, 2) clotted hemothorax at 2 days, 3) empyema, 4) estimated blood loss after chest tube placement of greater than 1000 ml initial with ongoing bleeding, 5) air leak greater than 2 days, 6) second chest tube required for air or fluid evacuation, 7) suspected cardiac injury.

12. The most senior level resident available should talk with consultants and provide all necessary history and physical exam information

13. Trauma patients with isolated orthopedic injuries and no complicating medical issues may be directly admitted to the Orthopedic Trauma Service.

14. When Dr. Africk’s patients are discharged write an order “Discharge when OK with Dr. Africk.” If she has signed off, then she will indicate that in the chart.

15. Maxillofacial Trauma: Face Call a. For visualized or suspected maxillofacial injures:

The maxillofacial surgeon on call is responsible for treating and coordinating additional subspecialty care for all their patients. S/He should be called first, and will expect you to know the answer to the following questions: Mechanism of injury? Time of injury? General condition of patient and immediate plans (i.e. to O.R., ICU, etc.)? C – spine clearance? Results of Max-Face CT Scan

b. Non-emergent max-face calls after 9pm should be held until 6am. If Chief is unable to call, then the PA should do this.

16. When consulting ortho service, Consult ortho resident first for hand, spine, etc. 17. When consulting vascular surgery, call attending directly. 18. The Trauma Service does do inpatient consults for injured in-house patients. 19. Routine/non-emergent specialty consultation calls should be placed during regular business hours

(not after 9 pm). Some specialists take call a week at a time and are understandably upset when they are unnecessarily awakened late at night.

20. Neurosurgery wants to be called for all consults as soon as the consult is needed. Changeover is at 0700, so be sure and call well before this so they can plan their day.

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21. For inquiries relating to therapy consultation or treatment response times, please contact the Acute Therapy Administrative Assistant at extension 3078. An Acute Therapy Coordinator will contact the physician, unit-specific nurse manager, or ICM coordinator within 24 hours of receipt of the inquiry Monday through Friday.

22. Documentation regarding therapy services can be found in two Epic locations: a. Patient Summary section >> select “All Data Flowsheet Report” or >> select discipline specific

flowsheet report. b. Notes section >> scan “author type” for quick identification of therapy-specific authored notes. c. Please note that while the majority of the therapy notes are currently in the flowsheet format, a

Spring 2008 Epic upgrade will shift the preponderance of therapy information into a Notes section format.

23. Any trauma patient with multisystem injuries requiring inpatient admission should be admitted to the Trauma Service. “Multisystem” is defined as a patient requiring two different specialists, e.g. nasal fracture and ankle fracture.

24. Direct admission of patients from MVH South or inpatient to inpatient transfer of patients to the Trauma/EGS service must be paged or called directly to the Trauma Attending on-call. Should the Trauma Attending on-call not be immediately available, requests may be directed to the Trauma Chief Resident (ext. 7204). Those individuals should verbally approve this request for admission with the Trauma Attending on-call.

M. MOTOR VEHICLE LICENSES

Q: What is the procedure for reporting someone who should not drive because of age or because of medical, physical or vision problem? A: The Ohio Motor Vehicle laws allow the Registrar of Motor Vehicles to require an Ohio licensed driver to submit a medical statement and/or take a driver license examination upon receiving information giving “good cause to believe” that the driver is incompetent or otherwise incapable of safely operating a motor vehicle. The Ohio Administrative Code states that “good cause” is considered to be a request for recertification received from a law enforcement agency, court, physician, hospital, or rehabilitation facility. To take action on a request received from a law enforcement agency or court they require that the agency or court has had personal observation of the subject’s driving or personal contact with the driver. We cannot take action on the recertification request if it is based solely on the person’s age or hearsay.

The Bureau will also take action on a written and signed request submitted by a relative, friend, neighbor, etc. However, they are required to first conduct an investigation to determine if there is sufficient cause to require a medical statement and/or driver license examination. Again, age cannot be the only basis for the request. The letter writer must provide us with enough information so that they can locate a record of a valid Ohio driver license or temporary permit issued to the person.

Legally, they must inform the driver who is the subject of the investigation or recertification procedures of the source of information. Therefore, before an investigation or any other action is taken on a request received from a family member, neighbor, friend, or medical professional they must receive permission to use the letter writer’s name as the source of information. There is currently no law that requires a medical professional to report to the Bureau a patient who should not drive, nor is there any liability protection for the person that chooses to make a report. Any changes in our policies and procedures for reporting and recertifying unsafe drivers would necessitate the enactment of new laws by the Ohio Legislature.

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If someone would like to submit a written request to the Bureau to have a driver recertified for driving privileges, you may send or fax the letter to the Ohio Bureau of Motor Vehicles, Attention: Driver License Special Case Section/Medical Unit, P.O. Box 16784, Columbus, Ohio 43216-6784, fax number (614)752-7271, Attention Medical Unit. The letter should include a release allowing us to use the letter writer’s name as the source of information. The Ohio laws that govern driver license re-examination and medical recertification of a driver do not involve vehicle registration privileges or license plates. Therefore, registration privileges will not be affected even if driving privileges are denied. Ohio’s motor vehicle laws currently do not provide for mandatory retesting of elderly drivers, as it is considered discriminatory. All drivers, regardless of age, are only required to pass a vision screening prior to being issued a renewal driver license.

N. Trauma Unit Care Guidelines

Initial assessments including immunizations, medication reconciliation, and DVT screening will be completed on all patients within 24 hours of admission.

Patients and families will receive an orientation to the unit and the hospital and will receive an education folder.

Vital signs consisting of heart rate, rhythm, blood pressure, temperature, respiratory rate, oxygen saturation and pain level will be obtained every four hours or as needed with changes or follow up from abnormal reading.

Hourly checks will consist of position, activity, heart rate and rhythm, respiratory rate, and oxygen saturation for monitored patients.

Monitored patients will have an EKG strip mounted every eight hours and as needed with changes in rhythm.

A comprehensive assessment will be documented every four hours with updates as necessary. The physician may choose to have an assessment and vital signs completed every eight hours, but nurses

should complete this more frequently if the patient’s medical condition warrants it. Intake and output will be recorded on all patients. Patients with Foley catheters will have urine output documented every 1-2 hours. Non-vented patients will be encouraged to cough and deep breathe every hour while awake, along with

incentive-spirometer with proper education and reinforcement, whether an order has been written to do so or not.

Vented patients or patients with tracheostomies will have oral care provided per VAP protocol (shared responsibility between RN and PCT).

Ventilated patients are to be suctioned every two hours or as needed. Oral care for non-vented patients will be every eight hours and as needed. Patients will be repositioned every two hours unless contraindicated by condition. Independent patients will have position or activity documented every 1-2 hours (chair, side of bed, etc.). Sequential compression devices are to be worn at all times, when ordered, unless patient is actively

ambulating. Protective devices will be applied as necessary by RN for patient safety. The reasoning behind the

decision will be explained to patient and family and documented on restraint flow sheet per protocol. Ambu-bags will be available in all rooms. Suction set up will be present for all patients. PICC line dressings will be changed 24 hours after insertion and every Thursday thereafter (or in

accordance with MVH policy). All monitored patients traveling off the monitor will be accompanied by an RN unless the patient has a

specific order to do so. PCT will use “PCT Protocol” at the conclusion of each interaction with the patient and/or family. The call lights on the Trauma Unit will be answered using the “HUC Protocol” by any person that

answers the call, regardless of discipline.

Staff on the Trauma Unit will use locators at all times. Patients taking a diet (liquids or solids) should be out of bed for at least 2 meals of the day, as long as

there are no contraindications. Enteral pain medications are to be used before parenteral pain medications unless contraindicated.

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O. HYPOTHERMIA RESUSCITATION GUIDELINES ALL HYPOTHERMIC TRAUMA PATIENTS ARE CONSIDERED CATEGORY I

Victim Arrives/Assess for Appropriateness

Cardiac Monitor And

Core Temperature

Direct to OR Protocol

Notification of a) CT surgeon (TS) b) Perfusionist (OR) c) OR staff

Stat Lab Potassium, PT, PTT, Fibrinogen, FSP, and Routine

Trauma Lab

Core Temp <32˚C Core Temp >32˚C

(stable cardiac rhythms) conventional rewarming techniques (warmed gasses, Foley lavage, Inc.)

BP > 60 Systolic Non Arrested Rhythm (Junctional, Sinus Brady, Tachycardia), Decreased LOC

Arrested Rhythms (Asystole or Idioventricular Rhythm)

See Below See Below

Begin Level One continuous arterio- venus rewarming

Exclusion considered for Radiographic or clinical evidence of severe head injury or lethal injury

Change to arrested rhythm or BP < 60 To OR

Begin Fem-Fem Bypass with rapid rewarming

Stable vitals, Elevated core temperature Clinically Improving

Rewarm to 37°C Rewarm to 37°C

All patients should receive: 1. Glucose 1 AMP D50 2. Naloxone 1 AMP 3. Thiamine

Bretylium Tosylate IV for Ventricular fibrillation 5mg/kg IV push. Repeat in 5 min at 20 mg/kg.

Defibrillation usually ineffective Below temperatures 30°C.

IV fluids –warmed NS

If concern of frostbite exists, Burn Service should be consulted.

ER/ICU

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P. PAIN MANAGEMENT: APPROACHES IN TRAUMA Cathy Trame, MS, RN, CNS, BC; Townsend Smith, MD Pain in the trauma patient may result from a variety of injuries ranging from life-threatening to minor soft tissue injuries. It is known that the extent of tissue damage is not proportional to the amount of pain the person experiences. The experience of pain is most accurately measured by patient self-report with the use of a standardized scale. There is no neuro physical test to measure pain. Aggressive pain treatment should be initiated as soon as possible to prevent the development of chronic pain syndromes (shown to be linked to the degree of pain in the first 24 hours post-injury). Pain evokes a sympathetic nervous system response and triggers the following detrimental reactions: hyperglycemia, lipolysis, protein catabolism, elevated ADH and catecholamines, immunosuppression, and hypercoagulability. Resultant manifestations include HTN, tachycardia, DVT, pulmonary embolus, splinting, ventilation-perfusion mismatch, reduced GI motility, water and sodium retention, hypoxia, and increased risk of infections (Alexander et al., 2006; Pace et al., 2006; Campbell & Meyer, 2006). Management of pain should not interfere with neurological or neurovascular monitoring therefore choices may be limited for head-injured patients or peripheral injuries requiring sensory and motor evaluation. On the website listed below, one is able to reference a patient’s narcotic prescription history. The system gives data on the number and type of prescriptions obtained, who the prescribing practitioner was and which pharmacy filled the prescription. Access to the website is limited and can be gained by completing the on-line application form. The web address is http://www.ohiopmp.gov Pain is the 5th vital sign Good pain control in multiple injury trauma patients is an important facet of care. Patients are assessed regularly by the nurses and "pain level," as well as "pain goal," the maximum patients can tolerate, documented. The physician should also ask the patient about the adequacy of pain control on rounds. Initial pain control in patients who are NPO should be obtained with a PCA (use separate order sheet). • Moderate pain can be managed with Vicodin® or Percocet® 1-2 tabs p.o. every 4 hours. • Severe pain should be controlled with regional anesthesia if appropriate (epidural block) or with around-the-

clock long-acting opiate with break through coverage (see guidelines). • Use Colace routinely to reduce constipation. Add Mirilax 17 grams/day po if no BM daily. • Add NSAIDS or Celecoxib, or acetaminophen on a scheduled basis as appropriate (limit acetaminophen to

no more than 4 grams/day). If using acetaminophen on a scheduled basis, use non-acetaminophen containing analgesics.

Definitions: Allodynia — painful sensation to even light touch. Causalgia — actual damage to nerve resulting in severe pain with any stimuli. Nociceptor — pain messenger Non-Steroidal Anti-Inflammatory Drugs (NSAID's) Patient Controlled Analgesia (PCA) — Intravenous route Patient Controlled Epidural Analgesia (PCEA) — epidural route Complex Regional Pain Syndrome (CRPS) - pain syndrome characterized by abnormal interpretation by the Central Nervous system of all sensation as painful; post trauma, typically occurring in the distal portion of an extremity (previously known as RSD (reflex sympathetic dystrophy)).

Treatment Options: Route: Oral – always preferred if patient can tolerate. Around-the-clock management with long-acting opioids

and NSAIDs scheduled with prn short-acting opioids. Contraindicated with nausea and vomiting,

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malabsorption syndromes including gastric bypasses for bariatric surgeries, or when immediate effects are imperative. Rectal – should be considered if immediate results not needed and oral route is not feasible. Some NSAIDs, opioids, and other medications can be administered via this route. Special compounding can be done by the pharmacy if the drug is not normally available for rectal administration. Transdermal – may be useful for around-the-clock management when baseline opiate use has been established; 24-48 hours of PCA or oral opiate dosing, or to cover opiate dependence from home use. May also be useful in patients with multiple side effects from opioids via other routes. See MVH Equianalgesic Dosing Chart. Intravenous - preferred when oral not feasible. Continuous opioid infusion for around-the-clock pain at 1/2-2/3 of the total 24 hour breakthrough use, with PCA breakthrough doses. Subcutaneous – should be used when IV access unavailable and oral not tolerable (most opioids can be administered in the same dosages and time intervals as IV). Some agonist-antagonist opiates cannot be given subcutaneously. Regional blockade: (Contraindicated if infection at or near injection area or patient anticoagulated.) Epidural – preferred for treatment of severe pain as in rib fractures, when sympathetic blockage is indicated to prevent a chronic pain syndrome (ex. Traumatic amputation, thoracotomy), or any time ventilatory status is compromised secondary to pain uncontrolled by systemic means. Contraindications for insertion include sepsis, platelet count < 100,000 (may be negotiable if platelets exhibiting an increasing vs. decreasing trend), INR > 1.2, increased intracranial pressure (r/o bleed with CT scan if LOC at scene or head injury), unstable C-spine or spinal cord injury (check with X-Ray, include C-Spine and thoracic or lumbar spine dependent upon potential site of placement), patient refusal, inability to position patient, unstable hemodynamic status (may not tolerate sympathetic blockade), or emergent situation with no time to place catheter. Keep in mind that no other CNS depressants or systemic narcotics should be used with epidural narcotics. The use of anticoagulants once the epidural is placed should be discussed with anesthesia before initiating.

• Intercostal nerve blocks – may be intermittent or continuous via an intrapleural catheter. Indicated for pain related to rib fractures when epidural contraindicated or patient refuses. Disadvantages include time-limited pain relief when intermittent (3-12 hrs.), risk of pneumothorax with insertion, loss of medication through chest tube suction, Increased plasma concentrations of local anesthetic, and position dependent (catheter can migrate). Contraindications include infection at the site of injection, platelet count < 100,000, INR > 1.2, patient refusal, hemodynamic instability, inability to position patient, or inability to turn off chest tube suction for 15-30 minutes after injection of medication.

• Brachial plexus block – indicated for pain in upper extremity (limited use of frequent neurovascular checks needed). Interscalene approach used for shoulder and upper arm pain; axillary approach used for hand and arm pain. (Note: the interscalene approach causes 100% ipsilateral phrenic nerve palsy and should not be used if pulmonary status is compromised.)

• Femoral nerve block – Indicated for control of perioperative pain in the leg. Utilized as triple nerve

block including femoral, obturator, and lateral femoral cutaneous nerves. May be used 4-12 hours for surgical correction and may provide analgesia for up to 48 hours.

(Note: IM Injections do not provide reliable absorption or analgesia and cause tissue damage. The MVH Pain Service does not recommend this route of administration)

Medications: Opioids – indicated for the management of moderate to severe pain. Opioids should be ordered on scheduled basis with additional doses available for breakthrough pain. Morphine, Dilaudid, or Fentanyl are preferably given intravenously or subcutaneously. (Note PCA doses below. Meperidine is NOT available for PCA use at MVH). Long-acting oral morphine or oxycodone are preferred orally with immediate release form available for breakthrough pain, MS Contin may be administered rectally; Fentanyl may be administered transdermally. Preferred epidural opioids are lipophilic to minimize side effects however hydrophilic opioids may be needed to obtain greater rostral spread in some situations (anesthesia will order epidural opioids and maintain the infusion). See opioid chart below for recommended dosages.

Guidelines or Intravenous Patient-Controlled Analgesia Opioid Loading Dose Subsequent

Dose Lockout (min) Basal Rate/h

Morphine 0.05-0.1 mg/kg 0.5-3.0 mg 6-8 0.5-2.0 mg Hydromorphone 0.01-0.02 mg/kg 0.1-0.5 mg 6-8 0.1-0.3 mg Fentanyl 0.5-1.0 µg/kg 15-75 µg 4-6 15-60 µg Sufentanil 0.07-0.1 µg/kg 2-10 µg 4-6 2-8 µg

NSAIDs – Indicated along with opioids to reduce the opioid requirement, and alone for minor pain. NSAIDs should be ordered on a scheduled basis. NSAIDs are contraindicated for patients with known renal compromise, active bleeding, recent history of bleeding ulcers (within 5 years), bleeding disorders, asthma, or anticoagulation. The NSAID with the lowest side effect profile is ibuprofen. Trilisate is a long-acting NSAID that does not affect platelets. Celecoxib does not affect stomach prostaglandins and should be used on patients with a history of GI distress. Use caution in patients with cardiovascular disease. If oral route cannot be used, IV Ketorolac may be ordered.

Recommended dosages are as follows: Ibuprofen 400-800 mg po q4h with food intake Trilisate 500-1000 mg po q6h with food Intake Celebrex 100 -200 mg po ql2h Ketorolac 15 mg IV q6h-maximum of 5 days, (recommend ordering daily and monitoring). MVH Pain Service has found 15 mg to be as effective as 30-50 mg.

Consider around-the-clock acetaminophen to a maximum of 4 grams/day (2.5 grams/day if elderly) if NSAIDs contraindicated. Antispasmodics – indicated for muscle spasm (lactic acid production triggers the nociceptive cycle). Recommended on scheduled or prn basis. Prefer Baclofen for centrally mediated spasms and Robaxin for externally mediated spasms. Start Robaxin 500 mg up to 1500 mg po/IV q6h. Start Baclofen 5 mg po qid. Tricyclic Antidedepressants/SSRI’s/Lyrica – indicated for neuropathic pain (burning, searing, or electric shock-like). Prescribed in lower doses than for depression. Start TCA’s at 10 mg qd at 6 pm (Desipramine, Nortriptyline, and Amitriptyline). SSRI – start Duloxetine (Cymbalta) at 20-30mg daily. Anticonvulsants – Indicated for neuropathic pain. Start gabapentin at 100 mg po four times a day; pregabalin 25-50mg q8h. Other – NMDA Inhibitors, Alpha-2 agonists, steroids, local anesthetics.

*Neuropathic or difficult pain syndromes often require consultation with the pain service. Blocks can be requested through the Anesthesia department on pager #1773. For a formal pain consultation with Dr.

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Townsend Smith contact the CNS on call (Acute Pain Service #1771), Mon-Fri. 0700-1730 or MVH Pain Center at 208-2723. During off hours, page Dr. Townsend Smith on pager 636-0388.

Non-pharmacologic management: Consider ice 30 min. 4 x daily, TENS, PO/OT (deep ultrasound, water therapy, and massage), biofeedback (pain psychologist), psychotherapy, splints, binders, positioning, foot board, relaxation and imagery (chronic pain CNS), music therapy (partnered with UD music therapy program). Site specific treatment: Thoracic trauma GSW, stabbing, rib fracture, pulmonary contusion (non-painful alone), disruption of great vessels. GOAL: Improve ventilation, deep breathing and cough. Prevent atelectasis, infection, hypoxia and avoid

mechanical ventilation. Control pain. OPTIONS: Epidural management- continuous, intermittent, PCEA, with opioid/local anesthetic – preferred. Intercostal nerve blocks – intermittent with local anesthetic – if epidural contraindicated and contained area of

injury. Intrapleural catheter – continuous with local anesthetic Systemic management – intravenous (PCA), subcutaneous, oral opioids along with NSAID (often inadequate

for management of pain associated with rib fracture). Use around-the-clock dosing with breakthrough medication.

Upper extremity Crush injuries, amputations, vascular disruptions GOAL: Provide regional anesthesia or sympathetic blockade to increase blood flow, decrease pain,

decrease chance of developing chronic pain syndrome. OPTIONS: Systemic management (see thoracic trauma)

Brachial plexus block – interscalene for shoulder or upper arm, axillary for hand and arm. Continuous, intermittent with local anesthetic – contact anesthesia on pager #1773.

Lower extremity Crush injuries, amputations, vascular disruptions GOAL: Provide regional anesthesia or sympathetic blockade to increase blood flow, decrease pain,

decrease chance of developing chronic pain syndrome. OPTIONS: Systemic management (see thoracic trauma)

Epidural management – amputations should be routinely managed with epidural blockade along with opioids and medications to treat neuropathic pain and spasms, to prevent chronic pain syndrome. Continuous/PCA with local anesthetic/opioid. Triple nerve block for femoral neck fractures – femoral, obturator, and lateral femoral cutaneous nerves. Intermittent with local anesthetic – contact anesthesia on cell #8576.

Abdomen Torn or ruptured viscus or organs. GOAL: Control pain while preventing ileus or other postoperative complications. OPTIONS: Systemic management with around-the-clock intravenous or oral opioids, around-the-clock

NSAID, breakthrough opioids. Head Injury Short-acting medications such as propofol and/or fentanyl should be used so that neuro status can

be frequently assessed. Special considerations:

Patient with history of substance abuse or opiate tolerance: Baseline use of opioid must be covered with additional dosing for acute injury. Abuse and addiction issues should be addressed AFTER the acute phase of recovery subsides. Substance abusers are best managed with long-acting versus short acting opioids (minimal euphoric effect). Due to recent media publicity regarding how to abuse OxyContin, this drug should be avoided on an outpatient basis if the patient has a known abuse history due to the risk of potential abuse and toxicity.

Equianalgesic Dosing — reduce the total 24 hour opiate usage by 1/3 to 1/2 when changing opiates due to unpredictable results. Always step down to the lower dose available versus the higher dose when converting. Oral morphine = 3 x the IV amount. Oral morphine dose divided by 3, then multiplied x 2 = oxycodone dose. 12 mg IV morphine or 36 mg oral morphine = 25 mcg Duragesic patch. See Equianalgesic Dosing Chart.

PAIN TREATMENT RECOMMENDATIONS Mild Pain:

1. 800 mg Ibuprofen q 8h. unless contraindicated or Acetaminophen* 1000 mg po q6h. 2. Ultram 50 mg po q6h 3. Oxycodone 2.5-5 mg po q 4h prn or Lortab* 5/325 1 tab. po q 4h prn 4. Consider ice 30 minutes 4 x daily or continuous. *Limit acetaminophen to maximum of 4 grams/day due to potential liver toxicity.

Moderate Pain:

1. Use PCA morphine 1st 24 hours minimum 2. Lortab 5/325 or 7.5/325, 1-2 tabs. q 4h prn or Oxycodone 5-15 mg po q 4h prn 3. Consider adjuvant meds. for muscle spasm, neuropathic pain, etc. 4. Consider ice 30 minutes 4 x daily or continuous.

Severe Pain:

1. Continue PCA and consider continuous infusion 2. Use long-acting opiate to cover baseline pain such as OxyContin, MS contin or Fentanyl patch (see

conversions), unless using continuous PCA 3. Continue breakthrough dosing 4. Continue anti-inflammatory or acetaminophen around-the-clock with opiate to reduce opiate

requirement 5. If uncontrolled, consider pain consult – pager #1771.

Use of Long-Acting Opiate – use for around the clock pain, severe, or unrelenting pain. Rule of conversion: Reduce 24 hour dosage by 1/3 to 1/2 when converting short-acting opiates to long-acting to minimize risk of oversedation. Continue breakthrough dosing. For example: pt. used 20 mg IV morphine per PCA, reduce to 10-15 mg for conversion to Duragesic, would use 25 mcg Duragesic which = 12 mg IV morphine (closest conversion). *If patient was opiate tolerant prior to being hospitalized, a 24 hour equivalent dosage may be used to cover baseline use. Treat acute pain requirement in addition to baseline meds. General Tips: Any long-acting agent may be utilized while patient is hospitalized. Abuse hx: Maximize adjuvants (NSAID, muscle relaxer, neuropathic agents). At discharge, avoid short acting oral opiates. Short supply prescriptions. = 1 week. Quick conversions: (use 24 hour totals to convert) PCA – to convert to continuous, take 1/2 to 2/3 of 24 hour use and divide by 24 hours for hourly rate. IV/SQ morphine x 3 = oral morphine dose (Kadian 12-24 hour dosing, MS Contin 8-12 hour dosing, Oramorph 8-12 hour dosing, Avinza 8-12 hour dosing) 12 mg IV morphine = 25 mcg Duragesic patch q 72h (need to cover pain with other medication first 12 hours until patch starts working) 15 mg oral morphine (SR or IR) = 10 mg oral oxycodone (SR or IR) 10 mg IV morphine = 1.5 mg IV Dilaudid 1 mg IV morphine = 10 mcg IV Fentanyl 5 mg oral morphine = 1 mg methadone (cumulative effect, unpredictable) – consult pain service.

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Q. EMERGENCY THORACOTOMY GUIDELINES

*Not applicable in hypothermia patients.Signs of Life: Pupils Rhythm

Pulse ResponseVital Signs: Palpable pulse

Detectable BP

Arrest > 5 min

Work-up andDefinitive Rx

SBP 60-100

SBP>100

SBP <60

MaximumResusc10 min

YES

VitalSigns

ERAssessABC N

o

SBP>100

SBP 60-100

SBP<60

O.R.

Child < age 16

NO NO

Arrest<15 min

ResuscitativeThoracotomy

MajorHeadInjury

Blunt

PenetratingChest

Signs-of-life

NO NO NO

YES

Unrepairable injuries

SBP>70

SBP<70

STOP

STOP

Occlude Aorta Resusc x 30 min

SBP <60

Abd Injury

SBP >60

Cardiac Tamponade

Release tamponade, control bleeding restart heart

YES

NO NO NO

STOP

Organized Cardiac Activity

YES

NO

Arrest<15 min

CONSIDER RESUSCITATIVE THORACOTOMY BASED ON TIME OF ARREST IN THE FIELD,

TIME OF CPR INITIATION, ECG WIDE OR NARROW COMPLEX, AND PRESENCE OR ABSENCE OF SIGNS OF LIFE.

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R. HEAD INURY

1. Secure an airway in all comatose patients (GCS < 8) prior to leaving the ETC. 2. Clear C-spine with CT Scan (see spinal radiology protocol), especially in pre-op craniotomy

patients. 3. Licox, ICP monitoring ± ventriculostomy should be considered in patients with a GCS < 8 or

posturing. Patients should be euvolemic (PCWP 10-12) and normocapnic (pCO2 of 35) unless directed differently by the neurosurgeon. Also, keep normoglycemic.

4. Head and spinal injured patients should have at least a CVP line for monitoring. Complicating factors (age, underlying heart disease, pulmonary contusion, etc.) or mannitol administration are an indication for pulmonary artery catheter placement.

5. If a patient has significant head trauma and is anticoagulated, even with a negative CT, he should be admitted and observed. Repeat scan should be considered.

6. When Dr. Africk’s neuro patients are discharged with long term antibiotics, contact Tracy Kwiat at extension 3153 for management and medication follow-up.

7. Syncope Evaluation • Admitting ECG and admit to monitored bed • History: Current and previous episodes of syncope, especially falls from standing, signs or

symptoms of cerebrovascular or vertebrobasilar insufficiency, and seizures. Labs: Alcohol and Drug Screen

• Fall from standing after feeling diaphoretic/nauseated---hearing and balance center for tilt-table testing

• Neurologic Symptoms----carotid Duplex, MRI • Seizures----Neurology Service, EEG

-If no abnormality is detected from history or ECG and monitoring, then patient advised to see primary care physician. -If ECG and/or monitoring reveal ischemia or dysrhythmias, patients should have cardiac enzymes and ECHO. EPS are obtained on the basis of cardiology recommendation

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8. Control scalp hemorrhage by grasping the galea and everting the wound edges with hemostats or apply

Raney Clips (available in ETC).

GUIDELINES FOR THE MANAGEMENT OF SEVERE HEAD INJURY Definitions: Standards: represent accepted principles of pt management that reflect high degree of clinical certainty Guidelines: range of management strategies that reflect a moderate clinical certainty Options: remaining strategies for patient management for which there is unclear clinical certainty Classifications of Evidence: Class I – prospective randomized controlled trials Class II – clinical studies in which data collected prospectively and retrospective analyses which were based on clearly reliable data. Examples: observational, cohort, prevalence and case control studies.

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GUIDELINES FOR THE MANAGEMENT OF SEVERE HEAD INJURY Definitions: Standards: represent accepted principles of pt management that reflect high degree of clinical certainty Guidelines: range of management strategies that reflect a moderate clinical certainty Options: remaining strategies for patient management for which there is unclear clinical certainty Classifications of Evidence: Class I – prospective randomized controlled trials Class II – clinical studies in which data collected prospectively and retrospective analyses which were based on clearly reliable data. Examples: observational, cohort, prevalence and case control studies. Class III – retrospectively collected data. Examples: clinical series, database or registry studies, case reviews and case reports. Technology Assessment – devices evaluated in terms of accuracy, reliability, therapeutic potential, and cost effectiveness. Overview 1. Resuscitation of BP and Oxygenation Guidelines: Hypotension (SBP < 90 mmHg), hypoxia (pa02 < 60) must be avoided or corrected Options: MAP should be maintained > 90 to maintain CPP > 60 2. Indications for ICP Monitoring Guidelines: ICP appropriate in severe head injury (GCS 3-8) with abnormal head CT ICP monitoring appropriate with severe head injury and normal CT if: age > 40, unilateral or bilateral motor posturing, SBP < 90. ICP not routinely indicated in pts with mild to moderate head injury 3. Intracranial Pressure Treatment Threshold Guidelines: ICP treatment should be started at upper threshold of 20-25 mm Hg Options: Treatment of ICP should be corroborated with clinical exam and CPP data 4. Recommendations for ICP Monitoring Technology Ventriculostomy most accurate, low cost and reliable method Guidelines for Cerebral Perfusion Pressure Options: CPP should be maintained at minimum of 60 mm Hg 5. Use of Hyperventilation in the Acute Management of Severe Traumatic Brain Injury Standards: in absence of elevated ICP, chronic prolonged hyperventilation (pC02 < 25) should be avoided after TBI. Guidelines: the use of prophylactic hyperventilation (PaC02 < 35) during 1st 24 hrs after TBI should be avoided because it can compromise cerebral perfusion when CBF is low. Options: hyperventilation may be necessary for brief periods when there is neurological deterioration or for longer periods if high ICP is refractory to sedation, paralysis, CSF drainage, or osmotic diuretics. 6. Use of Mannitol in Severe Head Injury Guidelines: Mannitol is effective for control of elevated ICP Options: indications without ICP monitoring = signs of herniation, progressive neuro deterioration Hypovolemia should be avoided. Maintain euvolemia. Serum osmolarity should be kept < 320 mOsm when concern for renal failure 7. Use of Barbiturates in Control of Intracranial HTN (order set in Epic) Guidelines: high dose barbiturates may be considered in hemodynamically stable, salvageable pts with TBI who have elevated ICP refractory to medical and surgical therapy. 8. Role of Glucocorticoids in Treatment of Severe Head Injury Standards: glucocorticoids NOT recommended for reducing ICP or improving outcome

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9. Nutritional Support of Brain-Injured Patients Guidelines: replace 140% of resting metabolic expenditure in non-paralyzed pts Replace 100% in paralyzed pts Use enteral or parenteral formulas containing at least 15% protein calories by 7th day Options: preferable option is use of jejunal feeding 10. Role of Anti-Seizure Prophylaxis Following Head Injury Standards: Prophylactic anticonvulsants are not recommended for preventing LATE posttraumatic seizures (PTS). Options: Anticonvulsants may be used to prevent EARLY PTS in high risk pts Phenytoin and carbamazepine have been shown to be effective in preventing early PTS Prevention of early PTS has not been shown to improve outcome.

Reversal of anticoagulation-Patients with head injury

Coumadin Plavix, ASA No No

Yes Yes

Reversal Guidelines

Does CT show ICH ?

Does CT show ICH ?

Continue Evaluation Continue

Evaluation

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Admit-23 hour observation Admit-23 hour

observation

Platelet Function Abnormal

Platetlet Function-Normal

INR >=4?

Give Factor VII (50mcg/kg) AND 2 Units FFP or thawed plasma

-T&S, first Platelet Function screen, CBC -Give 5 pack of Platelets

-T&S, INR, CBC -Give 2 Units Thawed Plasma

INR>2.5 but

-Draw second Platelet Function Screen AFTER platelet infusion to assess adequacy of reversal

Give 2 Units FFP or thawed plasma

INR not corrected after 4 Units FFP--Give Factor VII (50 mcg/kg) Admit-23 hour

observation -Give additional 5 pack of platelets

GUIDELINES FOR CT SCANNING IN PATIENTS WITH HEAD TRAUMA All patients in the moderate or high risk group should undergo CT scanning.

Classification of Patients with Head Trauma Risk Group Characteristics Low Asymptomatic; headache; dizziness; minor external signs of trauma (scalp

hematoma, laceration, contusion, or abrasion) no moderate-risk or high-risk criteria.

Moderate Change in level of consciousness at the time of injury or subsequently, progressive headache, alcohol or drug intoxication, unreliable or inadequate history of injury, < 2 years old (unless injury very trivial), post–traumatic seizure, vomiting, post-traumatic amnesia, multiple trauma, serious facial injury, signs of basilar fracture, possible skull penetration or depressed fracture, suspected physical child abuse, any form of anti- coagulant (aspirin, Plavix, Coumadin).

High Depressed level of consciousness not clearly due to alcohol, drugs, or other cause (e.g., metabolic and seizure disorders); focal neurologic signs; decreasing level of consciousness; penetrating skull or palpable depressed fracture.

A. Questions Residents should have answers to before calling neurosurgeon: History of injury, past medical history (including anticoagulants) Time of injury Exam from scene if available Initial GCS + any subsequent change All known injuries C-spine status Sedation or paralytic status Physical exam: Pupil size and reaction Corneal reflex Sensation to pain response (if possible) level if spine injured DTR's Babinski Rectal tone + bulbocavernosus response if spine injury C.T. Radiology report and resident assessment after reviewing it personally Edema present or absent Clots: size, length and thickness in mm Amount of shift in mm if present Ventricular size Skull fractures present: depressed (thickness, e.g., width of inner or outer table), compound Labs all-including coagulation studies

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B. RANCHO LOS AMIGOS SCALE Level I No response to stimuli. Appears in deep sleep. Level II Generalized Response. First reaction may be to deep pain. Has delayed,

inconsistent responses. Level III Localized Response. Inconsistent responses, but reacts in a more specific manner

to stimulus. Might follow simple command “squeeze my hand”. Level IV Confused. Agitated. Reacts to own inner confusion, fear disorientation. Excitable

behavior, may be abusive Level V Non–agitated. Confused. Inappropriate. Usually disoriented. Follows tasks for 2-

3 minutes, but easily distracted by environment, frustrated. Level VI Confused appropriate. Follows simple directions consistently. Memory and

attention increasing. Self-care tasks performed without help. Level VII Automatic Appropriate. If physically able, can carry out routine activities.

Appears normal. Needs supervision for safety. Level VIII Purposeful, Alert, Oriented. May have decreased abilities relative to pre-morbid

state. GLASGOW COMA SCALE EXAMINER’S TEST PATIENT’S RESPONSE ASSIGNED SCORE Eye Opening (E) Spontaneous Speech Pain Pain

Opens eyes on own Opens eyes when asked to in a loud voice Opens eyes when pinched Does not open eyes

4 3 2 1

Best Motor Response (M) Commands Pain Pain Pain Pain Pain

Follows simple commands Pulls examiner’s hand away when pinched Pulls a part of body away when examiner pinches Flexes body appropriately to pain (decorticate posturing) Body becomes rigid in an extended position when examiner pinches victim (decerebrate posturing) Has no motor response to pinch

6 5 4 3 2 1

Verbal Response (V) Speech Speech Speech Speech Speech

Carries on a conversation correctly and tells examiner where he is, who he is, and the month and year Seems confused or disoriented Talks to examiner can understand victim but makes no sense Makes sounds examiner can’t understand Makes no noise

5 4 3 2 1

Coma Score (E+M+V) = Range 3-15

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S. SPINE EVALUATION OF THE CERVICAL SPINE

GCS = 15 Moderate or high risk history and/or directed clinical exam positive, no neurological deficit

Directed exam unreliable (i.e., intoxication) or neurological deficit Cervical, thoracic and lumbar spine evaluation

GCS < 15 Directed exam unreliable

High-risk history: Fracture at any level, neurologic deficit, coma, intoxication, very likely to have exceeded physiologic range of motion Moderate-risk history: History of high energy dissipation: falls, pedestrian, motorcycle, bicycle, ATV, ejection; sufficient to have exceeded physiologic range of motion

GUIDELINES FOR SPINE CLEARANCE

1) Definite fracture with or without neurologic deficit 2) Positive clinical exam, and/or neurological deficit 3) Unable to obtain accurate exam Ligamentous integrity verified by one of the following:

Normal physical exam (no pain/tenderness/neuro deficit) on full voluntary range-of-motion (touch chin to chest, shoulder and palpate spine) -Stable Flexion-Extension views in awake, cooperative patient -Fluoroscopic clearance by Radiologist -MRI

-Pursue appropriate studies and recommendation of spinal trauma consultant -Remove backboard, leave hard cervical collar on, LOG ROLL ONLY -Supplemental imaging as necessary (i.e, flexion/extension, CT, MRI)

SOFT COLLAR

BONY C-SPINE CLEAR

REMOVE C-COLLAR AND GET PATIENT UP

NO

CT OF CERVICAL SPINE

NO intoxication (BAC 0%); low-risk history and clinical exam negative (i.e., no pain, tenderness or neurologic deficit) NO distracting injuries No spine films necessary

78

T. OCULAR AND ORBITAL TRAUMA Ronald E. Warwar, M.D. Ophthalmology, Eye Plastic and Orbital Surgery

A. Ocular Examination Any trauma or injury involving the eye, orbit, or periorbital structures requires all of the following: 1. Visual acuity examination of both eyes. A near or distance visual acuity chart is used. Each eye is

checked individually with the other eye tightly covered. If the patient cannot see anything on the chart, or if a chart is not available, then ask him if he can count the number of fingers you display at a certain distance (e.g. “counts fingers 1 ft.”); if he can’t count fingers, ask if he can detect your hand moving, ask him if he can see a bright light such as a penlight directed into the eye (e.g. “light perception” or “no light perception”). The visual acuity of each individual eye is then documented. Visual acuity with both eyes open provides no information.

2. Motility examination. Ask the patient to track a penlight or a small readily visible object in all four directions of gaze. Document findings including any deficits.

3. Pupil examination. Check pupillary size, shape, reactivity to light, and check for the presence of an afferent pupil defect (Marcus-Gunn) via swinging flash light test. The swinging flash light test requires both pupils to be exposed simultaneously and may be difficult when eyelid edema is present. A PUPIL WHICH REACTS TO DIRECT LIGHT MAY STILL BE A MARCUS-GUNN PUPIL.

4. Eyeball (globe) examination. Check for scleral or choreal lacerations or foreign bodies, blood in the anterior chamber (hyphema), iris tears or a disfigured pupil, and at least the presence of a red-reflex on funduscopic examination. Document any abnormalities.

B. Orbital Examination • Presence of proptosis. Proptosis represents anterior displacement of the globe, not the periorbital

structures. • Palpable bony fractures. Palpate the facial bones and the orbital rims for displaced fractures. • Imaging studies. CT scan of head AND orbits required. Orbital or facial bone CT gives 3mm axial

cuts through the orbits. Head CT alone is inadequate for evaluation of orbital structures. Also, always get coronal cuts to image the orbit if possible.

U. ABDOMEN

1. GUIDELINES FOR DAMAGE CONTROL Purpose: To guide surgical therapy in a systematic phased approach in the exsanguinating trauma

patient. It is divided into 3 stages: Stage I: Control hemorrhage and contamination as rapidly as possible Stage II: Physiologic resuscitation Stage III: Re-exploration and definitive repair Indications:

Hemorrhage - Injuries with transfusion requirements > 10 units Hypothermia – Core temperature below 34 ºC Acidosis – pH < 7.2 Coagulopathy – Signs of coagulopathy (elevated coags, diffuse oozing) Decision for damage control should be made PRIOR to the development of coagulopathy and hypothermia. Consider packing sooner in patients arriving to the operating room cold, acidotic, and coagulopathic.

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Aspects of Control: Stage I: Initial laparotomy

• Control of “surgical” hemorrhage • Control of hollow viscus contamination • Laparotomy terminated once hemorrhage and contamination controlled • Definitive repairs of GI tract are deferred (including reanastomoses) • Abdominal packing for tamponade of bleeding areas • Temporary closure of abdomen (towel clips, suture of skin, prosthetic silo) Stage II: Physiologic Resuscitation in ICU • Core warming (warm IVF, air, room, warm lavage of body cavity, Level I) • Correction of coagulopathy with blood products • Maximization of hemodynamic values using PA catheter • Consider Factor VII 100 microgms/kg Stage III: Re-Exploration and Definitive Repair • Occurs usually 24-72 hours later • Packing removal • Definitive repair, restoration of bowel continuity, ostomy formation

2. ABDOMINAL COMPARTMENT SYNDROME

Definition: Syndrome of organ dysfunction secondary to sustained elevation of intra-abdominal pressure (IAP) above a critical level. Intra-abdominal organ dysfunction is due to decreased blood flow. a. Measurement

Route: Intraperitoneal catheter Stomach, IVC catheter or *BLADDER – preferred method

Technique: Instill saline into bladder

Measure at symphysis pubis Hook to manometer, transducer

b. Etiologies (1) Trauma

Pelvic fractures/hematoma Bowel edema from resuscitation (with or without laparotomy) Retroperitoneal hematomas

(2) Pancreatitis (3) Post surgical (4) Peritonitis

c. Clinical Manifestations

(1) Abdominal Decreased blood flow (a) GI tract

decreased mucosal blood flow and pH possible translocation of bacteria Hepatic decreased portal blood flow and hepatic mitochondrial fxn

(b) Renal increased renal vein pressure

increased plasma renin and aldosterone decreased renal blood flow, GFR, urine output

(2) Thoracic (a) Lung

increased intrathoracic pressure, PAP, PIP increased intrapulmonary shunt decreased dynamic compliance decreased FRC

(b) Heart/Cardiovascular Decreased venous return and cardiac output “false” increase of CVP and PAOP increased SVR, PVR

(c) CNS increased ICP secondary to decreased venous return decreased CPP

3. PRE-OPERATIVE CONSIDERATIONS

a. Obtain signed consent form b. NPO 12 hours prior to surgery c. Start maintenance IV fluids if patient is to be NPO d. Stop all anticoagulation e. Coumadin: correct INR to < 1.5 f. Aspirin: stop at least 1 week prior to procedure, or correct with platelets if undergoing major

procedure g. Heparin 4 hours h. Hold all scheduled short-acting insulin and administer only half of the regular long-acting dose.

Start D5 NS IV fluid. i. Administer appropriate antibiotics j. Bowel preparation, if appropriate k. Notify Anesthesia and the operating Attending Physician of any changes in patient’s condition that

may affect their operative eligibility, i.e. irregular cardiac rhythms, acute renal failure, unexpected change in mental status.

POST-OPERATIVE CONSIDERATIONS

a. Post-operative check and note. Watch for disease specific, post-operative complications. b. Restart diet and PO medications if no injury or procedure. c. Replace all output from GI losses, and maintain appropriate fluid balance. Discontinue unnecessary

IV fluids. d. Monitor input and output closely. e. Restart appropriate anticoagulation as per recommendation of operating attending surgeon. f. Bridge to PO pain medications as soon as taking PO well. g. Examine all incisions and drains, giving orders for care and frequency of drainage recording. h. Order appropriate AM labs and imaging, specific to pathology. Routine labs and imaging are not

required. i. Mobilize patient as soon as appropriate, minding weight-bearing restrictions. j. Instruct patient in incentive spirometry 4 times every hour while awake.

4. AAST GRADES OF ORGAN INJURY

Overview: The value of accuracy of CT in demonstrating solid organ injury (liver, spleen, and kidney) after blunt trauma is well established. An ongoing trend, especially children, toward nonsurgical management of

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82

hemodynamically stable patients with blunt splenic or hepatic injuries as well as the increased us of surgical procedures that preserve splenic or renal tissue compels and adequate staging of the initial trauma. Numerous studies have shown that conservative management is a viable option in those patients with limited trauma but is not based solely on CT findings but rather represents a combination of clinical status as well as CT and other laboratory findings. These studies have also demonstrated a good correlation between CT extent of hepatic or renal injuries and success of nonoperative management but this correlation especially in adults, is much less strong with splenic injuries which can progress on a delayed basis (necessitating serial lab and bedside assessments in those patients undergoing a nonoperative trial). Organ Scaling: Kidney Injury Scale

Grade* Injury Description I Contusion Microscopic or gross hematuria, urologic studies normal Hematoma Subscapular, non expanding without parenchymal laceration II Hematoma Non expanding perirenal hematoma confined to renal

retroperitoneum Laceration <1.0cm parenchymal depth of renal cortex without urinary

extravasation III Laceration <1.0cm parenchymal depth of renal cortex without collecting

system rupture or urinary extravasation IV Laceration Parenchymal laceration extending through the renal cortex,

medulla, and collecting system Vascular Main renal artery or vein injury with contained hemorrhage V Laceration Completely shattered kidney

Vascular Avulsion of renal hilum which devascularizes kidney *Advance one grade for bilateral injuries up to grade III Bladder Organ Injury Scale

Grade* Injury Description I Hematoma Contusion, intramural hematoma Laceration Partial thickness II Laceration Extraperitoneal bladder wall laceration <2m III Laceration Extraperitoneal (>2cm) or intraperitoneal (<2cm) bladder wall

laceration IV Laceration Intraperitoneal bladder wall laceration <2cm V Laceration Intraperitoneal or extraperitoneal bladder wall laceration extending

into the bladder neck or ureteral orifice (trigone) *Advance one grade for multiple injuries up to grade III Hemothorax is scored under thoracic vascular injury scale. Duodenum Injury Scale

Grade* Injury Description I Hematoma Involving single portion of duodenum Laceration Partial thickness, no perforation II Hematoma Involving more than on portion Laceration Disruption ,50% of circumference III Laceration Disruption 50%-75% circumference of D2

Disruption of 50%-100% circumference of D1, D3, and D4 IV Laceration Disruption >75% circumference of D2

Involving ampulla or distal common bile duct V Laceration Massive disruption of duodenopancreatic complex Vascular Devascularization of duodenum

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*Advance one grade for multiple injuries up to grade III D1-first position of duodenum; D2-second portion of duodenum; D3-third portion of duodenum; D4-fourth portion of duodenum Small Bowel Injury Scale

Grade* Injury Description I Hematoma Contusion of hematoma without devascularization Laceration Partial thickness, no perforation II Laceration Laceration <50% of circumference III Laceration Laceration >50% of circumference without transection IV Laceration Transection of small bowel V Laceration Transection of small bowel with segmental tissue loss Vascular Devascularized segment

*Advance one grade for multiple injuries up to grade III Colon Injury Scale

Grade* Injury Description I Hematoma Contusion of hematoma without devascularization Laceration Partial thickness, no perforation II Laceration Laceration <50% of circumference III Laceration Laceration ≥50% of circumference without transection IV Laceration Transection of colon V Laceration Transection of colon with segmental tissue loss

*Advance one grade for multiple injuries up to grade III Rectum Injury Scale

Grade* Injury Description I Hematoma Contusion of hematoma without devascularization Laceration Partial thickness, no perforation

II Laceration Laceration <50% of circumference III Laceration Laceration ≥50% of circumference IV Laceration Full thickness laceration with extension into the perineum V Laceration Devascularized segment

Liver Injury Scale Grade* Injury Description I Hematoma Subcapsular, <10% surface area Laceration Capsular tear, <1 cm parenchymal depth

II Hematoma Subcapsular, 10-50% surface area: Intraparenchymal, <10 cm in diameter

Laceration Capsular tear, 1-3 cm parenchymal depth, <10 cm in length III Hematoma Subcapsular, >50% surface area of ruptured subcapsular or

parenchymal hematoma, intraparenchymal hematoma >10 cm or expanding

Laceration 3 cm parenchymal depth IV Laceration Parenchymal disruption involving 25-75% of hepatic lobe or 1-3

Couinaud segments V Laceration Parenchymal disruption involving >75% of hepatic lobe or 3

Couinaud segments within a single lobe Vascular Juxtahepatic venous injuries; i.e., retrohepatic vena cava/major

hepatic veins Vascular Hepatic avulsion

*Advance one grade for multiple injuries up to the same organ

Splenic Injury Scale

Grade* Injury Description I Hematoma Subcapsular, <10% surface area Laceration Capsular tear, <1 cm parenchymal depth

II Hematoma Subcapsular, 10-50% surface area: Intraparenchymal, <5 cm in diameter

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

III Hematoma

Subcapsular, >50% surface area or expanding; ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma ≥ cm or expanding

Laceration 3 cm parenchymal depth or involving trabecular vessels IV Laceration Laceration involving segmental or hilar vessels producing major

devascularization (>25% of spleen) V Laceration Completely shattered spleen Vascular Hilar vascular injury which devascularizes spleen

*Advance one grade for multiple injuries up to grade III Pancreas Injury Scale

Grade* Injury Description I Hematoma Minor contusion without duct injury Laceration Superficial laceration without duct injury

II Hematoma Major contusion without duct injury or tissue loss Laceration Major contusion without duct injury or tissue loss

III Laceration Distal transaction or parenchymal injury with duct injury IV Laceration Proximal transaction or parenchymal injury involving ampulla** V Laceration Massive disruption of pancreatic head

Advance one grade for multiple injuries up to grade III **Proximal pancreas is to the patient’s right of the superior mesenteric vein Extrahepatic Biliary Tree Injury Scale

Grade* Injury Description I Gallbladder contusion/hematoma

Portal triad contusion/hematoma II Partial gallbladder avulsion from liver bed; cystic duct intact

Laceration or perforation of the gallbladder III Complete gallbladder avulsion from liver bed

Cystic duct laceration IV Partial or complete right hepatic duct laceration

Partial or complete left hepatic duct laceration Partial common hepatic duct laceration (<50%0

V ≥50% of transaction of common hepatic duct ≥50% of transaction of common bile duct Combined right and left hepatic duct injuries Intraduodenal or intrapancreatic bile duct injuries

Advance one grade for multiple injuries up to grade III Trunkey, DD, et al: Current therapy of trauma 4th edition. St. Louis, Mosby, pp. 230,235, 239, 241; 1999.

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5. NONOPERATIVE SPLENIC TRAUMA MANAGEMENT

Grade 1 Splenic Injury

Admit to floor CBC q 12° Pt unstable VS q 1 hr. on

presentation

VS Stable H & H Stable If stable after

1-2 days LOS, may DC

Patient may move out of ICU after 24 hours

Yes No

Admit to ICU Monitor on floor X3 days

Admit to floor House Arrest X1 wk CBC q 12o CBC q 8 hr. RTC 1 wk VS q 4 hr. VS q 1 hr. CBC q day No contact sports X1 mo RTC 1 mo

If stable after 3 day LOS on

floor may DC

House Arrest X2 wkRTC 1 wk No contact sports X2 mo RTC 1 mo

If stable after 2 day LOS,

may DC

House Arrest X3 wk RTC 1 wk No contact sports X3 mo RTC 1 mo Repeat Abd CT 3 mo if indicated RTC 3 mo

Admit to ICU CBC q 8 hr. VS q 1 hr.

Grade 2 Splenic Injury

Grade 3 or > Splenic Injury

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V. CHEST CHEST INJURY GUIDELINES

Need for chest tube identified HTX/PTX

Chest tube inserted -20cm H20 suction

Ancef 1 gm prior to CT placement CXR

Portable

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CXR Upright

CT Consult

Amount drainage

Complete evacuation/expansion x24 hours Incomplete evacuation/expansion

CXR CT Consult

Air leak or recent PTX No air leak Observation VATS 2nd tube

Reconnect suctionx 24-48 hours

Underwater seal x 24 hours

Air leak >3 days No air leak

2nd Tube VATS

Observation

<150 cc/day >150cc/day

PTX No PTX

Pull CT

F/U CXR 6 hours

CHEST

1. Beware of heart murmurs in patients with chest trauma. Do not assume they are functional or congenital.

2. Stab wounds to the chest without a hemopneumothorax need to be observed with a repeat chest film in 3-6 hours to rule out hemopneumothorax. After discharge, these patients should also be seen in the clinic for a follow-up chest film. (See penetrating trauma guidelines for abdominal evaluation.)

3. Major blunt chest trauma patients need an ECG. 4. Consider chest CT “ARCH protocol” with contrast in patients with high speed, sudden deceleration

chest impact injuries, even if the chest x-ray is nonspecific. THORACIC AORTIC TRAUMA EVALUATION

Suspicion for torn aorta based on CXR evidence or severe injury mechanism. Reverse Trendelenburg CXR may exclude wide mediastinum seen on initial port able chest radiograph.

1. Suggested Algorithm for Injuries

MULTIPLE TRAUMA PATIENT

WIDENED MEDIASTINUM

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Unstable FAST ⊕ OR DPL ⊕

High Suspicion

Stable

Low Suspicion

FAST θ or

DPL θOR for lap

CT Head/Abdomen/Pelvis

Chest CT with Contrast

“Arch Protocol” or Screening TEE

Angio Ready

Angio

CT Head/Chest/Abdomen/

Pelvis

Angio Call-in

Anesthesia to Perform Intraoperative TEE if available

Medical Imaging: • CXR evidence for torn aorta • Posterior mediastinal hemorrhage on CT scan around distal thoracic aorta • TEE verification

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• 30-minute response time for angiography after 6 pm • Leave femoral sheath in place and cap side arm if films confirm torn aorta • 2 view AP and LAO films to evaluate for injury. Aortogram to include flush image of chest and

cervical vessels to exclude dissection 2. Criteria for Positive CXR in Patients with Potential Aortic Injury Signs on CXR:

a. Widened mediastinum (> 8 cm on AP CXR @ T4); this is the most consistent finding. b. Fracture of first three ribs, scapula, or sternum. c. Obliteration of aortic knob. d. Deviation of trachea to right. e. Presence of pleural cap, usually on the left but occasionally bilaterally. f. Elevation and rightward shift of the right mainstem bronchus. g. Depression of the left mainstem bronchus >40 degrees from horizontal. h. Obliteration of aortopulmonary window. i. Deviation of nasogastric tube (esophagus) to right is an infrequent, but suggestive, sign. j. Left pleural effusion. k. No single sign reliably confirms or excludes aortic injury. However, a widened mediastinum is the

most consistent finding on CXR and should prompt further investigation. • Up to 15% of patients with traumatic rupture of the aorta will have a normal CXR

3. Operative repair of aorta

OR/Anesthesia for Cardiothoracic surgery: Circulating RN to complete checklist for set up:

• Notify blood bank • Obtain head light for use • Contact perfusionist to set up cell saver and centrifugal pump with heparin tubing • Bring rapid infuser into room for priming • ART line set up (two sites: R radial and femoral) • Large bore IV tubing

Anesthesia: Contact cardiac anesthesia for case (2 MD’s to start case) TEE availability Carlens tube and fiberoptic intubation IJ primed Femoral vein cordis optional Two large bore PIV’s Swan insertion only at CT surgeon request or at completion Nipride (±Esmolol) for induction hypertension Avoid barbiturate anesthesia Vasoactive meds per clinical assessment Do not insert right subclavian lines in OR (potential for right pneumo when left lung down for aortic repair)

4. Aortic Stent Graft When a diagnosis of ruptured aorta is made, page Dr. Simoni, in addition to the CT Surgeon, to allow discussion of options with the family (if Dr. Azie is not available).

5. Clinical Triggers to consult CT Surgery

• Positive FAST exam of the pericardium

• If performing a pericardiocentesis • If performing a pericardial window • Chest tube placement with >500 ml blood return

W. EVALUATION AND MANAGEMENT OF THE INJURED CHILD

The three most common causes of death are:

• Airway obstruction • Blood loss • Central nervous system (CNS) injury

Consider these critical issues in pediatric trauma:

• Beware of hypothermia. Children lose body heat rapidly. The room and IV fluids should be warmed. • Multi-system injury is common. Check all regions • Head injury is frequent. Observe closely for altered consciousness.

Determine pediatric trauma score

Pediatric Trauma Score PTS +2 +2 -1 Size >20kg 10-20kg <10kg Airway Normal Maintainable Not Maintainable Systolic BP

>90 mmHg <90-50 mm Hg <50 mmHg

CNS Awake Obtunded or any loss of consciousness

Comatose

Open None Minor Major or penetrating

Skeletal None Closed Fracture Open or multiple fractures

The PTS is an anatomic and physiologic scoring system useful for triage and prediction of severity of injury. PTS > 8 = no mortality; PTS ≤ 8 = 30% mortality. 1. Airway and breathing A child’s airway may easily be occluded.

• The upper airway may easily be occluded • The tonsils and tongue are large • The larynx is anterior and high in the neck • The trachea is short – avoid inadvertent extubation or endobronchial intubation

Suggestion for airway access: • “Sniffing” position • Chin lift or jaw thrust ) for obstruction by tongue or foreign material) • Use oral airway with bag and mask • Orotracheal intubation preferred – following preoxygenation, sedation, and paralysis • Needle cricothyroidotomy is preferable to tracheostomy

2. Circulation • Hypovolemia causes tachycardia and peripheral vasoconstriction before hypotension • Hemorrhage or hypovolemia makes surgical consultation essential • Be alert for shock caused by gradual and internal blood loss

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Physiologic guidelines • Normal blood volume = 80 ml/kg • Hypotension: Loss of 24% of blood volume • Blood pressure and heart rates are age-related

Special considerations

• Administer oxygen to ALL children • Do not hyperventilate for CNS injury. Ideal pCO2 = 35 torr • Consider NG tube to relieve gastric distention

Maintain adequate urine output: Infant 2 ml/kg/hr Child 1-1.5 ml/g/hr Adolescent 0.5-1 ml/kg/hr

Monitor all vital signs closely: • Complete a neurologic examination. Calculate Glasgow Coma Scale for all patients, and obtain

neurosurgical consultation in indicated • Infuse mannitol (0.5 – 1.0 gm/kg over 20 min) for rapid CNS deterioration or lateralizing signs (in

consultation with a trauma surgeon or neurosurgical consultant) • Be alert to ongoing, occult bleeding, and incomplete volume resuscitation.

Equipment necessary for pediatric resuscitation Airway/breathing Circulation Supplemental

equipment

Bag- Laryngo- O2 Oral valve scope ET BP IV NG Chest Urinary Cervical mask airways mask blades tubes Stylet Suction cuff catheter tubes tubes catheter collarPremature Premature Infant Infant 0-

straight 2.5-3.0 6F 6-8F Premature 22-24 12F 10-

14F5F ---

3kg newborn uncuffed newborn catheter Anderson feeding Newborn NB Infant Infant 1-

straight 3.0-3.5 6F 8F NB 22-24 12F 12-

18F5-8F ---

0-6 mo. small uncuffed infant catheter Anderson feeding 3.5 kg 6-12 mo. PED Small PED 1-

straight 3.5-4.5 6F 8-10F Infant 22-24 12F 14-

20F8F Small

7 kg uncuffed catheter Anderson 1-3 yrs. PED Small PED 1-

straight 4.0-4.5 6F 10F Child 20-22 12F 14-

24F10F Small

10-12 kg uncuffed catheter Anderson 4-7 yrs. PED Medium PED 2-

straight 5.0-5.5 14F 14F Child 20-22 12F 20-

32F10-12F Small

16-18 kg or curved uncuffed catheter Anderson 8-10 yrs. Adult Medium PED 2-3

straight 5.5-6.5 14F 14F Child 20-22 12F 28-

38F12F Medium

24-30 kg large adult or curved uncuffed adult catheter Anderson

X. ORGAN DONATION

LIFE CONNECTION OF OHIO DONOR REFERRAL HOTLINE Dayton Regional Office 877-223-1606 or 937-223-1606 IDENTIFICATION & REFERRAL CALL ASAP WHEN 1. Patient is:

a. Heart-beating b. Ventilated c. Neurological Insult with GCS < 5

2. Early enough to allow a thorough evaluation to determine stability

3. Before discussion of terminal wean with the family 4. Do not mention organ donation without consulting Life Connection first 5. This is monitored by hospital QA as “timely referral” 1. CLINICAL CRITERIA FOR BRAIN DEATH • No response to external stimuli (except spinal reflexes) • No spontaneous movement • No brain stem reflexes, including:

- Pupillary constriction to light - Corneal reflex - Oculocephalic reflex (Doll’s eyes) - Oculovestibular reflex (cold water calorics) - Gag/cough reflex

• Apnea in the presence of CO2 > 60 Note: these clinical criteria are only valid in the absence of barbiturates and hypothermia

2. CONFIRMATORY TESTING FOR BRAIN DEATH

• Cerebral blood flow study • EEG • 4 vessel angiogram (particularly useful in cases where barbiturates are present) • CTA is no longer considered adequate by radiology

3. CLINICAL CARE GUIDELINES FOR POTENTIAL ORGAN DONORS Purpose: To provide guidelines for the care of the patient who is a potential organ donor. Population: Those patients who have suffered severe traumatic brain injury. Identification and referral of potential donor: Call Life Connection (223-1606) within one

hour of the patient meeting the following clinical triggers: • Neurological impairment GCS < 5 • Heart beating • Ventilated • Progressive loss of neurologic function • Poor prognosis per physician r/t brain death • Elevated ICP refractory to treatment • Low CPP < 60 refractory to treatment • Initiation of paralytics or pentobarbital coma • Family request • Nurse discretion

Management:

a. Patients with neurosurgical intervention and suspected non survivable injury. (1) Neurological

Manage ICP/CPP & Pbt02 per neurosurgery Surgical intervention Place ICP/Ventriculostomy

(2) Respiratory Avoid hypoxia, maintain pCO2 34-38 mmHg

(3) Hemodynamics: Insert pulmonary artery catheter Establish hemodynamic stability, avoiding hypotension

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Control active bleeding MAP > 70, using crystalloid or colloid if PCWP < 12 HCT > 30, transfuse with PRBC Correct coagulopathy Establish and maintain euvolemia Correction of Base deficit Urine Output > 30 cc/hr Correction of lactate Maintain PCWP = 10-12 Avoid vasopressors until adequate hydration achieved. As pressors are increased, the

PCWP will remain stable (smaller tank with the same pressure) Be sure that the intravascular volume is maintained! Watch I & O’s each shift.

Establish and maintain electrolyte balance K+ replacement protocol Avoid hyponatremia and hypernatremia Monitor for DI Serum Na+ > 1.005(per laboratory) Urine Sp. Gravity < 1.005 (per laboratory) Serum Osmolality > 315 Urine Output > 300 cc/hr X 2 consecutive hours

Patients with non survivable injury and no intervention from neurosurgery requiring continued resuscitation by Trauma Services

(1) Respiratory: Maintain pa02 > 100, avoid hypoxia pC02 35-45 (2) Monitor for neurogenic pulmonary edema-increase ventilator support as needed

2. Hemodynamics/Cardiovascular – focus on end points of resuscitation include normalization of base

deficit/lactate a. Place Swan Ganz catheter

(1) Maintain PCWP 8-12 mmHg (2) Maintain CVP-8-12 mmHg (3) Avoid Levophed and Vasopressin if SVRI >1100

b. Control active bleeding c. Maintain MAP > 70 or Systolic BP > 100

(1) Early .9 NaC1 or LR and adjust based on electrolytes (2) 5% Albumin

d. Transfuse PRBC to maintain HCT > 30 e. Correct coagulopathy

(1) 4-6 units FFP w/o lab results, if clinical signs of DIC f. Vasopressors

(1) Dopamine (1st drug of choice) titrate for MAP >70 (2) Phenylephrine (2nd drug of choice once Dopamine @ 20 mcg/kg/min) titrate for MAP > 70 (3) Norepinephrine Only consider if CI > 4 and no suggestion of Diabetes Insipidus (4) Vasopressin 1-8 units/hr for clinical s/s of DI (contraindicated if SVRI > 1100)

g. Avoid treating tachycardia and hypertension if suspected herniation in progress h. Cardiac Arrest = ACLS protocol (verify code status, see below)

3. Electrolyte Balance a. Hypokalemia and hyperglycemia to be treated b. Monitor closely for DI

4. Diabetes Insipidus

92a. Vasopressin drip @ 1-8 units/hr

b. Vasopressin IVP 1-2 mcg q 2-8 hours prn c. Replace urine output > 200 cc/hr with .45 NaC1 ml for ml every hour

Common problems associated with potential organ donors requiring aggressive immediate intervention: 1. Disseminated Intravascular Coagulopathy 2. Diabetes Insipidus 3. Neurogenic pulmonary edema 4. Hypotension secondary to hypovolemia 5. Electrolyte Disturbances

Code Status: AVOID PURSUIT OF LEVEL IV COMFORT CARE. In the event legal next of kin request cessation or withdrawal of treatment, consult Life Connection to discuss possibility of organ donation with next of kin. If legal next of kin requests change in code status, Level III Comfort Care Arrest is appropriate and allows for addition of vasopressors and new interventions. Suitability: All patients meeting previously stated criteria are considered potential organ donors. Only Life Connection personnel will determine donor suitability. Medical diagnoses are not an adequate indicator of the possibility of organ donation. Consents from legal next of kin is not necessary if patient is listed in Ohio donor registry. All information regarding the donor registry should be given to the next of kin by Life Connection. Organ donation information requested by the family may be initiated by staff, but should be referred to Life Connection as soon as possible provided the family wishes to proceed with further discussion. ** Patient remains under care of Trauma Services until brain death has been confirmed and consent obtained by Life Connection either through the donor registry, verbal or written consent by legal next of kin. If Life Connection needs assistance with critical care after brain death is declared, the Trauma Service should be consulted. Please use the following terminology when discussing the donation process: “Recover” organs or instead of “harvest” organs or “Surgical Recovery” instead of “harvesting” “Deceased Donor” or instead of “cadaver” or “cadaveric” “Mechanical Support” or “Ventilated Support” instead of “life support” “Redirect care” instead of “withdrawal of care”

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IV. Geriatric Medication Management

BeersListOne The Beers’ lists are used as a national guideline and reference guide for pharmacists and physicians to improve the use of medication in the elderly. TABLE 1: MEDICATIONS TO AVOID OR USE WITHIN SPECIFIED DOSE AND DURATION RANGES IN ELDERLY PATIENTS

MEDICATION(s) EXPLANATION OF PROBLEM

SEVERITY

PSYCHOTROPIC MEDICATIONS Amitriptyline, alone or in combination products

Strong anticholinergic and sedating properties High

Barbiturates (other than phenobarbital) Side effects and addictive properties High Chlordiazepoxide (alone or in combination) or diazepam

Long half-lives, risk of sedation and increased falls High

Doxepin Strong anticholinergic and sedating properties High Ergot mesylates, cyclandelate isoxsuprine Not proven effective at doses studied Low Flurazepam Long half-life; risk of sedation and increased falls High Haloperidol

Doses > 3mg/day should be avoided; residents with psychotic disorders may require higher doses

. . .

Lorazepam 3 mg, oxazepam 60 mg, alprazolam 2 mg, temazepam 15 mg, zolpidem 5 mg, triazolam 0.25 mg

Total daily doses should not exceed these amounts; in the nursing facility resident, avoid any single dose of oxazepam > 30 mg or triazolam > 0.25 mg

Low

Meperidine

Not effective orally and has disadvantages compared with other narcotic analgesics

High

Meprobamate

Highly addictive and sedating. Avoid unless patient is already addicted to it.

High

Pentazocine

Has more CNS side effects, including confusion and hallucinations; is a mixed agonist-antagonist

High

Propoxyphene Few advantages over acetaminophen Low Thioridazine

Avoid doses > 30 mg/day; residents with known psychotic disorders may require higher doses.

. . .

EENT AGENTS Antihistamines (alone or in combination, including chlorpheniramine, diphenhydramine, hydroxyzine, cyproheptadine, promethazine, and dexchlorpheniramine)

Strong anticholinergic activity. Substitute cough and cold products without these antihistamines

Low

Decongestants (oxymetazoline, phenylephrine, pseudoephedrine)

Avoid daily use for > two weeks . . .

Diphenhydramine

Do not use as a hypnotic. For allergies, use the lowest possible dose.

Low

GASTROINTESTINAL AGENTS Cimetidine Avoid doses > 900 mg/day and therapy for > 12 weeks . . . Dicyclomine, hyoscyamine, propantheline, belladonna alkaloids, clidinium, chlordiazepoxide

Strong anticholinergic activity and questionable efficacy as antispasmodic agents. Avoid long-term use; other use is questionable

High

Ranitidine Avoid doses > 300 mg/day and therapy for > 12 weeks . . . Trimethobenzamide

One of the least effective antiemetic agents; produces extrapyramidal side effects

Low

ENDOCRINE AGENTS Chlorpropamide Can cause prolonged and serious hypoglycemia. Also can

cause syndrome of inappropriate antidiuretic hormone

High

CARDIAC AGENTS Digoxin

Except for treatment of atrial arrhythmias, doses > 0.125 mg in the elderly should rarely exceed this amount

High

Disopyramide

May induce heart failure because of strong negative inotropic activity. Also has strong anticholinergic activity

High

VASCULAR AGENTS Dipyridamole

Causes orthostatic hypotension. Beneficial only in patients with artificial heart valves.

Low

Hydrochlorothiazide Avoid doses > 50 mg/day Methyldopa (alone or in combination) causes bradycardia and exacerbates depression

High

Propranolol

Avoid except when used to treat violent behaviors; other beta blockers offer less CNS penetration or more beta-receptor selectivity

. . .

Reserpine (alone or in combination)

Causes depression, impotence, sedation, and orthostatic hypotension

Low

Ticlopidine More toxic than aspirin, yet no more effective High MUSCULOSKELETAL AGENTS Indomethacin Most CNS side effects of any NSAID Low Methocarbamol, carisoprodol, oxybutynin, chlorzoxazone, metaxalone, cyclobenzaprine, orphenadrine

Poorly tolerated by the elderly; cause anticholinergic side effects, sedation, and weakness. Effectiveness at tolerated doses questionable

Low

Phenylbutazone (off U.S. market) Serious hematologic side effects Low HEMATOPOIETIC AGENTS

Iron supplements exceeding 325 mg of ferrous sulfate

Higher doses no more effective but cause constipation Low

ANTI-INFECTIVE AGENTS Oral antibiotics

Avoid therapy for > four weeks except when treating osteomyelitis, prostatitis, tuberculosis, or endocarditis

. . .

TABLE 2: MEDICATIONS TO AVOID IN ELDERLY PATIENTS WITH SPECIFIC CONCOMITANT DISEASES

DISEASE MEDICATION(s) PROBLEM SEVERITY NEUROLOGIC DISORDERS Epilepsy

Clozapine, chlorpromazine, thioridazine, chlorprothixene

Agents lower seizure threshold Low

Metoclopramide Agents lower seizure threshold High PSYCHIATRIC DISORDERS Insomnia Decongestants May cause or worsen insomnia Low Theophylline May cause or worsen insomnia

Low

Desipramine, serotonin selective reuptake inhibitors, and monoamine oxidase inhibitors

May cause or worsen insomnia

Low

Beta agonists May cause or worsen insomnia Low GASTROINTESTINAL DISORDERS Constipation Anticholinergics Will worsen constipation Low Narcotics Will worsen constipation Low Tricyclic antidepressants Will worsen constipation High Ulcers NSAIDs May exacerbate ulcer disease, gastritis,

GERD High

Aspirin

May exacerbate ulcer disease, gastritis, GERD

Low

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Potassium supplements May exacerbate ulcer disease, gastritis, GERD

Low

ENDOCRINE DISORDERS Diabetes Beta blockers In people being treated with insulin or

oral agents, beta blockers may worsen symptoms

Low

Corticosteroids (started recently) May worsen diabetic control Low RESPIRATORY DISORDERS Asthma Beta blockers

May worsen respiratory function High

Chronic obstructive pulmonary disease

Beta blockers May worsen respiratory function High

Sedative-hypnotics

May slow respirations and increase carbon dioxide retention

High

CARDIAC DISORDERS Arrhythmias

Tricyclic antidepressants May induce arrhythmias High if started recently

Heart failure Disopyramide May worsen heart failure because of negative inotropic action

High

Drugs with high sodium content

Large sodium load may lead to fluid retention and thereby worsen heart failure

Low

VASCULAR DISORDERS Blood-clotting disorders being treated with anticoagulants

Aspirin May cause bleeding High

Hypertension

Amphetamines and other weight-control agents

May increase blood pressure High

Peripheral vascular disease

Beta blockers Negative chronotropic and inotropic activity

Low

Syncope Beta blockers Negative chronotropic and inotropic activity

Low

Long-acting benzodiazepines May contribute to falls High UROLOGIC DISORDERS Benign prostatic hypertrophy

Anticholinergic antihistamines May impair micturition and cause obstruction

High

Gastrointestinal

antispasmodics

May impair micturition and cause obstruction

High

Muscle relaxants

May impair micturition and cause obstruction

Low

Narcotic drugs (including propoxyphene)

May impair micturition and cause obstruction

Low

Flavoxate, oxybutynin May cause obstruction Low

Bethanechol May cause obstruction Low Anticholinergic

antidepressants

May impair micturition and cause obstruction

High

Incontinence Alpha blockers

Relaxes the external bladder sphincter High

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Criteria for Potentially Inappropriate Medication Use in Older Adults: Considering Diagnoses or Conditions

Disease or Condition

Drug

Concern

Severity Rating

(High or Low) Heart Failure Disopyramide (Norpace), and high sodium content

drugs (sodium and sodium salts [alginate, bicarbonate, biphosphate, citrate, phosphate, salicylate, and sulfate])

Negative inotropic effect. Potential to promote fluid retention and exacerbation of heart failure.

High

Hypertension Phenylpropanolamine hydrochloride (removed from the market in 2001), pseudoephedrine; diet pills, and amphetamines

May produce elevation of blood pressure secondary to sympathomimetic activity.

High

Gastric or Duodenal Ulcers

NSAIDs and aspirin (>325 mg) May exacerbate existing ulcers or produce new/additional ulcers.

High

Seizures or Epilepsy

Clozapine (Clozaril), Chlorpromazine (Thorazine), thioridazine ( Mellaril), and thiothixene (Navane)

May lower seizure thresholds. High

Blood clotting disorders or receiving anticoagulant therapy

Aspirins, NSAIDs, dipyridamole (Persantine), ticlopidine (Ticlid), and clopidogrel (Plavix)

May prolong clotting time and elevate INR values or inhibit platelet aggregation, resulting in an increased potential for bleeding.

High

Bladder outflow obstruction

Anticholinergics and antihistamines, gastrointestinal antispasmodics, muscle relaxants, oxybutynin (Ditropan), flavoxate (Urispas), anticholinergics, antidepressants, decongestants, and tolterodine (Detrol)

May decrease urinary flow, leading to urinary retention.

High

Stress Incontinence

Blockers (Doxazosin, Prazosin, and Terazosin), anticholinergics, tricyclic antidepressants, (imipramine hydrochloride, doxepin hydrochloride, and amitriptyline hydrochloride), and long acting benzodiazepines.

May produce polyuria and worsening of incontinence.

High

Arrhythmias Tricyclic antidepressants (imipramine hydrochloride, doxepin hydrochloride, and amitriptyline hydrochloride)

Concern due to proarrhythmia effects and ability to produce QT interval changes.

High

Insomnia Decongestants, theophylline (Theo-Dur), methylphenidate (Ritalin), MAOIs, and amphetamines

Concern due to CNS stimulant effects.

High

Parkinson disease

Metoclopramide (Reglan), conventional antipsychotics, and tacrine (Cognex)

Concern due to their antidopaminergic/cholinergic effects.

High

Cognitive Impairment

Barbiturates, anticholinergics, antispasmodics, and muscle relaxants. CNS stimulants: dextroamphetamine (Adderall), methylphenidate (Ritalin), methamphetamine (Desoxyn), and pemoline

Concern due to CNS-altering effects

High

Depression Long-term benzodiazepine use. Sympatholytic agents: methyldopa (Aldomet), reserpine, and guanethidine (Ismelin)

May produce or exacerbate depression.

High

Anorexia and Malnutrition

CNS stimulants: Dextroamphetamine (Adderall), methylphenidate (Ritalin), methamphetamine (Desoxyn), pemoline, and fluoxetine (Prozac)

Concern due to appetite-suppressing effects.

High

Syncope of falls

Short to immediate-acting benzodiazepine and tricyclic antidepressants (imipramine hydrochloride, doxepin hydrochloride, and amitriptyline hydrochloride

May produce ataxia, impaired psychomotor function, syncope, and additional falls.

High

SIADH/ hyponatremia

SSRIs: fluoxetine (Prozac), citalopram (Celexa), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft)

May exacerbate or cause SIADH.

Low

Seizure disorder

Bupropion (Wellbutrin) May lower seizure threshold. High

Obesity Olanzapine (Zyprexa) May stimulate appetite and increase weight gain.

Low

COPD Long-acting benzodiazepines: chlordiazepoxide (Librium), chlordiazepoxide-amitriptyline (Limbitrol), clidinium-chlordiazepoxide (Librax), diazepam (Valium), quazepam (Doral), halazepam (Paxipam), and clorazepate (Tranxene). β-blockers: propranolol

CNS adverse effects. May induce respiratory depression. May exacerbate or cause respiratory depression.

High

Chronic constipation

Calcium channel blockers, anticholinergics, and tricyclic antidepressant (imipramine hydrochloride, doxepin hydrochloride, and amitriptyline hydrochloride

May exacerbate constipation. Low

Criteria for Potentially Inappropriate Medication Use in Older Adults:

Independent of Diagnoses or Conditions

Drug

Concern

Severity Rating

(High or Low) Propoxyphene (Darvon) and combination products (Darvon with ASA, Darvon-N, and Darvocet-N)

Offers few analgesic advantages over acetaminophen, yet has the adverse effects of other narcotic drugs

Low

Indomethacin (Indocin and Indocin SR) Of all available nonsteroid anti-inflammatory drugs, this drug produces the most CNS adverse effects.

High

Pentazocine (Talwin) Narcotic analgesic that causes more CNS adverse effects, including confusion and hallucinations, more commonly than other narcotic drugs. Additionally, it is a mixed agonist and antagonist.

High

Trimethobenzamide One of the least effective antiemetic drugs, yet it can cause extrapyramidal adverse effects.

High

Muscle relaxants and antispasmodics: methocarbamol (Robaxin), carisoprodol (Soma), chlorzoxazone (Paraflex), metaxalone (Skelaxin), cyclobenzaprine (Flexeril), and oxybutynin (Ditropan). Do not consider the extended-release Ditropan XL.

Most muscle relaxants and antispasmodic drugs are poorly tolerated by elderly patients, since these cause anticholinergic adverse effects, sedation, and weakness. Additionally, their effectiveness at doses tolerated by elderly patients is questionable.

High

Flurazepam (Dalmane) This benzodiazepine hypnotic has an extremely long half-life (often days), producing prolonged sedation and increasing the incidence of falls and fracture. Medium- or short-acting benzodiazepines are preferable.

High

Amitriptyline (Elavil), chlordiazepoxide-amitriptyline (Limbitrol), and perphenazine-amitriptyline (Triavil)

Because of its strong anticholinergic and sedation properties, amitriptyline is rarely the antidepressant of choice for elderly patients.

High

Doxepin (Sinequan) Because of its strong anticholinergic and sedating properties, doxepin is rarely the antidepressant of choice for elderly patients.

High

Meprobamate (Miltown and Equanil) This is a highly addictive and sedating anxiolytic. Those using meprobamate for prolonged periods may become addicted and may need to be withdrawn slowly.

High

Doses of short-acting benzodiazepines: doses greater than lorazepam (Ativan), 3 mg; oxazepam (Serax), 60 mg; alprazolam (Xanax), 2 mg; temazepam (Restoril), 15 mg; and triazolam (Halcion), 0.25mg.

Because of increased sensitivity to benzodiazepines in elderly patients, smaller doses may be effective as well as safer. Total daily doses should rarely exceed the suggested maximums.

High

Long-acting benzodiazepines: These drugs have a long half-life in elderly patients (often High

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chlordiazepoxide (Librium), chlordiazepoxide-amitriptyline (Limbitrol) clidinium-chlordiazepoxide (Librax), diazepam (Valium), quazepam (Doral), halazepam (Paxipam), and clorazepate (Tranxene)

several days), producing prolonged sedation and increasing the risk of fail and fractures. Short- and intermediate-acting benzodiazepines are preferred if benzodiazepine is required.

Disopyramide (Norpace and Norpace CR) Of all antiarrhythmic drugs, this is the most potent negative inotrope and therefore may induce heart failure in elderly patients. It is also strongly anticholinergic. Other antiarrhythmic drugs should be used.

High

Digoxin (Lanoxin) (should not exceed >0.125 mg/d except when treating atrial arrhythmias)

Decreased renal clearance may lead to increased risk of toxic effects

Low

Short-acting dipyridamole (Persantine). Do not consider the long-acting dipyridamole (which has better properties than the short-acting in older adults) except with patients with artificial heart valves.

May cause orthostatic hypotension Low

Methyldopa (Aldomet) and methyldopa-hydrochlorothiazide (Aldoril)

May cause bradycardia and exacerbate depression in elderly patients.

High

Reserpine at doses >0.25 mg. May induce depression, impotence, sedation, and orthostatic hypotension.

Low

Chlorpropamide (Diabinese) May induce depression, impotence, sedation, and orthostatic hypotension. It has a prolonged half-life in elderly patients and could cause prolonged hypoglycemia. Additionally, it is the only oral hypoglycemic agent that causes SIADH.

High

Gastrointestinal antispasmodic drugs: dicyclomine (Bentyl), hyoscyamine (Levsin and Levsinex), propantheline (Pro-Banthine), belladonna alkaloids (Donnatal and others), and clidinium-chlordiazepoxide (Librax)

GI antispasmodic drugs are highly anticholinergic and have uncertain effectiveness. These drugs should be avoided (especially for long-term use).

High

Anticholinergics and antihistamines; chlorpheniramine (Chlor-Trimeton), diphenhydramine (Benadryl), hydroxyzine (Vistaril and Atarax), cyproheptadine (Periactin), promethazine (Phenergan), tripelennamine, dexchlorpheniramine (Polaramine)

All nonprescription and many prescription antihistamines may have potent anticholinergic properties. Non anticholinergic and antihistamines are preferred in elderly patients when treatment allergic reactions.

High

Diphenhydramine (Benadryl) May cause confusion and sedation. Should not be used as a hypnotic, and when used to treat emergency allergic reactions, it should be used in the smallest possible dose.

High

Ergot mesyloids (Hydergine) and cyclandelate (Cyclospasmol)

Have not been shown to be effective in the doses studied. Low

Ferrous sulfate >325 mg/d Doses >324 mg/d do not dramatically increase the amount absorbed but greatly increase the incidence of constipation

Low

All barbiturates (except phenobarbital) except when used to control seizures

Are highly addictive and cause more adverse effects than most sedative or hypnotic drugs in elderly patients.

High

Meperidine (Demerol) Not an effective oral analgesic in doses commonly used. May cause confusion and has many disadvantages to other narcotic drugs.

High

Ticlopidine (Ticlid) Has been shown to be no better than aspirin in preventing clotting and may be considerably more toxic. Safer, more effective alternative exist.

High

Ketorolac (Toradol) Immediate and long-term use should be avoided in older persons, since a significant number have symptomatic GI pathologic conditions.

High

Amphetamines and anorexic agents These drugs have potential for causing dependence, hypertension, angina, and myocardial infarction.

High

Long-term use of full-dosage, longer half-life, non-COX-selective NSAIDs; naproxen (Naprosyn, Avaprox, and Aleve), oxaprozin (Daypro), and piroxicam (Feldene)

Have the potential to produce GI bleeding, renal failure, high blood pressure, and heart failure.

High

Daily fluoxetine (Prozac) Long half-life of drug and risk of producing excessive CNS stimulation, sleep disturbances, and increasing agitation. Safer alternatives exist.

High

Long-term use of stimulant laxatives: bisacodyl (Dulcolax), cascara sagrada, and Neoloid except in the presence of opiate analgesic use

May exacerbate bowel dysfunction. High

Amiodarone (Cardarone) Associated with QT interval problems and risk of provoking torsades de pointes. Lack of efficacy in older adults.

High

Orphenadrine (Norflex) Causes more sedation and anticholinergic adverse effects than safer alternatives.

High

Guanethidine (Ismelin) May cause orthostatic hypotension. Safer alternatives exist. High

Guanadrel (Hylorel) May cause orthostatic hypotension High Cyclandelate (Cyclospasmol) Lack of efficacy. Low Isoxsuprine (Vasodilan) Lack of efficacy. Low Nitrofurantoin Potential for renal impairment. Safer alternatives available. High Doxazosin (Cardura) Potential for hypotension, dry mouth, and urinary problems. Low Methyltestosterone (Android, Virilon, and Testred)

Potential for prostatic hypertrophy and cardiac problems. High

Thioridazine (Mellaril) Greater potential for CNS and extrapyramidal adverse effects. High Mesoridazine (Serentil) CNS and extrapyramidal adverse effects High Short acting nifedipine (Procardia and Adalat)

Potential for hypotension and constipation High

Clonidine (Catapres) Potential for orthostatic hypotension and CNS adverse effects. Low Mineral Oil Potential for aspiration and adverse effects. Safer alternatives

available. High

Cimetidine (Tagamet) CNS adverse effects including confusion. Low Ethacrynic acid (Edecrin) Potential for hypertension and fluid imbalances. Safer

alternatives available. Low

Desiccated thyroid Concerns about cardiac effects. Safer alternatives available. High Amphetamines (excluding methylphenidate hydrochloride and anorexics)

CNS stimulant adverse effects High

Estrogens only (oral) Evidence of the carcinogenic (breast and endometrial cancer) potential of these agents and lack of cardioprotective effect in older women.

Low

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V. ACUTE CARE SURGERY SERVICE

A. Resident and Other Schedules Limited vacations are allowed on the ACS Service. Any days you will not be available during the regularly scheduled hours (professional leave, etc.) must be prescheduled at least 1 month prior to the rotation. Trauma Service Residents are expected to be in-house for their entire shift. Any out of hospital time during your scheduled hours must be approved by the Trauma Attending on call in advance. Critical care residents need only have 1 person in-house for changeover.

Resident Schedule Day Team 0600-1800 (with changeover)

Day Off PGY-5 Sunday (no coverage, attending must respond to all resuscitations) PGY-3 Tuesday PGY-2 Tuesday EM-1 Monday Friday afternoon (ER educational session) Night Team 1830-0600 (with changeover)

Night Off PGY-4 Monday (covered by PGY4 or 5) EM-3 Thursday PGY-1 Tuesday Day Team Duties:

PGY-5 • Ultimately responsible for ensuring that all work on floors is completed and delegating

responsibility as needed. • Oversee care of all patients • Schedule OR Cases. Coordination of multi-specialty operations • Respond to Trauma Alerts and review management plan with Attending • Administrative coordination of trauma residents and midlevel providers:

-designation of duties -clinic -consults -floor care -new admissions -OR procedures

• Receive morning report from PGY-4 night resident • End-of-day check-out summary with team—patient update, task completion and review of new

daytime admissions • Direct (scrubbed) supervision of operative procedures by junior resident • Participate in trauma OR procedures • Approve elective cases with attendings • Report case list and present deaths at Trauma Conference • Chief will coordinate and approve out-of-hospital times for all service residents to ensure service

coverage during duty hours. • Maintain list of EGS complications and submit Thursday AM to WSU DOS office. • ACS Clinic Thursday 12:30-3:00pm (at least 1 resident must be present in clinic each day) • Responsible for filling in the New Patient Admission Record, including all CT/Xray results

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PGY-3 Surgery • Conduct daytime resuscitation under supervision of Chief/Attending • Day Off coverage for PGY-2 ICU • Start pre-rounds on 6SAC patients or ICU patients depending on patient census • F/U on all studies, labs and plans of care/discharge on patients you saw in pre-rounds • Call appropriate consultants • Update all computer progress notes for patients you personally saw • Respond to all Trauma Alerts and Consults • First choice of operations during the day (unless the PGY-5 plans to cover) • ACS Clinic Tuesday 12:30-3:00 pm (at least 1 resident must be present in clinic each day) PGY-2: Surgical/Critical Care • Primarily responsible for all ICU patients/issues with PGY 3 CC as support • Responsible for morning report from night ICU coverage and checkout to night ICU resident • Priority is care and coordination of ICU—may assist in ETC or the OR when appropriate • Keep Trauma Service informed of plans of other specialties involved in multiply injured patients • Maintain list of complications and submit for Trauma Conference • Review all XR early in the day • F/U on all ICU studies, labs, call appropriate consultants • Update computer progress notes for the ICU patients daily • Procedures for ICU patients—always call/Vis-Page attending prior to starting procedures • Flexion-extension studies for ICU patients • Schedule operations for ICU patients • Discuss patient condition and plan of care with family members with input from Chief and

Attending • Cover any surgery that PGY-3 not covering • Present x-rays at Trauma Conference • Respond to Trauma Alerts only if: (free to return to the ICU ASAP if things are under control)

-Multiple > 2 simultaneous traumas -Category I/Direct to OR -On days when the PGY-3 or EM-1 are off

ICU Nurse/PA This trauma staff member will work collaboratively with the residents in the ICU, accepting patient assignments, and providing case management for all ACS patients in the ICU.

EM-1 • Start pre-rounds on 3ESE patients • Update the computer progress notes for patients you personally saw • F/U on all studies, labs and plans of care/discharge on patients you saw on pre-rounds • Call appropriate consultants • Respond to all Trauma Alerts • See trauma consults, discuss with senior resident • May help with ICU lines/procedures as desired • ACS Clinic each Monday 12:30-3:00 • Print out new patient lists for night team for checkout rounds (6 copies)

Medical Students (Year 4) NOT primary contact for family Provide care for ICU patients under critical care resident supervision

Performance of ICU procedures should be under supervision of PGY 3 or higher Medical Students are encouraged to add progress notes to the patient’s chart but are not authorized to complete the patient’s H&P

Medical Students (Year 3) Chief resident delegates student to the other house staff or TNS/PA for direct supervision each day Participates in service duties as delegated

All residents are expected to maintain ongoing communication with respect to patient care and trauma service activities in an effort to maximize continuity of care, to avoid oversights in patient care and to help the team run efficiently and effectively. This is important at all times but becomes increasingly important during times of high patient census.

Residents will be expected to perform at a level representative of their level of training. This will be at the discretion of the Chief Resident and staff as appropriate.

All residents will be expected to act responsibly and will be accountable for their respective duties. The Chief Resident must approve absence from any resident duties for any reason.

Any resident concerns should be directed to the Chief surgery resident first.

Special requests (i.e., specific procedures or research interests, etc.) should be identified early in the rotation so they can be adequately addressed. These requests should be directed to the Chief Resident or attending as appropriate.

Trauma Nurses/Physician Assistants • One nurse/PA primarily starts pre-rounds on the 4th floor, the other nurse/PA primarily starts

pre-rounds on the 6th floor • Facilitate discharge of patients to home/ECF, discuss home care needs with Integrative Care

Management, transfer of patients to Rehab or other services • Each nurse/PA responsible for updating the computer progress notes of the patients they

personally saw • F/U on all studies, labs and plans of care on patients you saw on pre-rounds • ACS Clinic each Monday, Tuesday and Thursday: 12:30-3:00 • Respond to Trauma Alerts and Direct to OR’s • Trauma Nurse Call Line • Trauma Coumadin Clinic • May help or perform lines/procedures • See Rehab 4NW patients on Tuesday and Friday • Give out Guide to Trauma Services books to patients/family members • Tertiary Surveys should be completed and documented on the appropriate form for all patients

admitted by the night team Discharge Nurse This trauma nurse will accept up to 5 discharges as her patient responsibility. The goal is for patients to leave by 11 a.m.

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Acute Care Surgery Service Schedule 6:00am-7:00am -Morning Report--Be on Time

-If census light, will end earlier. -Location: ETC Conference Room

7:00am-9:00/10:00am -Pre-rounds/notes/Patient Discharges (Discuss discharges early with

Attending—Checkout is 11am) 9:00am-11:00am -Formal Rounds with Attending and PGY-5 12:00pm-1:00pm -Goal is to have all rounds complete. The remainder of the day is used

to complete all plans not completed during pre-rounds, F/U on all labs/new culture results/studies/call consultants and check their recommendations. It is important to try to keep all patients’ families up to date on plans of care/patient status, particularly in the ICU.

12:30pm-3:00pm -Monday, Tuesday, Thursday - ACS Clinic 6:30pm-7:00pm -Evening Report. Be on time

-If the census is light, it may end earlier. -Location: ETC Conference Room

Night Team Duties: PGY-4

• Ultimately responsible for ensuring that all work is completed at night (including completion of H&P’s) and delegating responsibility as needed

• Round on all ICU and floor patients (if time available) every night in order to be familiar with the service and plans of care.

• Respond to all Trauma Alerts and personally examine each Trauma Consult • Take patients to operating room • Assist with completing changeover assignments • Ensure the computer progress notes are updated, including any new overnight admissions,

changes in patient room numbers or other pertinent information • Ensure operative exposure for the night PGY-1 Surgery to Neurosurgery and Orthopedics cases • Ensure postoperative checks are done by the junior residents on all general surgical and

subspecialty patients

EM-3 • First call for questions regarding ICU patients • Backup for PGY-1/critical floor issues • Respond to all Trauma Alerts and Consults • Assist with completing all changeover assignments • Assist with completing H&Ps and recording all CT/Xray results if PGY-1 busy/overwhelmed.

The PGY-1 is primarily responsible for doing this; however, it is your responsibility to ensure that this is being done and to help out if it is not.

• Responsible for filling in the New Patient Admission Record, including all CT/Xray findings • Update the computer progress notes including any new overnight admissions, changes in patient

room numbers or other pertinent information • ED and ICU procedures

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PGY-1 • First call for questions regarding floor patients • Respond to all Trauma Alerts • Assist with completing all changeover assignments • It is your responsibility to fill out all history and physical exams on new trauma admits,

including results of all CT’s/Xrays/labs • Update the computer progress notes including any new overnight admissions, changes in patient

room numbers or other pertinent information • Progress Notes should have 24 hour I/O recorded and new labs recorded in the boxes. If only the

previous days labs are available or recent ones, these should be dated and timed above the current lab recording box

• Print out new patient lists for day team for checkout rounds (6 copies) or Trauma Team Changeover Record

• If you are overwhelmed ask the EM-3 or PGY-5 to help with your duties

TNS/PA • Respond to all Trauma Alerts, complete duties as assigned • Assist in management of floor or ICU patients as assigned

Night Team Duties that must be completed prior to AM Check Out:

• Make sure that all changeover assignments checked out by the day team have been completed • Print out the new patient lists for the day team for checkout rounds or Trauma Team Changeover

Record • Do chart checks (generally after 3-4 am), noting any pertinent overnight events or issues and fill

in all available labs, vitals, pending study results, I/O’s, drain/chest tube outputs, ventilator settings, Swan readings, and drips on the progress notes for the day team. Be accurate. You do not need to necessarily see/wake up patients, although in the ICU this is usually not an issue.

• Be on time for AM & PM Report • Perform tertiary surveys on all patients admitted by the day team and document

**Unexpected things happen both during the day and at night. All team members have their “assigned duties,” but each team member should be willing to assist with completing work assigned to other members in order to ensure that all work is completed and nothing is missed.** **Make sure patients for admission have IV’s, OP consents, H&P’s, T&C, NG tube, Foleys, and x-rays and appropriate lab studies as indicated. OP Consents protect you---even in the case of urgent/emergent procedures they are a good idea.

Trauma Service Handoff Report Procedure

Change of Shift 1. On-coming and off-going trauma service members meet in the E.R. conference room every 12 hours to

exchange pertinent, issue oriented patient information. 2. A printed list of all patients on the service is prepared prior to the time of report and each patient’s daily

needs/results are given verbally to oncoming staff. 3. Brief question and answer exchanges occur as needed for clarification. 4. Report is grouped by patient type such as Intensive Care Unit, Emergency Surgical and Trauma. 5. Patients awaiting disposition or consultation in the Emergency Room are also presented – generally at the

end of the report.

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6. Patient assignment is usually done by the Chief Surgical Resident and the trauma mid-level. Surgical patients are assigned to Team A and are assigned to the residents.

7. Non-surgical trauma patients are assigned to Team B and are assigned to the mid-level providers. Transfer of Admitted Patients from Emergency Room 1. Trauma patients who present to the Emergency Department (ED) are assessed for acuity by the Trauma

Team and then disposition is determined. 2. Critical patients are admitted to the ICU and less severely injured patients are admitted to the inpatient

trauma unit. 3. The Chief Resident calls a summary report to the team member on the corresponding unit as patients are

transferred. Transfer of Patients from One Inpatient Unit to Another 1. The acuity level can change during a patient’s hospitalization. These changes necessitate intra-hospital

transfers. 2. When a patient transfer is required, the trauma team member caring for the patient calls the receiving team

and gives report. Patient Check-Out Guidelines The trauma service at MVH is very busy and the change of shift report process can be quite lengthy. The information which is relayed at shift change is critically important and needs to be conveyed in the most efficient, accurate format possible, in an effort to promote the highest quality of care for our patients. It is therefore requested that the following format be followed regarding staff shift report: 1. Last name of patient, mechanism of injury, brief summary of major injuries. 2. Summary of pertinent surgeries or interventions 3. Any current family/social issues 4. Code status if not full code 5. Diagnostic tests, labs, studies, or consults pending 6. Recent change in status/vital signs or mental status 7. Disposition plans 8. Aspects of care requiring close monitoring for the next 24 hours Please avoid digression/editorializing or labeling patients. If more detailed information or evaluation of imaging reports is essential, please keep reviews and questions brief and succinct. Communication PHONES

Phone Day Night 7203 Attending On Call Attending On Call 9178 Attending On Trauma Rounds 3056 Attending On ICU Rounds 7204 PGY5 PGY4 3292 PGY3 7201 ICU Resident ICU Resident (ER) 3141 ICU Resident #2 7202 ICU Resident #3 9176 PGY1 (ER) PGY1 (Surg) 6822 Trauma Nurse 1 6823 Trauma Nurse 2 9177 Trauma PA 1 Trauma PA 1

2658 Trauma PA 2 Trauma PA 2 6824 Trauma Ortho Nurse 4282 Integrative Care 3535 Social Worker 4537 Pam Shadley-Neuro CNS 5834 Attending Call Room 3513 EGS – ICM 6181 Angie Straughn Pharmacy

If a resident level is off for the day, then an alternate should carry the phone or it should be forwarded. The nursing staff and radiology have been given these phones as direct contact numbers.

PAGERS

Person/Position Pager 2290- Outside Pager Anderson, III, Harry 3106 334-3736

Baker, Jamie 4031 334-5889 Bruun, John 5096 334-4396

Comer, Jennifer 1870 DeCaestecker, James

Denlinger, Liz 1609 359-4673 Dock, Jason 5693 334-5788

Ekeh, A. Peter 4223 344-2260 Francis, Andrea 5316 334-1590

Goldblatt, Matthew 2496 480-0191 Green, Tara 1871 973-4976 Guye, Mary 5672 334-3083

Kimpel, Diane (Ortho RN) 3150 359-4610 Matosky, Debra 3469 334-5069

Matthews, Lynette 3121 359-0669 McCarthy, Mary 1661 359-0778

Ortho-ICU Resident 4020 PGY1 Days#1 1676 PGY1 Night 1626

PGY2/ICU-Days#1 1634 PGY2/ICU-Days#2 2234 334-2475

PGY3 Days 1658 PGY3 Nights 1677 334-2093 PGY4 Nights 1815 334-2195

PGY5 Trauma Chief 1080 973-2685 Roller, Jason 5374 334-4709

Saxe, Jonathan 5557 334-2502 Studebaker, Angela 1653 770-2057

Tchorz, Kathryn 4019 334-6496 Updyke, Glenda 2519 334-5828

Walusimbi, Mbaga 1909 220-5894 Weiss, Leeana 3200 334-2543 Woods, Randy 4451 369-9281

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Attending Schedule The Trauma Rounding (TR) schedule will generally be assigned in blocks of Monday through Thursday and Friday, Saturday and Sunday. The TC will be assigned on a rotating daily basis as 12 or 24 hour shifts. Trauma Call (TC) Responsibilities 7AM-6AM 24 hour or 7AM-6PM, 6PM-6AM, 12 hour shifts Respond to all trauma resuscitations In-house 7AM to 6PM; free of other responsibilities Attend PM changeover 6:30PM-7PM Assist with rounds or procedures Trauma Call 2 (TC2) First call backup for multiple trauma admissions Trauma Rounds (TR) Responsibilities See all Trauma Service patients daily and write attending notes Ensure that 4 NW patients are seen twice a week by the Trauma Team Arrive promptly for 6 AM changeover and cover Trauma Alerts 6AM-7AM Review pertinent positive films on the previous night’s admissions Available for PM cases and patient office hours If during assigned rounds a patient needs to be scheduled for a minor procedure (trachs, peg’s or filters) that can not be completed over the weekend, the following rule will apply:

The original rounding physician will complete the surgery or procedure if it occurs on the Monday following the end of the rounding assignment, but if the patient is scheduled for Tuesday or later in the week, the new rounding physician will assume that responsibility. If the schedule of the Attending coming off rounds conflicts with performance of the procedure, communication between the Attendings will allow a smooth transition to the new rounding Attending. For all other procedures the admitting Attending has the right of first refusal for all procedures.

ICU Rounds (ICU) Supervise all procedures in ICU Available for PM cases and patient office hours WSS Call (WSS) Assigned Monday-Sunday 1 week at a time, when possible Trauma Backup for multiple admissions call 208-2552 for response (rolls over to answering service at night). Trauma Clinic (TC) 1:00-3:30 pm - Monday, Tuesday and Thursday Covered by the Trauma Attendings on a rotating basis If the responsible attending is not available, then they should arrange alternate coverage and notify the clinic staff at ext 6822 or 6823.

Trauma Procedure Lab Occurs at 7:00 a.m. the first Friday of every month. The Chief Trauma Resident and/or the Trauma Attending on call will staff the lab, and all trauma personnel are required to attend.

Trauma Attendings Updated 11/5/08 Surgeon Call 1st Call 2nd Call 3rd H. Anderson, III 293-2250 pager 3106 937-29-0963 J. Bruun 885-3445 pager 5096 614-812-7608 J. DeCaestecker 238-5445 636-7127 J. Dock 257-9514 pager 5693 304-4640 P. Ekeh 344-2260 pager 4223 428-9820 M. Goldblatt pager 2469 855-1062 414-477-0634 M. Guye pager 5672 369-9732 369-9732 M. McCarthy 426-2555 pager 1661 266-7067 J. Saxe pager 5557 438-5424 344-2261 K. Tchorz 297-0509 pager 4019 214-354-2566 M. Walusimbi 344-2262 pager 1909 R. Woods 372-9153 pager 4451 369-9281

Outside pager 208-2290 Inside pager 2290

The Trauma BAT phone in the ETC is automatically programmed to attending cell phones. Use for prompt notification of Category I’s if the attending is out of house.

Indications to Call in TC2 TC1 in OR and a Category I patient is in route > 3 Category I patients simultaneously > 5 admissions in less than 2 hours > 1 Trauma/EGS OR case, OR available for the second case, too. Remember the Trauma Chief Resident is also available at night if needed.

Contacting the Trauma Research Department To reach the on-call research nurse, 24-hours a day/7 days a week (urgent or patient-related contact), use one of the following methods:

Digital Pager - 1969 (first enter the access code 2290) Wireless Office Paging – Send to “Research, Trauma” By phone or voice mail - Ext 4659 (If no answer, leaving a

message will generate a page to the on-call research nurse.)

To contact specific Research Nurse - (non-urgent matters) Jean Sands Pager 1213

Phone ext. 2913 Kay Lowe Pager 3352

Phone ext. 3307 Eileen Vagedes Pager 5097

Phone ext. 4878 Wireless Office Paging - By individual’s name

Through MVH Outlook email - By individual’s name

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Resident Meeting Schedule

WEEK MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY 1 • 7-8 am

M&M • 12:30-4

Clinic

• 12:30-4 Clinic • 5:00 pm

Resident Procedure Lab

• 7-9:30 am Surgical Grand Rounds & Jeopardy

• 11:30-12:30 Trauma Patient Review 3W/SW Conf. rm

• 7:00 Trauma Conference-3rd fl Surg Conf rm

• 11-12 ICU Multidisciplinary Conf. Pod C

• 12-1 ICU lunch Rounds/Presentation – Pod A

• 12:30-4 Clinic

2 • 12:30-4 Clinic

• 7am Trauma Committee 6NW2*

• 12:30-4 Clinic

• 7-9:30 am Surgical Grand Rounds & Jeopardy

• 11:30-12:30 Trauma Patient Review 3W/SW Conf. Room

• 7:00 Trauma Conference-3rd Fl Surg Conf Rm. (Cardiothoracic Service)

• 11-12 ICU Multidisciplinary Conf. Pod C

• 12-1 ICU Lunch Rounds/Presentation – Pod A

• 12:30-4 Clinic

3 • 12:30-4 Clinic

• 12:30-4 Clinic • 7-9:30 am Surgical Grand Rounds & Jeopardy

• 11:30-12:30 Trauma Patient Review 3W/SW Conf. Room

• 7:00 Trauma Conference-3rd Fl Surg Conf. Rm

• 11-12 ICU Multidisciplinary Conf. Pod C

• 12-1 ICU Lunch Rounds/Presentation – Pod A

• 12:30-4 Clinic

• 11:30-12:30 ICU Journal Club

(Pod A Conf. Rm.)

4 • 12:30-4 Clinic

• 8 am Trauma Joint Practice 6NW (Jan, Apr, July & Oct)

• 12:30-4 Clinic

• 7-9:30 am Surgical Grand Rounds & Jeopardy

• 11:30-12:30 Trauma Patient Review 3W/SW Conf. Room

• 7:00 Trauma Conference-3rd Fl Surg Conf Rm. (Orthopaedic Service)

• 11-12 ICU Multidisciplinary Conf. Pod C

• 12-1 ICU Lunch Rounds/Presentation – Pod A

• 12:30-4 Clinic

5 • 12:30-4 Clinic

• 12:30-4 Clinic • 7-9:30 am Surgical Grand Rounds & Jeopardy

• 11:30-12:30 Trauma Patient Review 3W/SW Conf. Room

• 7:00 Trauma Conference-3rd Fl Surg Conf Rm.

• 11-12 ICU Multidisciplinary Conf. Pod C

• 12-1 ICU Lunch Rounds/Presentation – Pod A

• 12:30-4 Clinic

* Trauma Chief Resident required attendance per Dr. Termuhlen

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MINI-DISASTER PLAN Purpose: To provide guidelines for the utilization of hospital resources, including personnel, to ensure optimum efficiency in the evaluation and treatment of multiple injured patients; to provide a quality patient care environment; and to minimize the rerouting of patients to other facilities.

Activation: Activation of the plan will be considered when:

Three (3) or more Category I trauma patients are expected in a short period of time and available in-house services may not be sufficient to provide adequate care.

Activation of the plan will be initiated when:

Five (5) or more Category I trauma patients arrive in a short period of time. or Fifteen (15) or more total patients arrive in a short period of time.

Decision of activation will be a collaborative effort of:

ETC Physician Director of Trauma (or designee) ETC Nurse Manager or Administrative Officer ETC Shift Manager

Decision-making will take into consideration:

Emergency and Surgery physicians Emergency Trauma and staff Specialty surgical resources, particularly Orthopedics and Neurosurgery Operating suites, staff, and anesthesia Critical care beds

Overwhelming circumstances: A community disaster causing large numbers of actual or potential patients will prompt the group to activate a Disaster Standby and notify the Administrator of a potential need for activation of a Disaster Alert.

Overwhelming numbers of trauma victims at MVH only will prompt the group to consider rerouting. Rerouting will only be utilized if patient care is compromised, and patient care would be better served at another hospital. If this group decides rerouting is indicated, the Administrator on-call will be contacted for administrative approval. It is preferable to reroute ground units prior to rerouting the helicopter. If permission to reroute is granted, use the reroute policy. References: Trauma Mini-Disaster Reference List for the ETC Shift Manager, Administrative Officer, ETC physician, and Trauma Director is to be utilized during a trauma mini-disaster.

PATIENT AND FAMILY INTERACTIONS

A. WHAT HEALTH CARE CUSTOMERS WANT Control over Their Own life

• Need to feel they are active participants in decisions that affect them and in their own care. • Do not want to feel taken advantage of, manipulated or deceived. • Important to treat a loved one's question/concern with the same respect, courtesy and prompt

action. Achieve Goals

• Want to feel whatever they do in organization is moving them toward a goal.

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• Want to know what you are doing to/for them serves an important purpose that will bring them satisfaction and achieve desired results.

Preserve Their Self Esteem • To be treated with courtesy, dignity and respect. • Need approval and acceptance and to be praised for their participation in their care.

Treated Fairly • Want to feel they're receiving the same attention, same degree of competence and same level of

treatment as everyone else. Friendliness

• Expect competence; want to like and trust you. • Hope for service to be friendly, warm and caring.

Information and Feedback • Want to know what is happening and why. • Become frustrated and angry when:

o Do not understand. o Are not given enough information to understand o Are given information in technical manner they are unable to understand

Security • Strong need to feel safe and secure - Physically

Staff Equipment

Feel Important/Appreciated

• Recognized for their importance. • Expect full and prompt attention and proper consideration. • Valued and appreciated.

Honesty • Need to believe organization and staff who represent it are honest and trustworthy. • Trust becomes a casualty when:

- Sense facts are being misrepresented - Feel they are getting runaround - Sense some dishonest dealing is happening

When Issues Occur Strategies for handling problematic patients/families Acknowledge problem and address immediately. (Use communication strategies.) Utilize a team approach and use your resources. Appoint a family spokesperson. Encourage a family member to use some method of getting information to other family members that are waiting for updates. This will add to the family’s satisfaction and could potentially eliminate excessive calls to nursing units for information. One helpful tool that can be suggested is Caring Bridge. Caring Bridge, www.caringbridge.com , is a non-profit web service providing free websites for families during critical illness and allows the family to set up the website for national or international communication about their loved one. This type of information sharing and ongoing communication within the patient’s family can be very helpful in difficult situations. Resources that can help

- Attending Physician - Family physician and/or specialist Nurse Manager - Consumer Relations

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- Pastoral Care - Palliative Care - Social Services/Discharge Planning - Risk Management/Hospital attorneys - The patient - Other family members

After Hours Integrative Care Management (ICM) Care Guidelines Saturday and Sunday Coverage: 9:00am to 5:00pm – ICM staff is in-house and will follow up on TDS referrals and personal contacts. You may contact the following staff: Care coordinator – pager 1281 Social Worker – pager 1232 Home Care Liaison – extension 8515

After 5:00pm and on Holidays:

Transportation

Advance Directives / witnessing / Notary

Home Medical Equipment

Home Care

Bus Tokens: Security – ext. 3366 Administrative Officer –

ext. 5745 (critical care unite); or ext. 5746 (Med/Surg or other units)

Contact Administrative Officer at ext. 5745 or 5746 regarding need for notary or witnessing service.

Contact ext. 6400, speak with operator; provide your name, phone number, name of patient, and type of equipment needed.

Contact ext. 6400, speak with operator; provide your name, phone number, name of patient, and type of equipment needed.

Taxi Transportation: Contact 222-2822

(Miami Liberty Cab) with pt. name, address going to, pick up at what MVH entrance

Charge to PO 2016

Fidelity Triage Nurse will call you back within 30 minutes

Fidelity Triage Nurse will call you back within 30 minutes

Ambulance/Ambulette: Contact EMT @ 1-800-566-6125 to request ambulance/ambulette service – will need face sheet info and physician order.

What Happens When Patients Don't Get What They Want? Communicating With the Patient and/or Family

Strategies: • Introduce self and explain role. • Listening is vital — let the patient/family talk. Identify focus of concern. • Acknowledge patients/families' feelings (empathize/sympathize). • Answer questions fully. • Apologize when appropriate. • Keep communication lines open.

What not to do: • Dismiss • Refute • Defend actions or colleagues

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BREAKING BAD NEWS

ISSUES THAT MAKE THE SITUATION MORE DIFFICULT: Denial

• May be strong coping mechanism • Relatives may encourage • May be total (rare) • May be ambivalent • Level may change over time

Dealing with difficult questions (Why me? How long does s/he have? What happens after this? What's next?)

• Check reason for questions — for example, "Why do you ask that now?" • Show interest in patient's idea — "I wonder how it looks to you?" • Confirm or elaborate. • Be prepared to admit that you don't know — "The uncertainty must be hard to take, but I'm

afraid we just don't know at this moment." • Empathize — "Yes, it must be seem unfair."

Major emotional reactions

• Anger — often misdirected towards health professionals • Guilt — feelings that this is a result from something that occurred in the past • Blame — belief that current situation is fault of others

Physician Factors (costs to professionals dealing with patients and their families)

• Fear of causing pain Inflicting pain is unpleasant No anesthetic to remove pain of hearing bad news Conscious infliction of pain against the "normal rules"

• Sympathetic pain Likely to experience considerable discomfort by being with those going through the distress caused by bad news Discomfort causes "need to flee" feeling.

• Fear of being blamed Blaming the messenger — anger/distress often directed at this person Somebody must be at fault — an illusion fostered by the public that all medical ailments are fixable.

• Feelings of failure Feelings of helplessness when faced with insoluble problems Imbalance between work and relaxation Risk of emotional burnout

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RECOMMENDED MANNER OF BREAKING BAD NEWS Give thought to location

Elicit person’s understanding

YESDoes person know or suspect the truth NO

Fire warning shot Explore level of knowledge

Break news at person’s pace in manageable chunks

Confirm news at person’s pace

Acknowledge immediate reactions

Allow person time for initial shock

Deal with emotional reactions and questions

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DEALING WITH ANGER

Offer support as appropriate

EFFECTIVE APPROACH INEFFECTIVE APPROACH

Acknowledge anger

Refute focus

Defend actions of colleagues

Anger spirals upward

Dismiss anger

Identify

Legitimize (if appropriate)

Anger is diffused

Encourage expression of anger

PATIENT SATISFACTION

The following information is to help you deal with patients and families while rotating on the Trauma Service at MVH. MVH has been using a nationally known company and their standard patient satisfaction survey to track problems and issues related to the patient's hospital stay. The Trauma Service tracks its performance based on the survey.

The Trauma Service receives quarterly reports on our scores. MVH sets a yearly goal for the Trauma Service in regard to our performance. MVH and the Trauma Service Administrative Staff take these scores very seriously. As physicians rotating on the Trauma Service, your performance is evaluated by the patients in your care. During the Trauma Service orientation, you will receive information on our discharge process and our pain management guidelines. It is the expectation of the Trauma Service attending physicians that you follow these pain management guidelines and communicate with your patients and families in a professional manner adhering to our customer service standards.

GUIDELINES FOR JEHOVAH’S WITNESSES

Purpose: To guide therapy for the multiply injured Jehovah Witness patient who refuses blood and blood products. Rationale: Guidance of therapeutic adjuncts related to bloodless surgery and/or conditions which necessitate therapeutic adjuncts to improve 02 delivery. Considerations: The information assists in treatment of impending life threatening situations. Personnel Qualified to Perform Procedure:

Trauma Attending Physician Surgery Resident Trauma CNS/PA Registered Nurse

Procedure: Preoperatively

Ask: "Will you take blood? or "blood products? fresh frozen plasma, albumin, platelet, etc. Will you accept cell saver blood?" (Describe and connect as a continuous circuit system) Ask about bleeding history Stop anticoagulants and anti-platelet drugs Minimize blood draws

use pedi tubes or istat need only 20ml for trauma labs, also draw type and cross 2 red tubes 1 lavender 1 blue

Hemodilution with fluids

Trauma Pelvic Orthotic Device (T-POD) to tamponade hemorrhage from pelvic fractures and traction splints to minimize blood loss from femur fractures. Obtain signed consent for any adjuncts given.

Intraoperatively

Hemodilution with fluids Modified washed cell autotransfusion if acceptable to patient

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Infuse cells at the conclusion of case Recycle chest tube blood as continuous circuit, or drains through chest tube drainage system

if blood loss is massive Halstedian principles-stop active bleeding

-Cautery, argon beam, coagulating scalpel -dissect along anatomic planes -clamp, then cut -stage complex procedures

Utilize orthopedic maneuvers for bleeding control -traction -external fixator

Pharmacologic adjuncts -Fibrin glue/tissue adhesives -Topical agents — Avitene, Gelfoam, Oxycel, Surgicel

Postoperatively Reduce phlebotomy

-pedi tubes, VAMP's on lines (setup as closed circuit system) -No routine labs, each lab must be individually ordered

Embolization Adequate nutrition Guidewire line changes rather than new sticks Stop menstrual period (female patient)

-after negative pregnancy test, give Depo-Provera 150mg IM one time only Do not use agents that increase bleeding times, e.g. Hespan Paralyzing agents (analgesia/sedation/paralysis)

-to minimize 02 consumption -Swan Ganz insertion to monitor pharmacologic adjuncts if needed

Pharmacologic Adjuncts IV Iron Indication - inadequate iron store (transferrin saturation < 20% and/or ferritin < 100 mg/ml/), intolerance to enteral iron (nausea/constipation) 1. Iron dextran – administer a test dose

Give IV Iron dextran 25 mg/50 ml Normal Saline IV test dose over 15 minutes. Monitor vital signs every 15 min for 1 hour. Monitor for shortness of breath, bronchospasm, chest or back pain, flushing of the skin, hypotension. If no adverse events, then give 975 mg/500ml normal saline IV over 4 – 6 hours (1gm elemental iron)

Advantages: can give as a total dose Disadvantage: A test dose is necessary. Patients can be allergic to the dextran component of the product.

2. Ferric gluconate (Ferrlecit) 125mg/100ml

Give 125 mg IV once daily x 8 days (total of 1gm elemental iron.) Advantages: no test dose is necessary (doesn’t contain dextran) Disadvantage: cannot be administered as a total dose. If the transferrin saturation > 20% and/or ferritin > 100, continue with enteral iron, Ferrous sulfate 324 mg tablet TID or Ferrous sulfate 300 mg liquid TID

3. Iron Sucrose (Venofer) 200mg/100ml NS Give 200mg IV three times per week times five doses (total 1gm elemental iron). Advantages: no test dose Disadvantages: can not be administered as a total dose.

Repeat transferrin saturation and ferritin every 2 weeks while on erythropoietin therapy. Erythropoietin — Each 1ml of solution contains 2.5 mg human albumin. This must be explained to the patient and erythropoietin should be given only to those patients who consent to its use. 150 U/kg SQ (preferred) or IV qd x 7 days, then three times weekly. The EPO dose in the most recent Corwin trial – Efficacy of Recombinant Human Erythropoietin in Critically Ill Patients (JAMA.2002;288(22):2827-2835.) was 40,000U SQ weekly X 3 doses (or 4 doses if the patient was in the ICU > 21 days). In the renal transplant population, enteral iron doesn’t support the RBC production by EPO. Dialysis patients get very regular parenteral iron supplementation.

VitaminB12 1,000 mcg IM (one time only) Folic Acid — 1 mg qd po/IV/IM PolyHeme Human polymerized hemoglobin (PolyHeme) is a universally compatible, disease free, oxygen-carrying resuscitative fluid. PolyHeme is safe in acute blood loss, maintains total (Hb) in lieu of red cells despite the marker fall in RBC (Hb), and reduces the use of allogeneic blood. However, because it is of human origin, most Jehovah’s Witnesses will not accept it.

References: MVH Division of Dialysis and Transplantation Iron Sucrose Protocol (Mar 2003). Pell, LJ, Martin BS, Shirk MB. Epoetin alfa protocol and multidisciplinary blood-conservation program for critically ill patients. Am J Health-Syst Pharm.2005;62:400-405.

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APPENDIX I TRAUMA PHONE BOOK

Name

Office Extension (prefix 208)

First contact

Pager

Home Phone

Trauma Phones Trauma Attending On-Call 7203 ICU Rounds (Attending) 3056 Trauma Rounds (Attending) 9178 MVH Trauma Attendings (Surgical Critical Care)

Anderson, Harry L. III 4741 3106 Secretary, Kathy 2951

Ekeh, A. Peter 6021 4223 Secretary, Mary P. 2468

McCarthy, Mary C. 2359 1661 Secretary, Mary P. 2468

Saxe, Jonathan M. 2601 5557 Secretary, Mary P. 2468

Tchorz, Kathryn M. 3775 4019 Secretary, Lorelei 2177

Walusimbi, Mbaga S. 6605 1909 Secretary, Kathy 2951

Woods, Randy J. 6063 4451 Secretary, Mary P. 2468

Other Trauma Attendings Bruun, John, MD 257-9922 DeCaestecker, James, MD 832-9310 Dock, Jayson, MD 257-9514 Dunn, Margaret , MD 775-2033 page 334-5216 Goldblatt, Matthew, MD 257-9514 none none Guye, Mary, MD 257-9922 none none Trauma PA Baker, Jamie 4084 4031 Francis, Andrea 6778 5316 Roller, Jason 4352 5374 Updyke, Glenda 4352 2519 Weiss, Leeana 4084 3200 Ortho PA 9180

Trauma Nurses Denlinger, Liz (Manager) 2380 1609 Comer, Jenny 2815 1870

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Green, Tara 2852 1871 Matosky, Debbi 2815 3469 Studebaker, Angie 2887 1653 Ortho Nurse, Diane Kimpel 6824 3150 ER phone #’s: North 3876

Name

Office Extension (prefix 208)

First

Contact

Pager

Home Phone

South 3877 East 3873 Select Care 3879 Obs 3879 Triage 3875 ER Security 8022

ER Trauma Rooms: Rm 36 8043

RN 5769 Rm 35 8044

RN 8853 ER Resource Nurse 5764

ER (STAT) Lab 8053 Max-Face Trauma On-Call Christman, Ken 435-5354 463-1575 Ewig, Jack 426-8083 463-1725 Fox, Matthew 886-2980 463-1585 Johnson, R Michael 208-3774 page 635-3737 Pettit, Dennis 878-8694 page 850-5413 Neurological Surgeons

Africk, Cynthia 2088 463-1829 334-4509 Eichert, Steven 2088 463-1500 334-2368 Minella, Phillip A. 2088 463-1829 220-0023 Moncrief, Hugh 2088 463-1733 940-2368 Shadley, Pam, Neuro RN 4537 none 2089 Opthalmology

Besson, Michael J. 320-2020 none Warwar, Ronald E. 297-7676 973-0725 Grandview Eye Clinic Daytime calls to Attending Night calls to Residents (See Opthalmology on-call schedule on-line under “Staff Rotating”)

Clinic # 723-4994 Attendings – David Or 427-2828 E.R. Thomas 223-4836

Resident Drs.’ pagers- Cook-334-5444 Mihok-334-2432 Riley-334-2650

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Orthopaedic Surgeons

Binski, James 312-1581 636-2130 DiCicco, Joe 428-0400 370-0945 Herbenick, Michael 2091 480-3025 Laughlin, Richard 2091 973-6149 Peters, Timothy 836-4042 227-0015 Powell, Shelli A. 836-4042 973-0727 Prayson, Michael 2091 638-1090 Rubino, Joe 2091 334-6505

Name

Office Extension (prefix 208)

First Contact

Pager

Home Phone

Plastics

Alexander, Stanley 439-5500 201-4747 Christman, Ken 435-5354 none Johnson, R Michael 208-3774 635-3737 Schmidt, Steven P. 886-2980 330-2384 Rehab MDs: On call pager

is 800-212-1297

Gilliotte, Benjamin 2020 4274 Jacob, Antony 2020 2497 Pedoto, Michael 2020 2499 Watts, Michael 2020 3109 Urology

Litscher, Lawrence 2540 463-1643 220-7514 Key, David 2540 463-1643 none Monsour, Mark A. 2540 463-1643 334-4542 Vascular Surgeons

Rundell, William K 6264 636-2989 Simoni, Eugene 276-2642 none Hospitals/Centers/Clinics Main Number ER Phone ER Fax Cleveland Clinic (216)444-2200 Clinton Memorial (937)382-6611 Community Hospital, Springfield

(937)325-0531 (937)328-9372 (937) 328-9185

Dayton Childrens 641-3000 223-8410 641-5402 Dayton Heart 221-8000 221-8911 221-8509 Far Hills Surgical Center 294-9840 Good Samaritan 278-2612 897-8311 897-8217 Grandview 226-3200 226-3419 226-3864 Greene Memorial 429-3200 352-2508 352-3501 Kettering Memorial 298-4331 395-8166 395-8347 Lima Memorial Hospital (419)228-3335 Mercy Hospital, Urbana (937)653-5231 (937)484-6160 (937) 484-6183 121

Mercy Med Canter, (Springfield)

937-390-5000 (937) 390-5028 (937) 390-5526

MVH South 894-0 438-2400 Miami Valley Urgent Care 252-0990

Name

Office Extension (prefix 208)

Hospitals/Centers/Clinics Main Number ER Phone ER Fax Middletown Regional (513)424-2111 (513)420-3924 (513) 420-5133 OSU (614)293-8000 Reid Memorial (765)983-3092 Samaritan North Health Center 276-6784 Southmed Imaging 208-6979 Southview 439-6000 439-6228 439-6158 Springfield Community (937)325-0531 Springfield Mercy (937)390-5000 SureCare Medical Center 439-6000 Sycamore Hospital (937)866-0551 384-8787 384-8729 University of Cincinnati (513)584-1000 Veterans Admin Med Center 268-6511 262-2134 262-5962 Wayne Hospital, Greenville 937-548-1141 547-5777 547-5790 Wilson Memorial 937-498-2311 (937) 498-5300 (937) 498-4201 WPAFB Medical Center 257-1110 257-3295 656-1673 RELATED CONTACTS Pager Acute Occupational Therapists

4629 3083 (hand)

Acute Physical Therapists 2102, vestibular 7450, 6090, 4868

Acute Speech Therapists 6277 or 4629 Anesthesia on Call 8576 BAT Consult MVH 6387 2018 Chaplain 2499 1945 Drake Center (513)948-2500 Delaney, Beth (ICM) 5287 2607 Dental Clinic 2704 or 6191 Downing, Donna (Social Serv.) 3535 1198 Endoscopy 2309 or 3540 Enterostomal Therapy Dept: 3780 1528 or 2060 Fidelity 6400 Fluoro in ICU 3029 or 4079 General Counsel Office 2266 Gilchrist, James, PhD (Psych) 3563 ICU Resource RN 8590 1796 Jobst Stockings 461-BONE LaForsche—OrPro 228-5462 491-1991 Life Connections 223-8223 122

LifeCare Nursing 384-8314

Name Office Extension (prefix 208)

Pager

Montgomery County Coroner 225-4156 Nolan, Dan 2858 3360 Pain Service: 1771 Cathy Trame 5127 3132, 5127 April Hickey 6639 4136,6639 Cheri Rowe waiting 4277,4731 Parilo, Miguel A. 7241 480-0142 Smith, Townsend 2723 636-0388 Trame, Cathy 5127 3132,1771 Rehab Coordinators: Sheryl 4823 Kris 3870 Paula 1410 Transcription 2424 Dictation 2309 (Work type

89 for all ACS patients)

Trauma Program Doersam, Winnie (Assistant) 2312 Trauma Registry Burton, Carolyn 3321 Delinger, Jim 6135 English, Shirley 4109 Matthews, Lynn 2932 Miller, Julie 4242 Philpot, Darcus 2456 Pager Ultrasound 2261 or

591484

Vascular Lab 2373, 591866, 3375

1298

Dial this prefix and the extension for direct connect to these hospitals:

Good Samaritan Hospital 897 – extension Middletown Regional Hospital 895 – extension

Miami Valley Hospital (when off-site) 896 – extension

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