Trauma Center Pocket Manual

November 2012
University of Virginia Health System
LEVEL I
TRAUMA CENTER
TRAUMA HANDBOOK
Final Editing by:
Jeffrey S. Young, MD
Director, Trauma Center
Professor of Surgery
Senior Associate Chief Medical Officer for Quality
James Forrest Calland, MD
Assistant Professor of Surgery
Associate Chief Medical Officer, Acute Care
http://tinyurl.com/uvatraumamanual
2 11/12 UVA TRAUMA HANDBOOK
This handbook is also available online via the

Clinical Portal: http://www.healthsystem.virginia.edu/clinicianportal/index.cfmh
Trauma Intranet: http://www.healthsystem.virginia.edu/pub/
trauma-center/intranet and as an EPIC link in the Trauma
Admission Order Set.
Additional educational information can be found at
www.clinicalbraintraining.com or at Clinical Brain Training
on iTunes.
UVA TRAUMA HANDBOOK 11/12 3
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
Senior Associate Chief Medical
Officer for Quality
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.
Suggestions for revisions and additions are encouraged
and should be emailed to kmb4r@virginia.edu
Produced by the Trauma Program.
Project Lead: Kathy Butler
Project Assistant: Shannon Lohr
All rights reserved.
Sixth Edition
November 2012
Mission Statement
The Trauma Center at the University of Virginia seeks to
provide and support the highest standard of healing and
compassionate care to the injured people of Virginia and its
surrounding regions uninfluenced by the lifestyle,
socioeconomic status, race, gender or political beliefs of
patients we serve.
Vision Statement
The Trauma Center at the University of Virginia seeks a world
free of preventable morbidity and mortality from injury. We
further seek to become the premiere organization in supporting
its state, populace, and patient population to reduce the burden
of injury through excellence in patient care, research,
education, and participation in planning and advocacy.
Values
Team members of the Trauma Center at the University of
Virginia believe in and adhere to the following values:
1)
Patient and family centered care:
a. We will always put the needs of the patient and families

FIRST.
b. We will always create systems of care that maximize
transparency, safety, and participation.
c. The only patient and family need that will be emphasized
higher than satisfaction and comfort shall be SAFETY.
d. We agree to the need to standardize our care as much as
possible to reduce the incidence and impact of variation.
e. We shall scrutinize our outcomes, near misses, and
accidents to ensure that we are doing all we can to
promote superlative processes and outcomes.
f. We shall maintain a culture that simultaneously recognizes
our potential for excellence AND the possibility of
catastrophic failure of our care systems
CONTINUED

CONTINUED FROM PREVIOUS PAGE
2)
Stewardship:
a. We will use limited and precious resources responsibly to
ensure sustainability through effective and transparent
budgeting and resource allocation.
b. When facing conflict in the use of system resources, our
primary allegiance is to the patient.
c. We will do everything within our power to ensure that
patients needing expert care have access to our services at
all times.
3)
Scholarship and Collegiality

a. Expertise shall take precedence over rank in high risk
clinical scenarios.
b. We shall support all of our academicians in their pursuits to
create new knowledge through academic publication,
participation, and attainment of external funding.
c. We shall be always be inclusive and respectful so as to
ensure creation and sustainment of effective teams.
5TH EDITION CHANGES

Disclaimer: this list is not comprehensive
Pelvic Fracture
Trauma Nurse Practitioners
Mild TBI
Moderate-Severe Traumatic Brain Injury
Coagulopathy Neurotrauma Guideline
Deep Vein Thrombosis
Mangled Extremity Guideline
Cardiovascular Evaluation-Perioperative
Cardiovascular Evaluation
Spinal Cord Inujury Management
Syncope
MET Team
2012-13 CHIEFS & FELLOWS

PAGER
PAGER
GENERAL SURGERY
6623 Flohr, Tanya R.
4422 Hennessy, Sara
4882 Hranjec, Tjasa
6582 Nagju, Alykhan
2880 Parker, Anna
VASCULAR & TCV

3870 Adams, Joshua
6895 Carrot, Phil
3396 Griffiths, Eric
4627 Tesche, Leora
TRANSPLANT
6234 Kane, Bart
2866 Ladie, Danielle
2006 Rasmussen, Danielle
4853 LaPar, Damien
4705 Riccio, Lin
4705 Shada, Amber
2995 DeGeorge, Brent
6552 Judge, Joshua
6554 McLeod, Matthew
6954
6994
2146
6178
4063
Davis, John
Dietch, Zachary
Edwards, Brandy
Hanna, Kasandra
Hu, Yinin
4429 Charles, Eric

4833 Coster, Jenalee
4985 Day, Matthew
3591 Downs, Emily
3600 Elmer, Donald
6884 Eymard, Corey
2264 Gilsdorf. Daniel
6203 Johnston, Lily
3152 McEarchern, Rachel
3185 McPhillips, Kristin
4TH YEARS
4061 Turza, Kristin
3158 Walters, Dustin
3RD YEARS
4088 Politano, Amani
6635 Rosenberger, Rosa
2878 Umapathi, Bindu
2ND YEARS
4038 Mehta, Gaurav
6442 Wagner, Cynthia
4715 Willis, Rhett
4782 Yount, Kenan
1ST YEARS
3334 Olenczak, Bryce
3970 Poiro, Nathan
4028 Rueb, George
3826 Shaheen, Basil
3844 Shah, Puja
4068 Smith-Harrison, Luriel
3165 Wheeler, Karen
4420 Wong, Scott
4532 Zee, Rebecca
RESEARCH
6939 Stone, Matthew (Kron)
2276 Guidry, Christopher (Sawyer)
4992 Davies, Stephen (Sawyer)
2685 Newhook, Timothy (Bauer)
6966 Lindberg, James M. (Bauer) 2744 Pope, Nicholas (Ailawadi)
3767 Gillen, Jacob (Lau)
6988 Salerno, Elise P. (Slingluff)
6587 Petroze, Robin (Calland)
6963 Johnston, W Forrest (Ailawadi)
CONTACT DIRECTORY
TRAUMA ALERT GROUP MEMBERS
Phone
Pager
9162 Adult Trauma Alert Intern
1294 Trauma Alert 2nd yr
531-3494 1560 Trauma Chief
1459 Trauma Alert Backup Chief
1311 Anesthesia Resident
9248 Anesthesia PACU Resident
1564 Trauma Attending
1450 Trauma LIP Acute Care
1294 Trauma Resident ICU
1297 Trauma Consult Day
1824 Pediatric Trauma Chief
1356 Peds Trauma Intern
1707 Peds Trauma Attending
531-5703
ED: 2nd yr (consults)
3-6341, 3-6317
ED: Attendings
1391 Chaplain
1576 NSGY Resident 2
1822 Nursing Supervisor
1371 OR Charge Nurse
1616 Respiratory Therapy-Adult
1716 1684 (RT Back-ups)
1742 Respiratory Therapy-Pediatric
1989 Radiology Portable
4-2120
1384 Social Worker-ED
1908 Back up Trauma Attending
CONTACT DIRECTORY
284-2845
2-3549
242-9458
2-4278
465-5152
227-1278
825-2503
202-841-5535
284-1923
3462 Trauma Center Director, Jeff Young, MD

Administrative Assistant, Amy Bunts
4425 Assoc. Trauma Director, Forrest Calland, MD
Administrative Assistant, Cynthia Carrigan
3404 Trauma Attending: Rob Sawyer, MD
6151 Trauma Attending: Carlos Tache Leon, MD
6356 Trauma Attending: Zequan Yang, MD
3994 Trauma Attending: Michael D. Williams
3868 Trauma Center Manager: Kathy Butler, RN
CONTINUED

CONTACTS
Phone
Pager
9558 IRPA (in-house rescue physician)
9520 Floor Attending
Trauma Service Nurse Practitioners

962-1974 4334 Deborah Baker, ACNP
813-731-9736
Heather Passerini, ACNP-BC
882-1375 6744 Gabriele Ford, FNP-C
465-8083 4735 Sherry Child, ACNP-BC
865-8064 6822 Matt Robertson, ACNP-BC
465-8943 2333 Kwame Boateng, ACNP-BC
531-5839
531-0701, 02
4-9295
4-1201
4-0351
4-5227 (1)
4-2273
3-9218
3142
2-1794
ED Charge Nurse 2-0201

ED Attending #1, #2
ED Registration Fax
ED back Fax
STBICU Fax
LAB
Blood Bank
Bed Center RN
Neuro CNS
Translator
RADIOLOGY
3-9296
CT
1234 CT Tech
1404 Head CT ResidentED Board
Body CT ResidentED Board
4-9338
Diagnostic Work Area
4-9400 (3,2)
Image Management
9416, After hours 1329
1844 IR Resident (Request on-call IR Nurse also)
3-9535, 06
IR Department
2-3155
MRI
2-2526
4701 MSK Reading Room Coordinator (even months)
2-3432
1492 Neuro Reading Room Coordinator (odd months)
2-3988
Body CT Reading Room Coordinator
CONTINUED

CONTACTS
CONSULTS
1415 Acute Pain Service
1251 Orthopedics ED
1609 ENT
4-8738
3819 Geriontology NP M-F 08-5:00
1518 Plastics- Consult ER
1800 Plastics Intern
6811 Psych Nurse - Brenda Barrett
1288 TCV night
1847 Thoracic Chief
1847 Thoracic Day Consult
1253 Urology
1378 Vascular Day Consult
1818 Vascular Chief
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
Danville
434-799-2100
Lewis Gale
Film Room
540-932-4483
540-829-4144 or 4145
434-200-4139
434-654-7104
540-981-7126
540-433-4380 or 4386
540-776-4035
QUALITY CONCERNS
284-1923 3868 Kathy Butler, RN
Please share adult or pediatric trauma concerns with the trauma
center manager promptly (within 72hrs) by phone or pager.
TRAUMA REGISTRY REPORT REQUESTS
3-4858
Michelle Pomphrey RN
4-1770
Sera Downing
Extensive adult and pediatric injury data are available.
Please allow 7 business days for report generation.
TABLE OF CONTENTS
PAGE
14-17
TRAUMA ALERT PROCESS

TRAUMA ALERT CRITERIA
Trauma Alert Considerations
PEARLS
Trauma Service Communications
Trauma Service NPs
Discharge Planning
Discharge Summary Guidelines
TRAUMA PRACTICE GUIDELINES ADULT (Alphabetical)
Abdominal Penetrating Trauma
Airway Management Emergent
Blood Alert
Tranexamic Acid
Brain Injury
Mild TBI
Moderate to Severe TBI
Brain Injury Sedation
Guidelines for Craniotomy / Craniectomy
Coagulothopy in Neurotrauma
Burn
Major, Respiratory Management
Adult Burn Fluid Resuscitation Guidelines
Cardio-Evaluation-Perioperative
Cardiovascular Failure, Non-Hypovolemic
Chest Trauma
Aortic Transection (Actual or suspected)
Blunt Myocardial Injury
Blunt Thoracic Trauma
Epidural Protocol
Penetrating Central
Deep Venous Thrombosis
Extremity Trauma Penetrating or Blunt
Mangled Extremity Guideline
Free Fluid-No Solid Organ Injury
Hematuria
Pelvic Fracture Algorithm
Pregnancy CT Algorithm
Pulmonary Embolism Workup & Treatment
Resuscitation
Rhabdomyolysis
18-20
21
22-24
25-26
27
28
29-30
31
32
33-35
35
36
37
38
39
40
41-42
43-48
49-50
50-51
53
54
55
56-57
58
59-60
61
62
63
64
65
66
67
68
69
CONTINUED

TABLE OF CONTENTS
PAGE
Syncope
Spine Clearance Algorithm
Spinal Cord Injury Mgmt
Spleen and Hepatic Trauma, Non-operative Management
70
71-74
75-76
77-78
REFERENCES
ARF Tracheostomy Planning
Tracheostomy Patients In Adult Acute Care
Ventilator Paralysis Trial
Ventilation Proning
ARDS Patients - Ventilated STBICU
Against Medical Advice Discharge
79
80
81-82
83
84-85
86
87
Injury Scales
Lung
Spleen
Liver
Kidney
Heart
Diaphragm
LTAC
MET Team
Organ Donation
Pain and Sedation
Palitative Care
Physical and Occupational Therapy
88
89
90
91
92-93
93
94-95
96
97-98
99-100
101-102
103
CONTINUED

TABLE OF CONTENTS
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
IV. Sequential Treatment of Decreased MAP / CPP
Sequential Treatment for ICP >20 mmHg (All Ages)
Second Tier Treament for ICP > 20 mmHg (All Ages)
Severe, Abrupt Elevation ICP and/or Manifestation
of Impending Herniation
Treatment of Decreased MAP Decreased CCP
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
MEDICATION REFERENCES
104-130
107
108
109-110
111-112
113
114-115
116
117
118
119
120
121-122
123-124
125-126
127-128
129-130
131-140

In general, the adult trauma service shall be the
evaluating and admitting service for all patients 16
years of age and older with multi-system injury.
PRE-ALERT CONSIDERATIONS
Team conference with introductions, review of roles
responsibilities, and contingency planning
Reference trauma indicators for activation criteria
Standard for notification of team: immediately upon meeting
criteria
Trauma team response immediate based on expected
arrival, to be in ED prepared for patient prior to arrival
Chief needs to reference outside hospital imaging prior to
patient arrival whenever possible
BASIC EVALUATION
ABCDE assessment
2 large bore IVs
Adequately resuscitate patient before leaving the ED
CXR, pelvis x-ray and trauma labs (if patient
hemodynamically stable, pelvis may be withheld if patient
A&Ox4 and non-tender)
INDICATIONS FOR IMMEDIATELY SECURING AIRWAY
Inability to follow commands
Inability to protect airway
Inability to safely complete workup
Hypotension/shock
Severe inhalation injury
BREATHING
Decompress chest if decreased breath sounds or
subcutaneous emphysema with Sa02 < 90%
Bilateral chest decompression for blunt agonal or anterolateral
thoractomy if indicated
King Airway: If oxygenating well, good O2 Sats- leave King in
place until after CT
CONTINUED

CIRCULATION
Hemorrhage control (consider suture, pelvic binder, BP cuff,
splints)
Consider resuscitative thoracotomy if:
witnessed arrest (blunt)-Patient must have had palpable pulse or CLEARLY measurable
PulseOx at lease once on hospital grounds
recent arrest (penetrating)-Patient should have had RECENT signs of life

-Survival may be as high as 18% in those with the recent arrest
after thoracic stab wounds
`
-May withhold thoracotomy if Wide Complex PEA at <40 BPM
Aggressive volume resuscitation ( PRBC) indicated for blunt

agonal
May hold/withdraw thoracotomy if PEA, wide complex and
HR <40
NEUROLOGICAL DEFICITS
Assess neurologic status (GCS) and extremity movements,
sensation x 4.
EXPOSURE
Mark penetrating wounds with paperclips where appropriate
(open= posterior)
FAST EXAM
IMAGING
CXR - All patients
Pelvis xray all blunt trauma (may be withheld if patient
A&Ox4, non-tender and hemodynamically stable)
CONTINUED

Head CT
Loss of consciousness
Altered LOC
Significant trauma above clavicles
Facial CT
Severe facial injuries
CTA Neck
Fractures through C1 - C4
Seat belt sign or extensive bruising on neck
Cerebral infarct
Acute anisocoria
Neuro deficits / decline / clinical picture not consistent
with injury
Petrous fracture
GCS < 8 w/out explanatory findings on the head CT
CT Thorax
Significant thoracic injuries on CXR
Rapid deceleration mechanism (see #11 Gamma criteria)
Abnormal mediastinal contour
Abdominal CT
Abnormal CXR
Abnormal pelvis x-ray
Spine fracture
Abnormal abdominal exam
Abnormal labs (HCT, LFTs, amylase)
Hematuria or GU injury
Inability to examine patient for the next 4 hours
Any prior hypotension
mechanism (see #11 Gamma criteria)
(if any of above criteria are not met, likelihood of
intraabdominal injury is <1%)
CONTINUED

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
Situations where the good of the patient would be served
STBICU ADMISSION
Any intubated multiple trauma patient
Any intubated acute post-op trauma patient (except
neurosurgery for isolated head injury) e.g. patient with
isolated femur fracture who cannot be extubated post-op
Any trauma patient with significant risk for respiratory
compromise because of their injuries OR BECAUSE of their
baseline medical fraility.
Any trauma patient with significant risk of bleeding
Any trauma patient with evidence of active bleeding
Any trauma patient with multiple rib fractures who cannot blow
1000cc on incentive spirometry (especially elderly patients)
Any of these patients who cannot be admitted to the STBICU
must have their admission location cleared by the 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

*Any conflict with other teams during an alert must be
communicated immediately to the attending on-call or
Dr.s Young, Calland
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 or facial burns/
singed facial hair with dyspnea.
2. Confirmed hypotension
a) SBP < 90 on 2 consecutive measurements
b) age-specific hypotension in children [SBP < 80 + (2* age)]
c) Absence of peripheral pulses
d) Transfer patients receiving blood to maintain SBP >90
3. Gunshot wounds to the neck, chest, or abdomen
4. Advanced pregnancy (fundus above umbilicus) with 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 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 or King Airway
b) Mechanically assisted ventilation and NOT intubated
c) Facial Burns or singed facial hair with altered phonation
CONTINUED

3. Cardiovascular
a) Cardiac Arrest blunt mechanism
b) Relative Hypotension: SBP > 90 but < 100 mm Hg
(<110 mm Hg in > 65 yrs)
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)
5. MSK
a) Two or more proximal long-bone fractures
b) Amputation proximal to wrist or ankle
c) Crushed, degloved, or mangled extremity
d) Greater than 2cm diastasis, sig. crushed pelvis or
widening of SI joint
6. Stab wounds to neck, chest, or abdomen
7. Burns: Adults > 40%, Pediatric > 25% TBSA
8. Concomitant thermal / multi-system injury
9. Or per Emergency Medicine Physician / Trauma Service
discretion
*Any patient may be upgraded to alpha status according to EITHER
Emergency Medicine OR 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. Trauma service consults should be initiated as gamma alert
minimally and as a higher alert if meeting the criteria
2. Altered mental status (GCS lower than baseline by only 1
point) and/or intracranial blood present on in-house CT
(even if from GLF)
3.
4.
5.
6.
Severe pain in chest, abdomen, neck, or back

Significant solid organ injury
Pelvic fractures
2 or more organ systems/body areas significantly injured
CONTINUED

7. Operative therapy anticipated / planned by subspecialty service

8. Moderately injured with severe medical co-morbidities
9.Time-sensitive extremity injury
10. Early Pregnancy with abdominal pain / signs of abdominal
trauma
11. 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;
High-risk motor vehicle collision:
extrication or intrusion intrusion: >12 inches to the
occupant site or >18 inches to any site
ejection (partial or complete) from automobile
death in same passenger compartment
vehicle telemetry data consistent with high risk of injury;
Auto versus pedestrian/bicyclist thrown, run over, or with
significant (>20 mph) impact
Motorcycle collision >20 mph
12. Trauma transfers unless meeting alpha/beta criteria

CONTINUED FROM PREVIOUS PAGES
TRAUMA ALERT CONSIDERATIONS

Pre-Patient Arrival
Pre-alert conference held to review responsibilities / priorities,
including probable drug needs
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
Discuss plan to 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.
Trauma Surgery Service Pearls

Indicators for Speech Evaluation:
- Altered mental status, > 1 point difference from baseline
- Trauma to mandible, oropharynx, or larynx
- Intubation > 72 hours
- Clinical suspicion of ongoing aspiration
-Medical conditions (myasthenia gravis, Parkinsons...)
All advance directive/DNR discussions should be carried out
with an attending present or with immediate attending
notification after such conversations have occurred
All PEGS in patients on the TRAUMA SERVICE are to be
sewn into place at the time of placement WITHOUT
EXCEPTION.
King Airway: If oxygenating well, good Sats leave in place until
after CT.
Blood Alert early activation of massive transfusion process
may improve survival. Remember calcium, bicarbonate and
warming patient. Call 4-2012 to activate. All patients receiving
blood in the ED for hemmorrhage/hypotension in the ED
should ALSO receive Trenexemic acid if within 3 hours of
injury
Do not bolus propofol
Key physical exam findings should be demonstrated during
bedside sign-out
Do not copy forward the previous days note unless you can be
certain that the outdated portions have been deleted
ALL trauma patients shall have a .tricutransfer note completed
in EPIC prior to transitioning to the acute care (ward / floor)
service.
Collaborative notes should be completed during rounds on
each patient-either on a sticky note, or on the white board
SPECIFIC necessity to maintain central venous and urinary
catheters must be documented DAILY in the progress notes.
All central venous catheters and arterial lines from outside hospitals
(or that were placed in the trauma bay under questionable aseptic
technique) must be replaced within 48 hours of admission by A
FRESH STICK they may no longer rewired!!
CONTINUED

PEARLS
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 generally occur 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
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.
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.
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.
Penetrating trauma initial assessment roll early! Mark all
wounds.
Operative Treatment of Abdominal Hemorrhage if you pack
it, squirt it
If initial chest CT is consistent with aspiration, bronch patient
Bleeding scalp lacerations consider early whip stitch instead
of staples.
In general, injured patients belong on the Trauma Service, not
the Medicine Services.
CONTINUED

PEARLS
In general, we admit most patients to trauma for the first 24hrs

with some exceptions such as isolated severe TBI.
Any bad ABG must be repeated or treated with intubation.
Psych must leave note in the chart that a sitter is no longer
needed.
Incidental Findings: All incidental findings that 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.
Consider removing one line or tube daily on patients who are
improving clinically.
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.
Simultaneous craniotomy / thoracotomy / laparotomy is
possible
Opthathmology consult is needed for orbital wall fracture,
obvious injury to eye, pain on exam, visual changes (changes
in visual acuty, double vision, floaters)
If initial chest CT positive for aspiration, bronch pt.
Bedside report is expected for the night resident prior to A.M.
rounds to sign-out the service
Patients with radiographic evidence of severe pancreatic injury
require imaging (ERCP, or cholecystopancreatography, or
MRCP) to assess ductal integrity
Attending should be notified of all planned DNR discussions
before they occur and afterwards if such occur in impromptu
fashion
Institutional clinical guidelines Sepsis, sedation, and elimination
of life/sustaining measures can be accessed on the UVA clinical
portal: http://www.healthsystem.virginia.edu/docs/manuals/
guidelines/cpgguidelines
TRAUMA SERVICE COMMUNICATIONS

JUNIOR RESIDENTS/NPs TO CONTACT CHIEF IF:
MET team activation
Saturations < 90 not responding to one intervention
Arrhythmia with hypotension
Lactic acidosis not corrected by 8 hours after admission
Urine output <0.5 cc/kg/hr not responding to one intervention
Before any antibiotics are begun
Before Swan-Ganz catheter or bronchoscopy procedure
Before calling any consult (except Ortho, Face, Spine, NSGY)
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

TRAUMA SERVICE COMMUNICATIONS
CHIEF TO CONTACT ATTENDING TO:

Discuss: all floor changes with the attending who is rounding
in the ICU on the weekends
Call Attending If:
MET team activation
Significant family conflict
Any conflict with other teams during an alert must be
communicated immediately to the attending on-call or
Dr.s Young/Calland
Transfer to ICU
All admissions and consults
Any major conflict with Consult service
Cardiac, respiratory arrest
Any complication of procedure or consult procedure
Death (if not DNR)
Text Attending If:
MET team activation
Death if DNR
On evidence of organ failure (CV, resp, renal, neuro)
Missed injury
Consult operation
Before bronchoscopy, Swan-Ganz, or other major bedside
procedure during daytime hours
Patient leaving AMA
Trauma Service Nurse Practitioners
Medical management of patients on acute care

trauma in collaboration with trauma chief and
attending
Daily physical assessment of all patients on acute

trauma
Daily notes
Collaborating with case managers and SW to

identify and achieve individualized discharge plan
Ordering and follow up on indicated imaging
Daily review and update of orders
Timely discharge
Communicating with all consulting services
Communicating daily plan with patient and families
Responding to trauma alerts
Documentation including daily notes, discharge

summary.
Providing communication and updates to patients

PCP
Responding to patient phone calls.
DISCHARGE PLANNING
DISCHARGE ORDERS
Trauma Service Clinic appointments should be with either Dr.
Young, Calland, Tache-Leon, Williams, or Yang. 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
CONTINUED

DISCHARGE SUMMARY GUIDELINES
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, Dr. Tache Leon.
Dr. Sawyer does not have trauma follow-up appointments
unless he requests to see the patient.
Dr. Williams and Dr. Yang will see trauma follow-up.
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?
Stable
Unstable
OR for Laparotomy1 /
Thoracotomy2
Stab Wound
Non-tender:
Local wound exploration
or laparoscopy
Lap. if violation of post.
fascia / peritoneum
GSW
Tender / tachycardic /
nauseated:
Laparotomy
Mark Wounds3
Flat plate X-Rays of all
possible trajectories4
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

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 if not already present.
5. If a crichothyroidotomy is a possibility (facial injuries, history of
difficult intubation, unfavorable anatomy) equipment for surgical
airway should be at the bedside BEFORE the intubation is
attempted. At the least a knife, betadine, and a 6.0 endotracheal
tube should be at the bedside.
6. Upon arrival at the bedside, the anesthesiologist assumes
leadership for directing the management of the patient airway. The
anesthesiologist performs endotracheal intubation or, clinical
situation permitting, the local physician or other 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.
7. In the critical care units or the Emergency Department, a
credentialed physician with advanced airway management training
and competency may assume responsibility for managing the
patient airway. In the STBICU, a trained respiratory therapist may
initiate advanced airway management. In these situations, the
physician or other credentialed provider determines the need for
anesthesiology consultation.
8. Anesthesiology will be called to the ED as part of the trauma alert.
9. Obturator / King Airways should be converted to difinitive airways
immediately if problems with oxygenation or ventilation. Otherwise,
they may be converted when patient arrives in OR or ICU
10. Significant bleeding around a trache (soaking of a 4x4 pad, or constant flow)
should be treated as an emergency with notification of the senior resident
and stat CTA of neck and chest). Life threatening bleeding (hypotension,
arterial hemorrhage) should initiate immediate thoracic surgery consult and
transfer to OR.
TRANSFUSION MEDICINE SERVICES
BLOOD ALERT
MASSIVE TRANSFUSION PROTOCOL
Phase I:
A.
1.
B.
Indications
Trauma patient with suspected or known clinical massive
hemorrhage. (The patient is likely to bleed to death in
the next 15 minutes)
Activation
1.
The BLOOD ALERT will be activated by the trauma

attending, or trauma chief resident, or anesthia attending
calling the Blood Bank.
2.
a. The blood bank staff will complete the top portion of

the Blood
Alert form located in the front of the Window
procedure book.
b. Call 4-2012 (emergency operator) and request
Blood Alert Activation and provide the patient location.
When the Blood Alert is activated, the trauma surgeons,
trauma coordinator, OR charge nurse, transportation
services, blood bank bench on call and the blood bank
manager are paged with a text message indicating a
blood alert and the delivery location of the blood products.
The Blood alert will be cancelled in the same manner it
is activated (the physician will request cancellation and
the Blood Bank staff will call 4-2012 to initiate Blood
Alert cancelled text message distributed to the pager
group.
3.
Make 4 copies of the Blood Alert Activation form.

Send one copy with each of the coolers.
Continued

Phase II:
Upon notification, immediately thaw 6 AB plasma and prepare
4-6 uncrossmatched O neg red cell units and place in a cooler.
(If patient has a current Blood Bank sample, type specific blood
may be issued.)
#1
Initial Issue four - six uncrossmatched O neg red cell
units with Blood Alert Form (or type specific if patient has a
current BB sample.) Thaw six AB plasma. Prepare and issue
one dose
#2
15 minutes, or immediately after the 1st group is
picked up. Prepare six more O neg uncrossmatched red cell
units, or six type specific red cells if sample has been received
and typed. Issue when transportation arrives. Issue six AB
plasma. Thaw six ABO compatible plasma Prepare and issue
one dose. Thaw cryo pool if ordered
#3
15 minutes, or immediately after the 2nd group is
picked up.Prepare six type specific red cell units. Issue when
transportation arrives. Issue six ABO compatible plasma. Thaw
six more ABO compatible plasma. Prepare and issue one
dose
#4
15 minutes, or immediately after the 3rd group is
picked up. Prepare six type specific red cell units. Issue when
transportation arrives. Issue six ABO type compatible
plasma.Thaw six more ABO compatible plasma. Prepare and
issue 1 Dose. Every other dose
#5
Alert cancelled? Page activating physician to
determine if the blood alert needs to continue or be cancelled.
#6.
The Blood Bank will continue to set up a cooler every
15 minutes until the protocol is cancelled by the activating
physician or the patient expires.
Transportation staff will come to the Blood Bank to retrieve a
new cooler and a copy of the Blood Alert activation form
approximately every 15 minutes. They will return a cooler and
the form every time products are picked up. Transportation
staff may also relay any ongoing needs and deliver a Type &
Crossmatch specimen when available.
A trauma team member should place orders for 30 red cells, 30
plasma, and 3 platelets after the blood alert is cancelled.
Continued

Products and coolers will be returned after the protocol is cancelled by the unit staff.
Note: Patients with active Blood Bank specimens will receive type specific red cells
and plasma. The patient care team should secure a properly labeled Blood Bank
sample as early in the procedure as possible and deliver it directly to the Blood Bank.
Prompt blood typing is essential to maintaining the availability of universal donor
plasma (AB) and universal red cells (O neg) which are on limited supply.
Reference:
AABB Technical Manual, 17th edition, 2011, pp 748-751, 458
The Use of Tranexamic Acid for Adult Trauma Patients

Inclusion Criteria:
All adult (>16 yo) trauma patients presenting to

the Emergency Department (ED) within 3 hours
of injury who:
o
Exhibit ongoing signs of significant

hemorrhage (SBP < 90 mmHg and/or HR
> 110 bpm) that receive TRANSFUSION
IN THE TRAUMA BAY (especially those
that require activation of the Blood Alert).
Are considered to be at risk of significant

hemorrhage
OR
Table 1. Dosing, Reconstitution, and Administration

Treatment
Dose
Reconstitution
InfusionRate
Duration
LoadingDose
1gm
1gmin100mlNS
600ml/hr
10minutes
Maintenance
Dose
1gm
1gmin250mlNS
31.3ml/hr
8hours
Dosing:
There is no evidence to support additional doses of tranexamic acid
References:
1. CRASH-2 trial collaborators. Effects of tranexamic
acid on death, vascular occlusive events, and blood
transfusion in trauma patients with significant
hemorrhage (CRASH-2): a randomized, placebocontrolled trial. Lancet, 2010; 376 (9734): 23 32.
2. CRASH-2 protocol. http://www.crash2.lshtm.ac.uk/.
MILD TBI
(Ongoing symptoms or loss of consciousness at time of injury)
LOC?
Neurological SX?
(headache,
impulsivity
confused)
No
Standard
Care
Yes
Obtain PMR
Consult*
Obtain Speech and

OT Consults*
Arrange Outpatient
Follow Up According
to Consult Recs
* May have to occur as outpatient consult if discharge

can otherwise occur between 3 PM Friday and 0600
ModeratetoSevereTBI(GCS<9)
TreatmentGoals
INR<1.4
ICP<20mmHg*
CPP>60and<70mmHg**
Maintainadequatepreload(CVP812)
SBP>90mmHg
HOB30degrees
AssessforneedtoremoveCcollar
Platelets>75100
PaCO23540mmHg
SaO2>92%
Maintainpreload(CVP812mmHg)
PlaceICPMonitor
MaintainSerumSodium@150165
HeadMidline
*Placemonitorwithin2
hoursofadmission
**Vaso+Levo(or
Phenylephrine)are
firstlinetherapy
ICP>20mmHg(>5min)*
Sedationandanalgesia+/paralysis
***chkNa+/sOSMq4
hours,stopHTSifNa>
165,nomannitolif
sOSM>320
ICPstill>20mmHg?
No
Yes
Mannitol(0.250.5g/kg)orHTSbolus***
ICPstill>20mmHg?
No
Yes
ConsiderrepeatHeadCT
ICPstill>20mmHg?
No
Yes
Considerventriculostomy/CSFDrainage
NotifyTrauma
AttendingSTATand
ContactNSGYfor
decompression/
operative
intervention
ICPstill>20mmHg?
Yes
ABTFIndication(s)forsurgical
decompression present?
Yes
No
OptimizemedicalMGMT
No
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.
*Propofol may not be a good choice for sedation in the hemodynamically

unstable patient and should NEVER be administered IV push in trauma
patients
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.
Coagulopathy in Neurotrauma
Head Injury with GCS <9
Pt taking ASA
or Plavix?
No
Yes
Administer 1-2u pooled PLT STAT
No
Pt taking Coumadin?
Yes
Administer 2u Thawed FFP STAT

Consider 10cc/kg FFP
INR<1.4?
Yes
Proceed with NSGY intervention
No
Consider PCC (or

FVlla) STAT
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
CONTINUED

BURN (MAJOR) RESPIRATORY MANAGEMENT
Extubation Criteria:
Patient follows commands
Audible leak around a 7.0 or higher ET tube
Meet extubation criteria by Respiratory Therapy
No evidence of progression of airway disease
Tracheostomy Considerations:
Intubated >7 days without immediate expectation
of extubation
Extubation failed twice
Major problem with secretions (suctioning
required q2h, recurrent mucus plugging, etc.)
Unable to follow commands when ready for
extubation
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, Dr. Yang,
Dr. Williams 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
CONTINUED
ADULT BURN FLUID RESUCITATION GUIDELINES

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
CONTINUED

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
CONTINUED

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
CONTINUED

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
CONTINUED

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 are at increased risk of:
inhalation injury
extensive FT burns to the torso
large %TBSA
Cardiovascular Evaluation-Perioperative
(If previous percutaneous coronary intervention see next page)
Need for
emergency
noncardiac
surgery?
Active
cardiac
conditions?
Yes?
Good functional
capacity without
symptoms?
Vascular
surgery
Consider
testing if it will
change
management
*MET level
greater than or
equal to 4
Evalutate & treat

per ACC/AHA
guidelines**
Consider
operating Rm
Yes?
Low risk
surgery?
3 clinical
risk factors
Operating Rm
Perioperative
surveillance &
postop risk
stratification &
risk mgmt
Yes?
Proceed with
surgery
Yes?
Proceed with
planned
surgery
Unknown or no
clinical risk
factors
Intermediate
risk surgery
Proceed with
planned surgery
1-2 clinical
risk factors
Vascular
surgery
Intermediate
risk surgery
Proceed with planned surgery with HR

control (ClassIIa LOEB) or consider
noninvasive testing (Class IIB) if it will
change management
** http://www.anesthesia-analgesia.org/
content/106/3/685.short
Cardiovascular Evaluation
Perioperative
Previous PCI
Balloon
angioplasty
Bare-mental
stent
Drug-eluting
stent
<365 days
Time
since PCI
<14 days
>14 days
>30-45 days
<30-45 days
Delay for elective or

nonsurgent surgery
>365 days
Delay for elective or

nonsurgent surgery
Proceed to the
operation room
with aspirin
Proceed to the
operation room
with aspirin
http://content.onlinejacc.org/cgi/content/full/50/17/e159
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
NON-HYPOVOLEMIC CARDIOVASCULAR FAILURE GUIDELINE

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
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
MVC > 30 MPH, Fall > 15 feet, Ped struck, MCC > 20 MPH
If extravasation present, prepare for emergent thoracotomy.
Use these parameters with caution in patients with severe closed
head injury and elderly patients with a medical history of poorly
controlled hypertension.
4
Patient s with actual (or potential for) severe injuries who are not
intubated should NOT, in general, receive conscious sedation.
2
3
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
No Routine
Care
Yes
Yes
Troponin /
EKG
Abnormal?
First line intrope for cardiogenic

shock due to blunt myocardial is
Dobutamine
Admit Telemetry
Repeat 12 Lead EKG
in 24 hours
Troponin x3 (Q8 hours)
STBICU / CCU Admission
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
In the setting of displaced rib fractures and chest deformity
consider early rib fixation.
1
2
Incentive Spirometry < 18 ccs / kg IBW/sec

See Epidural / Analgesia Guideline for Trauma Pts with Rib Fxs

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)
3)
4)
No major coagulopathy (INR < 1.4, 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.
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
CONTINUED
EPIDURAL/ ANALGESIA GUIDELINES FOR PATIENTS WITH RIB

FRACUTRES
such catheters to 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)
2)
3)
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.
CHEST TRAUMA - PENETRATING CENTRAL WOUND

Trajectory between nipples,
sternal notch, xiphoid
or transmediastinal *
Yes
Consider Chest tube,

pericardiocentesis, ACLS,
or no therapy
Tube Thoracostomy (as

indicated by physical
exam / trajectory)
Recent / witnessed
arrest or moribund
No
and HR <40
and/or wide
complex
SBP < 90
Stable
ED
thoracotomy
OR for
Pericardial window,
thoracotomy, or
sternotomy
CXR,
Consider:
- CTA of chest or
- STAT Echo or
- Pericardial window
trajectory uncertain or if trajectory

potentially passes below
diaphragm
* Consider / Perform Laparotomy if
Repeat CXR in 6 hrs

if no Chest CT
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
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**
Low molecular weight heparin,

unless contraindicated* + SCDs
Bilateral lower extremity duplex
Positive duplex study

below the knee? ***
Positive duplex study above knee?

(pelvic,femoral or popliteal) ***
Progressive or symptomatic?
Yes
Anticoagulation OK?
No
No
Yes
IVCF**
** All filters should be removeable ones in

patients < 65 years old
Therapeutic Enoxaparin
or Heparin infusion
(according to institutional
nomogram)
* Enoxaparin is contraindicated in
patients with:
Chronic renal insufficiency
Excessive bleeding risk
First 24-48 hrs after SCI
Recheck duplex q 5 d
Coumadin for 3-6 mo or

Therapeautic Enoxaparin
Target hep Ptt + INR
Per institutional protocol
*** For + DVT assess leg daily for phlegmasia

(neuro & vasc)
For dosing guidelines see Adult Medication References at back of manual.
CONTINUED

Patients with high risk for intra-cranial or epidural bleeding

from head or spinal cord injuries shall receive 5,000u
unfractionated heparin TID approximately 24 hours after a
STABLE neurologic exam AND / OR stable cross-sectional
imaging.
If such patients develop thromboembolic complications (e.g.,
DVT or PE) they should ALL receive IVC Filters.
Patients undergoing the following procedures do NOT require
that their heparin / lovenox be stopped for the OR:
1) Ankle ORIF (not PILON)
2) ORIF lisfranc
3) Pinning metatarsals
4) Pinning of hip fractures
5) Distal femir ORIF (not femoral nailing)
Superficial Venous Thrombosis

Cephalic and saphenous vein thrombosis are NOT deep vein
thrombosis should be followed with ultrasound and NOT
anticoagulation
For dosing guidelines see Adult Medication References at back of manual
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
Risk classification
High
ABI < 0.9
Pulse deficit
Low
ABI>0.9
No pulse deficit
Arteriography
Observation
Minimal
arterial
injury
Major
arterial
injury
Normal
Observation Observation Operation

serial
arteriography
*Consider blood pressure cuff above site of hemorrhage.
Mangled Extremity Algorithm*

Lower Extremity
Clinical Evaluation
Physical Exam
NISSAA Score
ABIs
Dislocated
Fracture/joint?
Yes
Reduce splint prior

to additional
vascular studies
No
ABI<.9
Decreased or absent pulse
after reduction/splinting?
Yes
Vasc consult
Consider CTA
Known or suspected
vascular injury?
Consider temporary shunt
No
Anticipate Ex- fix placement

Compartment Release
NISSA<7-acute vs. delayed fixation

NISSA>10-consider acute amputation
NISSA 7-10-expert clinical judgment,
multiple service input
*Upper Extremity under construction
Definitive vasc repair

Consider Plastic Surgery consult
Hematuria
Practice Guidelines
Unstable pelvic fracture*

w/gross hermaturia? Or
significant (>50RBCs
per hpf) microscopic?
Yes
GU Work-up:
1. RUG for urethra
2. CT scan for kidney and ureter
3. 3.Cystogram for bladder
No
No Work up
Surgical Note:
Laparotomies with Urethra prepped into field and sterile foley
*Pelvic fracture: comminuition of anterior ring, blood at meatus, high riding

prostate, gross hematuria
Pelvic Fracture
Hemodynamicallyunstablepatientwithhighriskmechanism
and/orlateraloranteriorcompressionIIIIIorverticalsheer
injuries
ABCDEs
Pelvicplainfilm
Considerneedfor
binder
PerformFAST
Severe
Pelvic
FX?
No
Usual
care
Yes
No
Lap+/
ExfixinOR
then
postop
Angio
Fast
Neg.?
No
Stable
VS?
Yes
CT
Yes
Equivocal
FAST?
Angio
No,clearlynegative
Yes
Blush
?
No
Yes
TraumaAttendingto
bedside,repeatFAST,
considerDPL
RoutineICU
care,Remove
binderin
consultwith
Ortho
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
Obtain routine trauma

imaging.
Known pregnancy?
or
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., IVP / cystogram for imaging of GU
system, or MRI of pelvis.
Consider obtaining
pre-imaging Beta-HCG
if not otherwise
contraindicated by
patient status.
Pulmonary Embolism Workup & Treatment

PE Suspicion includes:
(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
Yes
Treatable process
(pneumothorax,
mucous plug,
effusion)
ff i ?
Treat cause and

reassess
Problem
resolved?
No
Saturated <90%
w/>4L oz?
No
Yes
Heparinize if possible
Observe
CTA LE Duplex
LE Duplex in 5 Days
If inpatient
No
Positive
?
Yes
IVC filter +
anticoagulatuon
If patient persistently hemodynamically unstable, Cardiac surgery should be consulted for

emergent pulmonary emboloectomy
*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**
Evaluate for hemorrhage/missed injury

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
*Document time interval from admission to ED to correction of

LA in progress note
**Do not use LA as an endpoint in SCI pts.
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 & urine PH every 12
hours after goal has been achieved
*Check urine PH as often as necessary to achieve this goal
ReasonforFall/MVCUnclear
(i.e.injurycouldbeintentionalorduetosyncope?)
PerformHx,PE,12leadEKG

Initialevaluationdiagnostic/

suggestiveoforthostatichypotension/
benigncauseorpossiblesuicidality?

(Asdeterminedbymedicationhistory,

autonomicdysfxnorsinglevehicle
collisionvs.stationaryobject,and/or

Toxicologyscreen)
Initialevaluationsuggestiveofspecific
anatomic/physiologicproblem?
UnexplainedSyncope
(Possiblearrhythmia,Aorticstenosis,PE,
neurologic
sx,familyHXsyncope/suddendeath)
AdmittotelemetryorICU
ANDperformtestingasindicated:
(e.g.,ECHO,EEG,asindicatedby
Obtainappropriate

consultsasindicatedby
findingsoftesting
Yes
Hx/PhysicalExam)
Age>60?
Known/suspected
CVD?
Signs/SxofCHF?
AbnormalECG?
Reviewalarmhistoryq1224h!!
DONOTOBTAINCAROTIDDUPLEX!!
No
Yes
AlarmHx,ECHOor
otherTests
Positive?
No
Considercardiologyconsultation,tilttabletest,andother
outpatientdiagnostictests
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?
SPINE CLEARANCE ALGORITHM

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.
Yes
Remove collar (unless

desired for pt.) comfort
document exam clearance
date & time, update activity
orders, including d/c old
activity orders
No
See Next Page
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: Call the appropriate Reading Room Coordinator by
0800 for needs.
MSK:2-2526 (even months) NSGY: 2-3432 (odd months)
Follow up Spine Studies-Uprights, MRIs, etc.- order as priority 2

*** High Risk Mechanism:
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

CONTINUED

Patient Not Examinable*

Imaging Indicated:
CT C-Spine, T & L recons of CT Torso **
Plain Films of T&L spines if no CT Torso indicated
Preliminary Reads POSITIVE

(or suspicion for bony injury / malalignment)***
Spine Consultation
(Complete consult request w/ date & time,
clarify activity orders in Epic)
Yes
No
See next page for Cervical,

Thoracic and Lumbar Spines
Negative Bony Imaging
*Examinable- GCS 15, Alert, and NONE of the following:

neurologic deficits,distracting injury (pt can participate in exam)
**CTA Neck is indicated if a pt has any of the following: Fx through C1C4; 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 activity in such cases.
Positive C Spine Imaging needs a spine consult!
CONTINUED

CERVICAL SPINE CLEARANCE

NEGATIVE BONY IMAGING
Preliminary Cervical spine bony imaging reads

negative (No new, old or undetermined findings)?
Yes
PATIENT EXAMINABLE?
neurologic deficits,distracting injury
(pt can participate in exam)
No
Consider MRI
if anticipating that patient
is un-examinable
for > 5 days
Yes
Perform Tertiary Exam /
Clinical Exam of C spine.
Remove the patients collar
and palpate the C-spine.
No
Yes
STOP
the cervical spine clearance
process, replace the patients Ccollar, 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)*
No
Remove collar,
document exam clearance
date & time,
update activity orders including
dc old activity orders
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?
Pain, tenderness and/or

peripheral sensory/motor signs/
symptoms
* 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)
CONTINUED

THORACIC & LUMBAR SPINE CLEARANCE

NEGATIVE BONY IMAGING
Preliminary reads negative
(No new, old or undetermined findings)
HOB to 30 degrees, update activity orders

including dc old orders
PATIENT EXAMINABLE?
neurologic deficits,distracting injury
(pt can participate in exam)
Yes
Examined patient before advancing

positioning. Patients with negative
imaging, but severe pain/tenderness
in T/L spine should be evaluated for
potential discogenic disease or occult
FX.
No
Final read needed to

advance position
Age indeterminate spine injury image interpretations should be

considered acute except in the clear absence of pain, tenderness and
limitation of mobility.
Patients with no bony abnormalities or malalignment on imaging who are
awaiting ligamentous cervical spine clearances may be upright and OOB
with collar.
Spine clearance procedures must be documented in the clinical record
(progress notes) and with orders.
All patients with >48 hours flat bed rest due to spine injury/evaluation
should be on Rotorest beds unless countermanded by spine consultant
or otherwise contraindicated.
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!
Traumatic Spinal Cord Injury: Early Acute Management

Based mainly on Consortium for Spinal Cord Medicine
Clinical Practice Guidelines: Early Acute Management in
Adults with Spinal Cord Injury
1)
2)
3)
4)
5)
6)
Resuscitation
a) Monitor and treat symptomatic bradycardia (from
unopposed vagal innervation to heart).
i) If problematic, hyperventilate prior to orotracheal
care.
ii) If still problematic, consider use of IV atropine
prior to orotracheal care or turning.
b) Monitor and regulate temperature (patients are at risk
for poikilothermia).
i) Consider warm IV fluids and/or a patient-warming
device.
Neuroprotection:
a) No clinical evidence exists to definitively recommend
any neuroprotective agent, including steroids.
b) Stop methylprednisolone immediately in those whose
prior neurological symptoms have resolved.
Diagnostic Assessments
a) Image the entire spine, and get an MRI for the known
or suspected area(s) of SCI.
Associated Injuries
a) Screen for thoracic and intra-abdominal injury in all
patients with SCI.
b) Consider placing an NG tube to low intermittent
suction for abdominal decompression.
Anesthetic Concerns: Avoid succinylcholine after the first
48 hours post-SCI.
Secondary Prevention
a) Order a pressure-reduction mattress or a mattress
overlay.
b) Use a pressure-reducing cushion when the patient is
sitting out of bed.
c) Reposition/turn at least q2 hours (right sidebackleft
side).
e) Respiratory Management:
i) Get baseline Vital Capacity, FEV1, and ABG
initially and at intervals until stable.
d) DVT/PE Prophylaxis:
i) Begin Lovenox 30 mg subcu BID plus SCDs once
primary hemostasis is evident.
CONTINUED

ii)
Consider an IVC Filter only in those with active bleeding

antisipated to persist >72 hours, and begin
anticoagulants as soon as feasible.
iii)
Get baseline lower extremity ultrasound to rule

out DVT
e) Respiratory Management:
i)
7)
Get baseline lower extremity ultrasound to rule out

DVT.
ii) In patients with expiratory muscle weakness (SCI
involving T6-T12 myotomes) treat retained secretions
with manual assisted coughing (relative contraindication
is IVC filter), aggressive pulmonary hygiene, mechanical
insufflation-exsufflation (Cofflator), etc.
f) Place a Foley catheter at admission and keep in place until
hemodynamically stable and 24-hour urine output is
consistently <2,400 ml.
i)
When time to discontinue the Foley, order in/out caths
q4 hours.
g) Evaluate swallowing prior to any PO feeding in any patient
with cervical SCI.
h) Initiate a bowel program:
i)
When bowel sounds return, the patient will need daily
scheduled bowel cares with bisacodyl suppository
followed in 5-10 minutes by digital stimulation (one
finger inserted into the rectum, moving in a gentle
circular motion x ~30 seconds), with digital stimulation
repeated q5-10 minutes until only clear mucus comes
out or there is no more stool x 2 dig stim cycles (usually
4-7 cycles of dig stim are needed).
(1) This should be repeated daily and needs to be
done even if the patient had an incontinent BM that
day.
i) Pressure Ulcer Prevention: Avoid semi-recumbent positions
(HOB between 30-70 degrees) both in- and out-of-bed.
j) Orthostatic Hypotension Management:
i)
Use an abdominal binder and elastic leg wraps to
prevent orthostatic hypotension
(1) The abdominal binder and wraps should be
removed when the patient is back in bed.
(2) Consider pharmacologic options (e.g. PO
Midodrine; Florinef often causes severe edema)
Rehabilitation Intervention
a) Consult rehabilitation specialists early (PM&R as well as PT
and OT).
Non-operative Management of Blunt

Splenic and Hepatic trauma
Clinical Practice Guideline
Grade I or II
Grade III V
No intra-peritoneal fluid
IR Embolization?4
OR if Unstable5
Admit Floor
Day 1
(0-24 hours)
Admit STBICU
CBC q8 X 24h
Strict Bedrest2 + Hold LMWH
Lactate, CBC q8 X 24h

Strict Bedrest2 + Hold LMWH
If
embolized
Day 2
(24-48
hours)
CBC in AM & assess abd

exam
If Hb Stable and no change
in abd exam and > 24 hours
after injury:
Give diet and allow OOB
THEN, recheck Hb3 and
consider discharge 6 hours
after OOB
1.
Duration of bed rest may be altered depending on trauma

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

strict bedrest if spines are clear.
3.
Remember to check CBC after walking.
4.
Embolization is appropriate for normotensive patients without

other serious traumatic injuries who have arterial blush,
pseudoaneurysm, or large subcapsular hematoma.
5.
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. Use GIA for liver resection, if needed.
6.
In general, only IV contrast is necessary for the repeat CT.

However, consider enteral contrast if the patient is not
tolerating enteral feeds.
CBC q12 X 24h

If hb stable, transfer to floor
and start clear liquids
Continue strict bedrest2
Start LMWH if Hb stable
CBC q12 X 24
Advance diet
Continue bedrest2
Verify type and screen
Day 3
(48-72 hours)
CBC
OOB, Repeat CT*
Duplex and CBC in AM
Discharge in PM if Hb
stable, tolerating pos and
no change in abdominal
exam
GIVE VACCINES!
Day 4
(72-96 hours)
SPLEEN AND HEPATIC TRAUMA

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.
Reference Page
Acute Respiratory Failure
Proning
80
84
Against Medical Advice Discharge
87
Injury Scales
88
LTAC
94
MET Team
96
Organ Donation
97
Pain and Sedation
99
Pallitative Care
101
Physical and Occupational Therapy
103
Medication References-Adult
131
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 < 10
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.
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. Significant bleeding around a trache
(soaking of a 4x4 pad, or constant flow) should be treated as an
emergency with notification of the senior resident and stat CTA
of neck and chest). Life threatening bleeding (hypotension,
arterial hemorrhage) should initiate immediate thoracic surgery
consult and transfer to OR.
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:
CONTINUED

TRACHEOSTOMY PATIENTS IN ADULT ACUTE 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.
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 O 2 (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, kinking of ETT 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
CONTINUED

VENTILATION PRONING
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.
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
INJURY SCALES
http://www.aast.org/Library/TraumaTools/InjuryScoringScales.aspx
LUNG INJURY SCALE

Grade* Injury Type Description of Injury
AIS-90
ICD-9
Contusion
Unilateral, <1 lobe
861.12
861.31
II
Contusion
Unilateral, single lobe
861.20
861.30
Laceration
Simple pneumothorax
860.0/1
Contusion
Unilateral, > 1 lobe
861.20
861.30
Laceration
Persistent (> 72 hrs) air leak

from distal airway
860.0/1
860.4/5
862.0
3-4
Hematoma
Nonexpanding intraparenchymal 861.30
Laceration
Major (segmental or lobar)

air leak
862.21
861.31
4-5
Hematoma
Vascular
Expanding intraparenchymal
Primary branch intrapulmonary
vessel disruption
901.40
3-5
Vascular
Hilar vessel disruption
901.41
901.42
VI
Vascular
Total uncontained transection of

pulmonary hilum
901.41
901.42
III
IV
*Advance one grade for bilateral injuries up to grade III.
CONTINUED
SPLEEN INJURY SCALE (1994 REVISION)

ICD-9 AIS-90
Contusion
Unilateral, <1 lobe
861.12
Hematoma
Subcapsular, <10% surface area 865.01

865.11
Laceration
Capsular tear, <1cm

parenchymal depth
865.02
865.12
2
2
Hematoma
Subcapsular, 10%-50% surface

area intraparenchymal,
<5 cm in diameter
865.01
865.11
Laceration
Capsular tear, 1-3cm

865.02
parenchymal depth that does not 865.12
involve a trabecular vessel
Hematoma
Subcapsular, >50% surface area

or expanding; ruptured
subcapsular or parecymal
hematoma; intraparenchymal
hematoma > 5 cm or expanding
Laceration
>3 cm parenchymal depth or

involving trabecular vessels
Laceration
Laceration involving segmental

or hilar vessels producing major
devascularization
(>25% of spleen)
II
III
IV
Laceration
Vascular
Completely shattered spleen

Hilar vascular injury with
devascularizes spleen
865.03
865.13
4
865.04
865.14
*Advance one grade for multiple injuries up to grade III.
CONTINUED

INJURY SCALES
LIVER INJURY SCALE (1994 REVISION)

I
ICD-9 AIS-90
Hematoma
Subcapsular, <10% surface area 864.01

864.11
Laceration
Capsular tear, <1cm

parenchymal depth
864.02
864.12
Hematoma
Subcapsular, 10% to 50%

surface area intraparenchymal
<10 cm in diameter
864.01
864.11
Laceration
Capsular tear 1-3 parenchymal

depth, <10 cm in length
864.03
864.13
Hematoma
Subcapsular, >50% surface area

of ruptured subcapsular or
parenchymal hematoma;
intraparenchymal hematoma
> 10 cm or expanding
Laceration
>3 cm parenchymal depth
864.04
864.14
IV
Laceration
Parenchymal disruption involving 864.04

25% to 75% hepatic lobe or
864.14
1-3 Couinauds segments
Laceration
Parenchymal disruption involving

>75% of hepatic lobe or >3
Couinauds segments within a
single lobe
Vascular
Juxtahepatic venous injuries;

ie, retrohepatic vena cava/central
major hepatic veins
Vascular
Hepatic avulsion
II
III
VI
*Advance one grade for multiple injuries up to grade III
CONTINUED

INJURY SCALES
KIDNEY INJURY SCALE TABLE 19

ICD-9 AIS-90
Contusion
Microscopic or gross hematuria, 866.01

urologic studies normal
866.11
Hematoma Subcapsular,
nonexpanding without
parenchymal laceration
2
2
II
Hematoma
Nonexpanding perirenal
hematma confirmed to renal
retroperitoneum
866.01
866.11
Laceration
<1.0 cm parenchymal depth of

renal cortex without urinary
extravagation
866.02
866.12
Laceration
<1.0 cm parenchymal depth of

renal cortex without collecting
system rupture or urinary
extravagation
866.02
Laceration
Parenchymal laceration
extending through renal cortex,
medulla, and collecting system
Main renal artery or vein injury
with contained hemorrhage
Completely shattered kidney
866.12
III
IV
V
Vascular
Laceration
Vascular
Avulsion of renal hilum which

devascularizes kidney
4
866.03
866.13
*Advance one grade for bilateral injuries up to grade III
CONTINUED

INJURY SCALES
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
II 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

INJURY SCALES
HEART INJURY SCALE (CONT.)

ICD-9 AIS-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 right 861.03 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

ICD-9 AIS-90
I
Contusion
862.0
2
II
Laceration <2cm
862.1
3
III Laceration 2-10cm
862.1
3
IV Laceration >10 cm with tissue loss < 25 cm2
862.1
3
V Laceration with tissue loss > 25 cm2
862.1
3
*Advance one grade for bilateral injuries up to grade III.
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
CONTINUED
TRANSITIONAL CARE HOSPITAL (LTAC)

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 comorbidities
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
MET Team
The Medical Emergency Team, or MET, is a dedicated rapid
response team here at the University of Virginia Health System
Mission: To provide urgent/ emergent medical care for adult
Medical Center patients.
Members: A core group of experienced and very capable
critical care RNs with back-up from critical care float and
ICU RNs
Who can Activate a MET?: The primary RN, Shift Manager,
PCA, HUC, MD.
The MET RN provides critical care support to the
decompensating patient in the acute care setting. It is often
thought of as a Nursing Consult Service. All interventions
are performed in conjunction with the patients physician in the
multi-disciplinary setting to improve patient outcomes.
Activation Triggers
Neuro: New seizure, stroke-like symptoms, changes

in mental status, patient describing altered sensorium. Consider
calling a Stroke Code
Resp: dyspnea, RR >30 or <8; Sao2 <90% or <93%

with other trigger present, increasing oxygen requirement to
maintain saturations
CV: HR <60 or >130, new dysrhythmia, hard-tocontrol hemorrhage, SBP <90 or >180, chest pain
Other: critical lab values, New difficulty swallowing,

airway risk/not protecting airway. Somethings just not right
here
Listen to your gut, trust your insincts!
Call Early!
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 called 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

ORGAN DONATION
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/
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
TRAUMA: PAIN AND SEDATION GUIDELINES

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
Needs
Sedation?
Yes
Ativan
to
} Titrate
Effect*
Drip
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
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

ASSIGNMENT OF PALLIATIVE CARE CODE
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
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
Get patient out of bed
Post-op ambulation
Patient is bored/not motivated From SNF, back to SNF
Check O2 Sat. while walking
Force pt to get OOB
Long standing mobility deficits Passive range of motion
Non-responsive pts
Improve endurance
OT for a pt w/ no desire to be
Lots of lines/bags to carry
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 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
96
Brain Injury
97
Guidelines for the Management of Intercranial

98
I. Standard Therapy for All Children
98-99
II. Sequential Treatment of Elevation in Intracranial

100-102
Pressure (ICP > 20 mmHg All Ages)
III. Severe, Abrupt Elevation in ICP and/or
Manifestation of Impending Herniation
IV. Sequential Treatment of Decreased MAP
Decreased CPP
103
103-104
105
Second Tier Treamtnet for ICP > 20 mmHg (All Ages)
106
Severe, Abrupt Elevation ICP and/or Manifestation

of Impending Herniation
107
Treatment of Decreased MAP Decreased CCP
108
109
Severe TBI Standard Therapy Checklist
110-111
Clinical Pathway Evaluation of the Pediatric

Cervical Spine
112-113
Near Drowning/Submersion Injury
114-115
Non-accidental Trauma (Abusive Injury)
116-117
Hemostasis in Pediatric Neurotrauma
118-119
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
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.
BRAIN INJURY
Guidelines for the Management of Intracranial
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
BRAIN INJURY
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 Hg
> 60 mm Hg
> 65 mm Hg
> 70 mm Hg
ICP1
< 20 mmHg
< 20 mmHg
< 20 mmHg
< 20 mmHg
CPP
> 45 mmHg
> 50 mmHg
> 55 mmHg
> 70 mmHg
*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
BRAIN INJURY
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
BRAIN INJURY
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
BRAIN INJURY
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 train-of-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 re-established
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
BRAIN INJURY
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
BRAIN INJURY
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 Hg
> 60 mm Hg
> 65 mm Hg
> 70 mm Hg
ICP1
< 20 mmHg
< 20 mmHg
< 20 mmHg
< 20 mmHg
CPP
> 45 mmHg
> 50 mmHg
> 55 mmHg
> 70 mmHg
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
BRAIN INJURY
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
BRAIN INJURY
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
BRAIN INJURY
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
BRAIN INJURY
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
BRAIN INJURY
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
BRAIN INJURY
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
BRAIN INJURY
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
BRAIN INJURY
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
Obtunded or Intubated
Awake & Alert
Age > 3 yo and

Cooperative and
No Dev Delay
Age < 3 yo OR
Uncooperative
OR Devel Delay
YES
NO
YES
Getting
Head
CT?
NO
YES
High Risk
Mechanism
or Pain on exam
Age > 9 yo?
NO
Abnormal,
or pain
on exam
Meets Nexus Criteria:

AP, Lateral Cspine
1. Absence of midline
swimmers. Odontoid
tenderness
only if age > 9 yo (if
2. No evidence of intoxication NO odontoid is sufficient,
3. Normal level of alertness
get CT occiput-C2)
4. Normal neurologic exam
5. Absence of painful,
distracting injury
Normal &
YES
Meets NEXUS
Criteria
C-Spine Clear
C-Spine Clear
*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
CONTINUED

PEDIATRIC TRAUMA ALERT OR CONSULT
Abnormal
Normal
Abnormal,
or MRI
not done
within
48-72 hrs
Spine
Consult
YES
C-Spine
Clear
YES
MRI w/in 48 to
72 hrs
Meets Nexus Criteria?

NO
Obtunded?
NO
Alert?
Normal
Abnormal
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
Normal
Upright Cspine
Lat with
then without
collar
Abnormal
Normal
C-Spine
Clear
Approved By Ped Trauma Committee
Revised 4/06
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
NEAR-DROWNING/SUMBERSION INJURY
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
CONTINUED
NON-ACCIDENTAL TRAUMA (ABUSIVE INJURY)

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.
CONTINUED
PEDIATRIC TRAUMA ALERT OR CONSULT

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)
5-10
Two tablets (10mg)
every 4 hrs
CONTINUED

Hydrocodone+acetaminophen 5/325mg PO tablet (Vicodin)

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- PROPOFOL INFUSION 25mcg/kg/minute based on
CONTINUED

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 @ 0.2-1.5
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 2mg
CONTINUED

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
CONTINUED

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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November 2012

University of Virginia Health System

2 11/12 UVA TRAUMA HANDBOOK

This handbook is also available online via the

UVA TRAUMA HANDBOOK 11/12 3

Guidelines are general and cannot take into account all of

4 11/12 UVA TRAUMA HANDBOOK

Patient and family centered care:

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

UVA TRAUMA HANDBOOK 11/12 5

Scholarship and Collegiality

6 11/12 UVA TRAUMA HANDBOOK

5TH EDITION CHANGES

UVA TRAUMA HANDBOOK 11/12 7

2012-13 CHIEFS & FELLOWS

VASCULAR & TCV

4429 Charles, Eric

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3462 Trauma Center Director, Jeff Young, MD

UVA TRAUMA HANDBOOK 11/12 9

Trauma Service Nurse Practitioners

ED Charge Nurse 2-0201

10 11/12 UVA TRAUMA HANDBOOK

UVA TRAUMA HANDBOOK 11/12 11

TRAUMA ALERT PROCESS

12 11/12 UVA TRAUMA HANDBOOK

UVA TRAUMA HANDBOOK 11/12 13

14 11/12 UVA TRAUMA HANDBOOK

TRAUMA ALERT PROCESS

UVA TRAUMA HANDBOOK 11/12 15

recent arrest (penetrating)-Patient should have had RECENT signs of life

-May withhold thoracotomy if Wide Complex PEA at <40 BPM

Aggressive volume resuscitation ( PRBC) indicated for blunt

16 11/12 UVA TRAUMA HANDBOOK

UVA TRAUMA HANDBOOK 11/12 17

18 11/12 UVA TRAUMA HANDBOOK

TRAUMA ALERT CRITERIA

UVA TRAUMA HANDBOOK 11/12 19

GAMMA ALERT - Surgical Chief presence within 30 minutes of

Severe pain in chest, abdomen, neck, or back

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7. Operative therapy anticipated / planned by subspecialty service

UVA TRAUMA HANDBOOK 11/12 21

TRAUMA ALERT CONSIDERATIONS

22 11/12 UVA TRAUMA HANDBOOK

Trauma Surgery Service Pearls

UVA TRAUMA HANDBOOK 11/12 23

It is expected that a chief or attending physically be present to

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In general, we admit most patients to trauma for the first 24hrs

UVA TRAUMA HANDBOOK 11/12 25

TRAUMA SERVICE COMMUNICATIONS

26 11/12 UVA TRAUMA HANDBOOK

CHIEF TO CONTACT ATTENDING TO:

UVA TRAUMA HANDBOOK 11/12 27

Trauma Service Nurse Practitioners

Medical management of patients on acute care

Daily physical assessment of all patients on acute

Collaborating with case managers and SW to

Ordering and follow up on indicated imaging

Daily review and update of orders

Communicating with all consulting services

Communicating daily plan with patient and families