ut trauma handbook
TRANSCRIPT
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TRAUMA RESIDENT
HANDBOOK
Elvis Presley Memorial Trauma Center Department of Surgery
Division of Trauma and Surgical Critical Care University of Tennessee Health Science Center
Memphis, Tennessee
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Contents GENERAL POLICIES
Trauma Service Policies 4 Conferences and Clinics 10 Service Assignments and Transfer 11 Universal Precautions in the Trauma Rooms 12 Criteria for Triage to Trauma Rooms 13 Routine Trauma Labs 14 Consults 15
HEAD/SPINE Cervical Spine Clearance 16 Spinal Cord Injury with Deficit 17 Dermatomes 18 Sensory Levels 19 Classification of Spinal Cord Injury 20
NECK Blunt Cerebrovascular Injury 22 Penetrating Neck Injuries 23 CHEST Blunt Aortic Injury 24 Emergent Thoracotomy 25 Hemothorax 26 ABDOMEN/PELVIS Hemodynamically Unstable Blunt Abdominal Trauma 27 Hemodynamically Stable Blunt Abdominal Trauma 28 Antibiotics for Penetrating Abdominal Trauma 29 Anterior Abdominal Stab Wounds 30 Blunt Liver Injury 31 Blunt Splenic Injury 32 Pancreatic Injury 33 Organ Injury Scales 34 Management of Pelvic Fractures 37 Tile Classification of Pelvic Fractures 38 VASCULAR Ligate vs. Repair 39 Neurovascular Injuries 40 EXTREMITIES Fracture/Dislocations 41 Muscles and Nerves 42 Mangled Extremity Severity Score 43 SURGICAL CRITICAL CARE Diagnosis & Empiric Therapy of VAP 44 Risk Factors & Prophylaxis for DVT 47 Herbal Supplements 48 Ventilator Weaning 52 Management of Hypertension 53 Pharmacologic Agents 54 Alcohol Withdrawal 55 Sedation 56 Stress Ulcer Prophylaxis 58 ICP Management 59
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Criteria for Triage to Shock / Trauma Room
Physiological Alterations
• Trauma Score ≤ 13
• Known GCS <14
• Core temperature <28° C or <82° F
• Abnormal vital signs: SBP <90, pulse <60 or >120, respirations <10 or >30
Mechanism of Injury (assumes physiological stability)
• Strangulations/hangings
• GSW/SGW of head, neck, torso
• Penetrating injuries of extremities with neurovascular deficit
• Stab wounds of head, neck, torso
• Steering wheel/windshield deformity
• Fatality within the vehicle
• Rollovers/ejection from vehicle
• Pregnant patients when history is suggestive of major trauma
• Intoxicated patients when history is suggestive of major trauma
• Blunt trauma with complaints relative to abdomen or thorax
• Extrication time > 20 minutes
• Intrusion of space > one foot
• Falls > 15 feet
• Pedestrian struck
• Motorcycle crash
Anatomical Alterations
• Airway obstruction • Depressed skull fracture/scalp avulsion • Pelvic instability • Maxillofacial trauma, severe • Significant bleeding • Spinal cord injuries • Crush (major) injury • Subcutaneous emphysema, massive • CSF leak • Tension pneumothorax • Flail chest • Major amputations (not fingers/toes) • Open long bone fracture • Multiple long bone deformities
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Routine Trauma Labs: Adult
The following laboratory tests should be ordered for all adult surgical trauma patients evaluated
in the trauma rooms:
• CBC with differential
• Trauma BMP (to include total bilirubin, ALT, AST)
• P-amylase
• INR
• Lactate
• Arterial blood gas
• UA -- also UCG in female patients
• Type and screen. Type and crossmatch only for any patient who receives
uncrossmatched blood (“red tag”) for resuscitation in Shock/Trauma, or any patient going
directly to the OR from Shock/Trauma.
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Cervical Spine Clearance
Blunt neck trauma
Awake, alert, no distracting injuries, asymptomatic,
NEUROLOGICALLY NORMAL
Altered mental status, or multiple system injury, or
awake with cervical pain or tenderness, or clinical signs of spinal cord injury
No neck pain AND
No tenderness to palpation
C-spine cleared (document on chart),
remove collar
AP, Lateral, Odontoid plain films
Adequate, normal films
Poorly visualized area or abnormal
Leave collar on and consult Orthopedics (admission date an odd day) or Neurosurgery (admission date an even day) for evaluation
MRI of affected area
CT scan C-spine
Normal Abnormal
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Spinal Cord Injury with Neurologic Deficit
Penetrating Blunt
Bolus methylprednisolone (Solumedrol) 30 mg/kg over 15 min
(if within 8 hours from injury)
45 minute steroid free pause
Continuous infusion 5.4mg/kg/hr for 23-47 hours* 23 hours if started 0-4 hours after injury 47 hours if started 4-8 hours after injury
Obtain CT of affected area
Consultation: Orthopedics on odd admission date, Neurosurgery on even admission date
Strict log roll Take off backboard
Keep in cervical collar if cervical injury or altered sensorium
*In conjunction with Orthopedics/
Neurosurgery
Obtain MRI of affected area
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Dermatomes
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Sensory Levels
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Standard Neurological Classification of Spinal Cord Injury MOTOR KEY MUSCLES
R L C2 C3 C4 C5 Elbow flexors C6 Wrist extensors C7 Elbow extensors C8 Finger flexors (distal phalanx of middle finger) T1 Finger abductors (little finger) T2 T3 0 = total paralysis T4 1 = palpable or visible contraction T5 2 = active movement, T6 gravity eliminated T7 3 = active movement, T8 against gravity T9 4 = active movement, T10 against some resistance T11 5 = active movement, T12 against full resistance L1 NT = Not testable L2 Hip flexors L3 Knee extensors L4 Ankle dorsiflexors L5 Long toe
extensors
S1 Ankle plantar flexors
S2 S3
S4-5 Voluntary anal contraction (Yes/No)
TOTALS + = MOTOR SCORE
maximum 50
50 100
NEUROLOGICAL R L COMPLETE OR INCOMPLETE?
LEVELS SENSORY Incomplete = Any sensory or motor function in S4-S5
The most caudal MOTOR
segment with ASIA IMPAIRMENT SCALE
normal function
American Spinal Injury Association ©1996
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SENSORY KEY SENSORY POINTS
Light Touch
Pin Prick
R L R L C2 0 = absent C3 1 = impaired C4 2 = normal C5 NT = not testable C6 C7 C8 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4-5 Any anal sensation (Yes/No)
+ = PIN PRICK SCORE Max: 112 ↓ ↓
TOTALS{ + = LIGHT TOUCH SCORE Max: 112
Maximum 56 56 56 56
R L
SENSORY
MOTOR
ZONE OF PARTIAL PRESERVATION
Partially innervated segments
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Blunt Cerebrovascular Injury
Appropriate mechanism with • Unexplained neuro deficit (inconsistent with CT) • Horner’s syndrome • LeFort II or III (unilateral or bilateral) • Cervical spine injury, including transverse process
fractures C-1 – C-6 • Neck soft tissue injury
4 vessel cerebral angiogram
Carotid injury Vertebral injury
Neurosurgery consult
Neurosurgery consult
Treatment** Treatment**
Heparin** if no contraindication (preferred for carotid & complex vertebral injuries) Start @ 1000 units/hour – NO bolus
Aspirin ± Plavix** (ASA only if vertebral occluded with back-fill)
Repeat angiogram in 14 days and/or 6 weeks if necessary
Serial PTT, 1st value 4 hours after drip started
then q8hrs Goal is 1.5-2.0 x normal
**In conjunction with Neurosurgery
Conversion to Coumadin or antiplatelet therapy depending on pathology/clinical course for at least 6 weeks, follow up in Trauma Clinic and with Neurosurgery
CT angiogram
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Penetrating Neck Injury
Hemodynamically unstable Expanding hematoma Excessive bleeding Dysphonia* Dysphagia* Air leak from wound Tracheal deviation Retropharyngeal air*
To OR
Platysma Violation DO NOT PROBE WOUND!
Zone I Zone II Zone III
unstable stable unstable stable unstable stable
4 vessel cerebral angio, +/- arch angiogram, barium
swallow
Injury No Injury
TO OR Observe
To OR To OR To OR
*May benefit from diagnostic test such as plain lateral c-spine X-ray, barium swallow, bronchoscopy, or laryngoscopy
Helical chest CT
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Appropriate mechanism of injury includes high speed impact injuries (MVC, MCC, fall, decelerating blunt injury). *BP & HR goals: systolic BP ≤120 mmHg, HR <90. Obtain ECG prior to β−blockade therapy Medications: Esmolol: 0.5 mg/kg IV loading dose over 1 minute, then 0.05 mg/kg/min over 4 minutes, then 0.1 mg/kg/min; titrate to HR <90. Advantage: very short half life (9 minutes) Disadvantage: side effect of hypotension may require cessation of therapy Labetalol: 10-20 mg IV slowly followed by continuous IV infusion of 1-2 mg/min. Additional bolus dose of 20 mg may be given up to a total of 300 mg. Continuous infusion must be titrated to the desired endpoints. Advantage: blockade of α and β with single agent therapy Disadvantage: half life 5-8 hours Nitroprusside: 0.3 mcg/kg/min initial dose, then titrate to BP goal. Maximum dose is 10 mcg/kg/min. Advantage: extremely short half life
Disadvantage: can increase dP/dT and cause reflex tachycardia. NEVER use without β−blockade therapy.
Blunt Aortic Injury
Appropriate mechanism of injury
Chest CT
Positive Negative Mediastinal hematoma
Control BP & HR*
Continue work-up for other injuries
Control BP & HR
Arch aortogram
Positive Negative
Stop BP & HR control
Appropriate sedation
Vascular Surgery and/or Thoracic Surgery consult
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Emergent Thoracotomy
* Only for penetrating wounds to the upper abdomen or chest (“cardiac box”). Resuscitative thoracotomy for penetrating abdominal wounds without suspicion of cardiac injury is not indicated.
Blunt Penetrating*
No vital signs in route or in
Shock/Trauma
Pronounce
Loss of vital signs in route or in Shock/Trauma
Cardiac ultrasound
Negative Positive
No vital signs or CPR > 20 minutes
Loss of vital signs in route or in Shock/Trauma
Pronounce
Mechanism of Injury
Emergent thoracotomy
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Hemothorax Management
No
Place Chest Tube
Daily Chest X-Rays
CT Chest
Clot Resolved Remove Tube
Clot Resolved
Repeat CT Chest in 48 hours
1) Residual clot > 500cc OR 2) Residual clot occupies >1/3 of thoracic cavity OR 3) Unchanged
VATS
Place Second Chest Tube
Yes
No
2 TPA Contraindications 1) Active bleeding OR 2) CVA in past 30 days OR 3) Intracranial hemmorhage OR 4) Intracranial Neoplasm OR 5) Coagulopathy OR 6) Pregnancy OR 7) Chest tube with air leak
Repeat CT Chest
Repeat TPA infusion x 3 days (check daily chest x-ray)
TPA Infusion Protocol 1) Obtain HCT, PT, PTT prior to infusion (if abnormal consider not using rTPA) 2) Mix 4mg of rTPA (Reteplase) in 50cc sterile saline. 3) Instill mixture into chest tube and flush tube with 50cc of sterile saline. 4) Clamp chest tube for 4 hours (observe patient for 10 minutes for problems with breathing). 5) Mobilize patient. 6) Check HCT, PT, PTT 1 hour after infusion (if significantly changed from baseline, consider stopping infusion)
Candidate for TPA infusion per chest tube?2
Infuse TPA per chest tube q 24 hours x 3 days (check daily Chest x-ray)
48 Hours
Clot Resolved
Repeat CT Chest
Remove Tube
Clot Resolved
Repeat CT Chest
Daily Chest X-Rays
Candidate for VATS?1
Yes
No
Yes
No
Yes
No Yes
Yes
No
48 Hours
Clot Resolved
1 VATS Contraindications 1) Coagulopathy 2) Hemodynamic instability 3) Inability to tolerate single lung ventilation
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Blunt Abdominal Trauma
Hemodynamically unstable
Physical exam
F.A.S.T. DPL
Large amount of fluid in abdomen
Scant/no fluid in abdomen
Grossly positive*
Microscopically positive for
WBC*
Microscopically positive for
RBC*
To OR To OR To OR
Continue search for
other sources of hemorrhage
*Criteria for positive DPL: Grossly positive - >10cc blood RBC - >100,000 cells WBC - >500 cells at least 1 hour after injury
Consider DPL if unstable
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Blunt Abdominal Trauma
Hemodynamically stable
Physical exam
Reliable, awake, alert, no distracting injuries
Unreliable, abnormal mental status,
distracting injuries
CT scan
Nontender
Observation period
Remains nontender
Discharge1
Tender
CT scan
Normal Abnormal2
Admit for 23 hour
observation
Admit, follow
protocols
Admit, treat other
injuries
1 If any doubt, admit the patient for at least 23 hours 2 May require DPL or other evaluation depending on findings
Normal
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Antibiotics for Penetrating Abdominal
Trauma
Penetrating abdominal injury requiring
laparoscopy/laparotomy
Ertapenem 1 gram IV prior to skin incision
No hollow organ injury
No further antibiotics
Hollow organ injury
No further dosing
*For patients with penicillin allergy, give ciprofloxacin 400 mg IV every 12 hours (2 total doses for hollow organ injury, only the preop dose for no hollow organ injury) and metronidazole 500 mg every 6 h (4
total doses for hollow organ injury, only the preop dose for no hollow organ injury)
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Anterior Abdominal Stab Wounds
Hemodynamically stable, nontender abdominal exam
Yes No
To OR Local wound exploration
Violation of anterior fascia
Definitely no violation of
anterior fascia
Equivocal violation of
anterior fascia
To OR for laparoscopy/ laparotomy
To OR for laparoscopy/ laparotomy
Discharge
For the cooperative patient, consider awake laparoscopy in
Shock / Trauma
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Nonoperative Management of Blunt Liver Injury
Hemodynamic stability mandatory for nonoperative management
Quantitation of hemoperitoneum Small- perihepatic Moderate- Small + paracolic gutter Large-Moderate + pelvis
CT scan
Grades 1,2,3 Grades 4,5
Stable Stable
Admit to floor, observe, AM Hct
ICU *
Stable, improving
Pseudoaneurysm DC from
ICU
Angiography for embolization
Outpatient management
Grade 4,5 Grade 1,2,3
Repeat CT 1 month if pain or jaundice
Repeat CT 1 month
healed Not healed
Ad lib activity Light duty - repeat CT 1 month until healed
*ICU- serial Hct q6h,
close observation
Becomes unstable
OR
Abdominal pain, jaundice,
unexplained signs of infection
CT scan
Abdominal fluid collection
Consider drainage
Improved, unchanged
Search other sources
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Nonoperative Management of Blunt Splenic Injury
Hemodynamic stability mandatory for nonoperative management
CT scan Pseudoaneurysm
Age ≥ 50 Age < 50 Becomes unstable
OR Grade 3-5 Grade 1,2
ICU*
Large hemoperitoneum
Small, moderate hemoperitoneum
ICU* OR
Grade 1 Grade 2-5
Floor ICU*
F/U CT 24 hours
Stable, improving
Floor
Worse
Angio-embolization
Stable Unexplained blood loss
Consider splenectomy OR
*ICU- serial Hct q6h,
close observation
Quantitation of hemoperitoneum: Small – perihepatic/splenic Moderate – small + paracolic gutter Large – moderate + pelvis
Outpatient Management
Grade 1,2 Grade 3-5
CT if clinically indicated
CT in 1 month Healed Not healed
Activity ad lib Light duty, repeat CT in 1 month if indicated
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Pancreatic Injury Management
Pancreatic Injury
Drain
Proximal to mesenteric vessels (right)
Distal to mesenteric vessels (left)
Duct injury
No Yes Indeterminate
Low probability
High probability
Resection + drainage
High probability of ductal injury: - direct ductal visualization - complete pancreatic transection - >50% pancreatic laceration - severe maceration - pancreatic fluid leak
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AAST Spleen Injury Scale Grade*
Injury type
Description of injury
Hematoma Subcapsular, <10% surface area I Laceration Capsular tear, <1cm parenchymal depth
Hematoma Subcapsular, 10%-50% surface area; intraparenchymal, <5 cm in diameter II
Laceration Capsular tear, 1-3cm parenchymal depth that does not involve a trabecular vessel
Hematoma Subcapsular, >50% surface area or expanding; ruptured subcapsular or parecymal hematoma; intraparenchymal hematoma > 5 cm or expanding III
Laceration >3 cm parenchymal depth or involving trabecular vessels
IV Laceration Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen)
Laceration Completely shattered spleen V Vascular Hilar vascular injury with devascularizes spleen
*Advance one grade for multiple injuries up to grade III
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AAST Liver Injury Scale Grade*
Type of Injury
Description of injury
Hematoma Subcapsular, <10% surface area I Laceration Capsular tear, <1cm parenchymal depth
Hematoma Subcapsular, 10% to 50% surface area: intraparenchymal <10 cm in diameter II
Laceration Capsular tear 1-3 parenchymal depth, <10 cm in length
Hematoma Subcapsular, >50% surface area of ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma > 10 cm or expanding III
Laceration 3 cm parenchymal depth
IV Laceration Parenchymal disruption involving 25% to 75% hepatic lobe or 1-3 Couinaud’s segments
Laceration Parenchymal disruption involving >75% of hepatic lobe or >3 Couinaud’s segments within a single lobe V
Vascular Juxtahepatic venous injuries; ie, retrohepatic vena cava/central major hepatic veins
VI Vascular Hepatic avulsion
*Advance one grade for multiple injuries up to grade III
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AAST Kidney Injury Scale Grade*
Type of Injury
Description of injury
Contusion Microscopic or gross hematuria, urologic studies normal I
Hematoma Subcapsular, nonexpanding without parenchymal laceration
Hematoma Nonexpanding perirenal hematoma confirmed to renal retroperitoneum II
Laceration <1.0 cm parenchymal depth of renal cortex without urinary extravagation
III Laceration >1.0 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravagation
IV Laceration Parenchymal laceration exteding through renal cortex, medulla, and collecting system
Laceration Completely shattered kidney V
Vascular Main renal artery or vein injury with contained hemorrhage
VI Vascular Avulsion of renal hilum which devascularizes kidney
*Advance one grade for bilateral injuries up to grade III
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Pelvic Fracture Management
Initial assessment & A-P pelvic x-ray
Open fracture
Exsanguinating hemorrhage
(BP~ <70)
OR
Closed fracture
Supraumbilical DPL, F.A.S.T
Positive Negative
T-pod T-pod
OR
Continued hemodynamic
instability
Angiography
Marginal hemodynamic stability
(BP~ 90-110)
Supraumbilical DPL, F.A.S.T
Positive Negative
T-pod T-pod
OR CT
Hemodynamically stable
(BP~ >110)
Algorithm for stable blunt abdominal
trauma
Orthopedics consult
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Tile Classification of Pelvic Fractures Type A – Stable fractures
A1 Fractures not involving ring; avulsion injuries
A2 Stable, minimal displacement; iliac wing, isolated rami A3 Transverse fracture of sacrum
Type B – Rotationally unstable, but vertically and posteriorly stable
B1 External rotation instability; open book injury
B2 Internal rotation instability; lateral compression injury B3 Bilateral rotationally unstable injury
Type C – Rotationally, posteriorly, and vertically unstable
C1 Unilateral injury; ileal fracture, SI disruption, sacral fracture
C2 Bilateral injury; one side rotationally unstable, one side vertically unstable
C3 Bilateral injury; both sides completely unstable
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To Ligate or Not to Ligate
Injury Best Mode of Action
Infrarenal vena cava Repair Can ligate
Suprarenal vena cava Repair Cannot ligate - at least 50% mortality)
Internal jugular vein Repair Can ligate unilaterally
Brachiocephalic vein Repair Can ligate unilaterally
Subclavian vein and artery Repair Can ligate
Superior vena cava Repair Can ligate in life-threatening situations
Carotid artery Repair Can ligate in life-threatening situations
Mesenteric veins Ligate
Portal vein Repair
Can ligate if isolated injury, but at least 50%
mortality rate secondary to massive fluid
sequestration in splanchnic vascular bed and bowel
necrosis
Right renal vein Repair Cannot ligate - fewer collaterals than left renal vein
Popliteal vein Repair Cannot ligate
Femoral vein Repair Can ligate
Lobar bile duct Ligate
Celiac artery Ligate
Left gastric artery Ligate
Common/proper hepatic
arteries Ligate Especially if proximal to gastroduodenal branch
Right/left hepatic arteries Ligate Especially if portal vein is intact
Splenic artery Ligate Short gastric a. from left gastroepiploic
Iliac vein - comm/ext Ligate
Iliac artery - comm/ext Repair
Femoral/popliteal arteries Repair
Tibial arteries Repair Can ligate but need to ensure patency of other leg
arteries
Brachial artery Repair Can ligate if distal to profunda brachi branch since
the elbow has rich collateral blood flow
Radial/ulnar arteries Repair Can ligate but need to ensure patency of other artery
and palmar arch
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Neurovascular Injuries Associated with Fractures or Dislocations
Orthopedic Injury Neurovascular Injury Anterior shoulder dislocation Axillary nerve, axillary artery Humeral shaft fracture Radial nerve Supracondylar humeral fracture Brachial artery
Distal radius fracture Perilunate dislocation
Median nerve
Posterior hip dislocation Sciatic nerve Supracondylar femur fracture Posterior knee dislocation
Popliteal artery
Tibial plateau fracture Popliteal artery, tibioperoneal trunk
Proximal fibula fracture Peroneal nerve
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Fracture/dislocation of Extremity
Equal pulses, ABI ≥ .7
Pulse deficit, ABI < .7
Orthopedics consult, reduce injury
Orthopedics consult, reduce injury
Pulses still equal
Orthopedics management of
injury
Pulses equal Pulse deficit
Angiogram in operating
room
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Chart of Muscle Groups and Nerve and Nerve Root Supply
Muscle Nerve Root Nerve
Cervical flexors C1 – C4
Cervical extensors C1 – C4
Trapezius Cranial nerve XI
Sternocleidomastoid Cranial nerve XI
Arm abduction 0 – 15o, supraspinatus
15 to 90o, deltoid >90o, trapezius & serratus anterior
C4 – C6
C5 – C6 C5 – C7
Suprascapular
Axillary Long thoracic
Biceps C5 – C6 Musculocutaneous
Forearm supination C5 – C6 Musculocutaneous
Forearm pronation C6 – C7 Median
Wrist flexors C7 – C8, T1 Median
Wrist extensors C6 – C8 Radial
Hand intrinsics C7 – T1 Median and Ulnar
Hip flexion L1 – L3 Femoral
Hip extension L4 – S1 Sciatic
Thigh abduction L4 – S2 Superior gluteal
Thigh adduction L2 – L4 Obturator
Leg flexion L4 – S2 Sciatic
Leg extension L2 – L4 Femoral
Foot plantar flexion L5 – S1 Superficial peroneal and tibial
Foot dorsiflexion L4 – L5 Deep peroneal
Great toe extension L4 – L5, S1 Deep peroneal
Foot inversion L4 – L5 Deep peroneal
Foot eversion L5 – S1 Superficial peroneal
Rectal spinchters S2 – S4 Pudenal
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Mangled Extremity Severity Score
Skeletal / soft-tissue injury
Low energy (stab; simple fracture; pistol gunshot wound) 1
Medium energy (open or multiple fractures, dislocation) 2
High energy (high speed RTA or rifle GSW) 3
Very high energy (high speed trauma + gross contamination) 4
Limb ischemia
Pulse reduced or absent but perfusion normal 1*
Pulseless, paresthesias, diminished capillary refill 2*
Cool, paralyzed, insensate, numb 3*
Shock
Systolic BP always > 90 mm 0
Transient hypotension 1
Persistent hypotension 2
Age (years)
< 30 0
30-50 1
> 50 2 * Score doubled for ischemia > 6 hours The MESS is the sum of scores from each category. Scores < 7 are associated with limb salvage, Scores > 10 are associated with primary amputation. Outcome is variable for scores 7-10.
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Diagnosis of Ventilator Associated Pneumonia Indications for bronchoscopy with bronchoalveolar lavage (FOB + BAL)
- Patient must have at least three of the following: 1. Fever (temperature > 100.5) or hypothermia (T < 96) 2. Abnormal WBC (>10,000, <4,000, or >10% bands)
3. Purulent sputum
4. New or changing infiltrate on chest x-ray BRONCHOSCOPY + BAL TECHNIQUE 1. Routine suctioning with in-line catheter of the upper airway until clear.
2. Increase FiO2 to 100%, change IMV rate if necessary. 3. Sedate patient as necessary. Pharmacologic paralysis is NOT necessary.
4. Advance bronchoscope into affected lung segment (as seen on CXR) or LLL (if bilateral infiltrates). DO NOT USE SUCTION OR CONNECT
SUCTION LINE TO BRONCHOSCOPE.
5. Scope should be advanced to the smallest bronchial segment possible to perform BAL.
6. Use 100cc sterile nonbacteriostatic saline in 20cc aliquots. Inject 20cc
then immediately aspirate and pool the effluent for quantitative cultures. 7. Follow up with chest radiograph.
8. Proceed to VAP Pathway for treatment.
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Clinical Suspicion of VAP †
Fiberoptic Bronchoscopy with BAL
<7 days in ICU
Ampicillin/sulbactam (Unasyn®) 3g IV q6h *
>7 days in ICU
Vancomycin 20mg/kg IV q12h * + Cefepime 2g IV q8h *
Empiric antibiotic therapy based on timing of ICU admission
No growth to date Insignificant (1-99,999 cfu/mL)
Significant (≥100,000)
Streamline antibiotic therapy**
Discontinue antibiotic therapy**
Continue empiric antibiotic therapy
<100,000 cfu/mL
Empiric therapy discontinued
>100,000 cfu/mL
Definitive antibiotic therapy (see Definitive Therapy Pathway for TICU)
† Defined as the appearance of a new or changing infiltrate on chest radiograph and at least 2 of the following: −Abnormal temperature (>38oC or <36oC); −Abnormal white blood cell count (>10,000 cells/mm3 or <4000 cells/mm3 or the presence of >10% immature bands); −Macroscopically purulent sputum -If severe beta-lactam allergy, change: Unasyn to Levofloxacin 750 mg IV Q24H, Cefepime to Ciprofloxacin 400 mg IV Q8H; dosage adjustment may be necessary based on renal function **Continue to monitor for changes in Final culture results
Final culture results
Preliminary culture results >24 hours
Trauma ICU Ventilator-Associated Pneumonia Clinical Pathway Diagnosis and Empiric Management
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* Adequate antibiotic therapy is antibiotic therapy with in vitro activity against the pathogen. Patients extubated or not eligible for repeat BAL should be treated for 7 full days (consider 10-14 days if Pseudomonas or not responding clinically) ** Consider treatment for 10,000 cfu/mL in severely injured patients with Pseudomonas and/or Acinetobacter † Use final culture result. †† Continue antimicrobial therapy in patients with septic shock † Pseudomonas requires a follow-up BAL regardless of being early or late VAP
Trauma ICU Ventilator-Associated Pneumonia Clinical Pathway Definitive Therapy
VAP pathogen(s) <10,000 cfu/mL? †
Repeat BAL on Day 4 of Adequate Antibiotic Therapy *
Continue Antibiotics for 10-14 days
Continue Antibiotics for 7 full days†
Early VAP? (≤7 days in ICU)
Yes No
Discontinue Antibiotics
Yes No
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Guideline for the Prevention of Venous Thromboembolism in Critically ill Patients Approved by Pharmacy and Therapeutics Committee May 2004
Evidence-based references • Geerts WH, et al. Chest 2001; 119: 132S-175S.
– Available at http://www.chestjournal.org/cgi/reprint/119/1_suppl/132S (accessed 5/14/04)
• Rogers FB, et al. J Trauma 2002; 53(1):142-164. – Also available at http://www.east.org/tpg/dvt.pdf (accessed 5/14/04)
Modified 5/14/04
No
Sequential compression devices (preferred) or A-V foot pumps. Consider serial duplex ultrasound in high-risk patients
No
[A] Consider Inferior Vena Cava (IVC) filter in: High-risk trauma patients with significant bleeding risk or Patient’s with injury pattern rendering them immobile for prolonged period of time:
a) Severe Traumatic brain injury b) Spinal cord injury with para- or quadriplegia c) Complex pelvic fracture with associated long bone fracture(s) d) Multiple long bone fractures
Unfractionated heparin 5,000 units sq every 8 hours plus Sequential compression devices (preferred) or A-V foot
pumps
Enoxaparin 30mg sq every 12 hours plus Sequential compression devices (preferred) or A-V foot
pumps
Unfractionated heparin 5,000 units sq every 8 hours plus
Sequential compression devices (preferred) or A-V foot
pumps
Enoxaparin 30mg sq every 12 hours plus
Sequential compression devices (preferred) or A-V foot pumps
Yes
Operative acetabulum
fracture?
> 24 h post-operative Pre-operative
Yes
4
Contraindication to heparin pharmacotherapy? [A] examples include: • Active hemorrhage • Recent hemorrhagic stroke • INR > 1.6 • PTT > 60 sec • Platelet count < 50 x 109 cells/L
• Traumatic brain injury with progression on head CT >24h post-injury (consult neurosurgery)
• Hx of Heparin-induced Thrombocytopenia (HIT) • Epidural catheter present (consult anesthesia)
2
Primary risk factor present? [A] • Spinal cord injury • Spinal column fractures • Long bone fracture • Pelvic fracture • Sacral fracture
• Acetabulum fracture • Traumatic brain injury • Laparotomy • Age > 40 plus major surgery, cancer, history of VTE, or hypercoagulable state
3
No
Yes
Reevaluate all patients for continuation of venous thromboembolism prophylaxis upon ICU discharge
Baseline CBC, BMP, PTT, and PT/INR
*Note: May not be indicated in burn patients unless other risk
factors are present.
*
1
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Natural Products with Potential to Act as Blood Modifiers
Natural Products THOUGHT to have Blood Modifying Effects Herb (other names)
Effect Ingredient(s) Responsible
Comments
Angelica root (Angelica archangelica, root of the Holy Ghost)
Anticoagulant Antiplatelet
Coumarin consitiuents
There is some evidence that the related Angelica species can inhibit platelet aggregation and lower prothrombin time when combined with warfarin. The coumarin constituents of related Angelica species can inhibit human platelet aggregation in vitro. The related species, Angelica sinensis, can lower prothrombin time in rabbits when coadministered with warfarin.
Anise (Pimpinella anisum, aniseed, sweet cumin)
Anticoagulant Coumarin constituents Anticoagulant effects have been seen with excessive doses of anise. (Typical dose is 0.5-1 gram of the dried leaf or 50-200 mL of the essential oil.)
Theoretically, excessive use of anise might prolong coagulation, increasing PT/INR and test results, due to coumarins contained in anise.
Asafoetida (Ferula assa-foetida, assant, devil’s dung, fum, giant fennel)
Anticoagulant Coumarin constituents Anticoagulant effects have been noted in vivo.
Dong Quai (Angelica sinensis, Chinese angelica, Danggui)
Anticoagulant Antiplatelet
Coumarin constituents Dong quai can potentiate the therapeutic and adverse effects of warfarin and antiplatelet drugs.
Fish Oils (omega-3 fatty acids)
Antiplatelet Docosahexaenoic acid (DHA)
Eicosapentaenoic acid (EPA)
The antithrombin activity of fish oil is due to prostacyclin synthesis, vasodilation, reduced platelet counts and adhesiveness, and prolonged bleeding time.
Fucus (Fucus vesiculosis, bladderwrack, kelp, black tang, cutweed)
Anticoagulant Fucoidin The isolated fraction, fucoidin, has 40-50% of the blood anticoagulant activity of heparin, and fucus can increase the risk of bleeding.
49
Natural Products with THEORETICAL Potential to Have Blood Modifying Effects Herb (Other names) Effect Ingredient(s)
Responsible Comments
Agrimony (Agrimonia eupatoria, agromonia, cocklebur)
Coagulant Vitamin K constituent Excessive doses of agrimony could interfere with anticoagulant therapy. (Typical dose is 3 grams/day.)
Arnica montana, leopard’s bane, wolf’s bane, mountain tobacco)
Anticoagulant Coumarin constituents Arnica could potentiate the effects of anticoagulant and antiplatelet drugs.
Aspen (Populi cortex, Populi folium)
Antiplatelet Salicin Salicin is a salicylate constituent. However, in vitro studies provide preliminary data that suggest salicin might not potentiate the effects of anticoagulant drugs.
Black cohosh (Cimicifuga racemosa, baneberry, black snakeroot, bugwort)
Antiplatelet Salicylate There is insufficient reliable information to determine if there is enough salicylate present in black cohosh to have significant effects.
Bogbean (Menyanthes trifoliata, buckbean, marsh trefoil, water shamrock)
Bleeding risk Unidentified constituent
Excessive doses of bogbean can increase the risk of bleeding due to the hemolytic effects of an unknown constituent. (Typical dose is 1-2 mL of the 1:1 liquid extract in 25% alcohol TID or 1-3 grams of the dried leaf TID.)
Boldo (Peumus boldus, boldine)
Anticoagulant Coumarin constituents Excessive doses could increase the risk of bleeding. (Typical dose is 60-200 mg of the dried leaf TID.)
Borage Seed Oil (Borago officinalis, burage, starflower)
Anticoagulant
Antiplatelet
Gamma linolenic acid Borage seed oil could prolong bleeding time.
Bromelain (Ananas comosus, bromelin)
Antiplatelet Enzyme constituent Bromelain could increase the risk of bleeding when used in combination with antiplatelets or anticoagulants.
Capsicum (Capsicum frutescen, African pepper, cayenne, chili pepper)
Antiplatelet Capsaicinoid constituents
Capsicum has led to increased fibrinolytic activity and could prolong bleeding time.
Celery (Apium graveolens, smallage, Apii fructus)
Antiplatelet Apiogenin (coumarin) Celery could have anticoagulant effects due to the apiogenin constituent.
Clove (Syzygium aromaticum, caryophyllus)
Antiplatelet Eugenol Clove contains a volatile oil that consists primarily of eugenol.
Danshen (Salvia miltiorrhiza, red sage, salvia root)
Anticoagulant Protocatechualdehyde
3,4-dihydroxyphenyl-lactic acid
There is one case report of increased international normalization ratio (INR) with concomitant use of danshen and warfarin.
European Mistletoe (Viscum album, all-heal, devil’s fuge, drudenfuss)
Coagulant Lectin Studies show that lectin can have agglutinating activity and could interfere with anticoagulant or coagulant therapy.
Fenugreek (Trigonella foenum-graecum, bird’s foot, Greek hay)
Anticoagulant Coumarin constituents Fenugreek could potentiate the effects of anticoagulant and antiplatelet drugs.
Feverfew (Tanacetum parthenium, featherfew, midsummer daisy, bachelor’s button)
Antiplatelet Crude extracts The crude extracts can inhibit platelet aggregation and the neutrophil and platelet secretory activity. This could potentiate the effects of anticoagulant and antiplatelet drugs.
Ginseng, Panax (Asian ginseng, Korean red, jintsam)
Anticoagulant Antiplatelet
Active constituents Panax ginseng could decrease the effectiveness of warfarin and affect clotting time.
Goldenseal (Hydrastis canadensis, yellow puccoon, eye balm)
Coagulant Berberine Goldenseal could inhibit the anticoagulant effects of heparin.
Horse Chestnut (Aesculus hippocastanum, escine, venostat)
Anticoagulant Aesculin (coumarin) Aesculin may increase bleeding time due to antithrombin activity, which could increase the risk of bleeding when used concomitantly with anticoagulants or antiplatelets.
50
Horseradish (Armoracia rusticana, pepperrot, mountain radish)
Anticoagulant Coumarin constituents Peroxidase stimulates the synthesis of arachidonic acid metabolites, which could potentiate the anticoagulant activity of other drugs or natural products.
Licorice (Glycyrrhiza glabra, sweet root)
Antiplatelet Coumarin constituent Licorice has shown antiplatelet activity in vitro.
Meadowseet (Filipendula ulmaria, bridewort, dropwort)
Anticoagulant Salicylates There is insufficient reliable information to know if the side effects and toxicity normally associated with salicylates could occur.
Northern Prickly Ash (Zanthoxylum americanum, toothache bark, pepper wood)
Anticoagulant Coumarin constituents Excessive ingestion of northern pickly ash might potentiate anticoagulant therapy.
Onion (Allium cepa) Antiplatelet Unidentified constituent
Inhibits platelet aggregation in humans and could increase the risks of bleeding with antiplatelet drugs or natural products.
Papain (Carica papaya) Risk of bleeding
Unidentified constituent
There is one case report of increased INR associated with the use of warfarin and papaya extract.
Passionflower (Passiflora incarnata, Maypop, apricot vine)
Anticoagulant Coumarin constituents Excessive doses of passionflower could increase the risk of bleeding. (Typical dose is 0.5-1 mL of the 1:1 liquid extract in 25% alchohol TID or 0.25-2 grams of the dried plant.)
Pau D’Arco (Tabebuia impetiginosa, taheebo tea, ipes, lapacho)
Anticoagulant Lapachol Pau d’arco may potentiate the effects of anticoagulants and increase bleeding tendency.
Plantain (Plantago major, common plantain, greater plantain)
Coagulant Vitamin K Excessive doses of plantain could interfere with anticoagulant therapy. (Typical dose is 2-4 mL of the 1:1 liquid extract in 25% alcohol TID or 2-4 grams of the dried leaf TID.)
Poplar (Populus tacamahacca, balm of Gilead)
Antiplatelet Salicin Salicin is a salicylate constituent. However, in vitro studies provide preliminary data that salicin might not potentiate the effects of anticoagulant drugs.
(Quassia amara, bitterwood) Anticoagulant Coumarin constituents Excessive doses of quassia could increase the risk of bleeding.
Red Clover (Trifolium pratense, cow clover, trefoil, beebread)
Anticoagulant Coumarin constituents Large amounts of red clover can increase the effects and bleeding risk of anticoagulant drugs or natural products.
Roman chamomile (Chamaemelum nobile, English chamomile, garden chamomile, whig plant)
Anticoagulant Coumarin constituents Large amounts of Roman chamomile could have anticoagulant effects.
Safflower (Carthamus tinctorius, saffron, zaffer)
Anticoagulant Safflower yellow Large amounts of safflower could potentiate the risk of bleeding with anticoagulant drugs or natural products.
Southern Prickly Ash (Zanthoxylum clava-herculis, sea ash, yellow wood)
Anticoagulant Coumarin constituents Excessive ingestion of southern pickly ash might potentiate anticoagulant therapy. (Typical dose is 3-4 mL of the 1:1 liquid extract in 25% alcohol TID.)
St. John’s Wort Coagulant Multiple cases of decreased INR have been reported, although none have involved thromboembolic complications.
Stinging Nettle (Urtica dioica, nettle)
Coagulant Vitamin K Excessive doses of stinging nettle could interfere with anticoagulant therapy.
Sweet Clover (Melilotus officinalis, common melilot, hay flower, sweet lucerne)
Anticoagulant Dicumarol Large amounts of sweet clover could potentiate the risk of bleeding with anticoagulant drugs or natural products.
Sweet Vernal Grass (Anthoxanthum odoratum, spring grass)
Anticoagulant Coumarin constituent Large amounts of sweet vernal grass could potentiate the risk of bleeding with anticoagulant drugs or natural products.
Tonka Bean (Dipterux Anticoagulant Coumarin constituent Tonka bean can contain up to 10%
51
odorata, coumarouna, torquin bean)
coumarin and theoretically potentiate the risk of bleeding associated with anticoagulant drugs or natural products.
Turmeric (Curcuma longa, tumeric, Indian saffron)
Antiplatelet Curcumin Curcumin has anti-inflammatory activity and could potentiate the antiplatelet activity of other drugs or natural products.
Wild Carrot (Daucus carota, Queen Anne’s lace, beesnest plant)
Anticoagulant Coumarin constituents Large amounts of wild carrot could potentiate the risk of bleeding with anticoagulant drugs or natural products.
Wild Lettuce (Lactuca virosa, green endive, lettuce opium)
Anticoagulant Coumarin constituents Large amounts of wild lettuce could potentiate the risk of bleeding with anticoagulant drugs or natural products.
Willow Bark (Salix alba, white willow, silberweide)
Antiplatelet Salicylate constituents Data suggests irreversible inhibition of thrombocytes is unlikely and there might be no increase interaction with blood coagulants.
Yarrow (Achillea millefolium, thousand-leaf, wound wort)
Coagulant Achilleine There is some evidence to suggest that achilleine has decreased clotting time.
HERBS WITH ANTICOAGULANT/ANTIPLATELET POTENTIAL: Concomitant use of herbs that have coumarin constituents or affect platelet aggregation could theoretically increase the risk of bleeding in some people. These herbs include anise, arnica, asafoetida, bogbean, boldo, capsicum, celery, chamomile, clove, danshen, fenugreek, feverfew, garlic, ginger, ginkgo, Panax ginseng, horse chestnut, horseradish, licorice, meadowsweet, prickly ash, onion, papain, passionflower, poplar, quassia, red clover, turmeric, wild carrot, wild lettuce, willow, and others.
52
Weaning from Mechanical Ventilation
Daily screening
Problem for which patient was intubated is controlled
No
Continue mechanical ventilation
Yes
SaO2 ≥ 90% FiO2 ≤ 0.5 PEEP ≤ 5 cm H2O Airway reflexes intact No vasopressors or significant sedation
Yes
No
Therapist to measure RR/Vt
No RR/Vt < 105 breaths/min/L
Spontaneous breathing trial
RR > 35 breaths/min for more than 5 minutes SaO2 < 90%
HR > 140 or ± 20% of baseline Systolic BP > 180 or < 90 mmHg Increased anxiety or diaphoresis
Yes
No
Extubate
53
MANAGEMENT OF HYPERTENSION Diagnosis of Hypertensive Crisis Immediate control to minimize end organ damage (CNS - hypertensive encephalopathy; cardiac - AMI, BAI, dissecting aortic aneurysm; renal – ARF) is necessary. Otherwise BP should be lowered slowly and cautiously. Management of Hypertension There are many causes of hypertension in ICU patients, common causes include:
- underlying hypertension - agitation - pain - withdrawal
- cold, shivering - hypoxia, hypercarbia - increased ICP - transducer height etc.
Treat underlying causes prior to administration of antihypertensives Common intravenous antihypertensive agents: Drug Action Effect Dose Comments
Metoprolol β-1 antagonist (min β-2 antagonist)
Negative chronotropy Negative inotropy
IVP: 2.5 to 15 mg slow IVP every 6 hours
Half-life 4 to 6 hours Oral:IV conversion 2.5:1 No vasodilation
Labetalol β-1 antagonist (mod β-2 antagonist) α-1 antagonist
Negative chronotropy Negative inotropy Vasodilation
IVP: 5 to 20 mg slow IVP every 1 to 4 hours Bolus: 5-20 mg IVP Infusion: 0.5 to 4 mg/min (Titrate)
Half-life 4 to 6 hours Monitor closely in asthmatic patient (beta-2 antagonist)
Esmolol β-1 antagonist (min β-2 antagonist)
Negative chronotropy Negative inotropy
Bolus: 250-500 mcg/kg slow IVP Infusion: 25-100 mcg/kg/min (Titrate)
Half-life ~ 15 min No vasodilation
Nitroglycerin Exogenous source of nitric oxide
Venous vasodilation (min arterial dilation)
Infusion: 5 to 20 mcg/min (Titrate; max 400 mcg/min)
Methemoglobinemia Headache
Nitroprusside Exogenous source of nitric oxide
Arterial and venous vasodilation
Infusion: 0.1 to 10 mcg/kg/min (Start low and Titrate)
Profound hypotension Cyanide toxicity Reflex tachycardia
Hydralazine Direct arterial smooth muscle relaxation Arterial dilation IVP: 5 to 20 mg slow IVP every 4
to 6 hours Intrapatient variability Reflex tachycardia
Enalapril ACE Inhibition Vasodilation (arterial > venous)
IVP: 0.625 to 1.25 slow IVP every 6 hours
Hyperkalemia Acute renal failure Angioedema
Oral antihypertensives can be used in patients with stable hemodynamics. Otherwise use of IV antihypertensives is more easily titratable in ICU patients. Note on choice of antihypertensives: • avoid β-blockers in patients with increased adrenergic activity (pheochromocytoma, use of sympathomimetic drugs such as cocaine, amphetamine etc) • avoid β-blockers in patients with poor LV function, also check for other contraindications (bronchospasm) • nimodipine produces cerebral vasodilation, effect noticeable in areas of brain with restricted circulation than healthy areas, usually used in patients with vasopasm after subarachnoid hemorrhage • nitrates and nitroprusside can produce cerebral vasodilation and hence should be avoided in patients with intracranial pathology • prolonged nitroprusside administration can lead to acidosis and cyanide toxicity
57
1 Mechanically ventilated trauma
patient requiring sedation
2 Patient w/TBI,
↑ICP, or requiring frequent
neurologic examinations?
6 Pt expected to
require sedation for ≥24 hours?
9 Preferred – Midazolam prn agitation3 PLUS Morphine sulfate prn pain/agitation2
Alternative - Propofol (generic) continuous infusion1 PLUS
Morphine sulfate prn pain/agitation2
Titrate to Riker SAS of 4
10 Continued need for sedation past
24 hours?
12 D/C Sedation Protocol, continue Morphine
sulfate prn pain (or morphine sulfate continuous infusion)2
7 Lorazepam prn agitation, THEN
Lorazepam continuous infusion if dosing requirements are high 4
PLUS Morphine sulfate prn pain/agitation, THEN
Morphine sulfate continuous infusion if dosing requirements are high2
Titrate to Riker SAS of 4 In refractory cases, may use
Propofol (generic) continuous infusion1 PLUS Morphine sulfate prn pain/agitation2
3 Preferred - Propofol (Diprivan® brand) continuous
infusion1 PLUS Morphine sulfate prn pain/agitation 2 OR
Alternative - Fentanyl continuous infusion 2 Titrate to Riker SAS of 4
May consider use of neuromuscular blocker to assist with ventilator compliance
4 Patient w/TBI, ↑ ICP,
or requiring frequent neurologic
examinations?
5 Go to 12
8 Pt requiring
sedation after 24 hours?
11 Go to
12
YES
YES
YES
REASSESS Pt every
shift & as needed
REASSESS Pt every
shift & as needed
REASSESS Pt every
shift & as needed
NO
NO
NO
NO
NO
YES
YES
54
ICU Pharmacologic Agents ATRACURIUM Half life: 20 minutes. Cleared in plasma via Hoffman reaction; therefore, suitable for
usage in renal failure. Titrate to 2/4 TOF. Dosage (continuous infusion): 0.1 mg/kg/h. Cost: $11.46/100 mg.
24-hour cost (70 kg patient): ~$19.00/day.
PANCURONIUM Half-life: 2 hours. May cause tachycardia. Titrate to 2/4 TOF. Dosage (continuous
infusion): 0.06-0.1 mg/kg/h. Cost: $1.79/10 mg. 24-hour cost: ~$28.00/day.
VECURONIUM Half-life: 1.5 hours. Clearance adversely affected by renal failure. Titrate to 2/4 TOF.
Dosage (continuous infusion): 0.01 mg/kg/h. Cost: $12.39/10 mg. 24-hour cost: ~$20.00/day.
MIDAZOLAM Short acting benzodiazepine. Duration of action: 2 hours. Excellent amnestic effect. Use
with caution in elderly; may cause hypotension/respiratory depression. Contraindicated in hepatic failure.
Dosage (continuous infusion): 2 mg/h. Cost: $9.48/5 mg. 24-hour cost: ~$90.00/day.
LORAZEPAM Intermediate acting benzodiazepine. Duration of action: 8-20 hours. May cause
paradoxical reactions in the elderly. Prolonged use can lead to prolonged sedation. Dosage (continuous
infusion): 1 mg/h. Cost: $15.89/40 mg. 24-hour cost: ~$8.00/day.
HALOPERIDOL Butyrophenone/antipsychotic. Does not cause sedation per se; does not cause
respiratory or cardiovascular depression. Mechanism of action is to cause affective dissociation. Does have
limited anticholinergic effects; may cause dystonia/tardive dyskinesia. Should use Cogentin at regularly
scheduled intervals. Half-life: 18 hours. Dosage: 5-10 mg/dose. Titrate to affect up to 50 mg/dose. Cost:
$0.57/5 mg. Cost per dose: $0.57-5.70.
MORPHINE Opiate, the “gold standard” analgesic in the ICU setting. Has sedative as well as analgesic
properties. Metabolites accumulate in renal failure. Duration of action: 4-5 hours. Causes respiratory
depression, histamine release, and hypotension. Dosage (continuous infusion): 2-4 mg/h. Cost: $5.76/100
mg. 24-hour cost: $3.00-6.00/day.
FENTANYL Short acting opiate. Duration of action: 1-2 hours. Sedative and analgesic effects. Causes
respiratory depression. Does not have histamine release. Much more stable than morphine from
cardiovascular standpoint. Dosage (continuous infusion): 1-5 mcg/kg/min. Cost: $1.28/1000 mcg. 24-hour
cost: $12.80-64.00/day.
PROPOFOL Lipid soluble, ultra-short-acting anesthetic. Prepared in lipid carrier. Duration of action: 15
minutes. Easily titratable. Lowers ICP. Should not be used in patients with hypertriglyceridemia. Exhibits
three-compartment redistribution with prolonged use, leading to prolongation of action. Bolus doses may
cause hypotension. Rare fatal reactions noted in children. Dosage (continuous infusion): 20-200
mcg/kg/min. Cost: $49.95/1000 mg. 24-hour cost: $100.00-1,000.00/day. ALL PATIENTS RECEIVING
DIPRIVAN MUST HAVE DAILY SERUM LACTATE AND CPK CHECKED. IF EITHER RISES, STOP
DIPRIVAN IMMEDIATELTY.
55
Alcohol Withdrawal Protocol
Patient with risk factors for alcohol
withdrawal syndrome
Obtain: 1. liver function panel, INR/PT 2. BMP, magnesium, phosphorus, albumin 3. Blood glucose monitoring Provide: 1. Thiamine 100mg once daily IV/IM/PO 2. Folic acid 1mg once daily PO/IV 3. Multivitamin once daily or Cernevit 5ml in minimum 500ml IVF once daily 4. Adequate hydration
High clinical suspicion for
withdrawal
Active withdrawal
Lorazepam 2-4mg PO/IV/IM q 6 hrs x 4 doses, then 1-2mg PO/IV/IM q 6 hrs 2 8 doses (3 day prophylaxis wean). Monitor vital signs
and status q 4-6 hrs.
Ethanol 5% in D5W at initial rate of 50 ml/hr.
Titrate for symptoms of early withdrawal. Wean
over 3 days. Monitor vital signs and status q 4-6 hrs.
Transfer to monitored
unit
Lorazepam 2-4mg IV every 1 hr until lightly
sedated and symptoms resolved.
Monitor vital signs and status every hour
Select desired therapy: Lorazepam (preferred) or ethanol drip Note: ethanol is contraindicated in patients with pancreatitis and liver disease
56
Sedation Protocol
1. (Diprivan): Begin with 0.5 mg/kg/hr, increase by 0.5 mg/kg every 5-10 minutes, up to 5 mg/kg/hr. Patients receiving propofol infusion should have serum triglyceride levels monitored every 4-7 days; propofol should be discontinued if serum triglyceride levels are ≥300. Patients with closed head injury being followed by the neurosurgical service may receive Diprivan® brand propofol because it has been shown to decrease intracranial pressure. ALL PATIENTS RECEIVING DIPRIVAN MUST HAVE DAILY SERUM LACTATE AND CPK CHECKED. IF EITHER RISES, STOP DIPRIVAN IMMEDIATELTY.
2. Morphine sulfate: Standard regimen is 1-6 mg IV every 1-2 hours prn pain/agitation; alternative regimen is continuous infusion (100 mg/ 100 mL NS): start at 2-4 mg/hr. Patients with documented allergy to morphine sulfate and/or severe hypotension with morphine sulfate administration, may use fentanyl: load with 1-2 mcg/kg, then continuous infusion (1 mg/ 50 mL) at 0.5-5 mcg/kg/hr.
3. Midazolam (Versed): Standard regimen is 2.5-5 mg IV every 1-2 hours prn sedation.
4. Lorazepam (Ativan): Standard regimen is 1-2 mg IV every 1-2 hours prn sedation; alternative regimen is continuous infusion (20 mg/ 100mL NS): start at 1-2 mg/hr.
Patients with Renal Insufficiency/Failure The preferred agents are lorazepam (Ativan) and hydromorphone (Dilaudid) 0.5-1 mg IV every 1-4 hours prn pain/sedation; continuous infusion to start at 0.5 mg/hr. AVOID meperidine (Demerol) and morphine sulfate because of increased potential for accumulation of renally excreted metabolites, normeperidine and morphine-6-glucuronide, respectively. Riker Sedation-Agitation Scale (SAS) 1) Unarousable: Minimal or no response to noxious stimuli, does not
communicate or follow commands 2) Very sedated: Arouses to physical stimuli but does not communicate
or follow commands, may not move spontaneously 3) Sedated: Difficult to arouse, awakens to verbal stimuli or gentle
shaking but drifts off again, follows simple commands 4) Calm and cooperative: Calm, awakens easily, follows commands 5) Agitated: Anxious or mildly agitated, attempting to sit up, calms
down to verbal instructions 6) Very agitated: Does not calm, despite frequent verbal reminding of
limits; requires physical restraint, biting ET tube 7) Dangerous agitation Pulling at ET tube, trying to remove catheters, climbing
over bed rail, striking at staff, thrashing side-to-side
58
Stress Ulcer Prophylaxis
Patient Admitted to MICU/SICU/TICU
Evidence of active GI bleed on admission
MAJOR RISK FACTORS Severe Head Trauma Burns > 30% BSA Prior Organ Transplant Renal Failure Recent PUD (6 weeks)* Hypotension/Shock 1. Severe Sepsis 2. Major Surgery/Trauma
> 48h Mech. Ventilation OR
Coagulopathy
IV PROTON PUMP INHIBITOR i.e. Pantoprazole 40 mg IV every
24 hours
IV H2 BLOCKER i.e.Ranitidine 50 mg IV every 8 hours
(For Cr Cl < 50) 50 mg IV daily
ORAL H2 BLOCKER i.e. Ranitidine 150mg PO BID (For Cr Cl < 50) 75 mg PO BID
OR Oral Proton Pump Inhibitor
i.e. Pantoprazole 40 mg every 24 hours
Treat active bleeding
References 1. Cook DJ , Fuller HD, Guyatt GH et al.Risk factors for gastrointestinal bleeding in critically ill patients.N Engl J Med. 1994 Feb
10;330(6):377-81. 2. Levy MJ, Seelig CB, Robinson NJ et al.Comparison of omeprazole and ranitidine for stress ulcer prophylaxis.Dig Dis Sci
1997Jun;42(6):1255-9 3. CookD, HeylandD,Griffith L,et al:Risk factors for clinically important UGIB in patients requiring mechanical ventilation. Crit
Care Med 1999;27:2812–2817 4. Jung R, MacLaren R. Proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients. Ann Pharmacother. 2002
Dec;36(12):1929-37 *Endoscopic or radiographic evidence of peptic ulcer disease in preceding 6 weeks ** Presence and persistence and severity of risk factors should be reviewed every24h
No
No Prophylaxis Indicated Re-evaluate need for
treatment
No On Transfer/Discharge
OR Risk Factors Resolved
Discontinue Therapy
No
Yes
This clinical practice guideline is a systematically developed algorithm intended to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. This guideline is not a fixed protocol that must be followed, but is intended for health care professionals and providers to consider. While it identifies and describes generally recommended courses of intervention, it is not presented as a substitute for the advice of a physician or other knowledgeable health care professional or provider. Individual patients may require different treatments from those specified in this particular guideline.
No
Yes
Yes
Yes
Tolerating Tube Feedings or PO
intake
Patient with SRMD, PUD, or GERD*
*SRMD=Stress Related Mucosal Damage PUD=Peptic Ulcer Disease GERD=Gastroesophageal Reflux
59
General Management Principles for Severe (GCS 3-8) and Moderate (GCS 9-12) TBI
• Use very short-acting sedatives if needed, for frequent neurological exams
Especially important in first 24 hours Sedation holiday for nursing neuro check unless otherwise ordered
• Convert field collar to Miami J until ligamentous injury can later be ruled out • Insertion of intraparenchymal ICP monitor after coagulopathy (if present)
corrected (Normal PTT and INR < 1.2 desireable, <1.4 occasionally still done) • Avoid thrombocytopenia • Serial INR (repeat 6-8 hours after injury, then every 24 hours for 48-72 hours) • Rapid evacuation of mass lesions if indicated • Rule out vascular injury/hypoxic or embolic mechanisms of brain injury • Rule out intoxicants as contributors to neurological status • Ensure adequate ventilation and oxygenation and prevent hypercarbia • Elevate HOB to 30 degrees (reverse Trendelenberg if spine not cleared) • Avoid hypothermia • Avoid hyperglycemia and hypoglycemia (Goal Glucose 80-150) • Early nutrition, enteral preferred • DVT prophylaxis with TEDs and thigh-high SCDs if possible
Delay subcutaneous heparin until 24-48 hours post-injury Delay Lovenox until cleared by NSR
• Seizure prophylaxis (Dilantin) x 7 days for EDH, SDH, IPH/contusion, depressed skull fx, penetrating injury, GCS < 10, sz within 24 hours of injury
• Avoid symptomatic anemia • Maintain normal ICP and CPP within desired range For elevated ICP (> 20 mm Hg x > 5 minutes): Notify Neurosurgery First Tier Therapies: • Ensure HOB elevated • Ensure no compression from cervical collar and neck in neutral position • Ensure ventriculostomy (if present) patent and functioning • Sedation and analgesia with Diprivan Drip (discontinue if elevation of CPK or
lactate) or Fentanyl or Morphine Drip or Intermittent Dosage • Maintain Hyperosmolar Euvolemia
A Catheter, Mannitol +/- Lasix, hypertonic saline boluses, serum Na and osmolarity every 6 hours
No hyperosmolar agents if osmolarity > 320 Goal serum Na 145-155 usually
• Cerebral Perfusion Pressure Goals 50-70 mm Hg usually Neosynephrine preferred pressor if pressors needed Dopamine in low doses
60
General Management Principles for Severe (GCS 3-8) and Moderate (GCS 9-12) TBI (continued)
Second Tier Therapies: • Cerebrospinal fluid drainage/Ventriculostomy • Mild, temporary hyperventilation to pCO2 30-35 • Intermittent paralytics • Intermittent barbiturates Third Tier Therapies: • Decompressive craniotomy • Barbiturate coma • In general, these are used in somewhat of a step-wise progression by tier but
simultaneously within tiers (and sometimes across tiers). The idea is to have standards for all but tailor the therapy to the individual patient's physiology and injury patterns.
• The first tier therapies are used on essentially everyone with a severe TBI. • The second tier therapies may be used prior to some of the first tier therapies
or never at all. • The third-tier therapies may be used prior to any second tier therapies.