TRAUMA HANDBOOK
Jeffrey S. Young, MD
Director, Trauma Center
Professor of Surgery
Chief Patient Safety Officer
http://tinyurl.com/uvatraumamanual
7th Edition
January 2015
2 03/15 UVA TRAUMA HANDBOOK
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.
TABLE OF CONTENTS
INTRODUCTION...................................................................... 6
APPENDICES ........................................................................ 79
Against Medical Advice Discharge Checklist (AMA)........... 92
Acute Respiratory Distress Syndrome (ARDS) Patients -
Ventilated STICU .......................................................87-88
Cardio-Evaluation - Perioperative..................................93-94
Clinical Brain Training Topics .........................................95-98
Discharge Planning ......................................................99-101
ECMO ............................................................................89-90
Epidural Protocol .......................................................102-103
Injury Scales .................................................................... 104
Diaphragm..................................................................... 104
Heart.......................................................................105-106
Kidney ........................................................................... 107
Liver............................................................................... 108
Lung .............................................................................. 109
Spleen ........................................................................... 110
UVA TRAUMA HANDBOOK 03/15 5
TABLE OF CONTENTS (cont'd from previous page)
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.
Jeffrey S. Young, MD
Director, Trauma Center
Professor of Surgery
Chief Patient Safety Officer
Guidelines are general and cannot take into account all of the
circumstances of a particular patient. Judgment regarding the pro-
priety 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 circumstanc-
es presented by the patient.
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 organiza-
tion in supporting its state, populace, and patient popu-
lation 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:
2) Stewardship
We will use limited and precious resources respon-
sibly to ensure sustainability through effective and
transparent budgeting and resource allocation. When
facing conflict in the use of system resources, our
primary allegiance is to the patient. We will do every-
thing within our power to ensure that patients needing
expert care have access to our services at all times.
CONTACT DIRECTORY
Contact Number PIC
MEDCOM
Back-up line .............................................. 4-9287
Main line .................................................... 2-2000
TRANSPLANT
Rasmussen, Sara .............................................................2006
Mulloy, Daniel ...................................................................6557
Nagju, Alykhan .................................................................6582
UVA TRAUMA HANDBOOK 03/15 11
CONTACT DIRECTORY (cont'd from previous page)
CRITICAL CARE
Riccio, Lin......................................................................... 4705
Perry, Jason...................................................................... 6603
Swanson, Julia ................................................................. 4529
4th Years
Eymard, Corey.................................................................. 6884
Johnston, W. Forrest ........................................................ 6963
Lindberg, James............................................................... 6966
Petroze, Robin.................................................................. 6587
Salerno, Elise P. ................................................................ 6988
Stone, Matthew ................................................................ 6939
3rd Years
Davies, Stephen ............................................................... 4992
Gillen, Jacob..................................................................... 3767
Guidry, Christopher .......................................................... 2276
Newhook, Timothy ........................................................... 2685
Olenczak, Bryce ............................................................... 3334
Pope, Nicholas ................................................................. 2744
Willis, Rhett....................................................................... 4715
Yount, Kenan .................................................................... 4782
2nd Years
Archual, Anthony .............................................................. 6416
Hawkins, Robert............................................................... 4612
Martin, Allison................................................................... 6101
Mehaffey, Hunter .............................................................. 6140
Michaels, Alex .................................................................. 6506
Mullen, Matthew............................................................... 4977
Ramirez, Adriana .............................................................. 6186
Zimmerman, Anna ............................................................ 6758
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CONTACT DIRECTORY (cont'd from previous page)
1st Years
Baumgarten, Heron .......................................................... 4980
Clements, Matthew .......................................................... 6577
Contrella, Ben................................................................... 6589
Cullen, J. Michael ............................................................. 6071
Dufour, Robert .................................................................. 4271
Elwood, Nathan ................................................................ 6085
Etter, Mark ........................................................................ 6692
Guerrier, Jean ................................................................... 6719
Hassinger, Taryn ............................................................... 6876
Karlin, Justin..................................................................... 6097
Keefe, Nicole .................................................................... 4914
lobb, David ....................................................................... 6645
Peach, Matthew ............................................................... 3319
Schubert, Sarah ............................................................... 6373
Sharma, Devang............................................................... 4547
Siriwetchadarak, Rapipen ................................................ 6213
Warren, Harry ................................................................... 6251
Yemen, Sean .................................................................... 6740
RESEARCH
Charles, Eric ..................................................................... 4429
Davis, John....................................................................... 6954
Dietch, Zachary ................................................................ 6994
Downs, Emily.................................................................... 3591
Edwards, Brandi ............................................................... 2146
Johnston, Lily ................................................................... 6203
Shaheen, Basil.................................................................. 3826
Shah, Puja ........................................................................ 3844
Wagner, Cynthia ............................................................... 6442
Hu, Yinin ........................................................................... 4063
RADIOLOGY
CT .......................................................... 3-9296
CT Tech ............................................................................1234
Body CT Resident ............................................................1590
Head CT Resident ............................................................1404
Diagnostic Work Area ................................ 4-9338
Image Management ........ 4-9400 (press 3, then 2)
IR Fellow...........................................................................1844
IR Department ........................................... 3-9535
MRI ..........................................2-3155 or 3-0725
MSK Reading Room Coordinator
(even months) .......................................... 2-2526
Neuro Reading Room Coordinator
(odd months)............................................ 2-3432
Body CT Reading Room Coordinator......... 4-9331
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CONTACT DIRECTORY (cont'd from previous page)
PHARM-D
STBICU David Volles..................................................3924
Trauma ICU days.........................................................9610
ICU evenings, weekend ..............................................9518
6E ................................................................................1773
QUALITY CONCERNS
Lynn, Dusty, RN ......................... 434 465-0616 ............ 7049
Butler, Kathy, RN.........................434-465-0413 ............ 3868
TRANSFER HOSPITALS
Hospital Main Phone Film Room
Augusta 800-932-0262 540-932-4483
Culpeper 800-232-4264 540-829-4144 or 4145
Danville 434-799-2100
Lewis Gale 540-776-4035
Lynchburg 877-635-4651 434-200-4139
Martha Jeff. 434-654-7000 434-654-7104
Roanoke 540-981-7000 540-981-7126
Rockingham 800-543-2201 540-433-4380 or 4386
16 03/15 UVA TRAUMA HANDBOOK
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 started
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 neuro-
logic status
Updated DNR status (patient/family requests DNR/comfort
measures only)
Care is delayed due to lack or airway or access
If care is delayed for any reason
UVA TRAUMA HANDBOOK 03/15 17
TRAUMA SURGERY
SERVICE PEARLS
1. All patients with burn injuries and concomitant critical care
needs will be admitted to the Surgical Trauma Burn ICU for
primary management by the Trauma Service with a plastic
surgery consult for wound management. All patients with
thermal injuries without critical care needs will be similarly
admitted to the Surgical Intermediate Care Unit as their
first destination. Patients with Stevens Johnson syndrome
with TBSA >20% will be treated like patients with ther-
mal injuries. Those without a large burden of cutaneous
wounds may be admitted to the medical services.
2. All patients housed geographically within an intermediate
care unit or intensive care unit shall be interviewed and
examined daily in-person (and have their daily note written)
by the critical care team.
3. In general, patients without paraplegia / tetraplegia or
severe neck pain after penetrating head / neck trauma do
not require placement of cervical collars or spinal immobi-
lization. Spinal immobilization is such cases may obscure
expanding hematomas.
4. ICU patients in their first 72 hours of admission or who
have hemodynamic instability / physiologic frailty should
be assessed in-person by the ICU resident (1294) every
1-2 hours to assure maintenance of normothermia, neutral
serum pH, and correction of coagulopathy while undergo-
ing invasive off-service / off-unit procedures (e.g., proce-
dures performed by orthopedics, NSGY, IR, etc.)
5. TBI patients transferring to the floor will need to go to 6
West if their Ranchos Los Amigos Level is < 8. (A function-
al neuro nursing assessment tool in EPIC)
6. Any alert can be upgraded at any point until the patient is
admitted to STBICU
7. Do not bolus propofol to trauma patients within first 72
hours of admission. Some patients will require neuromus-
cular blockade without sedation if the BP is critically low to
maintain staff and patient safety and to obtain diagnostic
imaging.
UVA TRAUMA HANDBOOK 03/15 19
TRAUMA SURGERY SERVICE PEARLS (cont'd from previous page)
charge planning.
42. Attending / Chief Floor rounds generally occur 2 pm daily on
weekdays, and immediately after ICU rounds on weekends.
43. 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.
44. Psych must leave note in the chart when a sitter is no
longer needed.
45. Bedside report is expected for the night resident prior to
A.M. rounds to rounds to sign-out the service.
46. Incidental Findings: All incidental findings that possibly
represent neoplasm or metastatic disorders with potential
for severe consequence require definitive consultation or
appointment established prior to discharge and notation in
the discharge summary without exception.
47. In general, injured patients belong on the Trauma Service,
not the Medicine Services.
48. In general, we admit most patients to trauma for the first
24hrs with some exceptions such as isolated severe TBI.
49. All patients with defined organ injury associated with
bleeding risk (hemothorax, liver, spleen, kidneys and / or
acidosis / shock) who require ICU care must be placed in
the STBICU or TCV-PO (NOT the MICU, NNICU, or CCU).
50. 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 . . .)
UVA TRAUMA HANDBOOK 03/15 23
TRAUMA CLINICAL
PRACTICE GUIDELINES
24 03/15 UVA TRAUMA HANDBOOK
III. Disability:
1. GCS < 15, in the setting of severe headache, nausea, or
vomiting OR in patients taking pre-injury anticoagulants.
2. GCS 9-13 or GCS 1 point below baseline (including ground
level falls)
3. New tetraplegia, hemiplegia, or persistent neurologic deficit
4. Open or depressed skull fracture, GCS 9
5. Known fracture to a vertebral body from outside imaging
IV. Mechanism / Injury:
1. Stab wound neck, chest or abdomen (stable)
2. Stable severe system injury (e.g., known SDH / EDH or
severe pelvis fracture)
3. Two or more proximal long- bone fractures
4. Amputation proximal to wrist or ankle, or crushed,
de-gloved mangled extremity
5. Advanced pregnancy with abdominal trauma (fundus
above umbilicus)
6. Concomitant thermal / multi-system injury or TBSA
burns 40%
V. EM or Trauma Service physician discretion
When mechanism of injury is unclear and EMS providers that provided the
initial care of the patient are not present consider contacting the initial EMS
agency to more clearly discern whether the patient fits into a high risk
mechanism of injury classification.
Pertinent questions directed towards the patient, family members, etc. that
may help you classify the patient might include the following:
1. Did you exit the vehicle on your own / under your own power?
2. Was there a lot of damage to the vehicle? What do you know
about it?
3. Were any of the cars totaled?
Pertinent physical exam findings that imply high energy mechanism include
seat belt signs, abdominal tenderness, multiple abrasions and contu-
sions, bilateral calcaneal fractures (after a fall from height) and / or a tender
sternum (implying possible fracture).
When patient, care givers and family members are absolutely unable to
confirm that patient had a low energy mechanism consider undertaking
thorough imaging or, if patient highly reliable and coherent, conducting im-
aging as guided by the presence of history / physical exam findings i.e.,
any body part with an external mark on it should be definitively imaged.
28 03/15 UVA TRAUMA HANDBOOK
PRE-ALERT CONSIDERATIONS
Reference trauma indicators for appropriate activation level
Standard for notification of team: immediately upon meeting
criteria
Place orders
Review outside imagine prior to patient arrival when feasible
Prompt tech to obtain blood cooler if a possible need (hypo-
tensive, receiving blood, etc)
Clean hands pre-post gloving, Eye shield, mask, lead shield,
gown if bedside
Minimize the number of people in the room so staff have
unobstructed access to the patient and supplies
Introductions with team and nurse recorder
Team huddle with introductions, review of roles, responsibil-
ities, priorities, contingency planning, probable equipment
and medication needs.
PRIMARY SURVEY
AIRWAY
Assess patency, including tube depth and ETCO2 if applicable
Indications For Immediately Securing Airway
Inability to follow commands
Inability to protect airway
Inability to safely complete workup
Hypotension/shock
Severe inhalation injury
BREATHING
Access adequacy of ventilation, BBS
Decompress chest if decreased breath sounds or subcuta-
neous emphysema with Sa02 < 90%
Bilateral chest decompression for blunt agonal or anterolat-
eral thoracotomy if indicated.
UVA TRAUMA HANDBOOK 03/15 29
TRAUMA ALERT PROCESS (cont'd from previous page)
CIRCULATION
Access adequacy of perfusion, LOC, color, pulses
Hemorrhage control (consider need for; blood alert, BP cuff,
pelvic binder, splints, sutures)
Activate blood alert if blood administered
Minimize crystalloid if transfused
Consider resuscitative thoracotomy if:
Witnessed arrest (blunt):
Patient must have had palpable pulse or CLEARLY measurable
PulseOx at lease once on hospital grounds.
Chest decompressions, aggressive volume resuscitation (
PRBC)
May withhold thoracotomy if PEA, wide complex and HR <40
ACLS drugs indicated for blunt agonal patient
Recent arrest (penetrating):
Patient should have had RECENT signs of life.
Stab wound thoracotomy indications: <15 minutes of pre-
hospital CPR
Survival may be as high as 18% in those with the recent arrest
after thoracic stab wounds.
EXPOSURE
Mark penetrating wounds with paper clips where appropriate
30 03/15 UVA TRAUMA HANDBOOK
TRAUMA IMAGING
CXR - All patients
Perform FAST exam
Pelvis Xray all blunt trauma (may be withheld if patient
A&Ox4, non-tender and hemodynamically stable)
Head CT
Loss of consciousness
Altered LOC
Significant trauma above clavicles
Any visible injuries or high risk mechanism in patients on oral
anticoagulants
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
Fx through foramen transverserum
CT Thorax
Significant thoracic injuries on CXR
Rapid deceleration mechanism (see High Risk MOI page 27)
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
(If any of above criteria are not met, likelihood of intra abdominal
injury is <1%.)
UVA TRAUMA HANDBOOK 03/15 31
TRAUMA IMAGING (cont'd from previous page)
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 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
High Risk Mechanism of Injury (refer to page 27) = CT C. T, L with
recons
If known fracture anywhere in the spinal column, perform a com-
plete spine work-up.
OSH process: All OSH spine films will be read for Trauma Alerts.
An order must be placed indicating this need.
TTP (Tenderness To Palpation) Either lumbar, cervical, or
thoracic spine = CT C. T, L spine with recons
32 03/15 UVA TRAUMA HANDBOOK
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 neu-
rosurgery 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 frailty.
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
inspire/pull 1000cc on incentive spirometry (especially elderly pts)
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 evi-
dence or risk of hemorrhage (negative abdominal, chest, and
pelvic evaluation), admitted to trauma service
UVA TRAUMA HANDBOOK 03/15 33
AIRWAY MANAGEMENT
EMERGENT
PURPOSE
This document describes the expectations and roles of phy-
sicians 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 health-
care personnel within the scope of job responsibilities; in
life threatening situations a credentialed physician with ad-
vanced airway management training may manage the air-
way prior to the arrival of the anesthesiologist.
3. Page 1311 for the anesthesiologist on-call AND call 4-2012
to overhead page 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, histo-
ry 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 air-
way. The anesthesiologist performs endotracheal intuba-
tion 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.
34 03/15 UVA TRAUMA HANDBOOK
AIRWAY MANAGEMENT EMERGENT (cont'd from previous page)
CARDIOVASCULAR FAILURE
NON-HYPOVOLEMIC
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 systol-
ic, 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
36 03/15 UVA TRAUMA HANDBOOK
NON-HYPOVOLEMIC CARDIOVASCULAR FAILURE (cont'd from previous page)
SITUATIONS:
Low cardiac index , pump failure
Cardiac parameters
Increase preload (PCWP) to 12 mm Hg taking into account possi-
ble interference from ventilator
If no response:
If hypotensive
The Trauma Attending must be informed beforepressors 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 car-
diac 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
UVA TRAUMA HANDBOOK 03/15 37
ABCDE's
CXR
FAST Exam
Cefoxitin or Zosyn + Tetanus
Previous GSW?
38 03/15 UVA TRAUMA HANDBOOK
AORTIC TRANSECTION
(ACTUAL OR SUSPECTED)
PRACTICE GUIDELINE
INDICATIONS FOR IMPLEMENTATION/UTILIZATION:
1. Widened mediastinum (in patient with high-risk mechanism)1
2. CT evidence of aortic injury (without extravasation)2
PROCEDURE:
Maintain SBP < 110 mm Hg and HR < 110 BPM3
BLOOD ALERT
MASSIVE TRANSFUSION PROTOCOL
A. INDICATIONS
Blood Alert should be activated if blood administered:
prior to arrival
In UVa ED
B. ACTIVATION
1. The BLOOD ALERT will be activated by the trauma attend-
ing, or trauma chief resident, or anesthesia 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 canceled in the same manner it is ac-
tivated (the physician will request cancellation and the
Blood Bank staff will call 4-2012 to initiate Blood Alert
canceled text message distributed to the pager group.
PHASE II:
Upon notification, immediately thaw 6 AB plasma and prepare
4-6 uncross matched O neg red cell units and place in a cooler.
(If patient has a current Blood Bank sample, type specific blood
may be issued.)
40 03/15 UVA TRAUMA HANDBOOK
BLOOD ALERT - MASSIVE TRANSFUSION PROTOCOL (cont'd from previous page)
1. Initial Issue four - six uncross matched O neg red cell units
with Blood Alert Form (or type specific if patient has a cur-
rent BB sample.) Thaw six AB plasma. Prepare and issue
one dose platelet.
2. 15 minutes, or immediately after the 1st group is picked up.
Prepare six more O neg uncross matched red cell units, or
six type specific red cells if sample has been received and
typed. Issue when transportation arrives. Issue six AB plas-
ma. 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 trans-
portation arrives. Issue six ABO compatible plasma. Thaw
six more ABO compatible plasma. Prepare and issue one
dose (of what?)
4. 15 minutes, or immediately after the 3rd group is picked up.
Prepare six type specific red cell units. Issue when trans-
portation arrives. Issue six ABO type compatible plasma.
Thaw six more ABO compatible plasma. Prepare and issue
1 Dose. Every other dose.
5. Alert canceled? Page activating physician to determine if
the blood alert needs to continue or be canceled.
6. The Blood Bank will continue to set up a cooler every 15
minutes until the protocol is canceled by the activating phy-
sician 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 ap-
proximately 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 & Cross-
match specimen when available.
A trauma team member should place orders for 30 red cells,
30 plasma, and 3 platelets after the blood alert is canceled.
Products and coolers will be returned after the protocol is can-
celed by the unit staff. Note: Patients with active Blood Bank
specimens will receive type specific red cells and plasma. The
UVA TRAUMA HANDBOOK 03/15 41
BLOOD ALERT - MASSIVE TRANSFUSION PROTOCOL (cont'd from previous page)
DOSING:
There is no evidence to support additional doses of tran-
examic acid.
REFERENCES:
CRASH-2 trial collaborators. Effects of tranexamic acid on
death, vascular occlusive events, and blood transfusion in trau-
ma patients with significant hemorrhage (CRASH-2): a random-
ized, placebo-controlled trial. Lancet, 2010; 376 (9734): 23 32.
Hemodynamic instability?
No Troponin/EKG Abnormal? No Routine Care
Myocardial Infarction?
Yes Yes
EKG
Echo (STAT if hypotension)
now Normal?
Cardiology Consultation
Troponins < 0.05?
Yes
No further workup
UVA TRAUMA HANDBOOK 03/15 43
To notify:
1. NSGY Consult Resident
2. NSGY Chief Resident
Intraparenchymal Hemorrhage? 3. NSGY Attending
- Clinical deterioration referable to lesion? Yes
4. Trauma Chief
- Or, Intracranial hypertension with mass 5. Trauma Attending
effect on imaging? 6. Trauma ICU (1294)
- Or, If GCS 6 8, is volume > 20 CM3 with >
7. OR Charge Nurse
5mm shift or cisternal compression?
8. STBICU Charge Nurse
- Or, Is volume > 50 CM3?
9. NNICU Charge Nurse
10. Radiology Resident
11. Anesthesia Attending
12. Anesthesia Consult Res.
No
Yes
Consult
Kenny Liu (2217) or
ASA ok? No
Webster Crowley
(6542)
Yes
CHEST TRAUMA -
PENETRATING CENTRAL WOUND
Trajectory between nipples,
sternal notch, xiphoid
or transmediastinal *
and HR <40
Yes and/or wide No
complex?
Recent / witnessed
SBP < 90? Stable?
arrest or moribund?
CXR, consider:
OR for Pericardial window, OR for Pericardial window,
-CTA of chest or
thoracotomy, or sternotomy thoracotomy, or sternotomy
-STAT Echo or
-Pericardial window
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
UVA TRAUMA HANDBOOK 03/15 47
COAGULOPATHY IN NEUROTRAUMA
Head injury with nausea, vomiting and/or AMS
Yes
No
Administer 1-2 units pooled PLT STAT *
No
Yes
Send STAT INR*
Then, administer 2 units Thawed FFP STAT*
No
And Administer Vitamin K 10mg IV
Determine time of
last dose and
Consider to
check PTT to
administer
determine if drug Rivaroxaban
No INR 1.5? Yes additional
still present Or
FFP 10-20ml/
Apixaban?
kg
Consider
Yes
Kcentra
STAT
Consider
Consider Determine time of last Kcentra
Yes
HD dose & Check Anti-Xa to STAT
determine if drug present No
Anti-Xa > 0.5
COAGULOPATHY IN NEUROTRAUMA
ADDENDUM
Head injury with nausea, vomiting and/or AMS
INR 1.5
yes Proceed
On Dabigatran? yes Last dose >24
yeshrs and eGFR normal with
(Pradaxa) Neuro-
no Surgical
Interventi
Is aPTT normal (40)? yes
no
Is Anti-Xa normal?
no (anti-Xa >0.5)
On Fondaparinux
yes If last dose <48 hrs, consider rFVIIa
(Arixtra)
On SQ (UFH) Heparin yes If last dose - 2hr: 0.5 mg protamine / 100u heparin
If last dose was 2 - 6 hrs: 0.25 mg protamine / 100u
CRANIOTOMY/CRANIECTOMY
ADULT GUIDELINES
INDICATIONS FOR SURGERY
from the American Brain Trauma Foundation 2006
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
Place OT Evaluation Risk Factors for High Risk Issues after Discharge:
Orders
1. Severe headache
2. Somnolence
3. Enrolled in school
4. Visual or Vestibular Sx
Consult PMR 4. High risk Employment:
e.g., roofers, professionals, executives, heavy
YES Potential for high risk issues in school / machinery operators, any work at height, law
work / family life or symptoms present? enforcement / public safety officers, et. al.
Identified Sleep/
Cognitive/Mood/
NO
Vestibular Issues
No
YES Mobility Issues
Yes Consult PT
Identified
PMR to create
Return to Work /
School plan
No
Execute
Discharge Plan
New major
Advance / Continue
issues post- No
Home Activities
DC?
Yes
Refer to Multi-Disciplinary Triage Nurse
434-982-7246 (98-BRAIN)
52 03/15 UVA TRAUMA HANDBOOK
Low molecular weight heparin, unless Low molecular weight heparin, unless
contraindicated* + SCDs + IVC filter** contraindicated* + SCDs
No
Positive
duplex?
Yes
No Yes
No
DVT PROPHYLAXIS:
SEVERELY/MULTI-INJURED PATIENT
(ISS 9)
DVT Prophylaxis
High Risk for Bleeding
Major solid organ injury
<48 hours after high risk ortho procedure
Moderate / Severely Injured <24 hours after major or multi-system injury
Patient (ISS>9) <24 hours after spinal surgery, with stable neuro exam/imaging
Hold chemoprophylaxis
Initiate SCDs
Low Ultrasound for DVT Q Mon (ICU) Q 7d (Acute Care)
Reassess if HCT stable after 24hrs
40 mg. LMWH QD
(or weight based) High risk for DVT?
Start SCDs AND
No
Assure Q 7d U/S for Acute Care bleeding risk to
Q Monday for ICU Last >5d?
No
54 03/15 UVA TRAUMA HANDBOOK
EXTREMITY TRAUMA
PRACTICE GUIDELINE
Yes No
Intraoperative anteriogram
Vascular repair Risk classification
+ orthopedic fixation
AAI/WWI >0.9
Pulse deficit?
No Yes
Arteriography Observation
Observation
Observation + serial Operation
Arteriography
FREE FLUID -
NO SOLID ORGAN INJURY
Peritonitis?
YES
Exploratory Laparotomy
Marked abdominal
tenderness?
NO
YES
Repeat abdominal CT Scan with IV AND 3 hours
Enternal contrast 6-10 hours after initial scans
HEMATURIA
PRACTICE GUIDELINES
1
>50 R C s per hpf
Yes No
GU Work-up:
RUG for urethra
No Work up
CT scan for kidney and ureter
Cystogram for bladder
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
UVA TRAUMA HANDBOOK 03/15 57
CBC q12 X 24
1.
Duration of bed rest may be altered depending on trauma Advance diet
attending interpretation of CT scan as low risk for bleeding.
Continue bedrest2
2.
Bed can be broken and HOB can be up to 30 degrees during Verify type and screen
strict bedrest if spines are clear.
3.
CBC
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. OOB, Repeat CT*
5.
Persistently hypotensive patients (SBP < 90 after 2L
Duplex and CBC in AM
crystalloid or 1u PRBCs) and a positive FAST or known Discharge in PM if Hb
splenic injury with hemoperitoneum on CT, should undergo
operative therapy with splenectomy and/or packing of the
stable, tolerating pos and
liver +/- pringle. Use GIA for liver resection, if needed. no change in abdominal
6.
In general, only IV contrast is necessary for the repeat CT. exam
However, consider enteral contrast if the patient is not
tolerating enteral feeds.
GIVE VACCINES!
58 03/15 UVA TRAUMA HANDBOOK
PREGNANCY CT ALGORITHM
CT scanner #4 should be used for all patients
with concern for current pregnancy
No
Yes
Use CT #4
PELVIC FRACTURE IN
HEMODYNAMICALLY UNSTABLE
PATIENT
Yes
FAST Clearly
No Stable VS?
Lap +/ - positive?
Exfix in OR Yes
Yes
then CT
post-op
Angio No
Any blush or
Equivocal Fast? No Angio Yes
extravasation?
Clearly Negative
No
Yes
PULMONARY EMBOLISM
WORKUP AND TREATMENT
PE Suspicion includes:
(oxygen desaturation that does not respond
immediately to simple measures, severe acute
dyspnea, acute decrease in P/FIO2 ration to
<200 with no evidence of hypoventilation)
CXR, ABG,
Supplemental Oxygen
Treatable process
Treat cause and
Yes (pneumothorax, mucous
reassess
plug, effusion)
No
Saturated <90%
Problem resolved? No
w/>4L oz?
Yes No
CTPA/LE Duplex
Hemodynamically unstable? Cardiac surgery should be consulted for emergent pulmonary emboloectomy
*For treatment of positive LE duplex, see DVT guideline
UVA TRAUMA HANDBOOK 03/15 61
RHABDOMYOLYSIS
PRACTICE GUIDELINE
Check serum creatine kinase on patients with:
Chest injury
Ischemic injury
Hyperpyrexia
Suspected rhabdomyolysis
Cranberry colored urine
Two or more long bone fractures
Combined long bone AND pelvic fracture
CK <5000 X2 on two
<5000? Yes
consecutive q12 checks?
No
Yes
CT positive?
(fx, edema, lig. Yes Spine Surgery Consult
Inj.)
Normal Neuro Exam Means: GCS 15, NO midline tenderness in thoracic or lumbar
No spine, NO peripheral or central neurologic deficits, and NO paresthesias.
A&0X4
and normal neuro exam C-Spine MRI
No C-Spine MRI Yes Spine Surgery Consult
(or expected to be within positive?
96 120 hours?)
Yes No
Yes Yes
No
Yes
Flex-ex films
C-Spine MRI No Yes Collar for comfort only
adequate?
C-Spine MRI
No
positive?
If the spine surgery consult team signs off and indicates that there is no need for spine surgery
follow up, then the Discharge Summary should indicate that the patient should contact the Trauma
Clinic or their PCP for persistent or worsening neck pain.
*PATIENT EXAMINABLE?
GCS 15, Alert, and NONE of the following: Intoxicated, midline cervical/thoracic/lumbar pain/
tenderness, neurologic deficits, parathesis high risk mechanism***, distracting injury (pt. can
participate in exam), no spine imaging is indicated.
UVA TRAUMA HANDBOOK 03/15 63
Obtain spine
consult and Evidence of 3 Column injury on initial
Yes
maintain flat imaging?
bedrest!!
No
No
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 misalignment 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!
64 03/15 UVA TRAUMA HANDBOOK
d) Respiratory Management:
i) Get baseline Vital Capacity, FEV1, and ABG initially
and at intervals until stable.
ii) All new tetraplegics MUST receive tracheostomy
within 7-10 days of admission unless rationale for not
doing so is personally documented (in EPIC) by the
attending who makes this decision.
e) 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.
f) Evaluate swallowing prior to any PO feeding in any
patient with cervical SCI.
g) Initiate a bowel program:
i) When bowel sounds return, the patient will need daily
scheduled bowel cares with bisacodyl suppository fol-
lowed in 5-10 minutes by digital stimulation (one finger
inserted into the rectum, moving in a gentle circular mo-
tion 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.
h) Pressure Ulcer Prevention: Avoid semi-recumbent po-
sitions (HOB between 30-70 degrees) both in- and out-
of-bed.
i) Orthostatic Hypotension Management:
j) 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)
7) Rehabilitation Intervention
a) Consult rehabilitation specialists early (PM&R as well as
PT and OT).
UVA TRAUMA HANDBOOK 03/15 67
SYNCOPE?
REASON FOR FALL / MVC UNCLEAR
DO NOT OBTAIN
CAROTID DUPLEX!!
No
Yes
Alarm Hx, ECHO or other Consider cardiology consultation,
No
Tests Positive? tilt table tests
68 03/15 UVA TRAUMA HANDBOOK
Treatment Goals
ICP < 20 mm Hg* PaCO2 35-40mmHg
CPP > 60 and < 70 mmHg ** SaO2 >92%
Maintain adequate preload (CVP 8-12) Maintain preload (CVP 8-12 mmHg)
SBP > 90 mmHg Place ICP Monitor
HOB 30 degrees Maintain Serum Sodium @ 150-165
Assess for need to remove C-collar Head Midline
* Place monitor within
2 hours of admission ICP > 20 mmHg (>5min)*
** Phenylephrine is
st
generally 1 line Sedation and analgesia +/- paralysis
therapy followed by (RASS of -5 is required prior to paralysis)
nd
Levo / Vaso as 2 line
No
Notify Neurosurgical and Trauma Attendings
Consider Mannitol (0.25-0.5g / kg) or HTS bolus/infusion***
No
ICP still > 20 mmHg?
Yes
No
ICP still > 20 mmHg?
Yes
BURN CLINICAL
PRACTICE GUIDELINES
70 03/15 UVA TRAUMA HANDBOOK
BURN FLUID
RESUSCITATION GUIDELINES
(All other applicable ICU protocols/
guidelines will be maintained)
ALL DEVIATIONS MUST BE APPROVED
BY ATTENDING PHYSICIAN
Charge RN should be consulted in the event of nurse-
Initiated call to Attending.
PRE-HOSPITAL
Administer routine wound care (removal of burning material,
gentle cleansing, and loose bandaging with clean, dry mate-
rial. Topical agents should be avoided.)
Initiate fluid resuscitation in the field if possible, but immedi-
ate fluid requirement should be low, so this is not imperative.
During transport: 500ml LR / hour (14 years and older)
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
FLUIDS:
Ignore first degree burns when calculating fluid management
Ringers Lactate 3ml x wt (kg) x % TBSA
Divide by 16 to find initial fluid start rate
AND
Maintain urine output of 0.5ml/kg/hr - 1ml/kg/hr
FLUID TITRATION:
See Fluid Titration Algorithm (Page 72)
If Albumin is indicated, the use of Albumin should continue
Ideally No Longer Than 24Hr from the time of initial burn
injury
This May Require the Use of A Large Amount of Albumin
AIRWAY:
NO ETT should be electively changed within the initial 48hrs
for bronchoscopy without Attending approval
LINE MANAGEMENT:
Transition femoral central access to subclavian through
nonburned skin
MAC/PA may be inserted through burned skin in emergent
situations
72 03/15 UVA TRAUMA HANDBOOK
Burn Patients with > 18% TBSA LR @ 3ml x kg x TBSA / 16 = initial IVF rate
Thermal Injury
No
IVF rate > 6ml /kg / hr ?
(or 8ml/kg/TBSA/hr if inhalation injury present) Yes
No
Recalculate TBSA
Assess for need of escharotomy Yes
Page Chief and Attending (FYI)
Consider Pulmonary Artery Catheter
Start 5% Albumin (replace 1/3 of LR rate) Decrease IVF by 20%
Yes No
Increase LR by 20%
Decrease LR by 20% and
Continue to Monitor UO
continue to monitor
monitor UOP hourly
UOP hourly
hourly Page Attending
Intensivist to
Bedside
(Come Now)
Discontinue
Yes Total IVF returned to
Albumin Yes
< 4ml/kg/TBSA/hr?
Infusion
UVA TRAUMA HANDBOOK 03/15 73
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
Serum creatinine kinase every 12 hours: refer to Rhabdomy-
olysis guideline
LFTs on admission and weekly
GI / NUTRITION:
Patients with post-pyloric feeding in setting of artificial airway
receive continuous TF until patient physically transfers to OR
NGT and post-pyloric** small bore feeding tube placed upon
admission with initiation of tube feeds
If unable to advance small bore feeding tube post-pyloric:
Begin trophic tube feeds (20ml/hr)
Check residual from NGT every 4 hrs
- If residual < 500ml: continue TF and reinfuse up to 250ml
of residual
- If residual 500ml: replace up to 250ml of residual and
hold TF x 2 hours. Recheck residual, if 500ml, hold
TF and start IV prokinetic medication. Assure patient not
constipated.
Obtain admission weight; daily weights
Obtain bladder pressure every 12 hrs if any concern present
for Abdominal Compartment Syndrome
Administer soap suds enema with Bowel Management Sys-
tem (i.e. Instaflo) placement first tanking after 24 hr. mark
(initiate bowel motility regimen)
Ensure order for daily vitamin regimen
TEMPERATURE:
maintain normal thermoregulation
insert rectal or esophageal temperature probe for continuous
Monitoring
74 03/15 UVA TRAUMA HANDBOOK
HYPOTHERMIA:
Ranger fluid warmer; Level 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
48-72 HOURS
FLUIDS:
Continue MIVF Ringers Lactate
In setting of hypernatremia, consider alternating LR with
0.45% NS or D5W
- Maintain urine output 0.5 ml/kg/hr-1ml/kg/hr
AFTER 72 HRS
Oxandralone: begin post-burn day 5
10mg BID enterally
Check AST/ALT weekly, hold if ALT/AST >100
Discontinue at discharge and/or wound healed (closure)
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.
BURN (MAJOR)
RESPIRATORY MANAGEMENT
PRACTICE GUIDELINE
ADMISSION:
All patients with burn injuries with concomitant critical care
issues are to be admitted to the Surgical Trauma Burn ICU
(STBICU) for management by the Trauma Service with a con-
sult to be placed for Plastic Surgery for wound management.
All burn admissions should have OT / PT consults. All patients
with burn injuries without critical care needs are to be
admitted to the Surgical Intermediate Unit (SIMU) for
management by the Trauma Service with a consult to be
placed for Plastic Surgery for wound management. All burn
patients, upon transfer from the STBICU or the SIMU are to be
managed on 5 West by the Trauma Service with a Plastic Sur-
gery consult for wound management.
INHALATION INJURY:
Inhalation injury should be suspected if there is history of en-
trapment 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 bron-
choscopy. Patients should be treated with vigorous pulmonary
toilet and ambulation (as appropriate) to assist in airway clear-
ance of particulate matter. Intubation and ventilator support
should be initiated if there is profound facial edema (anticipat-
ed 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 monox-
ide has normalized in the bloodstream.
76 03/15 UVA TRAUMA HANDBOOK
IDENTIFICATION:
All enclosed fires
Explosions
Carbonaceous sputum, increased carboxy hemoglobin
levels (>5%), hypoxia, and/or facial and mouth burns
ENDOTRACHEAL INTUBATION:
Referrals from OSH with facial burns from enclosed fires
should be intubated. Those with flash burns from non-
enclosed spaces are less likely to have inhalation injuries
Should be performed immediately by anesthesia (consider
paging Respiratory Therapy supervisor [1616] for bronch cart)
If any evidence of respiratory distress or upper airway swell-
ing (stridor, severe cough, hoarseness, voice change)
Avoid use of Succinylcholine for intubation in hyperkalemia
Bronchoscopy for diagnosis and treatment in first 24 hours
In cases of massive facial edema or those with otherwise
difficult to secure ET tubes, the tube should be wired to the
molar with the help of ENT/OMFS
NEBULIZED HEPARIN:
Heparin 10,000U nebulized every 4hrs for ventilated patients
with bronchoscopy-confirmed inhalation injury
Continue until clinical resolution of inhalation injury. Perform
endoscopic reassessment at 7 days (if still ventilated)
Consider albuterol adjunct therapy
Monitor Hep PTT QD
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
UVA TRAUMA HANDBOOK 03/15 77
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
78 03/15 UVA TRAUMA HANDBOOK
Ketamine Contraindications:
Severe CAD
Severe glaucoma
Consider instituting standard
Yes Contraindication Liver dysfcn (TBili>3, Alb<2.8, INR>2.3)
procedural sedation
Severe depression with SI
(benzo/opioid combination) to ketamine?
Known or suspected schizophrenia
No No
No
Consider changing to procedural sedation algorithm, transfer to higher level of care, or LIP/APS consult
Questions? Contact Trauma ICU PharmD (PIC 9610), James Ray, PharmD (PIC 3797), or JF Calland, MD (PIC 4425)
UVA TRAUMA HANDBOOK 03/15 79
APPENDIX
80 03/15 UVA TRAUMA HANDBOOK
ACUTE RESPIRATORY
FAILURE
UVA TRAUMA HANDBOOK 03/15 81
TRACHEOSTOMY PATIENTS IN
ADULT ACUTE CARE
CLINICAL PROTOCOL
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 trach
(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 satura-
tion > 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 med-
ication 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 as-
sessed and documented every shift by RT.
If cuff inflation becomes necessary, notify RT for patient
assessment.
UVA TRAUMA HANDBOOK 03/15 83
CLINICAL PROTOCOL TRACHEOSTOMY PATIENTS (cont'd from previous page)
Clinical decision tools are general and cannot take into account all of
the circumstances of a particular patient. Judgment regarding the pro-
priety of using any specc procedure or guideline with a particular patient
remains with that patients physician, nurse or other health care profes-
sional, taking into account the individual circumstances presented by the
patient.
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.
UVA TRAUMA HANDBOOK 03/15 85
VENTILATION PRONING
PRACTICE GUIDELINE
EXCLUSION CRITERIA
Hemodynamically unstable (patient requires frequent inter-
ventions 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
86 03/15 UVA TRAUMA HANDBOOK
VENTILATION PRONING (cont'd from previous page)
ARDS PATIENTS
VENTILATED STICU CRITERIA
FOR TRANSPORT
PRACTICE GUIDELINES
URGENT TRANSPORT TO OPERATING ROOM
AND INTERVENTIONAL RADIOLOGY:
Remember, it IS POSSIBLE to continue almost any aggres-
sive vent mode from the TICU in the main OR by transporting
the patient on their existing ventilator using a combination of
battery backups and extension cords for transport. Any trau-
ma patient on Bi-level, pressure control with inverse I:E ratio,
or a HFO (high-frequency oscillator) vent settings/ mode who
is NOT intended to be transported on their existing ventilator
must be stabilized on standard a ventilation mode compatible
with OR ventilators prior to being transported to the operating
room or any other procedural area where there primary vent
mode is otherwise unfeasible.
POPULATION DEFINITION:
PaO2 / FIO2 ratio < 100 mm Hg
Minute ventilation > 20 liters
PEEP > 18 cm H2O
BENEFITS
Potential for improved survival (~ 30 - 50% reduction in
mortality; CESAR Trial 6-month survival 63% with ECMO, 47%
with standard care).
BEST CANDIDATES
Consider ECMO for patients with primary respiratory
failure with potentially reversible cause, no/minimal serious
complicating conditions, age < 50 years (will consider ages
up to 65), duration of mechanical ventilation 0-5 days without
improvement in severe hypoxemia.
ELSO GUIDELINES
paO2:FiO2 < 80 mmHg and/or LIS 3-4
(80% predicted mortality)
EXCLUSIONS
Inability to undergo anticoagulation or receive blood products
Complicating conditions associated with high likelihood of
death that limit benefits of ECMO
Long duration of maximal mechanical ventilator support
(Pplateau > 30 cmH2O and/or FiO2 > 0.80 for > 7 days)
CNS hemorrhage
90 03/15 UVA TRAUMA HANDBOOK
ECMO CLINICAL PRACTICE GUIDELINE: ARDS (cont'd from previous page)
REFERENCES
Peek GJ, et al., CESAR Trial Collaboration. Efficacy and
economic assessment of Conventional Ventilatory Support
Versus Extracorporeal Membrane Oxygenation for Severe
Adult Respiratory Failure (CESAR): a multicentre randomised
controlled trial. Lancet. 2009;374:13511363. Age range of
patients 23-46 years.
http://www.thoracic.org/clinical/critical-care/refractory-ards/
pages/ecmo.php
http://www.lshtm.ac.uk/msu/trials/cesar/murrayscorecalcula-
tor.htm
http://www.elso.med.umich.edu/WordForms/ELSO%20Pt%20
Specific%20Guidelines.pdf
92 03/15 UVA TRAUMA HANDBOOK
AGAINST MEDICAL
ADVICE DISCHARGE
CHECKLIST
CARDIOVASCULAR EVALUATION
PERIOPERATIVE
Excellent No further
(>10 METs) testing
(Class IIa)
Moderate or greater Proceed
Low risk (<1%) Elevated risk
(>4 METs) functional to surgery
(Step 4) (Step 5) No further
capacity Moderate/Good
testing
(>4-10 METs)
(Class IIb)
No or unknown
No further testing
(Class III:NB)
Poor OR unknown
functional capacity (<4 METS): Pharmacological
Will further test impact decision making OR Yes stress testing
perioperative care? (Class Iia)
Proceed to surgery (Step 6)
If normal
If abnormal
No
Proceed to surgery
Coronary
according to GDMT OR
revascularization
alternative strategies
according to
(noninvasive treatment,
existing CPGs
palliation)
*GMDT-Guidelines Directed Medical Therapy (Class I)
(Step 7)
94 03/15 UVA TRAUMA HANDBOOK
CARDIOVASCULAR EVALUATION
PERIOPERATIVE
Previous PCI
Yes No
Http://content.onlinejacc.org/cgi/content/full/50/17/e159
UVA TRAUMA HANDBOOK 03/15 95
TRAUMA CARE
1. Major trauma resuscitation
2. Belly trauma
3. War games
4. Advanced trauma: head and hypotension
5. Advanced trauma: GSW abdomen and chest with damage
control
6. Trauma surgery Primer 1
7. Trauma Primer part 2
8. Patient Safety: the trauma patient in the field.
9. Backboards and the law of rare events
10. Medical Aspects of Vehicle Rescue
11. Complex Airway Issues
12. Selective Spinal Immobilizations Video
13. Patient Safety The trauma patient in the field
UVA TRAUMA HANDBOOK 03/15 97
CLINICAL BRAIN TRAINING (cont'd from previous page)
OTHER TOPICS:
1. Introduction and Pancreatitis
2. Handling Emergencies
3. Introduction and Pancreatitis
4. Tactical Decision Making
5. 911 to the ED: Multiple Casualty Incident Care and
Thoracotomy
6. Clinical Brain Training How-To Manual
7. Practice, practice, practice.
8. RSS and iTunes links
9. Initial Evaluation
10. Perspective..
11. Perspective..
12. Advice for the oral boards
13. Introduction to Performance Improvement
14. Fast and slow thinking
15. Critical Care: Surveillance is key
16. ICU Presentations Redux
17. Airway
18. Not accurately detecting the true state of the patient
19. Discussion with Ken Lipsky MD on Crisis Management
98 03/15 UVA TRAUMA HANDBOOK
CLINICAL BRAIN TRAINING (cont'd from previous page)
DISCHARGE PLANNING
DISCHARGE ORDERS
Trauma Service Clinic appointments should be with either Dr.
Young, Calland, Tache-Leon, Williams, or Yang. For Dr. Saw-
yers patients, he will specifically request when a f/u apt with
him is indicated.
Post-chest tube insertion: No flying for 4 weeks post dis-
charge date; follow up chest x-ray first.
Note follow-up plan for incidental findings:
Incidental Findings: All incidental findings that possibly repre-
sent neoplasm or metatastic disorders with potential for severe
consequence require definitive consultation prior to discharge
and notation in the discharge summary without exception.
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 contu-
sions with the most significant injuries first
3. Any relevant diagnostic imaging studies, laboratory and sur-
gical pathology findings, must be documented in the clinical
notes to be applicable for coding purposes. Pneumothorax
MUST be documented as traumatic.
PROCEDURES:
1. List all procedures
2. Specify sharp, excisional debridement if tissue was phys-
ically clipped or cut away, please dictate excisional de-
bridement within the heading of OP REPORT. Excisional
debridement should be documented when performed in OR
at the bedside.
3. Specify blood loss anemia if reason for blood transfusions
UVA TRAUMA HANDBOOK 03/15 101
DISCHARGE SUMMARY GUIDELINES (cont'd from previous page)
PHYSICAL EXAM:
RADIOGRAPHIC STUDIES:
LABORATORY STUDIES:
Specify lab values and if abnormal document hyper or hypo
conditions by specific name.
HOSPITAL COURSE:
DISCHARGE CONDITION:
DISPOSITION:
DISCHARGE MEDICATIONS:
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.
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 thepotential 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. No major coagulopathy (INR < 1.4, platelets > 100,000)
2. Cleared cervical, thoracic, and lumbar spines, or, at least,
minimal spinal trauma (e.g., <3 contiguous SP / TP frac-
tures at least 5 CM away from the level of entry for the
proposed epidural catheter).
3. Mental status clear enough to provide consent, OR a
designated medical power-of-attorney to provide con-
sent, OR a written statement of medical necessity com-
posed by a senior surgical resident or attending on the
trauma service.
4. An accurate detailed list of the pre-admission and cur-
rent 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 analge-
sia may not be that effective since it may be difficult to obtain
and sustain the desired level of analgesia above this level. Alter-
nate/additional methods for pain control will be necessary, and
the APS Team can consult to provide those.
The Acute Pain Service Team is in-house 0700 to 1800. After
these hours, reliance is placed on the overnight anesthesiology
team for most necessary patient management issues. However,
as they assume many responsibilities and are in many locations
beyond the operating room, it may not be feasible for them
to place epidurals simply upon the request of the Trauma
Service. Though it remains the standard of care for such cath-
eters 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.
UVA TRAUMA HANDBOOK 03/15 103
EPIDURAL/ANALGESIA GUIDELINES (cont'd from previous page)
INJURY SCALES
www.aast.org
108 03/15 UVA TRAUMA HANDBOOK
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 decompen-
sating 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. Consid-
er calling a Stroke Code
Resp: dyspnea, RR >30 or <8; Sao2 <90% or <93% with
other trigger present, increasing oxygen requirement to main-
tain saturations
CV: HR <60 or >130, new dysrhythmia, hard-to-control hem-
orrhage, SBP <90 or >180, chest pain
Other: critical lab values, New difficulty swallowing, airway
risk/not protecting airway. Somethings just not right here
ORGAN DONATION
Do not discuss organ donation with family.
Hypothermia:
Maintain core body temperature between 36C and 37.5C
Labs:
1. Basic metabolic panel, Magnesium, phos, 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
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
UVA TRAUMA HANDBOOK 03/15 117
ROLES
1. Evaluate pts to make recommendations re: next level of care/
discharge setting
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
Improve endurance Non-responsive pts
OT for a pt w/ no desire to be Lots of lines/bags to carry
more independent/hasnt when walking
been for yrs
APPROPRIATE REFERRALS
1. Pts with new musculoskeletal condition which affects func-
tion 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
118 03/15 UVA TRAUMA HANDBOOK
OCCUPATIONAL AND PHYSICAL THERAPY REFERRALS (cont'd from previous page)
PEDIATRIC GUIDELINES
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
122 03/15 UVA TRAUMA HANDBOOK
Second Tier Treatment for ICP > 20 mmHg (All Ages)...... 133
Treatment of Decreased MAP Decreased CPP............ 135
Severe TBI Standard Therapy Checklist....................136-137
Clinical Pathway Evaluation of the
Pediatric Cervical Spine.................................................... 138
Pediatric Alpha Alert Criteria (< 16 Y.O.)............................... 140
Pediatric Beta Alert Criteria (< 16 Y.O.) ................................ 141
Near Drowning/Submersion Injury ................................142-143
Non-Accidental Trauma (Abusive Injury) .......................144-145
Hemostasis in Pediatric Neurotrauma ..........................146-147
UVA TRAUMA HANDBOOK 03/15 123
PEDIATRIC TRAUMA
The following guidelines were created by a consensus in
the Pediatric Trauma Sub-committee. The Pediatric Trauma
Sub-committee is a multi-disciplinary group that includes
representation from Pediatric Surgery, Pediatric Emergency
Medicine, Pediatric Critical Care, Pediatric Neurosurgery, Or-
thopedics, and the University of Virginia Trauma Committee.
Mark Able, MD
Lillian T. Pratt Professor and Chair of Orthopedic Surgery
Professor of Pediatrics
Bartholomew J. Kane, MD
Associate Professor of Surgery and Pediatrics
124 03/15 UVA TRAUMA HANDBOOK
SEDATION SERVICE
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.
UVA TRAUMA HANDBOOK 03/15 125
BRAIN INJURY
Guidelines for the Management of Intracranial Hypertension
in Children with Closed Head Injury
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 out-
come. British Journal of Neurosurgery 2003; 17(1): 29-39.
UVA TRAUMA HANDBOOK 03/15 133
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
Maintain PaCO2 between 35-40 mmHg on Arterial Blood Gas
Adjust FiO2 to maintain oxygen saturations >92% - minimize
PEEP
138 03/15 UVA TRAUMA HANDBOOK
SEVERE TBI STANDARD THERAPY CHECKLIST (cont'd from previous page)
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 pancu-
ronium 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 1.2,
Platelets 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.)
UVA TRAUMA HANDBOOK 03/15 139
140 03/15 UVA TRAUMA HANDBOOK
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
i. undergoing CPR
ii. Respiratory failure (PaCO2 >45)
iii. unable to maintain PaO2 >60 mmHg on 100%
FiO2
iv. altered LOC with diminished airway reflexes
v. 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 > 30 degrees
144 03/15 UVA TRAUMA HANDBOOK
NEAR DROWNING/SUBMERSION INJURY (cont'd from previous page)
6. Lab Investigation
a. ABG
b. Electrolytes
c. DIC Panel
d. ETOH/Tox screen if indicated
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
UVA TRAUMA HANDBOOK 03/15 145
NON-ACCIDENTAL TRAUMA
(ABUSIVE INJURY)
PRACTICE GUIDELINE
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
INCONSISTENT HISTORY
Changing history
History isnt consistent with development (if you have
questions about what is developmentally possible ask 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
146 03/15 UVA TRAUMA HANDBOOK
NON-ACCIDENTAL TRAUMA (ABUSIVE INJURY) (cont'd from previous page)
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 ab-
normal
UVA TRAUMA HANDBOOK 03/15 147
HEMOSTASIS IN PEDIATRIC
NEUROTRAUMA REQUIRING URGENT
PROCEDURAL INTERVENTION
PRACTICE GUIDELINE
PURPOSE
1. To define appropriate goals for hemostasis in pediatric pa-
tients with neurotrauma requiring urgent procedural inter-
vention.
2. To outline therapeutic interventions to achieve goal hemo-
stasis.
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 proce-
dure such as placement, maintenance, and removal of an
intraparenchymal intracranial pressure monitor or an exter-
nal ventricular drainage (EVD) device.
2. Higher Risk Procedures: Applies to major surgical proce-
dure 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.
148 03/15 UVA TRAUMA HANDBOOK
HEMOSTASIS IN PEDIATRIC NEUROTRAUMA (cont'd from previous page)
TRAUMA SERVICE
CHECKLISTS
Severe Pelvic Fracture
Any instability call Trauma Alert
Large IV access
Blood Products
Antibiotics
Drugs
Rectal (+) for high riding prostate or
blood at meatus - NO Foley - call Urology
Distal pulses
Distal neuro exam
Examine anal sphincter
NG
Consider intubation for shock
Check CXR
Check CT for BLUSH
Open fracture - Tetanus and antibiotics
GU for hematuria
Ortho at bedside
ICU bed!
LA now & q4, call chief > 2.5
HCT q4 hours
Lytes q4 hours
Consider binder for public diastasis
Emergency Operative
Penetrating Trauma
Blood products
Antibiotics
Talk to consultants re: OR time
Talk to attending
Talk to family
Consent
Spine precautions
Home meds (steroids)
Foley
NG
IV access
Off backboard
Neuro exam before induction
ICU bed? STIBICU
Trauma Admission: ICU
Speak with Chief
Speak with Charge Nurse
Document Injuries
Review and implement consult recs.
Determine activity or spine status
DVT prophylaxis
Check LA + 4 hour LA, if > 2.5 call Chief
Check home meds
Speak with patient and/or family
Tertiary Survey (document and evaluate)
Listen to lungs
Check CXR
Check wounds
Check Peripheral pulses
Check Neuro exam
Find PMH & ID PCP
Bed ready (STBICU)
Vent ABG now and q AM, gastric
decompression
Review radiology films and update injury list
Review labs
Pain management
Fluid plans
CXR now and q am
ICU Daily Goals
A review of each item at the end of rounds
Discussion of the status of each item and
the patients goals
Inclusion of any items that need to be
changed, deleted, or added as tasks for
the day
Completion of the checklist for every
single patient prior to moving to the next
patient to make sure that all care team
members understand the patients status
and care plan.
Daily: ICU Stable
Is and Os
Pain control, wean sedation?
ABG if on vent
Vent settings
Mean airway pressure
New culture results
CXR
HCO3
LA
CV
WBC
HCT
OOB? PT/OT following?
Diet?
Get central line out / foley?
DVT prophylaxis
Can antibiotic stop?
Can you wean vent?
Review radiology
Daily ICU Unstable
Is LA rising?
UO > 0.5 cc/kg/hr
Signs of sepsis? (Do you need CAP CT?)
Mental status (Do you need a head CT?)
Medication Review
Are all positive cultures being treated?
MAP > 55
Can you wean pressors?
Do you need Flotrac or Swan?
Discuss plan with Chief?
Nurse concerns?
Talk with family?
Is patient bleeding?
Check wounds
Is abdominal exam changed?
Check Bilirubin
Is HCO3 dropping?
Volume status?
Review radiology
High Risk Checklist Respiratory
Go to Patients room
ABCs, oxygen saturations
Sats < 90% more than 5 minutes, and/or
respiratory distress
Call MET and intubate if any concern
Contact senior resident
IV
Supplemental high flow oxygen
Exam
Chest, wounds, legs, ?edematous
CXR (Stat)
Troponin
EKG
ABG
Hypoxia?
Contact senior resident
MET activation
CTPA
Hypercapnia (pCO2 > 50)
Contact senior resident
Move to ICU
Evidence of fluid overload
Contact senior resident to confirm
impression
One dose 20 mg Lasix IV
Moderate intensity If symptoms do not
resolve within 30 minutes of therapy, move
to ICU
Intubation
Tube
Scope
Suction
Bougie
Drugs
EtCO2
O2
Stethoscope
Cricoid / scalpel trauma chief
Neck Stable
Quiet Room
Backup
Gastric Tube
After Intubation
Check breath sounds
Check EtCO2 Detector
Check tube position at lips
OG Tube
Respiratory Change - Vented
See patient
Suction ETT
Listen to lungs
Check ETT position
Bag mask
CXR
ABG/Labs
If persists > 5 m, call Chief
Think about PE!
Evaluate medications
Stat CXR
High Risk Checklist
Hemodynamic Instability/Cardiac
Assess ABCs and patient
Do they appear ill?
Check vital signs
IV access and supplemental oxygen
Hypotension
Quick history review (recent procedures,
injuries with potentiakl for hemorrhage)
500-1000cc Saline bolus and reassess
Remember cardiac event!
Physical exam
EKG
Instability and ST elevation STEMI ALERT
Troponins
ABG
CXR
Issue resolved?
Yes
Contact senior resident and give report
No
Activate MET team
Contact senior resident
ICU bed
Stay with patient
Contact family when able
Post-Admission
Hemodynamic Failure: Severe
Bleeding? (HCT)
Septic? (T, WBC, Cultures, Exam)
Equipment error? (manual BP)
Adrenal failure? (Stim test, but may need to
treat empirically
MI?
PE?
Massive neurologic event?
Arterial line?
Fluid before pressors
Central access?
Evaluate invasives as possible source
Radiology (review results, ?reimage)
CXR/Labs
High Risk Checklist
Change in Mental Status
See patient
Check shift and 24 hour inputs and outputs
ABCs (especially peripheral perfusion)
Vital signs
Physical exam
Dehydrated?
Sepsis?
Well perfused? (Feet warm? Distal pulses?)
IV access
Place Foley catheter
If residual > 400 cc leave FC and call
senior resident
If no or low urine output confirmed
I >>O (+3 liters or more)
Check if patient is on home diuretics, if
so immediately give home dose IV
Give 20mg Lasix IV