UVa Trauma Pearls

University of Virginia Health System
LEVEL I TRAUMA CENTER
TRAUMA HANDBOOK
Final Editing by: Jeffrey S. Young, MD Professor of Surgery Medical Director, Quality and Performance Improvement Medical Director, Trauma Center James Forrest Calland, MD Assistant Professor of Surgery Associate Medical Director, Trauma Center
http://tinyurl.com/uvatraumamanual
2 6/11 UVA TRAUMA HANDBOOK
A summary of changes and additions in this version of the Trauma Handbook can be found in the reference section.
This handbook is also available online via the Clinical Portal, Trauma web pages, and the EPIC link from the Trauma Admission Order Set.
UVA TRAUMA HANDBOOK 6/11 3
MAJOR CONTRIBUTIONS BY: Kathy M. Butler, RN, CCRN Trauma Center Manager Kristi Kimpel, RN, MSN, CCRN, CCNS Surgical / Trauma / Burn ICU Julie Haizlip, MD Assistant Professor of Clinical Pediatrics Division of Pediatric Critical Care David Mayo, B.S., RRT Registered Respiratory Therapist David Volles, Pharm.D., BCPS Clinical Pharmacy Specialist Susan Murphy Lynn Welch Production Support Acknowledgements Mary Deivert, RN, MSN, ACNP, CCRN Suggestions for revisions and additions are encouraged and should be emailed to kmb4r@virginia.edu Produced by the Trauma Program All rights reserved. Fifth Edition June 2011 Fourth Edition August 2010; Revised February 2011 Third Edition July 2009; Revised October 2009
INTRODUCTION
The term cookbook medicine is much maligned. However, few chefs would attempt a complex dish without a recipe to guide them, and few musicians would attempt a complex piece without written music to direct them. These guidelines are not meant to mandate rigid adherence, but are meant to provide a framework, based on extensive experience and knowledge. Revisions to these guidelines are welcomed, but these revisions should be evaluated during a period of intellectual reflection, and not in the ED at 2AM. The clinician should use these guidelines to provide safe and effective care to injured patients. To the many individuals who have contributed to the Trauma Center Handbook, thank you. Jeffrey S. Young, M.D. Professor of Surgery Medical Director, Quality and Performance Improvement Medical Director, Trauma Center
Guidelines are general and cannot take into account all of the circumstances of a particular patient. Judgment regarding the propriety of using any specific procedure or guideline with a particular patient remains with that patients physician, nurse or other health care professional, taking into account the individual circumstances presented by the patient.
2011-12 CHIEFS & FELLOWS

PAGER PAGER
GENERAL SURGERY 3393 Butler, Paris 2241 Dengel, Lynn 6164 Stokes, Jayme B 3291 Taylor, Matthew D TRANSPLANT 2923 Dorn, Harry 6234 Kane, Bart
VASCULAR & TCV 3870 Adams, Joshua 6895 Carrot, Phil 4679 Gazoni, Leo 3396 Griffiths, Eric 2266 Grubb, Kendra 3167 Isbell, Jay 4627 Tesche, Leora 2925 Zamora, Alvaro 4TH YEARS 6582 Nagji, Alykhan 2880 Parker, Anna 3RD YEARS 4705 Shada, Amber L. 3158 Walters, Dustin M. 3119 Mericli, Alexander F Plastics
6623 Flohr, Tanya R 4422 Hennessy, Sara 4882 Hranjec, Tjasa 4061 Campbell, Kristin T. 4853 LaPar, Damien J. 6594 Riccio, Lin
2ND YEARS 4992 Davies, Stephen CAT 2276 Guidry, Christopher CAT 2995 DeGeorge, Brent Plastics 2685 Newhook, Timothy CAT 3767 Gillen, Jacob CAT 2744 Pope, Nicholas CAT 1ST YEARS 3024 Balireddy, Ravi ANES 4063 Hu, Yinin CAT 6181 Davila-Aponte, Jennifer URO 4038 Mehta, Gaurav NDP 6954 Davis, John CAT 4345 Nadar, Menaka RAD 6994 Dieth, Zachary CAT 6682 Sheeran, Daniel RAD 6177 Doerr, Matthew OPHth 4630 Timberlake, Matthew URO 2146 Edwards, Brandy CAT 6742 Ugas, Marco RAD 6121 Haddad, Zeina OPHth 6442 Wagner, Cynthia CARD 3921 Hankins, Jeanette RAD 4715 Willis, Rhett CAT 6178 Hanna, Kasandra Plastics 4782 Yount, Kenan CARD 6963 6552 6966 6554 6587 Johnston, W Forrest Judge, Joshua (Slingluff) Lindberg, James M. McLeod, Matt (Slingluff) Petroze, Robin (Calland) RESEARCH 4088 Politano, Amani (Sawyer) 6635 Rosenberger, Laura (Sawyer) 6988 Salerno, Elise P. 6939 Stone, Matthew (Kron)
CONTACT DIRECTORY TRAUMA ALERT GROUP MEMBERS

Phone Pager 9162 1294 531-3494 1560 1459 1311 9248 1564 1450 1294 1297 1824 1356 1707 531-5703 3-6341 3-6317 1391 1576 1822 1371 1616 1716 1742 1989 4-2120 1384 Adult Trauma Alert Intern Trauma Alert 2nd yr Trauma Chief Trauma Alert Backup Chief Anesthesia Resident Consult & PACU Trauma Attending Trauma Intern Acute Care Trauma Resident ICU Trauma Consult Day Pediatric Trauma Chief Peds Trauma Intern Peds Trauma Attending ED: 2nd yr (consults) ED: Attendings Chaplain NSGY Resident 2 Nursing Supervisor OR Charge Nurse Respiratory Therapy-Adult 1684 (RT Back-ups) Respiratory Therapy-Pediatric Radiology Portables (no charge) Social Worker-ED
1908 Back up Trauma Attending
CONTACT DIRECTORY
284-2845 2-3549 242-9458 2-4278 465-5152 227-1278 4-8000 284-1923 3462 Trauma Center Director, Jeff Young, MD Administrative Assistant, Amy Bunts Assoc. Trauma Director, Forrest Calland, MD Administrative Assistant, Cynthia Carrigan 3404 Trauma Attending: Rob Sawyer, MD 6151 Trauma Attending: Carlos Tache Leon, MD 3868 Trauma Center Manager, Kathy Butler, RN Cellular
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Pager 9520 Floor Attending Trauma Service Nurse Practitioners 4334 Deborah Baker, ACNP 2471 Jennifer Edwards, ANP 6744 Gabriele Ford, FNP-C 4676 6 East SW - Beverly Pitts 531-5839 ED Charge Nurse 531-5701,02 ED Attending #1, #2 4-9295 ED Reg Fax 4-1201 ED back Fax 4-5227 (1) LAB 4-2273 Blood Bank 3-9218 Bed Center RN 3142 Neuro CNS RADIOLOGY 3-9296 CT 1234 CT Tech 1404 Head CT ResidentED Board Body CT ResidentED Board 4-9338 Diagnostic Work Area 4-9400 Image Management (choose options 3, then 2) 1844 IR Resident (Request on-call IR Nurse also) 3-9535 IR Department 2-3155 MRI 2-2526 4701 MSK Reading Room Coordinator (even months) 2-3432 1492 Neuro Reading Room Coordinator (odd months) CONSULTS 1415 Acute Pain Service 1251 Orthopedics ED 1609 Consultants: ENT 1518 Plastics- Consult ER 1800 Plastics Intern 6811 Psych Nurse - Brenda Barrett 1288 TCV night 1847 Thoracic Chief 1847 Thoracic Day Consult 1253 Urology 1378 Vascular Day Consult 1818 Vascular Chief CONTINUED
Phone
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TRANSFER HOSPITALS Hospital Main Phone Augusta 800-932-0262 Culpeper 800-232-4264 Lynchburg 877-635-4651 Martha Jeff. 434-654-7000 Roanoke 540-981-7000 Rockingham 800-543-2201
Film Room 540-932-4483 540-829-4144 or 4145 434-200-4139 434-654-7104 540-981-7126 540-433-4380 or 4386
QUALITY CONCERNS Phone Pager 284-1923 3868 Kathy Butler, RN Please share adult or pediatric trauma concerns with the trauma center manager promptly (within 72hrs) by phone or pager. TRAUMA REGISTRY REPORT REQUESTS 3-4858 Michelle Pomphrey RN 4-1770 Sera Downing Extensive adult and pediatric injury data are available. Please allow 7 business days for report generation.
TABLE OF CONTENTS
TRAUMA ALERT PROCESS CT Algorithm for Pregnancy TRAUMA ALERT CRITERIA Trauma Alert Considerations PEARLS Trauma Service Communications Discharge Planning Discharge Summary Guidelines TRAUMA PRACTICE GUIDELINES ADULT (Alphabetical) Abdominal Penetrating Trauma Airway Management Emergent ARDS Patients - Ventilated STBICU ARF Tracheostomy Planning Tracheostomy Patients In Adult Acute Care Ventilator Paralysis Trial Ventilation Proning Brain Injury Brain Injury: Initial Assessment Brain Injury Sedation Intracranial Pressure Management Guideline Guidelines for Craniotomy / Craniectomy Burn Major, Respiratory Management Adult Burn Fluid Resuscitation Guidelines Cardiovascular Failure, Non-Hypovolemic Chest Trauma Blunt Myocardial Injury Blunt Thoracic Trauma Epidural Protocol Penetrating Central Deep Venous Thrombosis Extremity Trauma Penetrating or Blunt Hematuria Pelvic Fracture Algorithm Pulmonary Embolism Workup & Treatment Resuscitation Rhabdomyolysis Sepsis Alert Definitions for Inflammatory Response, Sepsis Spine Clearance Algorithm Spleen and Hepatic Trauma, Non-operative Management PAGE 12-16 15 17-18 19 20-21 22-23 24 25-26 27 28 35 29 30-31 32 33-34 36-37 38 39-40 41 42-43 44-49 64-65 50 51 52-53 54 55 56 57 61 62 63 58 70 71 66-69 59-60
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REFERENCES Overview of Guideline Changes Injury Scales Lung Spleen Liver Kidney Heart Diaphragm PT / OT Service Guidelines Long Term Acute Care Hospital Assignment of Palliative Care Code to Patient Med. Record Organ Donation Discharge Against Medical Advice Checklist Sedation Guideline Adult Critical Care Units High-Risk Agitation Guideline Richmond Agitation-Sedation Scale (Rass) Trauma: Pain and Sedation Guidelines PEDIATRIC GUIDELINES Sedation Service Brain Injury Guidelines for the Management of Intracranial Hypertension in Children with Closed Head Injury I. Standard Therapy for All Children II. Sequential Treatment of Elevation in ICP III. Severe, Abrupt Elevation in ICP and/or Manifestation of Impending Herniation IV. Sequential Treatment of Decreased MAP / CPP Sequential Treatment for ICP >20 mmHg (All Ages) Second Tier Treamtnet for ICP > 20 mmHg (All Ages) Severe, Abrupt Elevation ICP and/or Manifestation of Impending Herniation Treatment of Decreased MAP Decreased CCP Sequential Treatment for ICP >20 mmHg (All Ages) Severe TBI Standard Therapy Checklist Clinical Pathway Evaluation of the Pediatric Cervical Spine Near Drowning/Submersion Injury Non-accidental Trauma (Abusive Injury) Hemostatis in Pediatric Neurotrauma ADULT MEDICATION REFERENCES
PAGE 72-90 72 73-78 73 74 75 76 77-78 78 79 80-81 82-83 84-85 86 87 88 89-90 91-92 93-119 96 97-113 98 98-99 100-102 103 103-104 105 106 107 108 109 110-111 112-113 114-115 116-117 118-119 120-130
TRAUMA ALERT PROCESS

PRE-ALERT CONSIDERATIONS Team conference with introductions, review of roles and responsibilities, and contingency planning when time allows Reference trauma indicators for activation criteria Standard for notification of team: immediately upon meeting criteria Trauma team response immediate based on expected arrival, to be in ED prepared for patient prior to arrival Chief needs to reference outside hospital imaging prior to patient arrival whenever possible BASIC EVALUATION ABCDE assessment 2 large bore IVs CXR, pelvis x-ray (if patient hemodynamically stable, pelvis may be withheld if patient A&Ox4 and non-tender), and trauma labs
INDICATIONS FOR IMMEDIATELY SECURING AIRWAY Inability to follow commands Inability to protect airway Inability to safely complete workup Shock Severe inhalation injury BREATHING Decompress chest if decreased breath sounds or subcutaneous emphysema with Sa02 < 90% Bilateral chest decompression for blunt agonal or anterolateral thoractomy if indicated CIRCULATION Hemorrhage control (consider suture, pelvic binder, BP cuff, splints)
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Consider resuscitative thoracotomy if:
witnessed arrest (blunt) recent arrest (penetrating)

Aggressive volume resuscitation ( PRBC) indicated for blunt agonal May hold/withdraw thoracotomy if PEA, wide complex and HR <40 DEFICITS Assess neurologic status (GCS) and extremity movements, sensation x 4. EXPOSURE Mark penetrating wounds with paperclips where appropriate (open= posterior) FAST EXAM RADIOGRAPHY IMAGING CXR - All patients Pelvis xray all blunt trauma (may be withheld if patient A&Ox4, non-tender and hemodynamically stable) Head CT Loss of consciousness Altered LOC Significant trauma above clavicles Facial CT Severe facial injuries CTA Neck Fractures through C1 - C4 Seat belt sign or extensive bruising on neck Cerebral infarct Acute anisocoria Neuro deficits / decline / clinical picture not consistent with injury Petrous fracture GCS < 8 w/out explanatory findings on CT of the head
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CT Thorax Significant thoracic injuries on CXR Rapid deceleration mechanism Abnormal mediastinal contour Abdominal CT Abnormal CXR Abnormal pelvis x-ray Spine fracture Abnormal abdominal exam Abnormal labs (HCT, LFTs, amylase) Hematuria or GU injury Inability to examine patient for the next 4 hours Any prior hypotension - mechanism (?) (if any of above criteria are not met, likelihood of intraabdominal injury is <1%) Mediastinal Evaluation The trauma service will be responsible for mediastinal evaluation Patients with low-risk (mechanism only, obese, no significant thoracic injury (single rib fractures) get a dynamic chest CT with their abdominal CT Patients with significant thoracic injuries (high-risk) will get a CTA with their abdominal CT Positive dynamic chest CT will get a CTA Spine Evaluation If known fracture anywhere in the spinal column, perform a complete spine work-up. OSH process: All OSH spine films will be read for Trauma Alerts. An order must be placed indicating this need. Admission to the Trauma Service Any of the criteria noted in the trauma consult or alert Any situation where the good of the patient would be served
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CT ALGORITHM FOR PREGNANCY
Obtain routine trauma imaging. Is pt hemodynamically unstable and / or have abdominal tenderness and / or a known pelvis fx?
Consider obtaining Yes pre-imaging Beta-HCG if not otherwise contraindicated by patient status.
No
Known pregnancy? or
Obtain routine trauma imaging. Consider obtaining pre-imaging Beta-HCG if not otherwise contraindicated by patient status.
Fetus visible on plain film/Torso Scout Images on CT?
No
Yes
Avoid CT through pelvis to avoid radiation exposure to cranial vault / fetal brain. Consider CT options for lower radiation dosing (consult with radiologist), Or alternative to CT imaging of pelvis: e.g., CT IVP / cystogram for imaging of GU system, or MRI of pelvis.
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STBICU ADMISSION Any intubated multiple trauma patient Any intubated acute post-op trauma patient (except neurosurgery for isolated head injury) e.g. patient with isolated femur fracture who cannot be extubated post-op Any trauma patient at significant risk for respiratory compromise because of their injuries OR BECAUSE of their baseline medical fraility. Any trauma patient at significant risk of bleeding Any trauma patient with evidence of active bleeding Any trauma patient with multiple rib fractures who cannot blow 1000cc on incentive spirometry (especially elderly patients) Any of these patients who cannot be admitted to the STBICU must have their admission location cleared by the trauma attending before confirming bed assignment NNICU ADMISSION Patients initially admitted to Neurosurgery with reason for ICU admission Patients with isolated head or spinal cord injury, with no evidence or risk of hemorrhage (negative abdominal, chest, and pelvic evaluation), admitted to trauma service 6 WEST ADMISSIONS Acute care spinal cord and head injury 6 EAST ADMISSIONS Trauma/orthopedics CONSULTATIONS For patients transferred to other services or admitted to other services, the Trauma Service will no longer sign off on any patient until the Trauma Attending signs off, in writing.
TRAUMA ALERT CRITERIA

ALPHA ALERT - Attending Trauma Surgeon presence within 15
minutes of patient arrival 1. Airway obstruction or respiratory compromise including intubated patients who have been transferred from another facility with ongoing respiratory compromise. 2. Confirmed hypotension a) SBP < 90 on 2 consecutive measurements b) age-specific hypotension in children [SBP < 80 + (2* age)] c) Absense of peripheral pulses d) Transfer patients receiving blood to maintain SBP >90 3. Gunshot wounds to the neck, chest, or abdomen 4. Advanced pregnancy (fundus above umbilicus) with abdominal trauma 5. Mass casualty incident: >2 patients with Beta Alert Criteria 6. Or per Emergency Medicine Physician / Trauma Service discretion
BETA ALERT - Full Team response - Discretionary Trauma Attending presence. Patient has NO Alpha Alert Criteria and one or more of the following: 1. Severe single system injury (including penetrating head trauma) 2. Respiratory a) Intubated at scene or < 2 hours prior to arrival at UVA with NO ongoing respiratory compromise b) Mechanically assisted ventilation and NOT intubated c) Facial Burns or singed facial hair with altered phonation 3. Cardiovascular a) Cardiac Arrest blunt mechanism b) Relative Hypotension: SBP > 90 but < 100 mm Hg (<110 mm Hg in > 65 yrs) c) Active hemorrhage (with stable vital signs) 4. Neurological a) GCS < 13 or GCS > 1 point below baseline or N / V b) Tetraplegic, hemiplegic, or persistent neurologic deficit c) Open or depressed skull fracture d) Known intracranial bleeding from outside study with known or suspected history of injury (including GLF)
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5. MSK a) Two or more proximal long-bone fractures b) Amputation proximal to wrist or ankle c) Crushed, degloved, or mangled extremity 6. Stab wounds to neck, chest, or abdomen 7. Burns: Adults > 40%, Pediatric > 25% TBSA 8. Concomitant thermal / multi-system injury 9. Or per Emergency Medicine Physician / Trauma Service discretion
GAMMA ALERT - Surgical Chief presence within 30 minutes of activation; Patient has NO Alpha or Beta Alert Criteria and has one or more of the following: 1. Altered mental status (GCS lower than baseline by only 1 point) and/or intracranial blood present on in-house CT (even if from GLF) 2. Severe pain in chest, abdomen, neck, or back 3. Significant solid organ injury 4. Pelvic fractures 5. 2 or more organ systems/body areas significantly injured 6. Operative therapy anticipated / planned by subspecialty service 7. Moderately injured with severe medical co-morbidities 8. Time-sensitive extremity injury 9. Early Pregnancy with abdominal pain / signs of abdominal trauma 10. High energy mechanism: High-risk falls: adults: fall >20 feet (one story = 10 feet) children aged <15 years: fall >10 feet or 2 -3 x childs height; 11. High-risk motor vehicle collision: extrication or intrusion intrusion: >12 inches to the occupant site or >18 inches to any site ejection (partial or complete) from automobile death in same passenger compartment vehicle telemetry data consistent with high risk of injury; 12. Auto versus pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact 13. Motorcycle collision >20 mph 14. Or per Emergency Medicine Physician / Trauma Service discretion
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TRAUMA ALERT CONSIDERATIONS Pre-Patient Arrival Pre-alert conference held? Orders in? Prompt nurse/tech to obtain cooler with blood for transport if anticipated as a possible need (Hypotensive, receiving blood, etc. Clean hands pre-post gloving Eye shield, mask, lead shield, gown if within reach of patient Pre-alert review responsibilities / priorities, including probable drug needs Document time out on all invasive procedures unless true life-threatening situation Minimize number of people in the room so that staff can have unobstructed access to patient and supplies Chief and residents involved in care check in with nurse recorder and assure your name and pic are recorded. Equipment available: Ultrasound / dopplers / full 02 tank Uncrossmatched blood in room Limit number of staff in CT to 3 due to small space Post-patient Arrival Always send an ABG even if venous to get rapid HCT Vocalize ABC findings 1st Good neuro exam before intubating or going to the Operating Room. Obtain info, if possible, before intubation (weight, allergies, family contact) If blood administration Rapid Infuser / warmer Hemorrhage? Blood Alert (massive transfusion) call Blood Bank to request 4-2273 Examine under cervical collar 1 person call CT only when ready to leave resus area Initiate signing all verbal medication orders when in CT Notify bed center ASAP 3-9932 to request bed All ED Deaths need a note from the chief resident All OR Deaths need a dictated note from the senior resident or attending
PEARLS
Trauma Surgery Service Pearls All PEGS in patients on the TRAUMA SERVICE are to be sewn into place at the time of placement WITHOUT EXCEPTION. It is expected that a chief or attending physically be present to round on all Intensive Care Units with trauma service patients before noon. If the chief feels he/she will be unable to fulfill this expectation, the attending must be notified immediately so that he may fulfill this important responsibility. The chief/attending is to check in with the nursing staff at the time of the visit and leave a clear plan regarding discharge planning. Attending / Chief Floor rounds shall occur at 2 pm daily on weekdays, and immediately after ICU rounds on weekends. If a TLSO is ordered, it must be on before standing pt upright Indicators for Speech Evaluation: - Altered mental status, > 1 point difference from baseline - Trauma to mandible, oropharynx, or larynx - Intubation > 72 hours - Clinical suspicion of ongoing aspiration In general, morphine is to be avoided in patients on the TRAUMA Service. Use fentanyl for frail or hemodynamically unstable pts, use dilaudid in young pts with severe pain. Workup when cause of fall / injury / MVC is unclear: Holter Monitor or 24hr review of telemetry / ICU alarm history Assess for seizures (tongue soreness, incontinence) Assess for recent changes in medications Suicidality? Tertiary Survey If pt A&O perform tertiary survey. If not, perform within 48 hrs when A&O. Full visual & joint mobility assessment including UE & LE resistance strength evaluation assessing for reports of pain. Document completion and positive findings. Identify what hurts, what has ecchymosis and image it. Planter flexion checks for pain response (may indicate weight bearing concerns, joint imaging needs). Image areas of concern.
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Operative Treatment of Abdominal Hemorrhage if you pack it, squirt it Bleeding scalp lacerations consider early whip stitch instead of staples. Penetrating trauma initial assessment roll early! Mark all wounds. Blood Alert early activation of blood alert may improve survival. Interventional radiology / embolization may be an acceptable treatment modality for hypotensive patients with hemorrhage from isolated severe pelvic fractures and negative abdominal exam/FAST. Occasionally this will even occur before CT. If laparotomy precedes interventional radiology, temporary closure may be desirable. In general, injured patients belong on the Trauma Service, not the Medicine Services. Any bad ABG must be repeated or treated with intubation. In general, we admit most patients to trauma for the first 24hrs with some exceptions such as isolated severe TBI. Psych must leave note in the chart that a sitter is no longer needed. Yes, simultaneous craniotomy / thoracotomy / laparotomy / peripheral vascular repair are possible! Thoracic hemorrhage >1.5 liters must receive expeditious operative therapy. In general use of benzodiazepines in patients with natural airways is discouraged, especially in the elderly. Consider Haldol for delirium instead. Consider removing one line or tube daily on patients who are improving clinically. Incidental Findings: All incidental findings that possibly represent neoplasm or metatastic disorders with potential for severe consequence require definitive consultation prior to discharge and notation in the discharge summary without exception.
TRAUMA SERVICE COMMUNICATIONS

JUNIOR RESIDENTS TO CONTACT CHIEF Saturations < 90 not responding to one intervention Arrhythmia with hypotension Lactic acidosis not corrected by 8 hours after admission Urine output less than 0.5 cc/kg/hr not responding to one intervention Before any antibiotics are begun Before Swan-Ganz catheter is placed or bronchoscopy is performed Before any consult other than Ortho, Face, Spine, or Neurosurgery is called. Increase in PEEP > 8, increase in mean airway pressure > 15, increase in peak pressures > 30, increase in FIO2 greater than 50% for more than 30 minutes. Decrease in BP < 90 not responding to single intervention. Decrease in CI >1 L/ M, and/or increase in LA > 2.5 Significant change in abdominal exam. Significant change in lab tests (pancreatitis, drop in HCT of 10% or more, elevation of creatinine > 1.5) Temp > 39.5 Before any consult service cancels or performs a procedure or takes the patient to the OR Acute deterioration in neurologic status Updated DNR status (patient/family requests DNR/comfort measures only) CONTINUED
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CHIEF TO CONTACT ATTENDING Call Attending If: Significant family conflict Transfer to ICU All admissions and consults Any major conflict with Consult service Cardiac, respiratory arrest Any complication of procedure or consult procedure Death (if not DNR) Text Attending If: Death if DNR On evidence of organ failure (CV, resp, renal, neuro) Missed injury Consult operation Before bronchoscopy, Swan-Ganz, or other major bedside procedure during daytime hours Patient leaving AMA
DISCHARGE PLANNING
DISCHARGE ORDERS Trauma Service Clinic appointments should be with either Dr. Young, Calland or Tache-Leon. For Dr. Sawyers patients, he will specifically request when a f/u apt with him is indicated. Post-chest tube insertion: No flying for 4 weeks post discharge date; follow up chest x-ray first. Note follow-up plan for incidental findings: Incidental Findings: All incidental findings that possibly represent neoplasm or metatastic disorders with potential for severe consequence require definitive consultation prior to discharge and notation in the discharge summary without exception. For spleen & hepatic injuries No contact sports No strenous exercise
TRANSITIONAL CARE HOSPITAL The Transitional Care Hospital at the University of Virginia provides Long Term Acute Care (LTAC) services to medically stable but complex patients. Patients who require this level of care are too ill for discharge to home, a nursing facility, or an acute care rehabilitation facility. Transitional Care Hospital (LTAC) referrals for vent weaning: Discuss plans with RT, Request RT do a Negative Inspiratory Flow (NIF) and Vital Capacity (VC) Discuss the medical indications for LTAC referral with family Call Social Work
DISCHARGE SUMMARY GUIDELINES

Discharge summaries must be dictated before residents rotate off service and within 7 days of discharge. Non-compliance is tracked and reported. Patients Name Medical Record Number Admission Date Discharge Date Account Number Attending Physician Referring Physician PRIMARY DIAGNOSIS: 1. Multiple Trauma 2. List all injuries including lacerations, abrasions, and contusions with the most significant injuries first 3. Any relevant diagnostic imaging studies, laboratory and surgical pathology findings, must be documented in the clinical notes to be applicable for coding purposes. Pneumothorax MUST be documentated as traumatic. Injury Documentation Keys: 1. List specific number of rib fractures 2. Specify grade of all organ injuries 3. Specify LOC duration for all head injuries. DOCUMENT if patient did not return to their baseline mental status. 4. Specify head injury ex: concussion, contusion, etc NOT CHI 5. Note Hemoperitoneum if appropriate PROCEDURES: 1. List all procedures 2. Specify sharp, excisional debridement if tissue was physically clipped or cut away, please dictate excisional debridement within the heading of OP REPORT. Excisional debridement should be documented when performed in the OR or at the bedside. 3. Specify blood loss anemia if reason for blood transfusions
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PAST MEDICAL HISTORY: 1. List all co-morbid conditions including history of alcoholism or substance abuse, as well as COPD, Diabetic etc. PAST SURGICAL HISTORY: HISTORY OF PRESENT ILLNESS: 1. Primary reason for admission such as: rule out head injury, or treatment of splenic lac. NOT: multi trauma PHYSICAL EXAM: RADIGRAPHIC STUDIES: LABORATORY STUDIES: 1. Specify lab values and if abnormal document hyper or hypo conditions by specify name. HOSPITAL COURSE: DISCHARGE CONDITION: DISPOSITION: DISCHARGE MEDICATIONS: 1. If antibiotic list reason for, this is a potential acquired condition in house, and could affect severity of illness coding. FOLLOW UP APPOINTMENTS: Follow-up clinic appointments will be with Dr. Young, Dr. Calland or Dr. Tache Leon. Dr. Sawyer does not have trauma follow-up appointments unless he requests to see the patient. General Surgical attendings taking trauma call do not have trauma follow-up in clinic.
TRAUMA PRACTICE GUIDELINES - ADULT

ABDOMINAL PENETRATING TRAUMA GUIDELINE
Trajectory likely (or possibly) through abdomen: from nipples/ tip of scapula to inguinal ligaments: ABCDEs CXR FAST Exam Unasyn 1.5 g + Tetanus Previous GSW? Unstable OR for Laparotomy1 / Thoracotomy2

Stable Mark Wounds3 Flat plate X-Rays of all possible trajectories4 GSW
Stab Wound
Tender / tachycardic / nauseated: Laparotomy Non-tender: Local wound exploration or laparoscopy Lap. if violation of post. fascia / peritoneum
Tender / tachycardic or trans-abdominal: Laparotomy Non-tender: CT Scan w / contrast +/Laparoscopy Laparotomy if violation of peritoneum
1. Prep Chin to Knees, table-to-table, prep penis if urologic injury suspected. 2. Resuscitative thoracotomy acceptable prior to laparotomy 3. Closed paper clips: anterior wounds Open paper clips: posterior wounds 4. Bullets + Wounds: must = even number Obtain pediatric surgery / OB consult for pregnant patients. The SAFEST place for the UNSTABLE patient is in the Operating Room.
AIRWAY MANAGEMENT EMERGENT CLINICAL PROTOCOL

PURPOSE This document describes the expectations and roles of physicians and other credentialed providers, respiratory therapists and registered nurses caring for adult patients with the need for urgent or emergent airway management in the acute and critical care units and the Emergency Department. PROTOCOL 1. Identify the need for airway management. 2. Initiate basic airway management by locally trained healthcare personnel within the scope of job responsibilities; in life threatening situations a credentialed physician with advanced airway management training may manage the airway prior to the arrival of the anesthesiologist. 3. Page 1311 for the anesthesiologist on-call AND call 4-2012 to overhead page for respiratory therapy supervisor. 4. Page the respiratory therapist covering that unit/area if not already present. 5. Upon arrival at the bedside, the anesthesiologist assumes leadership for directing the management of the patient airway. The anesthesiologist performs endotracheal intubation or, clinical situation permitting, the local physician or other credentialed provider (or trained respiratory therapist in the STBICU: per Department of Respiratory Therapy Policy 210) continues to manage the airway under the anesthesiologists supervision. 6. In the critical care units or the Emergency Department, a credentialed physician with advanced airway management training and competency may assume responsibility for managing the patient airway. In the STBICU, a trained respiratory therapist may initiate advanced airway management. In these situations, the physician or other credentialed provider determines the need for anesthesiology consultation. 7. Anesthesiology will be called to the Emergency Department as part of the trauma alert.
ARF PATIENT TRACHEOSTOMY PLANNING PRACTICE GUIDELINES

EARLY EVALUATION Should occur at day 5. If the following criteria are met, schedule tracheostomy for day 7: Failure of CPAP trial, without explanation (sedation, head injury) FIO2 > 50% to maintain saturation greater than 90% Does not apply if patient presently on lung protective strategy Severe head injury with GCS< 8T and no evidence of rapid recovery. Patients undergoing treatment for ICH should not undergo tracheostomy. SUBSEQUENT EVALUATION: Should occur after first week of ventilator support: Patient unlikely to wean by day 10 due to: Mental status Secretions Pulmonary co-morbidities Large intra-pulmonary shunt All tracheostomies should be done by day 10 Tracheostomies performed after this undergo performance improvement evaluation in all cases. OTHER ISSUES: Complete clearance of spine should be completed by day 3 Peep < 8 Percutaneous tracheostomy at bedside is first choice Enteral access should always be considered in conjunction with tracheostomy. In general #4 Shiley trach should not be used in adult trauma patients. The cuff should be deflated on acute care patients. Consider pre-diet speech evaluation.
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CLINICAL PROTOCOL TRACHEOSTOMY PATIENTS IN ADULT ACUTE CARE

Purpose: This document describes the actions required by registered nurses caring for adult patients with a tracheostomy in the acute care setting Protocol: Order entry must be completed by MD or RN or RT 1. Set up patients room with the following equipment: Suction, oxygen flow meter, resuscitation bag and mask, air flow meter, Spare tracheostomy tube at bedside 2. Oxygen/Humidity: Use humidification for all patients with tracheostomy. Titrate oxygen (via trach collar) to maintain oxygen saturation > to 93%. 3. Assessment: Respiratory Therapy (RT) will assess the patient every 4 hours for the first 24 hours after transfer from ICU, and then, RT will assess at least - q 8 hours or as indicated by medication regimen. Suction prn as indicated by assessment. Notify MD for blood clots and/or moderate bleeding around and/or through the tracheostomy. 4. Tracheostomy cuff: The tracheostomy cuff should remain deflated for all acute care patients. If special circumstances require cuff to remain inflated, MD should place an order. Cuff pressure should be assessed and documented every shift by RT. If cuff inflation becomes necessary, notify RT for patient assessment. 5. Inner cannula care: Replace disposable inner cannula daily or more frequently if indicated. Clean and replace non-disposable inner cannula every shift or more frequently if indicated.
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UVA TRAUMA HANDBOOK 6/11 31 TRACHEOSTOMY PATIENTS IN ADULT ACUTE CARE CONTINUED FROM PREVIOUS PAGE
6. Suture Removal: Suture removal is the responsibility of the physician/ service that performed the tracheostomy. The RT may perform suture removal on day 7 if airway is secure and sutures remain in place (ENT patients excluded). 7. Speaking Valve: Speaking valve may be used as tolerated per procedure 18-9.2 in the Adult Acute Care Procedure Manual Remove speaking valve at bedtime (HS) per manufacturers guidelines and resume trach collar / T-piece with humidification. HME (heat moisture exchange) is not recommended. Supplemental O2 (not to exceed 6 LPM) may be delivered through the speaking valve. Notify RT to assess patient if oxygen requirements exceed 6LPM. 8. Nocturnal care of tracheostomy patient: Resume trach collar / T-piece with humidification. HME is not recommended. 9. Travel: When leaving the nursing unit, the patient should travel with a resuscitation bag and mask, spare tracheostomy (same size as the current tracheostomy,) obturator, if available, empty 10mL syringe, pink saline bullet, appropriately sized suction catheter, and size 8 sterile gloves. In general, patients on the TRAUMA Service should not be decannulated until the patient no longer requires acute care.
Clinical decision tools are general and cannot take into account all of the circumstances of a particular patient. Judgment regarding the propriety of using any specc procedure or guideline with a particular patient remains with that patients physician, nurse or other health care professional, taking into account the individual circumstances presented by the patient. Origin: Oxygen Therapy Workgroup Approved: Pt Care Committee 08/07
VENTILATION PARALYSIS TRIAL PRACTICE GUIDELINE

1. Consider neuromuscular relaxants (NMRs) when P/F ratio < 100 mm Hg 2. Monitor the pressure waveform on the ventilator screen to ascertain if the patient is making respiratory efforts or is dyssynchronous with the ventilator 3. The initial action is to increase the patients sedation 4. NMRs should be given only if the patient is dyssynchronous with the ventilator, is having frequent oxygen desaturations, and is unresponsive to increasing sedation.
VENTILATION PRONING PRACTICE GUIDELINE

EXCLUSION CRITERIA Hemodynamically unstable (patient requires frequent interventions to maintain SBP > 90 mm Hg) Unstable spine Elevated intracranial pressure Pregnancy Uncontrolled agitation Glaucoma / recent ophthalmic surgery Gross abdominal distension COMPLICATIONS Inadvertent extubation or loss of IV lines Pressure sores Corneal damage REASONS TO ABORT PRONING Persistent (> 5 minutes) hemodynamic instability Persistent (> 5 minutes) decrease in O2 saturation (> 5% decrease from baseline) PROCEDURE Ensure that the patient does not have an unstable spine Treat any agitation with increase in sedation Increase FiO2 to 100% for 5 minutes prior to turning Place cardiac electrodes on patients limbs or back Disconnect tube feeds and any nonessential lines/wires during the turning process Draw baseline ABG and record BP, HR and SaO2 before turning
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34 6/11 UVA TRAUMA HANDBOOK VENTILATION PRONING CONTINUED FROM PREVIOUS PAGE
Ensure that sufficient staff are present to assist in the turning processalways a minimum of 4 staffthe person most skilled in airway management should be assigned to manage the patients head and endotracheal / tracheostomy tube The direction of the turn should always be TOWARD the ventilator Once prone, elevate the patients head and dependent eye off the bed using a foam pillow or other suitable device, supported at forehead and chin. Ensure that the patients dependent eye is closed and not in contact with any surface. Perform frequent checks of the patients skin, pressure points, and eyes. The patients head should be turned every 2 hours by lifting the patients chest from the bed (requires 3 peopleRRT should always be present). The head of bed should be elevated (reverse Trendelenburg) to decrease head/facial edema. This position should be maintained when patient returned to supine position. RECOMMENDED SCHEDULE FOR TURNING Avoid turning the patient between the hours of 2100 and 0700 Patient should be turned every 12 hours Patient should be turned into the prone position in the early evening and maintained in this position until after 0700 the next day. Patient should then be turned supine in order to check skin and perform nursing care. If the patients oxygen saturation significantly deteriorates when supine, return to the prone position. A second attempt at turning the patient supine may be made in the afternoonreturning to the prone position overnight.
ARDS PATIENTS VENTILATED STICU CRITERIA FOR TRANSPORT PRACTICE GUIDELINES

POPULATION DEFINITION: PaO2 / FIO2 ratio < 100 mm Hg Minute ventilation > 20 liters PEEP > 18 cm H2O If patient meets above definitions, transport must meet the following conditions: Cranial CT for acute neurologic change Abdominal CT for acute physiologic change Thoracic angiography to rule out pulmonary embolism, or other life-threatening condition Other justification that bears in mind high-risk of transport Patients should not be transported for: Feeding tube placement Spinal clearance, without neurologic deficits Orthopedic workup without risk of SCI or spinal instability Routine CT for non life-threatening issues If transport still deemed necessary, 30 minute trial on travel ventilator must be done in ICU: Trial successful: O2 saturation > 90%, hemodynamics unchanged Trial failed: Sats < 90%, hemodynamic instability Respiratory therapist will remain with the patient while off unit, including operating room. These transports should be discussed with the unit charge nurse no later than 9AM on the day of transport, unless emergent.
BRAIN INJURY: INITIAL ASSESSMENT Assess airway and neuro status
Intubate if GCS < 10 or if airway compromise exists
Support using Resuscitation Guideline*
CXR, pelvic x-ray Large bore IV access Trauma labs (correct coagulopathy)**
Penetrating Injury: thorough examination for other GSW***
Reference the additional brain injury guidelines (resuscitation and increased intracranial pressure)
Immediate head CT Penetrating Injry: Angiogram follows head CT if Zone III TBI-RELATED TREATMENT GOALS: INR < 1.2 Goal PaCO2 if posturing or PaCO2 35-40 mmHg fixed, non-reactive pupils: SBP > 90 mmHg 25-30 mmHg
If Licox present: maintain Pbro2 > 20 Call attending / fellow if sustained < 20
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UVA TRAUMA HANDBOOK 6/11 37 BRAIN INJURY: INITIAL ASSESSMENT CONTINUED FROM PREVIOUS PAGE
Hyperventilation and Mannitol are only indicated if patient is posturing, and / or has dilated, asymmetric, or nonreactive pupils. 20% mannitol 0.25 - 1.0 g / Kg IVP Hyperventilate to goal PaCO2 25-30 mmHg All patients with traumatic brain injury and actual or suspected intracranial hemorrhage must receive RAPID correction of the INR (with FFP) AND / OR correction of platelet dysfunction with platelet transfusion.
**
*** In general, maxillofacial hemorrhage from a GSW to the face is best treated through angiographic intervention. In intubated patients, the nares and mouth may be packed with kerlix to attain hemostasis prior to definitive care.
Any acute cerebral hemorrhage should be admitted to NIMU or ICU for 1st 24 hrs. In general, all patients with intracranial blood in the setting of traumatic brain injury should receive 7 or > days prophylaxis with Dilantin or Keppra.
BRAIN INJURY SEDATION PRACTICE GUIDELINE

ICP PLACEMENT ICP monitors will be placed at the discretion of the Neurosurgery service. In general, patients with GCS <9 and/or intracranial mass lesions will require ICP placement. SEDATION ICP MONITOR IN PLACE YES Sedation (Midazolam) /Pain control (Fentanyl) should be attained so that patient is unresponsive. If paralysis needed, use Cisatracurium. 0-1 twitch from train of four should be present. When mental status needs to be evaluated, D/C paralytics and switch to continuous Propofol infusion. (See non-monitored guideline) NO Sedation/Pain Control (Fentanyl) and Propofol titrate to level where patient can be easily ventilated and cooperative with medical treatment. Confirm with NSGY resident time of exam, 30 minutes before scheduled neuro exam, stop Propofol and If patient cannot be controlled off Propofol, call NSGY resident immediately and ask if they wish to perform exam, if they are unavailable, try to sedate with Fentanyl. Restart Propofol if necessary. Neuro exam should be performed on NSGY rounds each morning; therefore, confirm with NSGY that Propofol can be stopped at 6:30 AM.
INTRACRANIAL PRESSURE MANAGEMENT GUIDELINE

Indications for ICP monitoring and consideration of other neuromonitoring (Licox, cerebral blood flow, etc): GCS < 8 and mass lesion on head CT GCS < 8 plus posturing with negative head CT GCS < 8 with expectation of prolonged wait for exam (e.g. going to OR or angio, requires heavy sedation for pulmonary management)
No
Yes
Maintain CPP > 60 mm Hg
Monitor patient. Consider other causes of decreased LOC. Consider withdrawing sedating medications.
Optimize positioning: Head midline HOB > 30 degrees (reverse Trendelenberg if spines not cleared) o Patients with bony clearance of C/T/L spines can have HOB up with c-spine immobilization o Determine optimal HOB for patient (typically 30-70 degrees) Check neck collar and endotracheal tube securing device remove jugular compression to permit venous
GOAL OF TREATMENT IS TO MINIMIZE SECONDARY BRAIN INJURY: PaCO2 35-40 mm Hg (continuous EtCO2 monitoring) CPP > 6O mm Hg with SBP > 90 mm Hg Temp < 38.0C Euvolemia or mild hypervolemia Na+normal or sightly high
* If
pressor support needed after preload optimized: levophed = 1st line vasopressin = 2nd line
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40 6/11 UVA TRAUMA HANDBOOK INTRACRANIAL PRESSURE MGT.GUIDELINE CONTINUED FROM PREVIOUS PAGE
ICP > 20 mm Hg for > 5 min? Call NSGY
Sedation/analgesia with fentanyl and midazolam OR propofol
ICP > 20 mm Hg for > 5 min?
If ventricular drain, check orders for CSF drainage intervention
ICP > 20 mm Hg for > 5 min? Neuromuscular blockade ICP > 20 mm Hg for > 5 min?
Contact neurosurgery to discuss 20% mannitol 0.25 1.0 gm/kg IV bolus OR hypertonic saline
ICP > 20 mm Hg for > 5 min? Neurosurgery will consider: Placement of EVD Craniectomy Pentobarbital
No
Yes
Note: In certain patients, neurosurgery may set an ICP goal of < 25 mm Hg. Post-craniectomy, the ICP goal may be set at < 15 mm Hg.
* See Clinical Portal for dosing of hypertonic saline
Yes
No
Yes
No
Yes
No
Yes
Consider gradual decrease in therapy once ICP< 20 mm Hg for > 12 h.
ADULT GUIDELINES FOR CRANIOTOMY/CRANIECTOMY
INDICATIONS FOR SURGERY

from the American Brain Trauma Foundation
Epidural Hematoma Volume > 30 CM3 or if GCS < 9, > 15 mm thick, or > 5 mm shift Subdural Hematoma * > 10 mm thickness or > 5 mm shift Change in GCS > 2 points or anisocoria or ICP > 20 Intraparenchymal hemorrhage Clinical deterioration referable to lesion Refractory intracranial hypertension Mass effect In patients with GCS 6 8, if volume > 20 CM3, and 5 mm shift or cisternal compression Volume > 50 CM3 * GCS < 9 = ICP Monitor The complete Brain Trauma Foundation Guidelines are available at http://tbiguidelines.org.
BURN (MAJOR) RESPIRATORY MANAGEMENT PRACTICE GUIDELINE

INHALATION INJURY Inhalation injury should be suspected if there is history of entrapment in a closed space. The patient may present with a hoarse voice, new onset cough or shortness of breath, and may also have carbonaceous sputum, singed nasal hairs and facial edema. Diagnosis may be confirmed by bedside bronchoscopy. Patients should be treated with vigorous pulmonary toilet and ambulation (as appropriate) to assist in airway clearance of particulate matter. Intubation and ventilator support should be initiated if there is profound facial edema (anticipated or present) or difficult ventilation and/or oxygenation based on direct airway injury. Persistent debris in the airway may need to be removed by serial endoscopic bronchopulmonary lavage. Evidence of carbon monoxide poisoning may warrant hyperbaric oxygen therapy consult even if the carbon monoxide has normalized in the bloodstream. Identification: All enclosed fires Explosions Patients with: carbonaceous sputum, increased carboxyhemoglobin levels (>5%), hypoxia, and/or facial and mouth burns ABG and CXR: mandatory Endotracheal Intubation: Should be performed immediately by anesthesia (consider paging Respiratory Therapy supervisor (1616) for bronch cart) If: any evidence of respiratory distress or upper airway swelling (stridor, severe cough, hoarseness, voice change) Bronchoscopy for diagnosis and treatment in first 24 hours
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UVA TRAUMA HANDBOOK 6/11 43 BURN (MAJOR) RESPIRATORY MANAGEMENT CONTINUED FROM PREVIOUS PAGE
Extubation Criteria: Patient follows commands Audible leak around a 7.0 or higher ET tube Meet extubation criteria by Respiratory Therapy No evidence of progression of airway disease Ventilator Management: see protocols to follow Tracheostomy Considerations: Intubated >7 days without immediate expectation of extubation Extubation failed twice Major problem with secretions (suctioning required q2h, recurrent mucus plugging, etc.) Unable to follow commands when ready for extubation
ADULT BURN FLUID RESUSCITATION GUIDELINES

(All other applicable ICU protocols/guidelines will be maintained) ALL DEVIATIONS MUST BE APPROVED BY ATTENDING PHYSICIAN (ICU Attendings: Dr. Young, Dr. Sawyer, Dr. Lowson, and Dr. Calland should be notified and utilized as a primary resource in the event of alternative Attending coverage) Charge RN should be consulted in the event of nursing-initiated call to Attending The clock begins at time of injury, and not at arrival at the hospital. INCLUSION CRITERIA: Burns > 20 % TBSA Pre-Hospital Administer routine wound care (removal of burning material, gentle cleansing, and loose bandaging with clean, dry material. Topical agents should be avoided.) Initiate fluid resuscitation in the field if possible, but immediate fluid requirement should be low, so this is not imperative. Administer airway control and support dependent on local skill level and patient condition. Referring Hospital Initiate contact with UVA as soon as possible Initiate IV therapy Large-bore (>18 ga.) peripheral IV in unburned skin Central or femoral access if peripheral access unavailable
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UVA TRAUMA HANDBOOK 6/11 45 ADULT BURN FLUID RESUCITATION GUIDELINES CONTINUED FROM PREVIOUS PAGE
Imperative that IV therapy with LR or NS be initiated prior to transfer. Even though the total burned BSA may not be known, if estimated at >40%, fluid should be administered at rate of 1liter per hour to prevent severe intravascular fluid deficits in the early post-burn period. Initiate airway control Immediately intubate any patient exhibiting airway symptoms (stridor, hoarseness, severe cough, voice change) or respiratory distress before swelling worsens Emergency Department/Burn Center Calculate and record prior fluid administration Administer fluid to keep patient on track for fluid requirements (see below) INITIAL 24-48 HOURS: TIME OUT: PRIOR TO INITIAL WOUND CARE, THE FOLLOWING MUST BE ADDRESSED: Adequate IV access Evaluation of respiratory stability Normothermia (maintain temp > 35C) Lab evaluation (assess for coagulopathy-INR < 2) If escharotomies/fasciotomies are deemed emergent despite alterations in the above items (other than chest for hemodynamic/respiratory instability) and decision conflict arises among the involved teams, Trauma and Plastic Surgery Attendings should be consulted. FLUIDS: Ringers Lactate 3ml x wt (kg) x % TBSA 1/2 calculated amount over first 8 hours second 1/2 over subsequent 16 hours & Hespan 40ml/hr (not to exceed 1 liter/24 hours) In setting of hyperkalemia, consider alternating LR with 0.9% NS
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46 6/11 UVA TRAUMA HANDBOOK ADULT BURN FLUID RESUCITATION GUIDELINES CONTINUED FROM PREVIOUS PAGE
MAINTAIN URINE OUTPUT OF 0.5ml/kg/hr-1ml/kg/hr HEART RATE GOAL < 130 Avoid beta blockers first 48 hours FLUID TITRATION: If calculated needs are met prior to 24 hour mark, utilize a MIVF rate of 3ml/kg/hr Hourly u/o < goal 2 consecutive hours => increase MIVF by 10% Following 2 hours continued inadequate u/o => increase MIVF by 10% Continued inadequate u/o over the following 2 hours: Initiate Dopamine at 3mcg/kg/min Swan-Ganz catheter or obtain stat echo if feasible Place Swan-Ganz (CCO) catheter under these circumstances: oliguria despite calculated resuscitation (>150% of calculated needs or 6 cc/kg/%TBSA) and Dopamine infusion hypotension severe respiratory failure (P/FiO2<100) pulmonary edema burns > 70% cardiac disease If excessive u/o (> 2ml/kg/hr), decrease MIVF by 10% in 2 hour intervals until u/o is below 2ml/kg/hr but meeting 0.51ml/kg/hr NO Fluid boluses unless approved by core faculty NO diuretics during resuscitation
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If persistent acidosis pH < 7.25 (> 12 hrs): Reassess fluid resuscitation Consider Swan-Ganz catheter MIVF (upon completion of initial 24 hour fluid resuscitation) is determined by the IV rate at the last hour of fluid resuscitation; continue to titrate as noted above to urine output AIRWAY: NO ETT should be electively changed within the initial 48hrs for bronchoscopy unless Attending approval LINE MANAGEMENT: Transition femoral central access to subclavian through nonburned skin MAC/Swan may be inserted through burned skin in emergent situations LABS: CBC/Chem/Coags: every 8 hrs Lactate: every 24 hrs (used as a guide to acid-base status, not a resuscitation endpoint) ABG: every 24 hrs Rhabdomyolysis: every 12 hrs (until 2 negative results) Positive and CK > 5000 Initiate NaHCO3 drip (1:1 concentration with central access) (150meq:150ml) Maintain u/o 100ml/hr Mannitol (12.5-25 gms) and/or increase MIVF rate for u/o < 100ml/hr
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48 6/11 UVA TRAUMA HANDBOOK ADULT BURN FLUID RESUCITATION GUIDELINES CONTINUED FROM PREVIOUS PAGE
Positive and CK<5000 Do not initiate NaHCO3 drip Maintain u/o 100mI/hr Mannitol (12.5-25 gms) and/or increase MIVF rate for u/o < 100ml/hr GI: Nutrition: NGT and post-pyloric Dobhoff placed upon admission with initiation of tube feeds If unable to advance Dobhoff post-pyloric: Begin trophic tube feeds (20ml/hr) Check residual from NGT every 4 hrs (residual > 250ml hold TF) Obtain admission weight; daily weights Obtain bladder pressure every 12 hrs Administer soap suds enema with Zassi placement first tanking after 24 hr mark (initiate Zassi bowel motility regimen) Ensure order for daily vitamin regimen Temperature: maintain normal thermoregulation insert rectal or esophageal temperature probe for continuous monitoring Hypothermia: Ranger fluid warmer; Rapid Infuser if needed Heated vent circuit Bair hugger Room temp elevated Warmed saline/water utilized for wound care Minimize large surface area exposure during wound care
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48-72 Hours: Fluids: D/C Hespan Initiate 5% Albumin-40ml/hr Continue MIVF Ringers Lactate In setting of hypematremia, consider alternating LR with 0.45% NS or D5W Maintain urine output 0.5 ml/kg/hr-1ml/kg/hr After 72 hrs: TF should be at goal D/C Albumin drip Reassess need for Dopamine gtt Titrate MIVF to adequate u/o Maintain urine output 0.5 ml/kg/hr-1ml/kg/hr Complications: **In setting of acute renal failure and decreased pulmonary compliance with ongoing high fluid resuscitation need, consider abdominal compartment syndrome (ACS) and/or cardiac failure. If severe respiratory failure ensues, consider CRRT for fluid management. Abdominal Compartment Syndrome Burn patients at increased risk: inhalation injury, extensive FT burns to the torso, and large %TBSA increased intra abdominal pressure (> 25mmHg) oliguria---------------decreased pulmonary compliance
WORKUP AND TREATMENT OF BLUNT MYOCARDIAL INJURY PRACTICE GUIDELINE
All patients with Blunt Thoracic Trauma who have: Unexplained Sinus Tachycardia / Ectopy, or Major chest wall contusion, or Multiple rib fractures Obtain 12 Lead EKG, Troponins Provide hemodynamic support
Hemodynamic instability? Myocardial Infarction?
No
Troponin / EKG Abnormal?
No Routine Care
Yes STBICU / CCU Admission
Yes Admit Telemetry Repeat 12 Lead EKG in 24 hours Troponin x3 (Q8 hours)
Echo (STAT iF hypotension) Cardiology Consultation
No
EKG now Normal? Troponins < 0.05? Yes No further workup
BLUNT THORACIC TRAUMA PRACTICE GUIDELINE

Retained Hemothorax: All patients with retained hemothorax should be aggressively drained with a combination LARGE CALIBER straight and Right-angle chest tubes as soon as such conditions are appreciated upon imaging tests. Consideration should be given to early VATS (within 72 hours of injury) to avoid late fibrothorax and empyema. Multiple rib fractures / flail segment: Non-ventilated patients with multiple rib fractures or flail segments and respiratory compromise1 who are otherwise good candidates for epidural analgesia should have epidurals catheters placed by the acute pain service or on-call anesthesia team as soon as adequate bony spine clearance is obtained.2
AORTIC TRANSECTION (ACTUAL OR SUSPECTED) PRACTICE GUIDELINE

Indications for implementation / utilization: 1. Widened mediastinum (in patient with high-risk mechanism) 3 2. CT evidence of aortic injury (without extravasation)4 Procedure Maintain SBP < 110 mm Hg and HR < 110 BPM5 Appropriate pharmacologic regimens: 1. Gradual titration of benzodiazepines / narcotics (no boluses!!)6 If inadequate response to gradual increase in sedation, then: 2. Labetolol gtt +/- nicardipine gtt as needed or, Esmolol gtt +/- nicardipine gtt as needed
1
2
Incentive Spirometry < 18 ccs / kg IBW/sec See Epidural / Analgesia Guideline for Trauma Pts with Rib Fxs 3 MVC > 30 MPH, Fall > 15 feet, Ped struck, MCC > 20 MPH 4 If extravasation present, prepare for emergent thoracotomy. 5 Use these parameters with caution in patients with severe closed head injury and elderly patients with a medical history of poorly controlled hypertension. 6 Patient s with actual (or potential for) severe injuries who are not intubated should NOT, in general, receive conscious sedation.
52 6/11 UVA TRAUMA HANDBOOK EPIDURAL/ ANALGESIA GUIDELINES FOR PATIENTS WITH RIB FRACUTRES
EPIDURAL / ANALGESIA GUIDELINES FOR TRAUMA PATIENTS WITH RIB FRACTURES

A) Timely / expeditious epidural analgesia is desirable for the trauma patient with multiple rib fractures and the potential for respiratory failure, and should be achieved within 12 - 18 hours after admission unless a contraindication to placement exists. For epidural analgesia, the patients MUST HAVE: 1) 2) No major coagulopathy (INR < 1.3, platelets > 100,000) Cleared cervical, thoracic, and lumbar spines, or, at least, minimal spinal trauma (e.g., <3 contiguous SP / TP fractures at least 5 CM away from the level of entry for the proposed epidural catheter). Mental status clear enough to provide consent, OR a designated medical power-of-attorney to provide consent, OR a written statement of medical necessity composed by a senior surgical resident or attending on the trauma service. An accurate detailed list of the pre-admission and current medications confirming no Plavix use in last 7 days, no Enoxaparin or Dalteparin administration in the last 18 hours, an INR < 1.3.
3)
4)
For rib fractures above T-4, the reality is that epidural analgesia may not be that effective since it may be difficult to obtain and sustain the desired level of analgesia above this level. Alternate/additional methods for pain control will be necessary, and the APS Team can consult to provide those. The Acute Pain Service Team is in-house 0700 to 1800. After these hours, reliance is placed on the overnight anesthesiology team for most necessary patient management issues. However, as they assume many responsibilities and are in many locations beyond the operating room, it may not be feasible for them to place epidurals simply upon the request of the Trauma Service. Though it remains the standard of care for such catheters to
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be placed as soon as there are adequate resources to facilitate such action, arrangements will need to be worked out on a case-by-case basis depending upon the existing workload of the in-house anesthesiology team. Most of the APS attendings acknowledge that they serve as a back-up to the in-house overnight team and in certain circumstances could be called in to facilitate epidural placement. B) If epidural catheter placement is not feasible, secondline alternatives to epidural catheter placement include: 1) Threading an epidural catheter adjacent to an existing chest tube, for the instillation of up to 20 mL 0.25% bupivacaine every 6-8 hours. This technique requires that the patient be placed for 30 minutes so that the volume will layer in the posterolateral paravertebral gutter AND that the chest tube be clamped for 30 minutes. Paravertebral blocks and/or catheters may be placed, as the expertise of the Departmental staff increases Separate intercostal nerve blocks can provide temporary benefit when only 4-5 levels are involved.
2) 3)
CHEST TRAUMA - PENETRATING CENTRAL WOUND

Trajectory between nipples, sternal notch, xiphoid or transmediastinal *
Yes
and HR <40 and/or wide complex
No
Consider Chest tube, pericardiocentesis, ACLS, or no therapy
Tube Thoracostomy
(as indicated by physical exam / trajectory)
Recent / witnessed arrest or moribund
ED thoracotomy
* Consider / Perform Laparotomy if

trajectory uncertain or if trajectory potentially passes below diaphragm
Precautions: CT Scan NOT reliable in determining trajectory of low velocity (stab) wounds ECHO / FAST 100% sensitive for pericardial / cardiac injury EXCEPT if associated with adjacent pleural effusion If unsure of trajectory through pericardium: OR for pericardial window
SBP < 90
OR for Pericardial window, thoracotomy, or sternotomy
Stable
CXR, Consider: - CTA of chest or - STAT Echo or - Pericardial window Repeat CXR in 6 hrs if no Chest CT
DEEP VENOUS THROMBOSIS

Assess Risk HIGH RISK: Spinal cord injury Severe head injury Severe (multiple/complex) pelvic fracture > 2 long bone fractures with bedrest > 5 days Major Iliac, Femoral, or Popliteal Venous Injury (e.g., penetrating trauma to groin) MEDIUM RISK: Trauma service patients who are not high risk
Low molecular weight heparin, unless contraindicated* + SCDs + IVC filter**
Positive duplex study below the knee? ***

Bilateral lower extremity duplex
Low molecular weight heparin, unless contraindicated* + SCDs
Progressive or symptomatic? No Recheck duplex q 5 d * Enoxaparin is contraindicated in patients with: Chronic renal insufficiency Excessive bleeding risk First 48-72 hrs after SCI or CHI ** All filters should be removeable ones in patients < 65 years old *** For + DVT assess leg daily for phlegmasia (neuro & vasc)
Positive duplex study above knee? (pelvic,femoral or popliteal) ***
For dosing guidelines see Adult Medication References at back of manual.
Yes
Anticoagulation OK?
No
Yes Therapeutic Enoxaparin or Heparin infusion (according to institutional
IVCF**
Coumadin for 3-6 mo or Therapeautic Enoxaparin Target hep Ptt + INR
EXTREMITY TRAUMA PRACTICE GUIDELINE

Active hemorrhage, expanding hematoma, severe ischemia* Reduce fracture / dislocation if present Ischemia persists or active hemorrhage
No
Yes Intraoperative anteriogram Vascular repair + orthopedic fixation
Normal
Observation Observation Operation serial arteriography *Consider blood pressure cuff above site of hemorrhage.
Risk classification
High ABI < 0.9 Pulse deficit Arteriography

Major arterial injury

Low ABI>0.9 No pulse deficit Observation
Minimal arterial injury
HEMATURIA PRACTICE GUIDELINES

Pelvic fracture with comminution of anterior ring, blood at meatus, high-riding prostate, gross hematuria
No significant pelvic fx. No blood at meatus. Normal rectal exam.
Unstable pts with gross hermaturia Or significant (>50RBCs per hpf) microscopic requires GU work-up. GU Work-up: 1. RUG for urethra 2. CT scan for kidney & ureter 3. Cystogram for bladder Surgical Note: Laparotomies with Urethra prepped into field and sterile foley
No work up
RHABDOMYOLYSIS PRACTICE GUIDELINES

Check serum creatine kinase on patients with: Chest injury Ischemic injury Hyperpyrexia Suspected rhabdomyolysis Cranberry colored urine Two or more long bone fractures A long bone fracture and a pelvic fracture
< 5,000 Check CK q12 hrs
Repeat until two consecutive negative results ** No need for bicarbonate infusion **
> 5,000
Add 100 meq Bicarb to 1 liter NS or LR Maintain urine output > 100 cc/hr Keep urine ph > 6.5 and Re-check CK every 12-24 hours
NON-OPERATIVE MANAGEMENT OF SPLEEN AND HEPATIC TRAUMA PRACTICE GUIDELINE

Grade I or II1 (little or no intraperitoneal fluid) Grade III to V1 (intraperitoneal fluid present) IR/embolization?4 OR if Unstable5
Admit Floor Day 1

(0-24 hrs)
CBC q 8 hrs x 24hrs Strict bedrest2 Hold LMWH
Admit STBICU LA, CBC q 4 hrs x 24hrs Strict bedrest2 Hold LMWH CBC q 8 hrs if Hgb stable Transfer to floor if stable Hgb Strict bedrest2 Start LMWH Continue bedrest2 CBC BID x 24hrs Verify Type & Screen
Day 2
(24-48 hrs)
CBC BID x 24hrs Strict bedrest2 Start LMWH and order diet if Hgb stable
Day 3
(48-72 hrs)
OOB, Duplex CBC in pm Discharge in PM if Hgb stable3 and no change in abd. exam
Day 4
(72-96 hrs)
See next page for footnotes 1-5
OOB repeat CT * Duplex and CBC in pm Discharge if Hgb stable3 when OOB and no changes in abdominal exam.
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Footnotes from Non-opertaive Management of Spleen and Hepatic Trauma Practice Guideline
1
Depending on trauma, attending interpretation of CT scan, duration of bed rest may be altered. HOB can be up to 30 degrees during strict bedrest if spines are clear. Remember to check CBC after walking. Embolization appropriate for normotensive patients without other serious traumatic injuries who have arterial blush, pseudoaneurysm, or large subcapsular hematoma. Persistently hypotensive patients (SBP < 90 after 2L crystalloid or 1u PRBCs) and a positive FAST or known splenic injury with hemoperitoneum on CT, should undergo operative therapy with splenectomy and/or packing of the liver +/- pringle.
* In general, only IV contrast is necessary for the repeat CT. However, consider enteral contrast if the patient is not tolerating enteral feeds.
No
SEVERE PELVIC FRACTURE ALGORITHM

LC 2 / 3 AC 2 / 3 VS Multi-Trauma pt w/ >2 cm of pubic diastasis / displacement
Place Pelvic Binder* & perform FAST
Yes FAST

Unstable VS
No Abdominal CT

Yes
- free fluid - abd. tenderness
No Pelvic Blush Laparotomy Yes
No
Equivocal
Repeat FAST** and / or DPL

(Discuss findings w/ attending)
Observe
* Do not remove binder for 1st 24 hrs, and thereafter, only after clearance to do so by trauma Attending, consult orthopedics. ** Obtain experienced ultrasonographer
Angiography
PULMONARY EMBOLISM WORKUP & TREATMENT PRACTICE GUIDELINE

Suspicion (oxygen desaturation that does not respond immediately to simple measures, severe acute dyspnea, acute decrease in P/FIO2 ratio to < 200 with no evidence of hypoventilation) CXR, ABG, Supplemental Oxygen Treatable process (pneumothorax, mucous plug, effusion) Treat cause and reassess

No treatable cause
Problem resolved
Sats < 90% with supp. O2
Sats > 90% with O2 < 4/L
Heparinize if possible CTA LE Duplex
Observe
Negative LE Duplex in 5 Days* if inpatient
Positive IVC Filter + Anticoagulation
*For treatment of positive LE duplex, see DVT guideline.
RESUSCITATION PRACTICE GUIDELINE

Concurrent Resuscitation: (ALL Patients) Stop bleeding, resuscitation with blood, blood products and crystalloid to SBP >100, pulse <100 Assess perfusion LA >2.5* Infuse fluids to achieve clinically normal perfusion and repeat LA LA >2.5 Place Swan-Ganz catheter and arterial line Increase PCWP >12 CI >3.5 SVO2 sat >65 CPP >60 Preferred fluids: blood blood products albumin or Hespan crystalloid (minimize glucose administration, Check serum sodium and intervene on values <135) If parameters not met Add: Dobutamine (Milrinone should be used in patients with cardiac index < 3.0, or patients with CI < 4 with elevated lactate. May cause hypotension) Search for continued bleeding FAST, consider ECHO Goal LA <2.5
*Do not use LA as an endpoint in SCI pts.
NON-HYPOVOLEMIC CARDIOVASCULAR FAILURE PRACTICE GUIDELINE

PATIENTS TO BE TREATED Fresh trauma patients (<48 hours PI), with no evidence of hypovolemic shock (workup without evidence of ongoing hemorrhage) Evidence of shock (Base deficit < -5, LA >3.0, pH <7.30) and/ or evidence of cardiovascular failure (BP<95 mm systolic, urine output <0.5 cc/kg/hour) with objective evidence of normovolemia (normal or stable hematocrit, normal CVP, no evidence of bleeding) PROCEDURE Physical examination Rule out murmur, pneumothorax, mainstem intubation, etc. Look for missed injury Evaluate known injuries (increased compartment size, etc.) Clinical evidence of perfusion Labs, studies Troponin, ABG 12-lead EKG CXR Repeat scans as needed to rule out ongoing hemorrhage ALGORITHM Hemorrhage Resuscitate Operation or angiography MI Swan-Ganz catheter Cardiology consult Echocardiogram Primary vascular failure (neurogenic shock, sepsis??) Swan-Ganz catheter (oximetric if possible) Goal-directed therapy
CONTINUED
UVA TRAUMA HANDBOOK 6/11 65 NON-HYPOVOLEMIC CARDIOVASCULAR FAILURE GUIDELINE CONTINUED FROM PREVIOUS PAGE
SITUATIONS Low cardiac index , pump failure Cardiac parameters Increase preload (PCWP) to 12 mm Hg taking into account possible interference from ventilator If no response If hypotensive The Trauma Attending must be informed before pressors are begun in a fresh (<24 hours) Trauma Patient Neosynephrine or Levophed to increase MAP to >65 mm Hg. If this is inadequate, consider Vasopressin at 0.04 units Once accomplished Milrinone or Dobutamine to augment cardiac index to point where acidosis begins to correct (at least 2.0, preferably 3.0) If normotensive Milrinone or Dobutamine as above Failure of therapy STAT echo to rule out tamponade Repeat cavitary scans to insure that there is no bleeding Consider aortic balloon pump, or surgery as recommended by Cardiology
GENERAL SPINE CLEARANCE ALGORITHM

GENERAL SPINE CLEARANCE INFORMATION: NEURO DEFICITS? Obtain prompt Spine Consultation (e.g. paraplegia, tetraplegia, weakness/parasthesia consistent with SCI) MSK Spine Service even months NSGY Service odd months A TRANSFER? Check PACS referral folder under the OSH pt info for outside images. If a trauma alert, place an outside read order under the ED Trauma Alert pathway (in Epic) to have images read. EXPEDITING READS: Reading Room Coordinators MSK: 2-2526 NSGY: 2-3432 PATIENT EXAMINABLE? Is the pt. GCS 15/Alert? No Yes Does the pt. have one or more of these? 1) intoxication 2) midline cervical/thoracic/lumbar pain/tenderness, 3) neurologic deficits, 4) high risk mechanism, distracting injury (pt cant participate in exam) Yes CT C-Spine, T & L recons of CT Torso * Plain Films of T&L spines if no CT Torso indicated
Preliminary Reads POSITIVE

(or suspicion for bony injury / malalignment)**?
No, See next page
Yes Spine Consultation

(Complete consult request w/ date & time, clarify activity orders in Epic)
*CTA Neck is indicated if a pt has any of the following: Fx through C1-C4; Extensive bruising or "seatbelt sign" on neck; Cerebral infarct; Acute anisocoria; GCS < 8 without explanatory findings on CT of the head; Neuro deficits, decline / clinical picture not consistent with injury, petrous fx. **If < 2 contiguous TP/SP fractures in the T or L spine and no severe adjacent torso trauma (e.g. sternal fx/flail chest) spine consultation is not required and HOB should be raised to 30 degrees to optimize pulmonary status. Subsequent tertiary exam 12 24 hours later is required to clear patient for unrestricted CONTINUED activity in such cases.
See page 68 for Cervical Spine and page 69 for Thoracic and Lumbar Spines
No
UVA TRAUMA HANDBOOK 6/11 67 GENERAL SPINE CLEARANCE ALGORITHM CONTINUED FROM PREVIOUS PAGE
PATIENT EXAMINABLE? GCS 15, Alert, and NONE of the following: Intoxicated, midline cervical/thoracic/lumbar pain/tenderness, neurologic deficits, high risk mechanism***, distracting injury (pt can participate in exam), no spine imaging is indicated.
Upon Tertiary Exam / Clinical Exam of the Complete Spine: Signs/ Symptoms abnormal?**
No
Yes
Remove Collar (unless desired for pt. comfort) document exam clearance date & time, update activity orders, including d/c old activity orders
Image C and/or T&L if indicated: CT C-Spine/T & L Recons (See note on previous page for CTA Neck indications)
Preliminary Reads POSITIVE or INDETERMINATE? No See page 68 for Cervical Spine, see page 69 for Thoracic and Lumbar Spines ** midline tenderness, limited ROM, peripheral or central sensory / motor deficit *** High Risk Mechanism: Yes
Spine Consultation (complete consult sheet with date & time) MSK even months, NSGY odd mo. If pt has < 2 contiguous TP/SP Fx in the T / L spine and no severe adjacent torso trauma (e.g., sternal fx / flail chest) spine consultation is not required and HOB should be raised to 30 degrees to optimize pulmonary status. Subsequent tertiary exam 12 24 hours later is required to clear patient for unrestricted activity in such cases.
Falls - > 20 ft. (one story = 10 ft.)
High-Risk Auto Crash - Intrusion: > 12 in. occupant site; >18 in. any site - Ejection (partial or complete) - Death in same passenger compartment
- Vehicle telemetry data consistent with high risk of injury Auto v. Pedestrian/Bicyclist Thrown, Run Over, or wtih Significant (>20 mph) Impact Motorcycle Crash > 20 mph
68 6/11 UVA TRAUMA HANDBOOK GENERAL SPINE CLEARANCE ALGORITHM CONTINUED FROM PREVIOUS PAGE
CERVICAL SPINE CLEARANCE NEGATIVE BONY IMAGING

Cervical spine bony imaging PRELIMINARY reads negative? Retain Collar, Cervical Spine Precautions Cervical spine bony imaging final reads negative? Yes Patient Examinable?
No Consider MRI if anticipating that patient is un-examinable for > 5 days
Ask the patient to touch chin to chest, extend neck backward and rotate from side to side. Does the patient experience pain or neurologic symptoms during these maneuvers? No Remove collar, document exam clearance date & time, update activity orders including dc old activity orders
* Prerequisites for flexion / extension films: no neuro deficits, cooperative patient, and C spine can be visualized to C7 on plain film (avoid in obese pts, short neck pts, or muscular male pts)
Yes Perform Tertiary Exam / Clinical Exam of C spine. Remove the patients collar and palpate the C-spine. Pain, tenderness and/or peripheral sensory/motor signs/ symptoms
No
STOP the cervical spine clearance process, replace the patients C-collar, and obtain imaging. (Flex / Ex or MRI) *
Yes STOP the cervical spine clearance process, replace the patients C-collar, and obtain imaging. (Flex / Ex or MRI)*
Yes
UVA TRAUMA HANDBOOK 6/11 69 GENERAL SPINE CLEARANCE ALGORITHM CONTINUED FROM PREVIOUS PAGE
THORACIC & LUMBAR SPINE CLEARANCE

Preliminary reads negative
HOB to 30 degrees, update activity orders
Final reads negative
Clinical exam of spine, advance orders
Notes/Precautions: Patients with negative imaging, but severe pain / tenderness in T / L spine should be evaluated for potential discogenic disease or occult FX.
Age
indeterminate spine injury image interpretations should be considered acute except in the clear absence of pain, tenderness and limitation of mobility. with no bony abnormalities or malalignment on imaging who are awaiting ligamentous cervical spine clearances may be upright and OOB with collar. clearance procedures must be documented in the clinical record (progress notes) and with orders. evaluation should be on Rotorest beds unless countermanded by spine consultant or otherwise contraindicated.
Patients Spine
All patients with >48 hours flat bed rest due to spine injury/
Respiratory complications and Decubitis ulcers are the two top sources of morbidity in patients with spine cord injury: Spine clearance must be efficient and thoughtful. DO NOT BE A COWBOY when it comes to evaluations of the spine!!
SEPSIS ALERT
Are any TWO of the items below present? Temperature >38.3 or <36 degrees? HR > 90 bpm RR > 20 or PCO2 < 32 mm Hg WBC > 12 OR < 4, or BANDS > 10%
Sepsis Alert / Pathway NO not indicated
YS E
Suspicion of Infection? AND Systolic Blood Pressure < 90 mm Hg OR Lactate >4 mmol / Liter OR Evidence of Dysfunction in >1 organ system Sepsis Alert / Pathway NO not indicated
WITHIN ONE HOUR OF DIAGNOSIS: Call MET Team and Notify ICU Draw lactate level Draw blood cultures If MAP < 65, place large bore IVs or Central Line and administer 1-3 liter Normal Saline over 30-60 minutes, And begin pressors if SBP remains < 65 Administer broad spectrum antibiotics Perform 12 lead ECG Place foley / central line
UVA TRAUMA HANDBOOK 6/11 71 SEVERE SEPSIS AND SEPTIC SHOCK CONTINUED FROM PREVIOUS PAGE
Table 1: Definitions for Inflammatory Response, Sepsis, Severe Sepsis and Septic Shock.
Definition Temperature > 38.3C or < 36C WBC < 12,000 or < 4,000 or > 10% Bands Systemic Heart Rate > 90 bpm Inflammatory > of the Respiratory Rate > 20bpm Response following: *Hyperglycemia > 120mg/dl Altered level of consciousness Lactate > 2 mmol/L Decreased capillary refill Systemic inflammatory response + Sepsis a presumed or identified source of infection Severe Sepsis + > 1 Organ dysfunction+ or Sepsis Lactate > 4mmol/L Septic Shock Severe Sepsis + hypotension (despite 20 40cc/kg crystalloid or colloid equivalent fluid challenge)
Variable
*Hyperglycemia without history of diabetes, Hypoglycemia, without diabetes, in an immunocompromised patient increases suspicion of infection. +Organ dysfunction can be defined as: respiratory failure, acute renal failure, acute liver failure, coagulopathy, or thrombocytopenia. Laboratories that will suggest organ dysfunction include: PaO2(mmHg)/ FiO2 < 300, Creatinine > 2.0 mg/dl OR Creatinine Increase > 0.5 mg/dL, INR >1.5, PTT > 60 sec, Platelets < 100,000/uL. Total bilirubin > 4 mg/dL Systolic Blood Pressure < 90 mmHg or Mean Arterial Pressure < 65 mmHg. Reprint with permission from Annals of Emergency Medicine.38 (Forms submitted)
REFERENCES UPDATES AND CHANGES TO THE 5TH EDITION OF THE TRAUMA MANUAL, JUNE 2011
Cover 7-8 9 12 15 16 17-18 21 31 41 47 50 51 54 55 58 59-60 61 68 69 70-71 79-81 86 88 117 126 127 New QR (Quick Response) code to direct your mobile device to the Trauma Manual on the Clinical Portal Updated MD and NP contact information Added additional transfer hospital and film room numbers Chief needs to view outside images New CT Algorithm for Pregnancy Removed reference to geriatric consult service Updated Trauma Alert Criteria New PEARLS re: Rounding Expectations, TLSO uprights, Speech Evaluation, PEGS, and Morphine use Clarification on decannulating patients New Adult Guidelines for Craniotomy / Craniectomy Updated Burn Resuscitation Guideline (Rhabdomyolysis) Updated Blunt Myocardial Injury Guideline New Blunt Thoracic Trauma Guideline Updated Chest Trauma Algorithm Updated Deep Venous Thrombosis Guideline Updated Rhabdomyolysis Guideline (Previously Myoglobinuria Guideline) Updated Non-Operative Spleen / Hepatic Trauma Guideline Updated Severe Pelvic Fracture Algorithm Updated Cervical Spine Clearance Guideline New Note regarding age-indeterminate spine findings Updated Sepsis Alert Guideline New References regarding PT / OT & LTAC Services New High-Risk Agitation Guideline Updated Sedation / Delirium Reference Added Relative Contraindications to Factor VIIa Administration to Pediatric Neurotrauma Guideline Updated Medication Reference for Treatment of Rhabdomyolysis (Previously Myoglobin Positive) Updated Medication Reference for Seizures Prophylaxis to prioritize Levetiracetam (Keppra)
13 & 66 Updated CTA Neck Criteria
REFERENCES INJURY SCALES LUNG INJURY SCALE

Grade* Injury Type Description of Injury I I Contusion Contusion Laceration III Contusion Laceration Unilateral, <1 lobe Unilateral, single lobe Simple pneumothorax Unilateral, > 1 lobe Persistent (> 72 hrs) air leak from distal airway ICD-9 AIS-90 861.12 861.31 861.20 861.30 860.0/1 861.20 861.30 860.0/1 860.4/5 862.0 3 3 3 3 3-4
Hematoma IV Laceration Hematoma Vascular V VI Vascular Vascular
Nonexpanding intraparenchymal 861.30 Major (segmental or lobar) air leak Expanding intraparenchymal Primary branch intrapulmonary vessel disruption Hilar vessel disruption 862.21 861.31 901.40 4-5 3-5
901.41 901.42
4 4
Total uncontained transection of 901.41 pulmonary hilum 901.42
*Advance one grade for bilateral injuries up to grade III. Hemothorax is scored under thoracic vascular injury scale.
CONTINUED
SPLEEN INJURY SCALE (1994 REVISION)

Grade* Injury Type Description of Injury I I Contusion Hematoma Laceration I Hematoma Unilateral, <1 lobe ICD-9 AIS-90 861.12 3 2 2 2 2
Subcapsular, <10% surface area 865.01 865.11 Capsular tear, <1cm parenchymal depth 865.02 865.12
Subcapsular, 10%-50% surface 865.01 area intraparenchymal, 865.11 <5 cm in diameter Capsular tear, 1-3cm 865.02 parenchymal depth that does not 865.12 involve a trabecular vessel Subcapsular, >50% surface area or expanding; ruptured subcapsular or parecymal hematoma; intraparenchymal hematoma > 5 cm or expanding >3 cm parenchymal depth or involving trabecular vessels Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen) Completely shattered spleen Hilar vascular injury with devascularizes spleen 865.04 865.14 865.03 865.13
Laceration
III
Hematoma
Laceration IV Laceration
4 5 5
Laceration Vascular
*Advance one grade for multiple injuries up to grade III.
CONTINUED
UVA TRAUMA HANDBOOK 6/11 75 INJURY SCALES CONTINUED FROM PREVIOUS PAGE
LIVER INJURY SCALE (1994 REVISION)

Grade* Injury Type Description of Injury I Hematoma Laceration I Hematoma ICD-9 AIS-90 2 2 2
Subcapsular, <10% surface area 864.01 864.11 Capsular tear, <1cm parenchymal depth Subcapsular, 10% to 50% surface area intraparenchymal <10 cm in diameter Capsular tear 1-3 parenchymal depth, <10 cm in length Subcapsular, >50% surface area of ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma > 10 cm or expanding >3 cm parenchymal depth 864.04 864.14 864.02 864.12 864.01 864.11 864.03 864.13
Laceration III Hematoma
2 3
Laceration IV Laceration
3 4
Parenchymal disruption involving 864.04 25% to 75% hepatic lobe or 864.14 1-3 Couinauds segments Parenchymal disruption involving >75% of hepatic lobe or >3 Couinauds segments within a single lobe Juxtahepatic venous injuries; ie, retrohepatic vena cava/central major hepatic veins Hepatic avulsion
Laceration
Vascular
VI
Vascular
*Advance one grade for multiple injuries up to grade III
CONTINUED
76 6/11 UVA TRAUMA HANDBOOK INJURY SCALES CONTINUED FROM PREVIOUS PAGE
KIDNEY INJURY SCALE TABLE 19

Grade* Injury Type Description of Injury I Contusion ICD-9 AIS-90 2 2
Microscopic or gross hematuria, 866.01 urologic studies normal 866.11 Hematoma Subcapsular, nonexpanding without parenchymal laceration Nonexpanding perirenal hematma confirmed to renal retroperitoneum <1.0 cm parenchymal depth of renal cortex without urinary extravagation <1.0 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravagation Parenchymal laceration extending through renal cortex, medulla, and collecting system Main renal artery or vein injury with contained hemorrhage Completely shattered kidney Avulsion of renal hilum which devascularizes kidney 866.01 866.11 866.02 866.12 866.02
Hematoma
Laceration
III
Laceration
Laceration IV V Vascular Laceration Vascular
866.12
4 4
866.03 866.13
5 5
*Advance one grade for bilateral injuries up to grade III
CONTINUED
UVA TRAUMA HANDBOOK 6/11 77 INJURY SCALES CONTINUED FROM PREVIOUS PAGE
HEART INJURY SCALE

Grade* Description of Injury ICD-9 AIS-90 I Blunt cardiac injury with minor ECG 861.01 3 abnormality(nonspecific ST or T wave changes, premature arterial or ventricular contraction or persistent sinus tachycardia) Blunt or penetrating pericardial wound without cardiac injury, cardiac tamponade, or cardiac herniation I Blunt cardiac injury with heart block (right or left 861.01 3 bundle branch, left anterior fascicular, or atrioventricular) or ischemic changes (ST depression or T wave inversion) without cardiac failure Penetrating tangential myocardial wound up to, 861.12 3 but not extending through endocardium, without tamponade III Blunt cardiac injury with sustained (>6 beats/min) 861.01 3-4 or multilocal ventricular contractions Blunt or penetrating cardiac injury with septal 861.01 3-4 rupture, pulmonary or tricuspid valvular incompetence, papillary muscle dysfunction, or distal coronary arterial occlusion without cardiac failure Blunt pericardial laceration with cardiac herniation Blunt cardiac injury with cardiac failure IV Penetrating tangential myocardial wound up to, 861.01 3-4 but extending through, endocardium, with 861.12 3 tamponade Blunt or penetrating cardiac injury with septal 861.12 3 rupture, pulmonary or tricuspid valvular incompetence, papillary muscle dysfunction, or distal coronary arterial occlusion producing cardiac failure Blunt or penetrating cardiac injury with aortic mitral valve incompetence Blunt or penetrating cardiac injury of the right ventricle, right atrium, or left atrium
CONTINUED
78 6/11 UVA TRAUMA HANDBOOK INJURY SCALES CONTINUED FROM PREVIOUS PAGE
HEART INJURY SCALE (CONT.) Grade* Description of Injury ICD-9AIS-90 IV Blunt or penetrating cardiac injury with proximal (cont.) coronary arterial occlusion Blunt or penetrating left ventricular perforation Stellate wound with < 50% tissue loss of the right861.03 5 ventricle, right atrium, or of left atrium V Blunt avulsion of the heart; penetrating wound 861.03 producing > 50% tissue loss of a chamber 861.13 5 861.03 5 VI 861.13 6 *Advance one grade for multiple wounds to a single chamber or multiple chamber involvement. From Moore et al. [3]; with permission.
DIAPHRAGM INJURY SCALE

Grade* Description of Injury ICD-9 AIS-90 I Contusion 862.0 2 I Laceration <2cm 862.1 3 III Laceration 2-10cm 862.1 3 862.1 3 IV Laceration >10 cm with tissue loss < 25 cm2 V Laceration with tissue loss > 25 cm2 862.1 3 *Advance one grade for bilateral injuries up to grade III.
ACUTE PHYSICAL AND OCCUPATIONAL THERAPY
PT Goal in the Acute Care setting is to restore functional mobility of the patient to achieve discharge to home or to the next level of care.
OT Goal in the Acute Care setting is to restore ADL skills of

the pt to achieve discharge to home or to the next level of care. ROLES 1. Evaluate pts to make recommendations re: next level of care/discharge setting 2. Evaluate pts and collaborate with nursing in terms of mobility/self-care/positioning needs 3. Evaluate and treat those pts with deficits requiring the skills of a physical therapist or occupational therapist INAPPROPRIATE REFERRALS Post-op ambulation Get patient out of bed Patient is bored/not motivated From SNF, back to SNF Force pt to get OOB Check O2 Sat. while walking Long standing mobility deficits Passive range of motion Non-responsive pts Improve endurance Lots of lines/bags to carry OT for a pt w/ no desire to be more independent/hasnt been when walking for yrs APPROPRIATE REFERRALS 1. Pts with new musculoskeletal condition which affects function e.g. joint replacement, burn pt, multi trauma, hip fx 2. A pt for whom nursing has noticed a persistent balance problem of unknown origin when walking 3. A medically complex patient with a decline in functional status who might need post-acute rehab 4. Pts with a new neurological deficit. e.g. brain injury, stroke, SCI, GB, MS 5. Patient must be hemodynamically stable and able to participate in therapy
Spending time on inappropriate referrals (including orders for patients not yet medically stable) takes time away from patients who require PT or OT. Complete info needs to be in chart - spine clearance, weight bearing status, precautions PT/OT Office - 924-8732
UNIVERSITY OF VIRGINIA TRANSITIONAL CARE HOSPITAL WHAT IS AN LTAC?

LTACHs are licensed as acute care or specialty hospitals and they are certified by Medicare as long-term care hospitals. LTACHs must maintain a 25-day average length of stay and be accredited by JCAHO. Patients must meet acute care admission and continued stay criteria. LTACHs provide acute services for patients who are medically complex and require a long hospitalization LTACHs offer specialized care for a variety of conditions including, but not limited to: Ventilator dependent and weaning difficulty Pressure wounds / wound care complications Cardiac diseases Neuromuscular / neurovascular diseases Multi-system organ failure Gastrointestinal diseases Post-op complications Pulmonary disease Acute renal failure including dialysis Infectious diseases requiring long-term IV therapy
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UNIVERSITY OF VIRGINIA LTAC CRITERIA

Patients who are admitted to a long-term acute care (LTAC) hospital typically: Require acute care services as determined by a physician Are not candidates for treatment at a lower level of care Require physician management of multiple acute complexities Patients that meet LTAC admission criteria usually have one or more of the following needs: Mechanical ventilation for respiratory failure Stabilization of underlying disease and ventilator weaning Pulmonary hygiene Tracheostomy with respiratory insufficiency Exacerbation of COPD Infectious disease with two or more co-morbidities Primary cardiac and /or peripheral vascular disease with co-morbidities Wound management requiring interdisciplinary team care High level orthopedic conditions Low-tolerance rehabilitation, 1-3 hours daily Other primary medically complex condition or illness Malnutrition requiring feeding tube or TPN, and speech therapy intervention with swallowing techniques Long Term Acute Care Services include: Multi-specialty medical and surgical consultations available Diagnostic services available Respiratory therapy services on-site 24/ 7 Continuous cardiac monitoring Weekly interdisciplinary team review Medical / Surgical services with nurse staffing the same as short-term acute care Wound management Daily physician rounds
ASSIGNMENT OF PALLIATIVE CARE CODE TO PATIENT MEDICAL RECORD

From the UVA Department of Coding Services Definition: Palliative care is comfort care provided to patients in the final stages of an illness who are no longer receiving curative and/or aggressive treatment. Purpose: UVA Health System defines guidelines for coding and documentation for patients that are provided palliative care within the inpatient setting. Background for Palliative Care: The code for palliative care, V66.7, became effective October 1, 1996. Code V66.7 can be used for any terminally ill patient receiving end-of-life palliative care. Code V66.7 may be assigned as an additional code to identify patients who receive palliative in any health care setting, including a hospital. The code is never assigned as the principal diagnosis. Physician Documentation: The physician documentation in the medical record must substantiate that palliative care is the primary goal of treatment rather than cure in a person with advanced disease that is life limiting and refractory to disease modifying treatment. Terms such as comfort care, end-of-life care, and hospice care, are synonymous with palliative care and are phrases that facilitate assignment of the V66.7 palliative care code. Palliative care provided within the inpatient setting must be documented clearly within the: Admission note Consult Note (consult Palliative Care only is insufficient by itself) Discharge Summary Physician orders Progress note Coding for Palliative Care: Specific ICD-9-CM guidelines must be followed, and the palliative care code will be assigned with the secondary ICD-9-CM code V66.7. A separate primary diagnosis must be documented.
CONTINUED
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For example, if a patient has been receiving curative care and is transferred to another service for Hospice or Palliative Care, the admission order or note by the receiving service should document that the patient is transferred for palliative care. Medical record documentation requirements must be followed to substantiate that palliative care was provided, and to justify the assignment of an ICD-9-CM code V66.7 as a secondary diagnosis for the inpatient encounter. REFERENCES American Hospital Association Coding Clinic. First Quarter 1998, PAGES 11-12 Submitted by: Paula Hathorn CCS, CPC, Coding and Compliance Manager Jonathon Truwit MD, Senior Associate Dean for Clinical Affairs
ORGAN DONATION
Do not discuss organ donation with family. If next of kin initiates discussion about donation, immediately notify LifeNet. Contact LifeNet (1-866-543-3638) whenever there is a patient who is: Intubated with a GCS < 4 or Brain death testing is discussed or Intent to discuss terminal withdrawal of support (vent / pharmacological) or Grave prognosis (no hope of meaningful recovery / non-survivable injury) or Family initiates discussion of donation LifeNet Health will be on-site to work with you on appropriate End-of-Life options for the family. All deaths are to be call into LifeNet Health within 1 hour (60 minutes) If the Organ Procurement Coordinator deems that the patient does meet criteria for donation, a Lifenet representative will initiate the request for organ donation to the next of kin only after the physician discusses the patient prognosis with the family. If the next of kin is not interested in discussing donation, further contact will only be at their request. See Medical Center Policy 0098. Catastrophic Brain Injury Guidelines Purpose: to offer management guidelines for the neurologically devastated patient when the Organ Donation Protocol is activated by established clinical triggers. These guidelines are to preserve organ function in the event that organ donation becomes an option. Organ donation should not be mentioned to the family before the physician along with the patient care team discusses the patients prognosis with them.
CONTINUED
UVA TRAUMA HANDBOOK 6/11 85 ORGAN DONATION CONTINUED FROM PREVIOUS PAGE
These suggestions must only be instituted when the Attending Physician has given permission to use all or part of these suggested clinical interventions. Maintain SBP>100 (MAP>60) 1. Consider invasive hemodynamic monitoring 2. Adequate hydration: Ensure adequate hydration to maintain euvolemia 3. Vasopressor support: If hypotensive post adequate rehydration, use Neosynephrine as the first pressor of choice up 2mcb/kg/min, followed by dopamine Maintain Urine Output >0.5ml/kg/hr<400ml/hr (consider DI if >400ml/hrx2hrs) 1. Treat DI with Vasopressin drip 1-2.5 units/hr, if UO still >400/hr 2. If UO falls below 0.5ml/kg/hr, assess fluid statusmay need rehydration or BP support Maintain PO2> 100 and pH 7.35-7.45 Adequate ventilation maintained by: 1. Peep 5.0-8.0 2. Aggressive pulmonary hygiene if not contraindicated by patients condition (sx and turn every 2 hrs) 3. Respiratory treatments to prevent bronchospasm Hypothermia Maintain core body temperature between 36C and 73.5C Labs 1. Basic metabolic panel, Magnesium, phosphage, heme8, ABGs a. Maintain Hgb>8g/dL and Hct>30% b. If PT>18, given 2 units FFP c. Replete electrolytes as needed d. Monitor glucose and treat with insulin drip if needed (keep 80-200) 2. Bloodbank sample for ABO typing Source: Organ Donation Breakthrough Collaborative http://www.organdonationnow.org/
DISCHARGE AGAINST MEDICAL ADVICE CHECKLIST

Please check all that are completed. I. Nurse and physician assess the patient Ask why do they want to leave? How can we meet their request? Strive to alleviate patient concerns II. Physician components 1. Notification of chief resident 2. Attending physician notified by chief resident 3. Determine capacity to make medical decisions or necessity for medical TDO 4. Documentation AMA form completed Decision making status addressed in progress notes Brief summary in progress notes of patient communications, include severity of condition and potential consequences for leaving AMA Discharge plans designed to ensure the safest possible discharge A. Discharge instructions, inform patient of clinical signs/symptoms that would prompt a return to the emergency department/PCP visit B. Arrange for clinic visits, home care as indicated C. Provide prescriptions Dictate discharge summary
CLINICAL PRACTICE GUIDELINE SEDATION GUIDELINE: ADULT CRITICAL CARE UNITS

1. Treat pain first with an analgesic. 2. If delirium is suspected (confused and/or disordered thinking), try non pharmacological interventions. If needed for patient comfort/safety consider the use of antipsychotics. 3. PRN/bolus dosing by IV or enteral route is the preferred method for managing sedation. PRN/bolus dose 1 - 2 times prior to considering the use of a sedation infusion. 4. Use of sedation infusions should be restricted to the following: neuromuscular blockade, altered intracranial dynamics, status epilepticus, acute medical or surgical interventions, ventilator dys-syncrony adversely affecting gas exchange, management of ETOH or other drug withdrawal, hypothermia protocol in use, open chest or abdomen, and invasive cardiac life support devices. 5. Choose a sedation target in collaboration with the health care team using the Richmond Agitation-Sedation Scale (RASS). RASS desired target level is determined daily by the health care team and documented on computer critical care flow sheet. Variances from the desired target level should be addressed by the health care team, and rationale noted on the flow sheet. When actively titrating infusions document sedation level Q1 hour until desired RASS level achieved. When RASS level is stable, document with each nursing systems assessment. 6. Sedation infusions are to be interrupted at the unitdetermined time (unless a criterion for sedation infusion use precludes a sedation interruption) 7. The decision to interrupt an analgesic infusion is separate and discussed on team rounds. 8. Select and record reason(s) for not attempting a daily sedation interruption on computer screen. 9. Chemically paralyzed patients should have the paralytic turned off before weaning any sedative or analgesic.
Guidelines are general and cannot take into account all of the circumstances of a particular pt. Judgment regarding the propriety of using a specific procedure or guideline with a particular pt remains with that pts MD, RN, or other health care professional, taking into account the circumstances presented by the pt. Approved: Critical Care Subcommittee 1/2009; Patient Care Committee 3/2009
HIGH-RISK AGITATION GUIDELINE
Patient identified as severely agitated
High-rish physiologic source? (Hypoxemia, shock, intra-cranial mass lesion, untreated ischemia) Or caused by pain / discomfort? Yes
ADULT CRITICAL CARE SEDATION GUIDELINE CONTINUED FROM PREVIOUS PAGE
Patient a potential danger to himself or others, or no clear etiology for agitation identified? Yes
Notify faculty, senior resident, and / or other experienced and responsible LIP and assess need for escalation of care to ICU / SDU and ONLY THEN consider use of sedatives, restraints, and / or intubation.
Treat Primary Problem
No
Ongoing agitation?
Yes
No
Rescreen as-needed
UVA TRAUMA HANDBOOK 6/11 89 ADULT CRITICAL CARE SEDATION GUIDELINE CONTINUED FROM PREVIOUS PAGE
RICHMOND AGITATION-SEDATION SCALE (RASS) Score Term +4 Combative +3 +2 +1 0 -1 -2 -3 -4 -5 Very agitated Agitated Restless Alert and Calm Not fully alert, but has sustained (more than 10 seconds) awakening, with eye contact, to voice Light Sedation Briefly (less than 10 seconds) awakens with eye contact to voice Moderate Any movement (but no eye Sedation contact) to voice Deep No response to voice, but any Sedation movement to physical stimulation Unarousable No response to voice or physical stimulation Drowsy Description Overtly combative or violent; immediate danger to staff Pulls or removes tube(s) or catheter(s) or has aggressive behavior towards staff Frequent non-purposeful movement or patient ventilator dyssynchrony Anxious or apprehensive but movements not aggressive or vigorous
PROCEDURE 1. Observe patient. Is patient alert and calm (score 0)? Does patient have behavior that is consistent with restlessness or agitation (score +1 to +4 using the criteria listed above, under Description)? 2. If patient is not alert, in a loud speaking voice state patients name and direct patient to open eyes and look at speaker. Repeat once if necessary. Can prompt patient to continue looking at speaker. Patient has eye opening and eye contact, which is sustained for more than 10 seconds (score -1). Patient has eye opening and eye contact, but this is not sustained for 10 seconds (score -2). Patient has any movement in response to voice, but no eye contact (score -3). CONTINUED
90 6/11 UVA TRAUMA HANDBOOK ADULT CRITICAL CARE SEDATION GUIDELINE CONTINUED FROM PREVIOUS PAGE
3. If patient does not respond to voice, physically stimulate patient by shaking shoulder and then rubbing sternum if there is no response to shaking shoulder. Pt has any movement to physical stimulation (score -4). Pt has no response to voice or physical stimulation (score -5). Bedside nurse responsibilities Document the sedation scale, infusion changes, and boluses on the CCFS, along with rationales. Long-Term Mechanical Ventilation Assure that the sedation goals are being addressed daily per health care team plan. Identify Patients at High-Risk for Delirium (Consider CAM-ICU Screening) Elderly Underlying dementia Previous history of delirium Dehydration Existence of co-morbidities Critically ill General Considerations Perform sedation interruption daily. Appropriately address and treat pain. Collaborate with health care team (to include LIP, nurse, and pharmacist) to evaluate for deliriogenic medications and adjust as appropriate. (Avoid Benzos!) Utilize patients Care Partners to assist in nonpharmacologic interventions. Initiate fall precaution strategies as needed. Sleep hygiene - minimal lighting at night, brighter lighting during day, control excess noise (extremely important intervention) Provide patient and family education regarding delirium Attempt consistency in staff Provide alternative stimuli: television during day with news/weather or non-verbal music Treat underlying metabolic derangements and infections Medical Center guideline is available on the Clinical Portal
TRAUMA: PAIN AND SEDATION GUIDELINES

Patient in Pain
Initiate Appropriate Analgesia Consider Epidural if Multiple Rib Fractures, patient Awake, and Spine Clearance Possible Consider Tylenol, NSAIDS (caution: NSAIDS may cause or exacerbate renal failure if low GFR) Consider PCA (Avoid morphine in renal failure. Consider Fentanyl if hemodynamic instability or elderly) o Initial Settings Dilaudid 0.2 - 0.4 mg Q8 min Fentanyl: 15-25 mcg Q6 min
Titrate to achieve analgesia without sedation
If adequate Analgesia not Appropriate / Possible with PCA or Epidural: o Consider Fentanyl drip: 25-75 mcg / hr if Elderly, Severe CHI, or Hemodynamic Instability o Consider Dilaudid drip: 0.4 to 2 mg / hr to minimize need for benzodiazepine gtts
CONTINUED
92 6/11 UVA TRAUMA HANDBOOK TRAUMA: PAIN AND SEDATION GUIDELINES CONTINUED FROM PREVIOUS PAGE
Needs Sedation?
Need for Sedative Drip? Severe Closed Head Injury? Ventilator Dysynchrony?
Propofol (for < 24 hours)** Daily Interruption
No Intermittent Sedative Consider Ativan 1-2 mg Q1h PRN Consider Haldol 2.5 - 5 mg q2 h PRN (Especially if need for sedation secondary to delirium)
* Turn off drip daily and reassess need for continuous benzodiazepine ** Especially useful for short term sedation such as in early CHI, short-term vent weaning. *** Utilize CAM ICU assessment to evaluate for delirium
Titrate Narcotic Drip to Effect Consider weaning with enteral narcotics or by switching to PCA Consider adding Haldol 2.5 - 5 mg IV q3 hrs PRN
Yes
Ativan
Drip
} Titrate to Effect*
University of Virginia Health System
LEVEL I TRAUMA CENTER
P E D I AT R I C G U I D E L I N E S
Final Editing by: Julie Haizlip, MD Assistant Professor of Pediatrics Division of Pediatric Critical Care Bradley Rodgers, MD Professor of Surgery and Clinical Pediatrics Division Head, Division of Pediatric Surgery Eugene McGahren, MD Professor of Surgery and Pediatrics
PEDIATRIC TRAUMA PROTOCOLS

TABLE OF CONTENTS
PAGE Sedation Service Brain Injury Guidelines for the Management of Intercranial Hypertension in Children with Closed Head Injury I. Standard Therapy for All Children 96 97 98 98-99
II. Sequential Treatment of Elevation in Intracranial Pressure (ICP > 20 mmHg All Ages) 100-102 III. Severe, Abrupt Elevation in ICP and/or Manifestation of Impending Herniation IV. Sequential Treatment of Decreased MAP Decreased CPP 103 103-104 105 106 107 108 109 110-111 112-113 114-115 116-117 118-119
Sequential Treatment for ICP >20 mmHg (All Ages) Second Tier Treamtnet for ICP > 20 mmHg (All Ages) Severe, Abrupt Elevation ICP and/or Manifestation of Impending Herniation Treatment of Decreased MAP Decreased CCP Sequential Treatment for ICP >20 mmHg (All Ages) Severe TBI Standard Therapy Checklist Clinical Pathway Evaluation of the Pediatric Cervical Spine Near Drowning/Submersion Injury Non-accidental Trauma (Abusive Injury) Hemostasis in Pediatric Neurotrauma
PEDIATRIC GUIDELINES UVA TRAUMA HANDBOOK 6/11 95
PEDIATRIC TRAUMA
The following guidelines were created by consensus in the Pediatric Trauma Sub-Committee. The Pediatric Trauma SubCommittee is a multi-disciplinary group that includes representation from Pediatric Surgery, Pediatric Emergency Medicine, Pediatric Critical Care, Pediatric Neurosurgery, Orthopedics, and the University of Virginia Trauma Committee. These guidelines were approved for patients < 18 who are under the care of the pediatric surgeons.
MAJOR CONTRIBUTIONS BY: John Jane, Jr, MD Associate Professor of Neurosurgery and Pediatrics Mark Abel, MD Lillian T. Pratt Professor and Chair of Orthopedic Surgery Professor of Pediatrics Bartholomew J. Kane, MD Assistant Professor of Surgery and Pediatrics
PEDIATRIC GUIDELINES 96 6/11 UVA TRAUMA HANDBOOK
SEDATION SERVICE
PIC# 1662 Peds Sedation Nurse Coordinator (Call this first!) PIC# 1813 Peds Sedation Attending Hours: Monday Friday 0700 1700
The pediatric sedation service is staffed by a pediatric intensivist and a pediatric sedation nurse. Its purpose is to provide moderate to deep sedation to pediatric patients to facilitate diagnostic and therapeutic procedures. With the exception of Doug Willson, MD, pediatric sedation providers are not qualified to provide general anesthesia or inhalational anesthesia. Patient MUST be NPO for solids/ full liquids for 6 hours prior to procedure (may have clear liquids until 2 hours prior to procedure) Peds Sedation does not electively intubate, and so cannot sedate anyone who requires oral contrast (this is equivalent to a full stomach). Children who require sedation but have not been NPO may be electively intubated and sedated by anesthesia for urgent procedures. If you are scheduling a radiology procedure put in order and request with Peds Sedation and radiology scheduling will coordinate with Pediatric Sedation. If it is urgent, you can also call the Peds Sedation nurse to help facilitate. Burns Acute burns require that the patient have been NPO for the 6 hours prior to the burn - if acute debridement is necessary, they will require anesthesia. Burns often require daily dressing changes and will need NPO orders prior to sedation every day. After the first debridement, Peds Sedation will coordinate times for subsequent dressing changes.
PEDIATRIC GUIDELINES UVA TRAUMA HANDBOOK 6/11 97
BRAIN INJURY
Guidelines for the Management of Intracranial Hypertension in Children with Closed Head Injury Please note: These are meant to be guidelines. No criteria, protocol or guideline can anticipate every clinical circumstance nor are these meant to substitute for clinical judgment. COMMUNICATION AND RESPONSIBILITIES The PICU team will be responsible for ongoing monitoring, and for safe and expedient transport to CT scan or other imaging procedures. The PICU Resident and Fellow, the Trauma Service Resident (Pediatric Surgery) and Neurosurgery Service Resident will be responsible for administration of these guidelines. Deviation from these guidelines or rapid or unexpected escalation of therapy will require notification of the Chief Resident and/or Attending Physician from each of the involved services with appropriate documentation entered into the patients chart. The Trauma Chief Resident and Attending, Neurosurgery Chief Resident and Attending, and PICU Attending must be available at all times for consultation regarding the management of these patients. INDICATIONS FOR ICP MONITORING Pediatric patients with closed head injury who meet one or more of the following criteria will have ICP monitoring devices placed by Neurosurgery.1 1. Patients with admission (E.D. or PICU) GCS < 8 2. Patients with GCS > 8 but who require operative or other interventions that compromise evaluation of the childs neurological status. 3. Patients with GCS > 8 who require intubation and sedation for accompanying traumatic injuries and are, thus, unable to be adequately evaluated neurologically.
CONTINUED
PEDIATRIC GUIDELINES 98 6/11 UVA TRAUMA HANDBOOK BRAIN INJURY CONTINUED FROM PREVIOUS PAGE
Guidelines for Management of Intracranial Hypertension in Children with Closed Head Injury Goals of therapy by age*: Age < 2 years 2-5 years >5 years Adolescents/ Adults MAP2,3 55 mm 60 mm 65 mm 70 mm ICP1 20 mmHg 20 mmHg 20 mmHg 20 mmHg CPP 45 mmHg 50 mmHg 55 mmHg 70 mmHg
> > > >
Hg Hg Hg Hg
< < < <
> > > >
*Correction of elevated ICP should occur before correction of MAP/CPP I. Standard Therapy for All Children: 1. Head elevated to 30, neutral position or reverse Trendelenburg position if Thoracic/Lumbar spine not cleared. 2. All patients should have an arterial line and a central venous line capable of monitoring central venous pressure (CVP). 3. Avoid obstruction of neck veins-> inspect cervical collar for proper fit; avoid circumferential endotracheal tube ties. 4. Minimal stimulation low light, minimal noise, room door closed. 5. After fluid resuscitation, IV fluids at full maintenance using Lactated Ringers or Normal Saline solution. Any additional IV fluids should be administered in bolus form and titrated to effect. 6. Monitor serum sodium at least every 6 hours hyponatremia must be avoided. Sodium falling by more than 3 mEq/L in 6 hours needs to be investigated and addressed immediately. 7. Analgesia with an initial fentanyl infusion at 1-2 mcg/kg/hr, titrated to effect. Avoid oversedation. Additional analgesia (fentanyl 1-2 mcg/kg bolus) should be given for painful procedures (laceration repair, central line placement, ICP monitor placement, etc.)
CONTINUED
PEDIATRIC GUIDELINES UVA TRAUMA HANDBOOK 6/11 99 BRAIN INJURY CONTINUED FROM PREVIOUS PAGE
8. Sedation with midazolam at 0.05-0.1 mg/kg/dose q1-2 hours prn, a midazolam infusion at 0.05-0.1 mg/kg hr may be started if prn doses are inadequate. Avoid oversedation. Agitation may be a sign of elevated ICP, hypoxia, or inadequate analgesia and should be investigated. Due to the risk of propofol infusion syndrome, propofol should not be used for long-term sedation in pediatric patients. 9. Controlled ventilation to maintain PaCO2 between 35 and 40 mmHg1. 10. FiO2 should be adjusted to maintain O2 saturation > 92%. High levels of PEEP should be avoided. 11. Colloid infusions as indicated: may consider PRBCs for HCT < 30, FFP for INR > 1.3, platelet infusions for platelet count < 100K if intracranial bleeding (SDH, SAH, intraparenchymal hematomas) is present. Consider Activated Factor VII if initial administration of FFP does not improve coagulopathy. 12. Temperature control (< 37 C, rectal temp.). Temperatures > 37 C must be brought down within 1 hour. Temperature control may require acetaminophen, a cooling blanket, fans, decreased ventilator humidifier temperature, and ice to groins and axillae. 13. Consider the initiation of prophylactic anticonvulsant medication (Phosphenytoin preferred), especially in children < 2 years old with intraparenchymal hemorrhages on admission CT scan.1 Anticonvulsant medication should be strongly considered for patients requiring prolonged neuromuscular blockade. 14. Initiate prophylactic antibiotics (cefazolin or other Staphylococcal sp. coverage) while ICP monitor is in place. 15. Initiate stress ulcer prophylaxis (famotidine or equivalent) 16. Severe, abrupt or recalcitrant elevations of ICP should prompt Neurosurgical evaluation and consideration of repeat CT scan.
CONTINUED
II. Sequential Treatment of Elevation in Intracranial Pressure (ICP > 20 mmHg, all ages) 1. Severe, abrupt or recalcitrant elevations of ICP at any point in these guidelines should prompt Neurosurgical evaluation and consideration of repeat CT scan. 2. If there is reason to believe the child is experiencing pain, a fentanyl bolus of 1-2 mcg/kg can be given and the infusion adjusted upward by 1-2 mcg/kg/hr. If there is a response but it is inadequate, the bolus should be repeated. 3. Sedation should be deepened with an initial bolus (midazolam 0.05-0.1 mg/Kg) and infusion increased proportionately. If there is a response but it is inadequate, the sedation bolus should be repeated. Agitation may be a sign of hypoxia or inadequate analgesia and should be investigated. 4. If elevations of ICP are associated with suctioning, consider lidocaine 1mg/kg IV q2 prn. Following consultation with the PICU Fellow or Attending, may consider barbiturates (thiopental or pentobarbital) prior to suctioning if the patient is hemodynamically stable. Monitor closely for hypotension and be prepared to intervene. 5. If ICP elevation is not responsive to additional sedation and analgesia and an External Ventricular Drain (EVD) is present, consider additional CSF drainage. The Neurosurgical service must be notified prior to EVD manipulation. CSF drainage should be replaced cc:cc with normal saline IV. 6. Occult seizures must be considered in cases of refractory or rising ICP. Consider emergent bedside EEG and Neurology consultation. Consider initiation of antiepileptic medications (Phosphenytoin or Phenobarbital). 7. If ICP elevation is not responsive to the above measures, give Mannitol 0.25 0.5 grams/Kg IV over 10-20 minutes. A working foley should be in place, urine output must be closely monitored and euvolemia should be maintained. Serum osmolarity should be monitored every 4 hours and should be maintained < 320 mOsm/L unless mannitol is used in conjunction with 3% saline (see #8).
CONTINUED
8. Consider initiation of 3% Saline infusion at 0.1 mL/kg/hr. May increase infusion every 6 hours to a maximum of 1 mL/kg/hr to maintain ICP < 20 mmHg,1,4 the lowest effective infusion rate should be used. Serum sodium should be monitored at least every 4 hours. Serum sodium should not be allowed to increase > 2 mEq/L in a 4 hour period (15 mEq/L/24 hours) and should not decrease by more than 1-2 mEq/L in a 4 hour period (10 mEq/L/24 hours). Serum osmolarity should be maintained < 360 mOsm/L whether or not mannitol is used. 9. If ICP elevation is not responsive to the above measures, initiate paralysis with non-depolarizing neuromuscular blockade (NMB) either intermittently (e.g., pancuronium 0.2 mg/kg) or as a continuous infusion (suggest vecuronium at 0.1 mg/kg/hr, titrated to effect). Paralysis should be monitored using nerve stimulator and NMB agent repeated/adjusted when 3/4 twitches return on trainof-four monitor. If not already initiated, anticonvulsant medication (Phenytoin or Phenobarbital) and continuous EEG monitoring should be strongly considered with the initiation of neuromuscular blockade. 10. If ICP refractory to the above measures and it has been at least 24 hours since the time of injury, may consider mild hyperventilation (PaCO2 30-35) until ICP can be controlled by other measures.1 Normocarbia should be reestablished as soon as other measures become effective. 11. Should these measures fail, depending on the timing and severity of ICP elevation, more aggressive measures should be considered in consultation with the Trauma team, Neurosurgery and the PICU Attending: a. Higher and/or repeated doses of mannitol (0.5-1 gm/kg IV) b. If an External Ventricular Drain (EVD) is present, consider additional CSF drainage. c. Decompressive craniectomy
CONTINUED
i. Can be considered immediately following injury in severe cases of elevated ICP. ii. Should be strongly considered for refractory elevation of ICP in patients with some or all of the following criteria1: 1. Diffuse cerebral swelling on CT 2. Within 48 hours of injury 3. Secondary clinical deterioration 4. Evolving cerebral herniation iii. Some patients may be candidates for decompressive craniectomy earlier in their clinical course. Therefore, close consultation with Neurosurgery is essential in any patient with rising or persistently elevated ICP at any stage in these guidelines. iv. If decompressive craniectomy is not performed, consider EVD placement if not already done. d. Barbiturate anesthesiamonitor closely for hypotension and be prepared to intervene (IV fluids, vasoactive medications). i. Must have continuous EEG monitoring. ii. Pentobarbital 1. Loading dose: 1-2 mg/kg IV aliquots until ICP controlled or burst suppression on EEG. 2. Maintenance: 1 mg/kg/hr, titrated to effect (ICP < 20 mmHg or burst suppression). e. Moderate hypothermia to 32-34 F.1 i. May be established using cooling blanket, fans, decreased ventilator humidifier temperature, and ice to groins and axillae. ii. Neuromuscular blockade (NMB) must be maintained to prevent shivering consider NMB infusion. iii. If hypothermia cannot be limited to 24 hours, consider daily blood cultures.
CONTINUED
III. Severe, abrupt elevation in ICP and/or manifestation of impending herniation (unequal pupils, pupillary dilatation or loss of reactivity) 1. Trauma Service, Neurosurgery and PICU Attendings will be called immediately. 2. Ventilation will be immediately taken over with hand ventilation to achieve hypocarbia (PaCO2 < 30 mmHg) until ICP can be controlled by other measures. 3. Mannitol 0.5 - 1 grams/kg will be administered as quickly as possible. 4. Thiopental 1-3 mg/kg IV or Pentobarbital 1-3 mg/kg IV monitor for hypotension and be prepared to intervene. 5. Severe, abrupt or recalcitrant elevations of ICP should prompt Neurosurgical evaluation and consideration of repeat CT scan. IV. Sequential Treatment of Decreased MAP causing Decreased CPP. 1. CPP = MAP ICP Correction of elevated ICP should occur before correction of decreased MAP/CPP. 2. If ICP is not elevated, low MAP/CPP should be treated if there are other clinical indications (poor perfusion, decreased urine output etc). Age < 2 years 2-5 years >5 years Adolescents/ Adults MAP2,3 55 mm 60 mm 65 mm 70 mm ICP1 20 mmHg 20 mmHg 20 mmHg 20 mmHg CPP 45 mmHg 50 mmHg 55 mmHg 70 mmHg
> > > >
Hg Hg Hg Hg
< < < <
> > > >
3. Fluid bolus of 10-20 cc/kg of Lactated Ringers or Normal Saline solution. If there is a response but it is inadequate, the fluid bolus should be repeated.
CONTINUED
4. Colloid infusions as indicated: PRBCs for HCT < 30, FFP for INR > 1.3, platelet infusions for platelet count < 100K if intracranial bleeding (SDH, SAH, intraparenchymal hematomas) is present. May also consider 1 gram/kg of 5% or 25% albumin for volume expansion. 5. Examine patient/review studies for occult sites of bleeding and address with the Trauma Service and Neurosurgery. 6. As needed, adjust medications that can affect blood pressure including narcotics, benzodiazepines, neuromuscular blocking agents, barbiturates. 7. Initiate vasoacitve medications such as dopamine, vasopressin, or phenylephrine. REFERENCES Adelson PD, Bratton SL, Carney NA, et al: Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents. Critical Care Medicine 2003; 31(6). Jones PA, Andrews PJD, Easton VJ, Minns RA: Traumatic brain injury in childhood: Intensive care time series data and outcome. British Journal of Neurosurgery 2003; 17(1): 29-39. Report of the second task force on blood pressure control in children1987-from the
CONTINUED
SEQUENTIAL TREATMENT FOR ICP > 20 MMHG (ALL AGES)

PAIN CONTROL Fentanyl 1-2 mcg/kg bolus Consider infusion at 1-2 mcg/kg/hour SEDATION Midazolam 0.05-0.1 mg/kg bolus Consider infusion at 0.05-0.1 mg/kg/hour OSMOLAR THERAPY 3% Saline infusion at 0.1 mL/kg/hr Monitor sodium level q2h until infusion and value stable CSF DRAINAGE Through EVD (if present) ***Consult with Neurosurgery*** CONSIDER SEIZURES Consider EEG Consider anti-epileptic medications ADDITIONAL OSMOLAR THERAPY Mannitol 0.25 0.5 gram/kg Monitor serum osmolality now and in 4-6 hours NEUROMUSCULAR BLOCKADE Pancuronium 0.2 mg/kg prn OR Vecuronium 0.1 mg/kg prn Consider continuous EEG monitoring &/or prophylactic anti-epileptic medications HYPERVENTILATION Mild hyperverntilation to PCO2 30-35 until ICP controlled by other measures GO TO SECOND TIER TREATMENTS
CONTINUED
SECOND TIER TREATMENT FOR ICP > 20 MMHG (ALL AGES)*

ICP remains > 20 mmHg despite First Tier Therapies Additional consultation with PICU Attending Neurosurgery Trauma Surgery Mannitol 0.5-1 gm/kg IV Decompressive Craniectomy
Barbiturate Anesthesia Need continuous EEG Prepare for hypotension
Moderate Hypothemia 32-34 degrees C
* See Text of Guidelines for details * Severe, abrupt or recalcitrant elevations of ICP at any point in these guidelines should prompt Neurosurgical evaluation and consideration of repeat CT scan.
CONTINUED
SEVERE, ABRUPT ELEVATION IN ICP AND/OR MANIFESTATION OF IMPENDING HERNIATION*

Immediately Notify: PICU Attending Neurosurgery Trauma Surgery Hand Ventialte to PaC02 < 30 mmHg until other measures become effective Mannitol 0.5 - 1 gm/kg IV Thiopental 1-3 mg/kg IV or Pentobarbital 1-3 mg/kg IV Be prepared for hypotension Consider repeat Head CT Scan
* See Text of Guidelines for details * Severe, abrupt elevations of ICP at any point in these guidelines should prompt Neurosurgical evaluation and consideration of repeat CT scan
CONTINUED
TREATMENT OF DECREASED MAP DECREASED CPP *

Treat elevated ICP before treating decreased MAP/CPP 20 cc/kg bolus of LR or NS Examine patient/review radiology studies for occult volume loss or bleeding Consider Colloid infusions PRBCs for HCT < 30 FFP for INR > 1.3 Platelets for < 100 if bleeding Adjust medications that affect blood pressure: benzodiazepines, narcotics paralytics, barbiturates Initiate vasoactive medications following consultation with PICU Attending, Trauma Surgery and Neurosurgery
CONTINUED
SEQUENTIAL TREATMENT FOR ICP >20 MMHG (ALL AGES)

Pain Control Fentanyl 1-2 mcg/kg bolus Consider infusion at 1-2 mcg/kg/hour. Titrate up if necessary. Sedation Midazolam 0.05-0.1 mg/kg bolus Consider infusion at 0.05-0.1 mg/kg/hour. Titrate up if necessary. Osmolar Therapy 3% Saline infusion at 0.1-0.2 mL/kg/hr (reduce maintenance fluid rate). Titrate. Monitor sodium level q2h until infusion and value >145 & stable CSF Drainage Through EVD (if present) ***Consult with Neurosurgery*** Consider Seizures Consider EEG Consider anti-epileptic medications Neuromuscular Blockade Pancuronium 0.2 mg/kg prn OR Vecuronium 0.1 mg/kg prn Consider continuous EEG monitoring &/or prophylactic anti-epileptic medications Additional Osmolar Therapy Mannitol 0.25 0.5 gram/kg Monitor serum osmolality now and in 4-6 hours Hyperventilation Mild hyperventilation to PCO2 30-35 until ICP controlled by other measures GO TO SECOND TIER TREATMENTS
CONTINUED
SEVERE TBI STANDARD THERAPY CHECKLIST

Nursing Head to 30 or reverse Trendelenberg Maintain Core Body Temperature < 37 C Inspect cervical collar for proper fit, change to Aspen Collar Minimal stimulation (light, noise) Earplugs if no otorhea Goal ICP < 20 mmHg, Goal CPP 50 70 (To Be Determined by PICU attending or fellow & NSGY) Monitoring Arterial Line Central Venous Line with CVP Monitoring Serum sodium checked every 6 hours (minimum) Goal Na > 145. Serum Sodium checked every 2 hours if receiving 3% NS (or other hypertonic saline) Blood glucose monitoring every 6 hours (minimum). Goal glucose 80-150. Avoid hypoglycemia Hourly blood glucose monitoring if on insulin infusion (until stable) Serum osmolality every 6 hours and prn if receiving mannitol Train of Four Monitoring every 4 hours if on neuromuscular blockade Daily holiday from neuromuscular blockade unless clinically contraindicated Respiratory Support Adjust FiO2 to maintain oxygen saturations >92% - minimize PEEP Maintain PaCO2 between 35-40 mmHg on Arterial Blood Gas
CONTINUED
Fluids/ Meds Maintenance IV fluids with 0.9%NS once resuscitation complete (NO dextrose containing fluids) Adequate analgesia (fentanyl preferred) Adequate sedation (midazolam preferred) Neuromuscular blockade if indicated (vecuronium or pancuronium preferred) Support BP with vasopressors if indicated (norepinephrine or phenylephrine preferred) DISCUSS with PICU Attending or Fellow Colloid infusions as indicated (PRBCs, FFP, Platelets) Maintain normal hematologic parameters (HGB > 8, INR d 1.2, Platelets e 100 ) Consider prophylactic anticonvulsant medication for high risk patients (Keppra preferred) [depressed skull fracture, post-impact seizure, neuromuscular blockade, epidural] Appropriate antibiotic prophylaxis for ICP monitor (cefazolin preferred, vancomycin if allergic) Stress ulcer prophylaxis (famotidine or equivalent) Consider lidocaine 1 mg/kg IV prior to suctioning (maximum 7 doses per day) DVT prophylaxis if post-pubertal Other Severe abrupt or recalcitrant elevations of ICP (>20 mmHg for > 5 mins) should prompt Neurosurgical evaluation and consideration of repeat CT scan. (assure adequate sedation, etc.)
C-SPINE INJURY CONCERN AGE < 17 YO
Awake & Alert
Age > 3 yo and Cooperative and No Dev Delay High Risk Mechanism or Pain on exam Meets Nexus Criteria: 1. Absence of midline tenderness 2. No evidence of intoxication 3. Normal level of alertness 4. Normal neurologic exam 5. Absence of painful, distracting injury C-Spine Clear
Obtunded or Intubated
*Traction Study (should not be used if ligamentous injury seen on post 72h MRI !) initial lateral radiograph is taken to eval for C0-C1-C2 subluxation initial wt applied should be stratified according to age and wt o For ped pts with adult habitus, adult protocol may be used o For infants and children, wt used should be % of total body wt Initial and incremental wt should be 5% of total body wt Ultimate wt should not exceed 1/3 total body wt The 5% value is a conservative extrapolation from adult population (initial wt = 10 lbs) Upright C-spine with and without collar prior to full clearance

YES
Age < 3 yo OR Uncooperative OR Devel Delay
Getting Head CT?
YES
Age > 9 yo?
YES
NO
NO
NO
AP, Lateral Cspine swimmers. Odontoid only if age > 9 yo (if NO odontoid is sufficient, get CT occiput-C2)
Abnormal, or pain on exam
YES
Normal & Meets NEXUS Criteria
C-Spine Clear

CONTINUED
PEDIATRIC GUIDELINES UVA TRAUMA HANDBOOK 6/11 113 PEDIATRIC TRAUMA ALERT OR CONSULT CONTINUED FROM PREVIOUS PAGE
Abnormal
Normal
Alert?
Meets Nexus Criteria? NO YES
C-Spine Clear
Abnormal
Approved By Ped Trauma Committee
Revised 4/06
Spine Consult
Abnormal, or MRI not done within 48-72 hrs
C-spine CT (Occiput to T1 with saggital and coronal recons) (If getting Head CT do at same time)
AP/Lat Cspine No odontoid view Must see C7 on T1 CT Occ to C2

Abnormal
Normal
Obtunded?
NO
YES
MRI w/in 48 to 72 hrs
Normal
Upright Cspine Lat with then without collar
Normal
C-Spine Clear
NEAR-DROWNING/SUBMERSION INJURY PRACTICE GUIDELINE

1. Provide 100% FiO2 2. Possible Traumatic Mechanism? a. Immobilize C-spine b. Consider abuse in bathtub drownings 3. Airway / Breathing A. Clear airway of debris B. Intubate if 1. undergoing CPR 2. Respiratory failure (PaCO2 >45) 3. unable to maintain PaO2 >60 mmHg on 100% FiO2 4. altered LOC with dimished airway reflexes 5. worsening ABGs C. Consider Cuffed ETT (will likely progress to ARDS) D. If doesnt require intubation and alert but w/ resp distress consider CPAP/BiPAP 4. Circulation A. CPR if necessary (especially if hypothermic) B. Consider ECMO if evidence of icy water submersion 5. Rewarming A. Warmed IV fluids B. Warmed oxygen (including thru vent circuit) C. Bladder lavage through foley with 40 degree fluid D. DPL can be performed for warm peritoneal lavage E. Thoracotomy with warm mediastinal lavage and open heart massage F. ECMO cannulation (thoracic preferable to femoral for rewarming but hypothermic atrium is prone to dysrhythmias) G. Do not abandon resuscitation until temp > 30degrees 6. Lab Investigation A. ABG B. Electrolytes C. DIC Panel D. ETOH/ Tox screen if indicated
PEDIATRIC GUIDELINES UVA TRAUMA HANDBOOK 6/11 115 NEAR-DROWNING/SUMBERSION INJURY CONTINUED FROM PREVIOUS PAGE
7. Radiology A. CXR B. If possible trauma 1. Lateral C-spine 2. Head CT 3. Skeletal survey (if concern for abuse) 8. Antibiotics A. Indicated if drowning was in grossly contaminated water B. Fever and Elevated WBC count may occur following near drowning in absence of infection C. At risk for septic shock associated with Strep Pneumo in 1st 24 hours
NON-ACCIDENTAL TRAUMA (ABUSIVE INJURY) PRACTICE GUIDELINE

Injuries that are concerning for non-accidental trauma SHAKEN BABY Subdural hematomas Retinal hemorrhages May have c-spine injury BRUISING In infants (If you dont cruise, you dont bruise) Bruising in patterns (ie. brush, hand, belt) FRACTURES Skull fractures in infants or in children without significant mechanism Rib fractures in infantsespecially posterior Bucket handle fractures Spiral fractures (however can be benign Toddlers fracture) Multiple fractures in different stages of healing BURNS IN CONCERNING DISTRIBUTIONS Bathtub scalds buttocks, plantar surface of feet, stocking/ glove distribution Cigarette burns INCONSISTENT HISTORY Changing history History isnt consistent with development (if you have questions about what is developmentally possibleask a pediatrician!) History doesnt explain injury Falling off a bed/ sofa onto carpeted floor doesnt cause a skull fracture 2 month old infants dont roll off anything
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PEDIATRIC GUIDELINES UVA TRAUMA HANDBOOK 6/11 117 NON-ACCIDENTAL TRAUMA (ABUSIVE INJURY) CONTINUED FROM PREVIOUS PAGE
ABDOMINAL INJURY WITHOUT APPROPRIATE MECHANISM Small bowel hematomas Pancreatic injury PROCEDURES Appropriate medical care and stabilization Fill out DOCTORS SCAN form (available from HUCs) this documents injuries for CPS Take pictures of visible injuries when possible Take a careful history determine who has been caring for child ask for specifics of how injury occurred DOCUMENT EVERYTHING. Use direct quotes when appropriate. Get Social Work involved Notify Child Protective Services (CPS) for the appropriate city/ county Albemarle County 972-4010 Charlottesville 970-3400 State Hotline 1-800-552-7096 Tell the family of your concern and that you have notified CPS Ancillary studies Ophthalmology consult specifically required for Shaken Baby Skeletal survey IF there are subdural hematomas, check coags - correct if abnormal
HEMOSTASIS IN PEDIATRIC NEUROTRAUMA REQUIRING URGENT PROCEDURAL INTERVENTION PRACTICE GUIDELINE PURPOSE 1. To define appropriate goals for hemostasis in pediatric patients with neurotrauma requiring urgent procedural intervention. 2. To outline therapeutic interventions to achieve goal hemostasis.
Please note: these are meant to be guidelines. No criteria, protocol or guideline can anticipate every clinical circumstance nor are these meant to substitute for clinical judgment.
IMPLEMENTATION / PROCEDURE Definitions 1. Standard Risk Procedures: Applies to minor surgical procedure such as placement, maintenance, and removal of an intraparenchymal intracranial pressure monitor or an external ventricular drainage (EVD) device. 2. Higher Risk Procedures: Applies to major surgical procedure such as decompressive craniectomy, or evacuation of a subdural or epidural hemotoma. Hemostatic Goals 1. Standard Risk Procedures: a. INR < 1.5 b. Platelet count > 70,000 c. PTT < 3 seconds above the appropriate upper limit of normal for age and gestation. 2. Higher Procedures: a. INR < 1.2 b. Platelet count > 100,000 c. PTT < 3 seconds above the appropriate upper limit of normal for age and gestation.
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Interventions to Achieve Hemostatic Goals for Intervention 1. To achieve goal INR and or PTT: a. Supplement fibrinogen if the value is less than 100 mg/ dl using cryoprecipitate 0.2 units/kg b. Administer Fresh Frozen Plasma (FFP) 30 mL/kg c. Repeat coagulatin testing and platelet number. If goals not met, then supplement platelets using 10 ml platelets per kg and d. Administer recombinent Factor VII (rFVIIa) 90 mcb/kg. (hour 0) NOTE rFVIIa should only be given when it is known with the highest confidence that everything and everyone is available to initiate the procedure in no more than 30 minutes. e. Once rFVIIa is given, there is no benefit to rechecking INR or PTT during the duration of action of rFVIIa (2 hours). However, figbinogen and platelet levels should be monitored every 3 hours. Supplement fibrinogen with cryoprecipitate, and low platelets, as above. f. Repeat rFVIIa dosing every 2 hrs for a total of 3 doses to maintain perioperative hemostasis. (Hours 2,4,6) 2. To achieve goal platelet count: 1. If patient is requiring FFP transfusion and patient has platelet count < 100,000 transfuse with 10mL/kg. (Based on assumption that ongoing platelet consumption may result in further drop in platelet count). b. Repeat Platelet count 30 minutes after transfusion. If platelet count is > 70,000 at time of appropriate INR correction, this number is sufficient to proceed with surgery. c. Notify blood bank to have additional platelets (10 mL/kg) available if needed during procedure. Relative Contraindications to Factor VIIa Administration 1. Multiple trauma including vascular injury 2. History within 30 days of new onset arterial or venous thrombosis 3. History within 30 days of myocardial infarction
ADULT MEDICATION REFERENCES

STBICU David Volles 6E Julie Kesley Pharm weekdays weekdays eve-nights Pager 3924 Pager 2440 Phone 4-5255
ANALGESICS
Fentanyl IV injection 25-50mcg slow IVP q1hr prn adequate analgesia IV infusion 2500mcg/50ml; Start at 50mcg/hr titrated to adequate analgesia IV PCA 2500mcg/50ml; 25mcg PCA dose, 6 min lockout delay, hourly limit of 250mcg Morphine IV injection 2mg slow IVP q2hr prn adequate analgesia IV infusion 100mg/100ml D5W; Start at 1mg/hr titrated to adequate analgesia IV PCA 100mg/100ml D5W; 1-2 mg PCA dose, q 6-8 min lockout delay, hourly limit of 12mg Hydromorphone IV injection: 0.4-0.6 mg q 2 hr PRN PCA: 10 mg (50 m) 0.2-0.6 mg q 6-8 min Oxycodone+acetaminophen 5/325mg (Percocet) Pain Score As needed: 1-4 One tablet PO (5/325mg) every 4 hrs 5-6 Two tablets PO (10/650mg) every 4 hrs (PO tablet, 5/325mg, Percocet) (PO/enteral tube liquid, 5/325mg per 5ml, 10/650mg/10ml, Roxicet) Oxycodone 5mg (PO tablets) Pain Score As needed: 5-10 Two tablets (10mg)
every 4 hrs
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Hydrocodone+acetaminophen 5/325mg PO tablet (Vicodin) Pain Score As needed: 1-4 One tablet PO (5/325mg) every 4 hours 5-6 Two tablets PO (10/650mg) every 4 hours Lidocaine Patch On pain site 12 hrs on (10:00 AM), 12 hrs off (22:00 PM) Methadone (Chief approval: consider pain consult) Long-term pain management. 5 to 10 mg po every 8 hours starting dose. Will peak in 3 days. Taper 10% qod.
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS*

* Avoid NSAIDs in patients with any renal insufficiency or in patients with history or risk of bleeding (GI bleeds, low platlets, spleen, liver lac and anticoaguant use). Ketorolac (Toradol) 30mg IVP now followed by 15mg q6hr prn (May not use ketorolac longer than 3 days; convert to oral NSAID or other agent) Ibuprofen (Motrin, Advil) 400-800mg PO, q6-8hr prn (Not to exceed 3200mg / day)
SEDATIVES
Midazolam IV injection 2-4mg slow IVP q1 hr as needed for sedation IV infusion (duration <48h) 100mg/100ml; Start at 2mg/hr and titrate for sedation Lorazepam (duration >48h) IV injection 1-2 slow IVP q1hr as needed for sedation IV infusion 40mg/40ml; Start at 1mg/hr and titrate for sedation Propofol (head injury and/or <24h) ED/Radiology phase where need for immediate control for diagnostic purposes. PROPOFOL INFUSION (preferable over bolusing due to hypotension risk) 25mcg/kg/minute based on
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estimated weight for the intubated patient. If ineffective for sedation after 5 minutes and no hypotension or other cardiac effect, titrate in increments of 5 mcg/kg/minute every 5 minutes until sedated. Observe closely for cardiac complications including mean BP < 70. To initiate unit IV infusion 1000 mg/100ml; Start at 25mcg/kg/ min and titrate for sedation Dexmedetomidine drip For 2nd line treatment after failure of other 1st line sedatives. (also for severe withdrawal agitation) 200 mcg/50ml @ 0.21.5 mcg/kg/hr. Adverse Events: Bradycardia, hypotension
NUTRITION PATHWAY
Lactobacillus 2 capsules qhs. For patients on broad spectrum antibiotics, tube feeding.
ANTIPSYCHOTICS FOR DELIRIUM

Haloperidol (Haldol) 2-10mg IV q8-6hr as needed for ICU psychosis Quetiapine (Seroquel) 25mg PO qHS q12hr; may titrate up to 300-400mg/day in divided doses as needed
ALCOHOL DETOXIFICATION
CIWA on presentation if score > 8 CIWA via orders in computer Chlordiazepoxide scheduled or symptom triggered based on CIWA order set 50mg PO now and then q6hr x 4 doses followed by 25mg PO q6hr x 8 doses 25 100mg PO q1hr as needed for CIWA >8 Lorazepam Scheduled or symptom triggered based on CIWA order set
CONTINUED
2mg PO or IV now and then q6hr x 4 doses followed by 1mg q6hr x 8 doses 1-2mg PO or IV q1hr as needed for CIWA score > 8 RALLY PACK: Thiamine 100mg IV now followed by 100mg PO q12hr x 3 days or 100mg IV qday x 3day Folic Acid 1mg PO or IV q12hr x 3 days Magnesium Magnesium sulfate 2g/50ml D5W over 60 min qday x 3 days Magnesium oxide 420mg q12hr x 3 days Multivitamins with minerals 1 tablet/liquid PO qday or 10ml MVI in maintenance IV qday Clonidine 0.1 0.2 mg q12hr x 3-4 weeks for withdrawal symptoms Quetiapine 50mg PO qday q12hr; may titrate up to300-400mg/day in divided doses. Consider higher night dose. Titrate down 25-50 mg qod
ANTIHYPERTENSIVES AND HEART RATE CONTROL

Metoprolol IV 2.5 5mg slow IVP q6hr initial doses; up to 10mg q4hr for tachycardia) PO 12.5 q12hr initial dose (Up to 50mg q8hr or 100mg q12hr as tolerated) Diltiazem IV 0.25mg/kg (15-20mg is typical) slow IVP as needed for rate control
CONTINUED
Continuous infusion at 5 - 10mg/hr not to exceed 15mg/hr titrated for rate control PO 30 60mg q6hr or SR formulation once daily Digoxin IV load with 0.5 - 1mg total given in divided doses (0.25 x 2 doses followed by 0.125mg x 2) IV/PO maintenance dose is 0.125mg 0.25mg qday Labatelol IV 10 - 20mg slow IVP q1hr as needed for blood pressure control PO 100mg oral q12hr initial dose, up to 200-400mg q12hr Hydralazine IV 10 20mg slow IVP q4-6 hr as needed for blood pressure control Clonidine PO 0.1 0.2mg q8-q12 hr initial doses; up to a maximum dose of 0.6mg q6hr Patch 0.1mg patch q7 days initial dose; up to 0.3 - 0.6mg patch q7days
ANTIFUNGALS
Fluconazole 400mg IV, qday to 800mg qday* if resistant fungal species suspected Amphotericin 0.5 0.7 mg/kg qday over 4-6hrs, Pre-medications and saline hydration Anidulafungin For resistant fungal species. 200 mg IV load followed by 100 mg IV q24h (for candidemia, intra-abdominal abscess)
CONTINUED
ANTIMICROBIALS*
* Requires adjustment for renal dysfunction (CrCl < 50ml/min); ask pharmacist GRAM NEGATIVE Cefepime 2grams IV, q12h* (Higher doses for meningitis: Cefepime 2grams, q8h) Ciprofloxacin 400mg IV, q12h, or 750mg PO, 1 12hr* (400 mg q8h for pneumonia) Meropenem 1gram IV, q8h* Piperacillin-tazobactam 3.375gram IV, q6h* (Pseudomonas Zosyn 4.5gram IV, q6h) GRAM POSITIVE Vancomycin 1gram IV, q12h or 15mg/kg, q12h* Linezolid 600mg IV/PO, q12h (weak MAO inhibitor, avoid use with SSRI drugs) ANAEROBES Clindamycin 600mg IV, q6h Metronidazole 500mg IV, q12 - 8h C. DIFFICILE Metronidazole 500mg PO, q8h or Vancomycin 125 mg po q 6 hr
BOWEL MOTILITY
Docusate sodium capsule/liquid 100mg, PO daily q12hr Milk of magnesia conc 10mL, PO, qod, if no bowel movement (May schedule qhs if no result) Bisacodyl suppository 10mg, #1 PR, qod, if no bowel movement Fleets phosphate enema #1 PR, qod if no bowel movement Senokot #1 tab qHS if no bowel movement
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DVT / PE*
PROPHYLAXIS Enoxaparin (Moderate to high risk patient including ortho and spinal cord injury) 30mg BID *Consider 40mg s.c. once daily (18:00) in preparation for possible epidural catheter placement. Remember that an epidural catheter may not be placed within 18 hours of enoxaparin & unfractionated heparin dosing or within 6 hours of heparin dosing. Consider venous foot pump if platelets less than 30K. Heparin (Low risk patients) Rarely appropriate for Trauma Service 5000units s.c. q8hr + Intermittent Pneumatic compression device (IPC) TREATMENT Heparin Load with 80 units/kg and initiate infusion at 16 units/kg/hr i.v. titrated to therapeutic aPTT (64 101 per Institutional Heparin Dosing Nomogram. Heparin Drip: 25,000 units in 250ml NS Coumadin 5mg PO, once daily to start and titrated to INR 2 3
ELECTROLYTES
Potassium IV (peripheral line) 10 meq in 100ml Sterile Water over 1hr IV (central line) 20 meq in 50ml Sterile Water over 1hr PO 20 40 meq (powder, liquid, SR capsule) as needed for K < 3.6 Magnesium IV 2-4g in 100ml D5W over 1hr PO Magnesium Oxide 400mg (#2- 4) as needed for Mag < 1.8
CONTINUED
Phosphorous IV 30 meq in 100ml D5W over 2 hr PO Sodium Phosphate (Neutra-Phos Powder) 2 packets as needed for Phos<2.2
EYE CARE
Lacrilube ointment to both eyes as needed every 4 hr
GI PROPHYLAXIS
Famotidine 20 40mg, IV/PO q12hr Lansoprazole Liquid suspension 30mg, NGT or feeding tube q 24hr unless high risk for GI bleed the q 12hr Esomeprazole 40mg, PO qday Esomeprazole IV 40mg slow IVP qday q12hr Continuous infusion for GI bleed 80mg in NS 50ml over 15 min, followed by continuous infusion 80mg/250 NS at 8mg/hr X 72 hours (After 72 hours change to PO or to prophylaxis dose listed)
GLUCOSE MANAGEMENT
Insulin infusion per STBICU unit guideline Insulin 250 units in 250ml NS titrated per STBICU guideline (Continuous infusion)
NAUSEA
Ondansetron 4 mg IV q8hr prn
CONTINUED
TREATMENT OF HYPERKALEMIA
Glucose and Insulin D50W 50ml IVP and 10 units regular insulin IVP Calcium Gluconate 1g slow IVP over 2 minutes Sodium Bicarbonate 1meq/kg slow IVP (1-2 amps, 50-100meq) Sodium polystyrene sulfonate (Kayexalate) 15-60g PO or by enema, q3-4 hrs (Higher doses for enema, 50g)
TREATMENT OF RHABDOMYOLYSIS (CK >5,000)

Sodium Bicarbonate 100 meq sodium bicarbonate in sterile water 1000ml IV, begin at 50 ml/hr and titrate to keep urine pH > 6.5, until CK < 5000
NEUROMUSCULAR BLOCKER
Cisatracurium IV bolus 0.1mg/kg IV push IV infusion 200mg/200ml D5W; Start at 3 mcg/kg/min and titrate for paralysis
ORAL CARE
Chlorhexadine 0.12% (Peridex mouth wash) 15ml swish and spit as needed Oral candidiasis prevention Nystatin 500,000 units Swish and Swallow or NG q6hr
PRESSORS/ INOTROPES
Dopamine (Emergency peripheral line 200mg/250ml D5W), 2-20mcg/kg/min Central line preferred 400mg/250ccNS, 2-20mcg/kg/min
CONTINUED
Dobutamine 500mg/250ml NS, 2-20 mcg/kg/min Norepinepherine 8mg/250ml NS, 1-30 mcg/min Phenylepherine 20mg/250cc NS, 10 100 mcg/min Vasopressin 100 units/NS 100ml, 0.02 0.04 units/min
SPINAL CORD INJURY, ACUTE

Methylprednisolone bolus (30mg/kg ) followed by an infusion at 5.4 mg per kg per hour for 23 hours.
SEIZURES PROPHYLAXIS
Levetiracetam (Keppra) 500 mg-1gm q 12hrs po or IVPB Phenytoin IV load with 20mg/kg (usual doses of 1000mg given as an infusion over 60 minutes) IV/PO maintenance dose of 200mg q12hr titrated in 100mg/ day increments to level of 10-20mg/L (IV and suspension products are NOT sustained release and must be divided q8-q12hr) (The 100mg phenytoin capsule is a SR product and may be given once daily up to 400mg/day)
SPLENECTOMY
VACCINES Within first 7 days or day prior to discharge. Pneumococcal polyvalent 23 vaccine 0.5ml s.c. x 1 Meningococal vaccine 0.5ml s.c. x 1 Haemophilis influenza (Haemoph B Conjugate) 0.5ml I.M. x 1 PLATLET COUNT > 1MILLION Aspirin 325mg PO qday
CONTINUED
TRAUMATIC BRAIN INJURY

3% saline Hyponatremia 3% Sodium Chloride (hot salt) 500ml Start at 15-20ml/hr; Follow serum sodium very closely, repeat as needed for hyponatremia Do not correct sodium too rapidly Mannitol IV 1g/kg (usual doses of 100g) as the 20% solution 500ml over 30-60 minutes q4-6hr as needed (The 25% mannitol solution is 25g/100ml and the 20% solution is 20g/100ml)

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University of Virginia Health System

LEVEL I TRAUMA CENTER

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2011-12 CHIEFS & FELLOWS

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CONTACT DIRECTORY TRAUMA ALERT GROUP MEMBERS

1908 Back up Trauma Attending

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TRAUMA ALERT PROCESS

Consider resuscitative thoracotomy if:

witnessed arrest (blunt) recent arrest (penetrating)

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CT ALGORITHM FOR PREGNANCY

Fetus visible on plain film/Torso Scout Images on CT?

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TRAUMA ALERT CRITERIA

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UVA TRAUMA HANDBOOK 6/11 21 PEARLS CONTINUED FROM PREVIOUS PAGE

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TRAUMA SERVICE COMMUNICATIONS

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DISCHARGE SUMMARY GUIDELINES

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TRAUMA PRACTICE GUIDELINES - ADULT

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AIRWAY MANAGEMENT EMERGENT CLINICAL PROTOCOL

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ARF PATIENT TRACHEOSTOMY PLANNING PRACTICE GUIDELINES

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CLINICAL PROTOCOL TRACHEOSTOMY PATIENTS IN ADULT ACUTE CARE

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VENTILATION PARALYSIS TRIAL PRACTICE GUIDELINE

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VENTILATION PRONING PRACTICE GUIDELINE

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ARDS PATIENTS VENTILATED STICU CRITERIA FOR TRANSPORT PRACTICE GUIDELINES

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BRAIN INJURY: INITIAL ASSESSMENT Assess airway and neuro status

Intubate if GCS < 10 or if airway compromise exists

Support using Resuscitation Guideline*

Penetrating Injury: thorough examination for other GSW***

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BRAIN INJURY SEDATION PRACTICE GUIDELINE

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INTRACRANIAL PRESSURE MANAGEMENT GUIDELINE

Maintain CPP > 60 mm Hg

ICP > 20 mm Hg for > 5 min? Call NSGY

Sedation/analgesia with fentanyl and midazolam OR propofol

ICP > 20 mm Hg for > 5 min?

If ventricular drain, check orders for CSF drainage intervention

* See Clinical Portal for dosing of hypertonic saline

Consider gradual decrease in therapy once ICP< 20 mm Hg for > 12 h.

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ADULT GUIDELINES FOR CRANIOTOMY/CRANIECTOMY

INDICATIONS FOR SURGERY