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LEVEL 1 TRAUMA CENTER

TRAUMA HANDBOOK

Jeffrey S. Young, MD
Director, Trauma Center
Professor of Surgery
Chief Patient Safety Officer

James Forrest Calland, MD


Associate Medical Director, Trauma Center
Associate Professor of Surgery
Associate Chief Medical Officer, Acute Care

http://tinyurl.com/uvatraumamanual

7th Edition
January 2015
2 03/15 UVA TRAUMA HANDBOOK

This handbook is also available online via the:

Clinical Portal
http://www.healthsystem.virginia.edu/clinicianportal/index.cfmh

Additional educational information can be found at:


www.clinicalbraintraining.com
or at Clinical Brain Training on iTunes. See Appendix pg 94-97 for
topic examples.

Trauma Intranet
http://www.healthsystem.virginia.edu/pub/trauma-center/intranet
and as an EPIC link in the Trauma Admission Order Set.

7th Edition, March 2015


UVA TRAUMA HANDBOOK 03/15 3

TABLE OF CONTENTS
INTRODUCTION...................................................................... 6

Mission Statement / Vision Statement / Values ....................... 7


Stewardship / Scholarship and Collegiality.............................. 8
Trauma Alert Group Members .................................................. 9

CONTACT DIRECTORY ...................................................10-15

Trauma Alert Criteria / Considerations / Process ..............24-29


Trauma Service Communications......................................16-17
Trauma Surgery Service Pearls .........................................18-23

TRAUMA CLINICAL PRACTICE GUIDELINES ADULT


(Alphabetical)
Abdominal Penetrating Trauma .......................................... 37
Admission to the Trauma Service ....................................... 32
Airway Management Emergent...................................33-34
Aortic Transection ............................................................... 38
Blood Alert .....................................................................39-41
Blunt Cerebrovascular Injury..................................................45
Blunt Hepatic and Splenic Trauma ..................................... 57
Blunt Myocardial Injury ....................................................... 42
Blunt Thoracic Trauma........................................................ 43
Brain Trauma Alert .............................................................. 44
Burn Clinical Practice Guidelines...............................69-77
Cardiovascular Failure, Non-Hypovolemic ....................35-36
Chest Trauma ..................................................................... 46
Coagulopathy in Neurotrauma.......................................47-49
Craniotomy/Craniectomy.................................................... 50
Deep Venous Thrombosis..............................................52-53
ECMO ............................................................................89-91
Extremity Trauma ............................................................... 54
4 03/15 UVA TRAUMA HANDBOOK
TABLE OF CONTENTS (cont'd from previous page)

Free Fluid ............................................................................ 55


Hematuria ........................................................................... 56
High Risk Mechanisms ....................................................... 27
Imaging ..........................................................................30-31
Mild TBI/Concussion ......................................................... 51
Pelvic Fracture Algorithm.................................................... 59
Pregnancy CT Algorithm..................................................... 58
Pulmonary Embolism Workup & Treatment ........................ 60
Rhabdomyolysis ................................................................. 61
Spinal Cord Injury Management ....................................65-66
Spine Clearance Algorithm ................................................. 62
Syncope.............................................................................. 67
Thoracic and Lumbar Spine Clearance .............................. 63
Trauma Activity Orders ....................................................... 64
Trauma Imaging .............................................................30-31
Traumatic Brain Injury/TBI .................................................. 68
Tranexamic Acid ................................................................. 41

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)

Long Term Acute Care Hospital (LTACH) ...................119-120


MET Team............................................................................. 111
Occupational and Physical Therapy ..........................117-118
Organ Donation..........................................................112-114
Palliative Care ............................................................115-116
Tracheostomy Patients In Adult Acute Care ..................82-83
Tracheostomy Planning ...................................................... 81
Transportation of the Ventilated Patient.........................87-88
Trauma Service Nurse Practitioners ................................... 84
Ventilation Proning ......................................................85-86
Ventilator Paralysis Trial.......................................................... 85

PEDIATRIC GUIDELINES ............................................121-148

TRAUMA SERVICE CHECKLISTS ..................................... 149


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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, 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.

Suggestions for revisions and additions are encouraged and


should be emailed to kmb4r@virginia.edu

The Seventh Edition of this manual was produced by the


Trauma Program.

Project Leaders: Kathy Butler, Dusty Lynn


Project Assistant: Shannon Lohr
All rights reserved.
UVA TRAUMA HANDBOOK 03/15 7

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:

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 maxi-
mize transparency safety, and participation.
c. The only patient and family need that will be em-
phasized 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.
8 03/15 UVA TRAUMA HANDBOOK
VALUES (cont'd from previous page)

f. We shall maintain a culture that simultaneously


recognizes our potential for excellence AND
the possibility of catastrophic failure of our care
systems.

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.

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 aca-
demic 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.
UVA TRAUMA HANDBOOK 03/15 9

TRAUMA ALERT GROUP MEMBERS


Contact Number PIC
Adult Trauma Alert Intern.................................................... 9162
Anesthesia PACU Resident ................................................ 9248
Anesthesia Resident........................................................... 1311
Burn Nurse Practitioner...................................................... 7248
Chaplain ............................................................................. 1391
ED Attendings ...................... 531-5701 / 531-5701
NSGY Resident 2 ............................................................... 1576
Nursing Supervisor............................................................. 1822
OR Charge Nurse ............................................................... 1371
Pediatric Trauma Chief ....................................................... 1824
Pediatric Trauma Intern ...................................................... 1356
Pediatric Trauma Attending ................................................ 1707
Respiratory Therapy Adult............................................... 1616
Respiratory Therapy Pediatric ......................................... 1742
Respiratory Therapy Back Ups ............................... 1716 / 1684
Radiology Portable ............................................................. 1989
Social Worker ED.......................................4-2120 .......... 1384
Trauma Alert 2nd yr ............................................................ 1294
Trauma Alert Backup Chief................................................. 1459
Trauma Attending ............................................................... 1564
Trauma Attending Back Up ................................................ 1908
Trauma Chief ...................................................................... 1560
Trauma Consult Day ........................................................ 1297
Trauma LIP Acute Care.................................................... 1450
Trauma Resident ICU....................................................... 1294
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CONTACT DIRECTORY
Contact Number PIC

Trauma Center Director,


Jeff Young, MD ...........................................284-2845............ 3462
Administrative Assistant, Amy Bunts..........982-3549

Associate Trauma Director,


J. Forrest Calland, MD ...........................242-9458............ 4425
Administrative Assistant, Amy Bunts..........982-4278

Trauma Center Manager,


Kathy Butler, RN.........................................465-0413............ 3868

Leon, Carlos Tache, MD .......................... 227-1278 ..........6151


Hennessy, Sara, MD................................ 806-1772 ..........4422
Sawyer, Robert, MD ................................ 465-5152 .........3404
Williams, Michael D., MD ........................ 465-3792 ..........3994
Yang, Zequan, MD................................... 825-2503 .........6356
Floor Attending...................................................................9520
IRPA (In-house Rescue Physician) ...................................9241

MEDCOM
Back-up line .............................................. 4-9287
Main line .................................................... 2-2000

2014-15 CHIEFS & FELLOWS


GENERAL SURGERY
Judge, Joshua..................................................................6552
Politano, Amani ................................................................4088
Rosenberger, Laura ..........................................................6635
Umapathi, Bindu...............................................................2878

TRANSPLANT
Rasmussen, Sara .............................................................2006
Mulloy, Daniel ...................................................................6557
Nagju, Alykhan .................................................................6582
UVA TRAUMA HANDBOOK 03/15 11
CONTACT DIRECTORY (cont'd from previous page)

Contact Number PIC

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)

Contact Number PIC

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

TRAUMA SERVICE NURSE PRACTITIONERS


Baker, Deborah, ACNP.......................... 962-1974 ..........4334
Bowles, Melinda, ACNP-BC.................. 465-4235 ..........2907
UVA TRAUMA HANDBOOK 03/15 13
CONTACT DIRECTORY (cont'd from previous page)

Contact Number PIC

Child, Sherry, ACNP-BC........................ 465-8083 ..........4735


Dennis, Scott, ACNP-BC....................... 760-6238 ..........7278
Ford, Gabriele, FNP-C .......................... 882-1375............ 6744
Hughes, Tracy, NP................................. 953-5234 ..........6573
Passerini, Heather, ACNP-BC .......813-731-9736 ..........3487
Robertson, Matt, ACNP-BC ................. 865-8064 ..........6822

Bed Center RN ......................................... 3-9218


Blood Bank ............................................... 4-2273
ED Attending #1, #2 ................... 531-5701 / 5702
ED back Fax ........................................... 4-1201
ED Charge Nurse ...................................... 2-0201
ED Registration Fax................................... 4-9295
LAB .......................................................... 4-5227
Neuro CNS, Dea Mahanes ...............................................3142
STIBCU CNS, Kristi Wilkins..............................................2865
STBICU Fax............................................... 4-0351
Translator .................................................. 2-1794

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
14 03/15 UVA TRAUMA HANDBOOK
CONTACT DIRECTORY (cont'd from previous page)

Contact Number PIC


CONSULTS
Acute Pain Service..........................................................1415
ENT .................................................................................1609
Orthopedics ED ..............................................................1251
Plastics- Consult ER .......................................................1518
Plastics Intern .................................................................1800
Psych Nurse Brenda Barrett ........................................6811
TCV night ........................................................................1288
Thoracic Chief.................................................................1847
Thoracic Day Consult .....................................................1847
Urology ...........................................................................1253
Vascular Day Consult......................................................1378
Vascular Chief .................................................................1818

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

Please share adult or pediatric trauma concerns promptly


(within 72 hrs) by phone, pager or email.
UVA TRAUMA HANDBOOK 03/15 15
CONTACT DIRECTORY (cont'd from previous page)

TRAUMA REGISTRY REPORT REQUESTS


Pomphrey, Michelle, RN ........................ 3-4858
Downing, Sera ....................................... 4-1770

Extensive adult and pediatric injury data are available.


Please allow 7 business days for report generation.

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

CHIEF TO CONTACT ATTENDING TO:


Call Attending if there is:
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
Any major conflict with Consult service
Cardiac, respiratory arrest
Any complication of procedure or consult procedure
Death (if not DNR)
AND
Within 30 minutes of Beta Alert
With all admissions and consults

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
18 03/15 UVA TRAUMA HANDBOOK

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)

8. Tx all patients on ASA/Plavix with pooled donor platelets if


any of the following apply:
N/V
Positive LOC
AMS
9. The surgical critical care fellow / resident may take in-
house call as the SIRPA, but will not be the trauma at-
tending of record. As such, the fellow may take the first
call from the in-house chief but must notify the trauma at-
tending of all admissions and planned procedures / inter-
ventions in a timely fashion that acknowledges standard
acceptable attending involvement for disposition (within
2 hours of consult) or as soon as possible / immediately
upon the moment when the patient meets alpha criteria.
10. Any bad ABG must be repeated or treated with intubation.
11. Blood Alert early activation of massive transfusion process
may improve survival. Remember calcium, bicarbonate and
warming patient. Call 4-2012 to activate. All patients re-
ceiving blood in the ED for hemorrhage/hypotension in the
ED should ALSO receive Trenexemic acid if within 3 hours
of injury.
12. Simultaneous craniotomy / thoracotomy / laparotomy is
possible.
13. Thoracic hemorrhage >1.5 liters must receive expeditious
operative therapy.
14. Bleeding scalp lacerations consider early whip stitch
instead of staples. General Surgery PGY >2 to perform.
15. Patients with any combination of severe epigastric pain,
amylasemia / lipasemia (wait 4 hours after admission be-
fore drawing) and peri-pancreatic fluid and / or suspicion
of pancreatic injury must either under MRCP +/- secretin
stimulation or laparoscopy / laparotomy with cholecysto-
pancreatogram (mix iv contrast 1:1 with methylene blue)
conducted transhepatically into GB with > 18g needle and
fluoroscopy. Examine pancreas for methylene blue extrav
after fluoro for duct disruption. THEN, consider drains
around pancreas for minor leak or distal pancreatectomy
for ductal transection.
16. If initial chest CT positive for aspiration, bronch pt.
20 03/15 UVA TRAUMA HANDBOOK
TRAUMA SURGERY SERVICE PEARLS (cont'd from previous page)

17. Interventional radiology / embolization may be an accept-


able treatment modality for hypotensive patients with hem-
orrhage 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.
18. All PEGS in patients on the TRAUMA SERVICE are to
be sewn into place at the time of placement WITHOUT
EXCEPTION.
19. King Airway: If oxygenating well, adequate Sats leave in
place until after CT.
20. SPECIFIC necessity to maintain central venous and urinary
catheters must be documented DAILY in the progress notes.
21. Consider removing one line or tube daily on patients who
are improving.
22. All central venous catheters and arterial lines from outside
hospitals (or that were placed in the trauma bay under ques-
tionable aseptic technique) must be replaced within 48 hours
of admission by A FRESH STICK they may no longer
be rewired!!
23. If a TLSO is ordered, it must be on before standing pt
upright
24. 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 evalua-
tion assessing for reports of pain.
25. Penetrating trauma initial assessment roll early! Mark all
wounds.
26. Operative Treatment of Abdominal Hemorrhage if you
pack it, squirt it.
27. All patients undergoing major operative procedures with
anticipated post-operative LOS > 48 hours shall have their
PCA / CADD remain in place for at least 24 hours unless
the end of this 24 hour period falls after 3 PM, in which
case the CADD pump should be left on until the next day
to avoid pain control problems overnight during periods of
low staffing.
28. In general use of benzodiazepines in patients with natural
airways is discouraged, especially in the elderly. Consider
Haldol for delirium instead.
UVA TRAUMA HANDBOOK 03/15 21
TRAUMA SURGERY SERVICE PEARLS (cont'd from previous page)

29. 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.
30. Start antibiotics on ALL patients with > 2 SIRS criteria AND
new organ dysfunction or hypotension.
31. Consider platelet function testing in asymptomatic pts.
and GCS >14 if taking ASA/Plavix.
32. Attending shall be notified of all planned DNR discus-
sions before they occur and afterwards if such occur in
impromptu fashion.
33. All advance directive/DNR discussions should be carried
out with an attending present or with immediate attending
notification after such conversations have occurred.
34. SIRPA will round at the bedside with the on call resident
overnight by 11 PM on all trauma patients designated as
level A by their primary physician team or STBICU nursing.
35. All calls that need escalation of care to the attending lev-
el for patients that existed on the trauma service prior to
1900 shall be directed to the Service Attending rather than
the SIRPA between 1900 and 0700.
36. Ophthalmology consult is needed for orbital wall frac-
ture, obvious injury to eye, pain on exam, visual changes
(changes in visual acuity, double vision, floaters) and for
facial/periorbital burns.
37. Trauma attending accepts trauma transfer patch-in calls if
the ED attending is delayed more than 30 seconds.
38. Key physical exam findings should be demonstrated
during bedside sign-out.
39. Do not copy forward the previous days note unless you can
be certain that the outdated portions have been deleted.
40. ALL trauma patients shall have a .tricutransfer note com-
pleted in EPIC prior to transitioning to the acute care (ward
/ floor) service.
41. 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 im-
mediately 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 dis-
22 03/15 UVA TRAUMA HANDBOOK
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

TRAUMA ALERT CRITERIA


Any conflict with other teams during an alert must be
communicated immediately to the attending on-call
or Dr.s Young, Calland.
Adult ALPHA Alert Criteria (16 y.o.)
I. Airway / Breathing:
1. All intubated patients transported to UVA directly from
the field.
2. All other patients with ongoing respiratory compromise
or those in need of an emergent airway.
a. Includes intubated patients transferred from another
facility with ongoing respiratory compromise. (Does
not include patients intubated at another facility who
are now stable from respiratory standpoint.)
II. Circulation:
1. Two consecutive BP readings of < 90
2. Trauma transfer patients from OSH requiring blood to
maintain vital signs.
III. Disability:
1. GCS < 9 with trauma mechanism
IV. Mechanism / Injury:
a. GSW to neck, thorax or abdomen or to extremities
proximal to knee or elbow.
V. EM or Trauma Service physician discretion

Adult BETA Alert Criteria (16 y.o.)


Residents must contact Attendings within 30 minutes of
Disposition Plan
Any alert can be upgraded at any point until the patient is
admitted into the STBICU
I. Airway / Breathing:
1. Intubated inter-facility transfer patients without ongoing
respiratory compromise.
2. Facial burns or singed facial hair with altered phonation,
especially in the setting of thermal injuries within an
enclosed space, i.e. house, car, etc.
II. Circulation:
1. Relative hypotension: SBP > 90 but < 100 mm hg
2. BP < 110 mm hg in > 65 y.o.
UVA TRAUMA HANDBOOK 03/15 25
TRAUMA ALERT CRITERIA (cont'd from previous page)

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

Adult GAMMA Alert Criteria (16 y.o.)


I. Disability:
1. Head trauma occurring in patients w/normal GCS receiv-
ing pre-injury therapeutic anticoagulants. (LOC, visible
injury above clavicles, or high energy mechanism of injury
page 27)
2. Patients GCS 15 or at baseline GCS with intracranial
blood present on inhouse CT, including patients with
ground level fall mechanism.
II. Mechanism / Injury:
1. Time-sensitive extremity injury, including all partial and full
thickness circumferential extremity thermal injuries.
2. All Trauma Service Consults not addressed by higher
level criteria.
3. Significant solid organ injury (e.g., known spleen or liver
laceration)
26 03/15 UVA TRAUMA HANDBOOK
TRAUMA ALERT CRITERIA (cont'd from previous page)

4. Stable severe system injury (low energy pelvis fracture)


5. Operative therapy anticipated/planned by sub-specialty
service
6. Severe pain in chest, abdomen, neck or back not clearly
due to medical illness
7. Two or more organ systems/body areas significantly
injured
8. Moderately injured (long bone/spine fracture) with
severe medical co-morbidities such as CHF, cirrhosis,
COPD, dialysis
9. Time-sensitive extremity injury
10. Early pregnancy with abdominal pain/signs of abdomi-
nal trauma
11. Major acute fractures to the anterior column (vertebral
body) resulting from falls and other modes of decelera-
tion/force
12. All patients with high risk mechanism of injury, as noted
on pg 27
13. All Multi-trauma/severe injury inter-facility transfers
(unless meets alpha/beta criteria)
III. Burns:
1. Partial thickness or full thickness burns > 18% total body
surface area (TBSA).
2. Electrical Burns, including lightning strikes
3. Burn injuries in patients with severe preexisting medical
comorbidities
4. Any patient with concomitant trauma (such as fractures)
and thermal injury
5. EM or Trauma Service physician discretion.

Burn/Plastics Consult (Discretionary Trauma Consult)


1. Burns to the face (without altered phonation or respiratory
compromise)
2. Burns to the hands, feet, genitalia / perineum, or major joints
3. Chemical burns
UVA TRAUMA HANDBOOK 03/15 27

HIGH RISK MECHANISM OF INJURY


Falls
adults: >20 feet (one story = 10 feet)
children: >10 feet or two to three times the height of the child
Automobile versus pedestrian/bicyclist thrown, run over, or
with significant (>20 mph) impact; or
Motorcycle / ATV crash >20 mph
Motor vehicle collisions
Ejection from vehicle
intrusion, including roof: >12 inches occupant site; >18 inches
any site
Bent steering wheel (driver)
Fatality in same vehicle
Prolonged extrication (>20 minutes)
Vehicle telemetry data consistent with a high risk for injury
Electrical injuries

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

TRAUMA ALERT PROCESS


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
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)

King Airway: If oxygenating well, adequate O2 Sats - leave in


place until after CT

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.

DISABILITY NEUROLOGICAL DEFICITS


Assess neurologic status (GCS) and extremity movements,
sensation x 4

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)

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 respi-
ratory therapist may initiate advanced airway management.
In these situations, the physician or other credentialed pro-
vider 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 definitive
airways immediately if problems with oxygenation or ven-
tilation. Otherwise, they may be converted when patient
arrives in OR or ICU
10. 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 hem-
orrhage) should initiate immediate thoracic surgery consult
and transfer to OR.
UVA TRAUMA HANDBOOK 03/15 35

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

TRAUMA PRACTICE GUIDELINES ADULT

ABDOMINAL PENETRATING TRAUMA


GUIDELINE

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

Appropriate pharmacologic regimens:


1. Gradual titration of benzodiazepines / narcotics
(no boluses!!)4

If inadequate response to gradual increase in sedation, then:

2. Labetolol gtt +/- nicardipine gtt as needed or, Esmolol gtt


+/- nicardipine gtt as needed

1 See High Risk Mechanism of Injury Criteria on Page 27.


2 If extravasation present, prepare for emergent thoracotomy.
3 Use these parameters with caution in patients with severe closed
head injury and elderly patients with a medical history of poorly
controlled hypertension.
4 Patients with actual (or potential for) severe injuries who are not
intubated should NOT, in general, receive conscious sedation.
UVA TRAUMA HANDBOOK 03/15 39

BLOOD ALERT
MASSIVE TRANSFUSION PROTOCOL
A. INDICATIONS
Blood Alert should be activated if blood administered:
prior to arrival
In UVa ED

1. Trauma patient with suspected or known clinical massive


hemorrhage. (The patient is likely to bleed to death in the
next 15 minutes)

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)

patient care team should secure a properly labeled Blood Bank


sample as early in the procedure as possible and deliver it direct-
ly to the Blood Bank. Prompt blood typing is essential to main-
taining the availability of universal donor plasma (AB) and uni-
versal red cells (O neg) which are on limited supply. Reference:
AABB Technical Manual, 17th edition, 2011, pp 748-751, 458.

TRANEXAMIC ACID USE


FOR ADULT TRAUMA PATIENTS
INCLUSION CRITERIA:
All adult ( 16 yo) trauma patients presenting to the Emergency
Department (ED) within 3 hours of injury who:

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),
OR
Are considered to be at risk of significant hemorrhage.

Table 1. Dosing, Reconstitution, and Administration

Treatment Dose Reconstitution Infusion Rate Duration


Loading Dose 1 gm 1 gm in 100 ml NS 600 ml/hr 10 minutes
Maintenance Dose 1 gm 1 gm in 250 ml NS 31.3 ml/hr 8 hours

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.

CRASH-2 protocol. http://www.crash2.lshtm.ac.uk/. [Accessed


November, 2012].
42 03/15 UVA TRAUMA HANDBOOK

BLUNT MYOCARDIAL INJURY


WORKUP AND TREATMENT
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?
No Troponin/EKG Abnormal? No Routine Care
Myocardial Infarction?

Yes Yes

First line intrope for cardiogenic Admit Telemetry


shock due to blunt myocardial is Repeat 12 Lead EKG in 24 hours
Dobutamine Troponin x3 (Q8 hours)

STBICU / CCU Admission No

EKG
Echo (STAT if hypotension)
now Normal?
Cardiology Consultation
Troponins < 0.05?

Yes

No further workup
UVA TRAUMA HANDBOOK 03/15 43

BLUNT THORACIC TRAUMA


PRACTICE GUIDELINE
RETAINED HEMOTHORAX:
All patients with retained hemothorax should be aggressive-
ly drained with a combination LARGE CALIBER straight and
Right-angle chest tubes as soon as such conditions are appre-
ciated 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 seg-
ments and respiratory compromise1 who are otherwise good
candidates for epidural analgesia should have epidurals cathe-
ters 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.
May also consider extra-thoracic catheter insertion and
continuous intercostal nerve block for pain control with the
On-Q Pump. See Trauma Rib Fracture protocol. Discuss with
Dr. Calland or Dr. Young for insertion.

1 Incentive Spirometry < 18 ccs / kg IBW/sec


2 See Epidural / Analgesia Guideline for Trauma Pts with Rib Fxs
44 03/15 UVA TRAUMA HANDBOOK

BRAIN TRAUMA ALERT


Injured inpatient (or at OSH) with head CT results available

Epidural hematoma present? If YES,


- Is Volume is greater than 30 CM3?
- OR: is GCS < 9 with thickness > 15 mm?
- OR: is GCS < 9 with > 5 mm shift?
Suggested paging data:
pt name and MRN
pt age, gender
Yes patient location
No
GCS
EDH, SDH or IPH

Subdural Hematoma present? If YES,


- Is there > 10 mm thickness or >5 mm shift?
Yes
- Or, recent negative change in GCS of > 2 pts?
- Or, patient recently developed anisocoria? Whomever first appreciates
- Or, ICP been > 20 mm Hg for > 15 minutes? that American Brain Trauma
Foundation Criteria have been
met (indicative of the potential
need for future operative
intervention) shall immediately
No call 4-2012 and initiate:

Brain Trauma Alert

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

Standard Care/Trauma Alert as indicated by other injuries


and / or physiology
UVA TRAUMA HANDBOOK 03/15 45

BLUNT CEREBROVASCULAR INJURY

Pt. w/ BCVI (eg. Occlusion of narrowing of


carotid/vertebral)

Consider heparin gtt


Pt. w/ other injuries @
and consult
high risk for bleed- No
Kenny Liu (2217) or
hemorrhage?
Webster Crowley
(6542)

Yes

Consult
Kenny Liu (2217) or
ASA ok? No
Webster Crowley
(6542)

Yes

Begin ASA 81 mg po/pv


46 03/15 UVA TRAUMA HANDBOOK

CHEST TRAUMA -
PENETRATING CENTRAL WOUND
Trajectory between nipples,
sternal notch, xiphoid
or transmediastinal *

and HR <40
Yes and/or wide No
complex?

Consider Chest tube, Tube Thoracostomy (as


pericardiocentesis, ACLS, indicated by physical
or no therapy exam / trajectory)

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

* Consider / Perform Laparotomy if trajectory uncertain or if Repeat CXR in 6 hrs


trajectory potentially passes below diaphragm 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
UVA TRAUMA HANDBOOK 03/15 47

COAGULOPATHY IN NEUROTRAUMA
Head injury with nausea, vomiting and/or AMS

*Order Platelet Function Assay in EPIC for Pt taking ASA and/or


ASA/Plavix effect available (P2Y212) Plavix?
Results available in 30 minutes

Yes

No
Administer 1-2 units pooled PLT STAT *

No

*Do not wait for INR


result before Pt taking Coumadin?
Pt taking Dabigatran? beginning FFP
infusion!!
Yes

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

Last dose > 10h No


No
ago

PTT > 40 sec? Consider Proceed with life-saving


Yes
Kcentra Yes
neurosurgical intervention
STAT
No
48 03/15 UVA TRAUMA HANDBOOK

COAGULOPATHY IN NEUROTRAUMA
ADDENDUM
Head injury with nausea, vomiting and/or AMS

Administer 1-2 units pooled PLT STAT*


On ASA or Plavix yes
(clopidogrel) *Order Platelet Function Assay in EPIC for ASA/Plavix effect
(P2Y212). Results available in 30 minutes

Send STAT INR* AND administer 2 units thawed FFP


On Coumadin? yes STAT* and Vitamin K 10mg IV
(*Do not wait for INR before beginning FFP infusion!!)

INR 1.5

Consider additional FFP 10-20ml/kg


Serious bleeding or emergent procedure: Consider Kcentra

yes Proceed
On Dabigatran? yes Last dose >24
yeshrs and eGFR normal with
(Pradaxa) Neuro-
no Surgical
Interventi
Is aPTT normal (40)? yes

no

Consider Kcentra STAT


(If serious bleeding or high risk consider rFVIIa)

On Rivaroxaban Last dose was > 24 hours


yes
(Xarelto) or Apixaban yes
no
Proceed
yes with Neuro-
Is INR normal? Surgical
Intervention
no yes

Is Anti-Xa normal?

no (anti-Xa >0.5)

Consider Kcentra STAT


UVA TRAUMA HANDBOOK 03/15 49
COAGULOPATHY IN NEUROTRAUMA ADDENDUM (cont'd from previous page)

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

On SQ LMWH If last dose <8 hours: 1 mg protamine / 100u dalteparin


yes
dalteparin (Fragmin) If last dose 8-12hs: 0.5 mg protamine / 100u dalteparin

On SQ LMWH yes If last dose <8 hours: 1 mg protamine / 1mg enoxaparin


enoxaparin If last dose 8-12hs: 0.5 mg protamine / 1mg enoxaparin

*Protamine dose range:


12-50mg IV
50 03/15 UVA TRAUMA HANDBOOK

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

*GCS < 9 = ICP Monitor

The complete Brain Trauma Foundation Guidelines are avail-


able at http://tbiguidelines.org 2006.
UVA TRAUMA HANDBOOK 03/15 51

MILD TRAUMATIC BRAIN INJURY /


CONCUSSION EVALUATION

Mild Traumatic Brain Injury:


Loss of Consciousness, concussion Symptoms, or alteration in cognition after injury

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

DEEP VENOUS THROMBOSIS


SCREENING AND TREATMENT

HIGH RISK: MEDIUM RISK:


Spinal cord injury**** Trauma service patients without any identified
Severe head injury**** high- risk factors
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)

Low molecular weight heparin, unless Low molecular weight heparin, unless
contraindicated* + SCDs + IVC filter** contraindicated* + SCDs

Bilateral lower extremity duplex [q Mon ICU, Q 7d Acute Care (floor)]

No
Positive
duplex?

Yes

Progressive or No Above knee?*** Yes Anticoagulation OK?


symptomatic?

No Yes
No

Recheck duplex q Mon. ICU Yes


Acute Care, q 7 days IVCF**
https://app.box.com/files

* Enoxaparin is contraindicated in patients with:


Chronic renal insufficiency Therapeutic Enoxaparin or
Excessive bleeding risk Heparin infusion (according to
First 24-48 hrs after SCI
institutional nomogram)
** All filters should be removeable ones in patients < 65 years old
*** The saphenous is NOT a deep vein, Assess leg daily for phlegmasia (neuro & vasc)
**** Pts w/high risk for intra-cranial or epidural bleeding from head or verterbral injuries Coumadin for 3-6 mo or
(including pts who have recently undergone spinal fixation) shall receive 5,000u Therapeautic Enoxaparin
unfractionated heparin TID approximately 24 hours after STABLE neurologic exam,
Target hep Ptt + INR
low drain output, AND/OR stable cross-sectional imaging.
Per institutional protocol
For dosing guidelines see Adult Medication References at back of manual.
UVA TRAUMA HANDBOOK 03/15 53

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

Daily assessment of bleeding


High
risk (CNS, solid organ, pelvis, etc.)

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?

High Risk for DVT


Propagating ileo-femoral DVT
despite x-coag
Spinal Cord Injury (new tetra- Yes
or para-plegia)
Severe closed head injury
(GCS < 9 with AIS-Head >3)
Major venous injury Weekly DVT Screening
Multiple/complex pelvis fx as per protocol:
>2 long bone fxs High risk for VTE Yes Place IVCF Deep Venous
Thrombosis Screening
and Treatment

No
54 03/15 UVA TRAUMA HANDBOOK

EXTREMITY TRAUMA
PRACTICE GUIDELINE

Active hemorrhage, expanding hematoma, severe ischemia*?

Reduce fracture/dislocation if present

Ischemia persists or active hemorrhage?

Yes No

Intraoperative anteriogram
Vascular repair Risk classification
+ orthopedic fixation

AAI/WWI >0.9
Pulse deficit?
No Yes

Arteriography Observation

Minimal arterial Major arterial


Normal?
injury? injury?

Observation
Observation + serial Operation
Arteriography

*Consider use of blood pressure cuff or tourniquet above site of hemorrhage.


UVA TRAUMA HANDBOOK 03/15 55

FREE FLUID -
NO SOLID ORGAN INJURY

Hemodynamically stable patient with abdominal wall contusion, seat-belt sign,


abdominal pain, positive FAST and/or high-energy mechanism of injury

Peritonitis?
YES
Exploratory Laparotomy
Marked abdominal
tenderness?

NO

Abdominal CT Scan with IV Contrast

Possible bowel injury?


Mesenteric stranding/hematoma? NO
Routine Care & Serial Exams
Fluid without solid organ injury?
Failure to correct lactate?

YES
Repeat abdominal CT Scan with IV AND 3 hours
Enternal contrast 6-10 hours after initial scans

Increase in free fluid?


NO
Worse stranding/hematoma?
Routine Care & Serial Exams
Worsening of possible bowel injury?*
Increasing LA?
*This scan MUST be reviewed
YES by the Trauma Surgeon on Call
or one of the Medical Directors
Exploratory Laparotomy within 8 hours of acquisition
56 03/15 UVA TRAUMA HANDBOOK

HEMATURIA
PRACTICE GUIDELINES

Unstable pelvic fracture*


w/gross ? Or
significant microscopic hematuria1?

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

Consider injecting 50cc contrast.


Wait 10 min and scan.

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

BLUNT HEPATIC AND


SPLENIC TRAUMA
NON-OPERATIVE MANAGEMENT
CLINICAL PRACTICE GUIDELINES

Grade I or II Grade III V


No intra-peritoneal fluid IR Embolization?4
OR if Unstable5

Admit Floor Admit STBICU

Day 1 CBC q8 X 24h Lactate, CBC q8 X 24h


(0-24 hours) Strict Bedrest2 + Hold LMWH Strict Bedrest2 + Hold LMWH
If
embolized

Day 2 CBC in AM & assess abd CBC q12 X 24h


(24-48 exam
hours) If hb stable, transfer to floor
If Hb Stable and no change and start clear liquids
in abd exam and > 24 hours
after injury: Continue strict bedrest2
Give diet and allow OOB
THEN, recheck Hb3 and Start LMWH if Hb stable
consider discharge 6 hours
after OOB

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

Obtain routine trauma


Imaging in CT #4
Is pt hemodynamically
unstable and / or have abdominal Consider obtaining
Yes
tenderness and / or a pre-imaging Beta-HCG
known pelvis fx? if not otherwise
contraindicated by
patient status.

No

Obtain routine trauma


Imaging in CT #4
Known pregnancy?
Consider obtaining
or
No pre-imaging Beta-HCG
Fetus visible on plain film/Torso
if not otherwise
Scout Images on CT?
contraindicated by
patient status.

Yes

Use CT #4

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.
UVA TRAUMA HANDBOOK 03/15 59

PELVIC FRACTURE IN
HEMODYNAMICALLY UNSTABLE
PATIENT

Primary / Secondary Survey identifies pelvic pain, tenderness,


hemodynamic instability OR patient is unexaminable

Obtain Pelvic plain film xray


Consider need for binder
Classes of Severe Perform FAST
Pelvic Fracture FYI: Do NOT repeat examination /
1. AC II or III manipulation of pelvis after X-Ray
2. LC II or III confirms severe pelvic fx
3. Vertical Shear

Severe Pelvic FX ? No Usual Care

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

Proceed with routine ICU care


Call Trauma Surgery Attending
Remove binder ONLY after clearance to
to bedside, repeat FAST,
do so obtained from ORTHO TRAUMA
consider DPL
and TRAUMA SURGERY Attending
60 03/15 UVA TRAUMA HANDBOOK

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

Observe Heparinize if possible

CTPA/LE Duplex

LE Duplex IVC filter +


No Positive? Yes
Q Mon./Tues. anticoagulation*

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

Check CK q12 hours No

CK <5000 X2 on two
<5000? Yes
consecutive q12 checks?

No
Yes

Add 100 meq Bicarb to 1 liter D5W or NS End protocol


Maintain urine output >100 cc/hr No need for further checks of
Keep urine PH >6.5* CK unless renal failure and / or
Check urine PH every 4 hours until Urine pH dark urine evolves / persists
goals are achieved and q12 hours thereafter

*Check urine PH as often as necessary to achieve this goal


62 03/15 UVA TRAUMA HANDBOOK

SPINE CONSULT SERVICE


ALGORITHM FOR PATIENTS WITH
NEGATIVE NECK CT
C-Spine CT complete

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?)

Distracting injury = patient No


cannot concentrate on exam due
Yes to pain or sedation from Collar, off, may reapply for comfort as needed
narcotics

Neck pain or Full, pain-free ROM and no


Distracting injuries? No midline No peripheral neuro deficits or
tenderness? paresthesia?

Yes No
Yes Yes

Trauma Service Clearance of Cervical Collar

High Risk Mechanism of Injury,


Flex-ex films
Obese / muscular body habitus, No Flex-ex films Yes Spine Surgery Consult
unstable?
or patient cooperation concerns?

No

Yes

Flex-ex films
C-Spine MRI No Yes Collar for comfort only
adequate?

C-Spine MRI
No
positive?

Yes Spine Surgery Consult

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

THORACIC AND LUMBAR


SPINE CLEARANCE
THORACIC & LUMBAR SPINE IMAGING COMPLETED

Obtain spine
consult and Evidence of 3 Column injury on initial
Yes
maintain flat imaging?
bedrest!!

No

Negative = no old vertebral body fx or body fx of indeterminate age

Prelim reads negative or fewer HOB to 45 degrees, update activity orders


Yes
than 3 TP / SP fractures in T / L including dc old orders
Spine?

No

Advance HOB to 30 Does risk for respiratory decline secondary to poor


degrees and pulmonary toilet exceed risk for spine instability?
obtain spine
consult
Yes
No Advance HOB to 45 degrees and
Examine patient before notify spine consultant
advancing positioning.
Patients with negative
imaging, but severe pain/
PATIENT EXAMINABLE? Examinable = GCS 15, Alert
tenderness in T/L spine Yes
should be evaluated for and NOT Intoxicated, NO
potential discogenic disease, severe midline cervical/
occult FX, or incorrect initial No thoracic / lumbar pain /
reading / missed injury on tenderness, NO neurologic
initial studies. Get patient deficits, NO paresthesias and
Final reads needed to advance
OOB and reassess during NO distracting injury (pt. can
position participate in exam)
ambulation.

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

TRAUMA ACTIVITY ORDERS

The order set/panel will guide you to specify if/when appli-


ances (C-collar, braces) should be used and if there are any
weight bearing limitations.

Level I Unstable/not imaged


No turning, logroll, or transfer except for medical necessity as
determined by LIP

Level II Anatomically grossly unstable bony or organ injury


Reverse trendelenburg to 20; no turning, log roll, or transfer
except for medical necessity as determined by LIP. Consider
early utilization of roto-rest bed.

Level III - Spine reads pending and/or known spine injury


Reverse trendelenburg to 20 ; turn q 2 hours maintaining spine
alignment using wedge positioning pillows.

Level IV Cervical injury or ligaments may not be cleared;


stable spine injury, or advancing positioning with brace support
in place

HOB 30 degrees with appliance; turn q 2 hours maintaining


spine alignment (with or without bedrest, device, wt. bearing
restrictions)

Level V no thoracic/lumbar spine injury, cervical injury or


ligaments not clearedmust wear C-collar,HOB 30, turn q
2hrs (with or without bedrest, OOB to chair, up ad lib, wt. bear-
ing rest.)

Level VI No spine injury


OOB, up ad lib as determined by PT/OT (wt bearing restrictions)
UVA TRAUMA HANDBOOK 03/15 65

SPINAL CORD INJURY:


EARLY ACUTE MANAGEMENT
Adapted from Consortium for Spinal Cord Medicine Clinical
Practice Guidelines: Early Acute Management in Adults with
Spinal Cord Injury.
1) Resuscitation
a) Monitor and treat symptomatic bradycardia (from unop-
posed 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
hypothermia)
i) Consider warm IV fluids and/or a patient-warming
device.
2) 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.
3) Diagnostic Assessments
a) Image the entire spine, and get an MRI for the known or
suspected area(s) of Spinal Cord Injury (SCI).
4) Associated Injuries
a) Screen for thoracic and intra-abdominal injury in all pa-
tients with SCI.
b) Consider placing an NG tube to low intermittent suction
for abdominal decompression.
5) Anesthetic Concerns
a) Avoid succinylcholine after the first 48 hours post-SCI.
6) 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 side-back-left
side).
66 03/15 UVA TRAUMA HANDBOOK
TRAUMATIC SPINAL CORD INJURY: EARLY ACUTE MGMT (cont'd from previous pg)

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

Perform Hx, PE, 12-lead EKG

Initial evaluation diagnostic/


suggestive of orthostatic Initial evaluation suggestive of Unexplained Syncope
hypotension/benign cause or specific anatomic/physiologic
possible suicidality? problem?
(As determined by medication (Possible arrhythmia, Aortic
history, autonomic dysfxn or stenosis, PE neurologic
single vehicle collision vs. sx, family HX syncope/sudden
stationary object, and/or death)
Toxicology screen)

Admit to telemetry or ICU AND


perform testing as indicated
by Hx/Physical Exam Age>60?
Known/suspected
Obtain appropriate consults as Review alarm history q12-24h! CVD?
Yes
indicated by findings of testing Signs/Sx of CHF?
Check troponins Abnormal ECG?

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

TRAUMATIC BRAIN INJURY


MODERATE TO SEVERE W/ GCS < 9
(REGARDLESS OF MOTOR SCORE)

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

*** chk Na +/- sOSM q4


hours, stop HTS if Na No
> 165, no mannitol if
ICP still > 20 mmHg?
sOSM > 320
Yes

No
Notify Neurosurgical and Trauma Attendings
Consider Mannitol (0.25-0.5g / kg) or HTS bolus/infusion***

No
ICP still > 20 mmHg?

Yes

Consider repeat Head CT

No
ICP still > 20 mmHg?

Yes

Consider ventriculostomy / CSF Drainage


Contact Trauma
Attending STAT and
Contact NSGY OR
No
for decompression / ICP still > 20 mmHg?
operative
Yes
intervention Optimize medical MGMT
No
ABTF Indication(s) for
decompression?
Yes
UVA TRAUMA HANDBOOK 03/15 69

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.

The clock begins at time of injury, and not at arrival


to 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 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

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)
UVA TRAUMA HANDBOOK 03/15 71

If escharotomies/fasciotomies are deemed emergent despite


alterations in the above items (other than chest for hemo-
dynamic/respiratory instability) and decision conflict arises
among the involved teams, Trauma and Plastic Surgery
Attendings should be consulted.

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

HEART RATE GOAL < 130


Avoid beta blockers first 48 hours
Boluses are to be used ONLY for hypotension, NOT low
urine output
NO diuretics during resuscitation
If persistent acidosis pH 7.25 (>12 hrs):
Reassess fluid resuscitation
Consider pulmonary artery catheter

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

Increase IVF by 20% and monitor UOP


hourly
Yes UOP < 0.5 ml /kg UOP = 0.5-1ml / kg
No
2 consecutive hours? 2 consecutive hours?

No
IVF rate > 6ml /kg / hr ?
(or 8ml/kg/TBSA/hr if inhalation injury present) Yes
No

monitor UOP hourly


UOP > 1ml / kg
2 consecutive hours?
No
Yes

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%

UOP < 0.5 ml / kg UO > 1 ml / kg


No
(>2 consecutive hrs) (>2 consecutive hrs)
Yes

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)

No CVP > 12 and


PAWP > 20?

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.

ABDOMINAL COMPARTMENT SYNDROME:


Burn patients at increased risk: inhalation injury, extensive
FT burns to the torso, and large %TBSA
Increased intra-abdominal pressure (>25mmHg)
Oliguria
Decreased pulmonary compliance
UVA TRAUMA HANDBOOK 03/15 75

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

ABG and CXR: mandatory

HYDROXYCOBALAMIN (CYANIDE KIT) Once time injection


5grams
Urine will turn dark purple. This is a common sequela of this
medication

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

PROCEDURAL SEDATION FOR


INITIAL BURN HYDROTHERAPY AND
BEDSIDE PROCEDURES
Pain Management Algorithm for Ongoing Burn Hydrotherapy and Wound Care

Maintain PCA/NCA with Yes PCA No Consider initiating PCA/NCA or


clinician boluses present? PO pain regimen

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

Procedural Sedation Algorithm Procedural Analgesia Algorithm


No
Cardiac monitor/NPO per procedure sedation protocol Cardiac monitor/NPO status NOT required
(link) unless burn patient tolerating post-pyloric feeds

Order lorazepam 1 mg IVP Yes 1st ketamine No Do not administer


(to be given 15 minutes prior administration? lorazepam
to hydrotherapy)
Unless receiving scheduled benzodiazepines

Ketamine 0.5mg/kg* IVP Yes Ketamine 0.5mg/kg* IVP


Procedure >1hr or No
(to be given immediately prior to (to be given immediately prior to
>0.75mg/kg ketamine
start of debridement) start of debridement)
needed?
*Ideal body weight *Ideal body weight

Yes Reassess pain every 15 minutes and Yes Pain


Pain
controlled? continue PCA/NCA as previously ordered controlled?

No No

Repeat ketamine Repeat ketamine 0.25 mg/kg*


0.25 mg/kg* IVP Patient/clinician IVP x1 dose only
*Ideal body weight satisfied with pain *Ideal body weight
regimen?
Yescontinue same algorithm

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 PLANNING - PATIENT


WITH ACUTE RESPIRATORY FAILURE
PRACTICE GUIDELINES
EARLY EVALUATION: Should occur at day 5.
Consider trach within 1st 48 hours injury in pts. with severe
thoracic trauma that also have:
Multiple rib fractures OR
Pulmonary contusions AND especially in patients with spinal
cord injury OR patients with pre-existing severe lung disease
and respiratory embarrassment
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 im-
provement 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.
82 03/15 UVA TRAUMA HANDBOOK

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)

5. Inner cannula care:


Replace disposable inner cannula daily or more frequently
if indicated.
Clean and replace non-disposable inner cannula every
shift or more frequently if indicated.
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 manufac-
turers guidelines and resume trach collar / T-piece with
humidification. HME (heat moisture exchange) is not rec-
ommended.
Supplemental O2 (not to exceed 6 LPM) may be delivered
through the speaking valve.
Notify RT to assess patient if oxygen requirements ex-
ceed 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, appro-
priately 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 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.

Origin: Oxygen Therapy Workgroup Approved: Pt Care Committee 08/07


84 03/15 UVA TRAUMA HANDBOOK

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 PARALYSIS TRIAL


PRACTICE GUIDELINE
1. Consider neuromuscular blockers (NMBs) 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. NMBs should be given only if the patient is dyssynchronous
with the ventilator, is having frequent oxygen desaturations,
and is unresponsive to increasing sedation.
5. Patients must be adequately sedated (RASS-5) and receiv-
ing continuous analgesia prior to initiating NMBs.

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)

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
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, sup-
ported at forehead and chin. Ensure that the patients depen-
dent 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 lift-
ing 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.
UVA TRAUMA HANDBOOK 03/15 87

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

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
88 03/15 UVA TRAUMA HANDBOOK
ARDS PATIENTS VENTILATED STICU CRITERIA (cont'd from previous page)

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.
UVA TRAUMA HANDBOOK 03/15 89

ECMO CLINICAL PRACTICE GUIDELINE:


ARDS WITH REFRACTORY HYPOXEMIA
PATIENT POPULATION
Potentially reversible severe ARDS with
1) refractory hypoxemia (paO2:FiO2 < 80 mmHg)
2) uncompensated respiratory acidosis (pH < 7.15)
3) excessively high plateau pressures (> 35 45 mmHg)
despite best conventional management.

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.

CESAR TRIAL ENTRY CRITERIA


Murray LIS 3.0 or greater
PaO2:FiO2 < 80 mmHg

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)

ECMO PROTOCOL FOR ARDS


Consult TCV Thoracic Fellow on call (PIC #1847) AND Jay
Isbell (PIC #3167)
Transfer to Thoracic-Cardiovascular ICU for ECMO
Venovenous ECMO via bicaval dual lumen cannula
ECMO adjusted to maintain arterial oxygen saturation levels
75-85% and arterial carbon dioxide tensions between 30
and 45 mm Hg Lung protective mechanical ventilation during
ECMO: respiratory rate of 5-10 breaths per minute, Vt 4-6
ml/kg IBW, peak inspiratory pressure of less than 30 cm H2O
(ideally 20-25 cm H2O), positive end-expiratory pressure of
10 to 15 cm H2O, and fraction of inspired oxygen (FIO2) of 0.3
Ultrafiltration for management of volume overload
Vasopressors for management of hypotension
Heparin anticoagulation goals: ACT 180-220. (In setting of
active bleeding, ACTs can be decreased to 160-180 with ap-
proval of supervising TCV surgeon)
Blood product transfusions parameters: maintain Hct 30%;
plt >50,000, or >80,000 if active bleeding)
Wean ECMO when ARDS begins to improve: increase in lung
compliance, improvement in CXR, and stable on convention-
al lung protective ventilation

COMPLICATIONS OF ECMO IN ARDS


Vascular access complications
Pulmonary hemorrhage
Intracranial hemorrhage or infarction (~10% in ARDS)
Other bleeding (total bleeding complications ~ 50% of
patients)
Thromboembolism
HIT, DIC, hemolysis
Complications of blood product transfusions
Infections
UVA TRAUMA HANDBOOK 03/15 91
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.

Noah MA, et al. Referral to an Extracorporeal Membrane


Oxygenation Center and Mortality Among Patients With
Severe 2009 Influenza A(H1N1). JAMA 2011;306(15):1659-
1668. Age range 28-46 years.

ANZ ECMO Influenza Investigators. Extracorporeal Membrane


Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory
Distress Syndrome. JAMA 2009. Age range of patients 26-
43 years.

Brodie D, et al. Extracorporeal Membrane Oxygenation for


ARDS in Adults. NEJM 2011; 365:1905-1915.

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

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 commu-
nications, include severity of condition and potential
consequences for leaving AMA
Discharge plans designed to ensure the safest possi-
ble 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
UVA TRAUMA HANDBOOK 03/15 93
ADULT MEDICATION REFERENCES (cont'd from previous page)

CARDIOVASCULAR EVALUATION
PERIOPERATIVE

Patient scheduled for


surgery with known risk
factors for CAD
MACE = Major Adverse Cardiac Events.
(Step 1)
MET= metabolic equivalents (METs) One MET equals the
oxygen consumption of a 70-kg, 40-year-old man in a
resting state.
Can take care of self, such as eat, dress, or use
Clinical risk stratification the toilet (1 MET)
Emergency? Yes
and proceed to surgery
Can walk up a flight of steps or a hill (4 METs)

No Can do heavy work around the house such as


scrubbing floors or lifting or moving heavy
furniture (between 4 and 10 METs).
ACS? Evaluate and treat
Yes Can participate in strenuous sports such as
(Step 2) according to GDMT*
swimming, singles tennis, football, basketball, and
skiing (>10 METs)
No

Estimated perioperative risk of MACE based


on combined clinical/surgical risk (Step 3)

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

Balloon Bare-metal Drug-eluting


angioplasty stent stent

<14 days? >30-45 days? >365 days?


No Yes No Yes

Yes No

Delay for Proceed to Delay for Proceed to


elective or the operation elective or the operation
nonsurgent room with nonsurgent room with
surgery aspirin surgery aspirin

Http://content.onlinejacc.org/cgi/content/full/50/17/e159
UVA TRAUMA HANDBOOK 03/15 95

CLINICAL BRAIN TRAINING TOPICS


www.clinicalbraintraining.com

HOW TO BECOME A BETTER CLINICIAN


1. After All this Work Why arent patients safer?
2. What is logical risk assessment and what is paranoia
3. Weak Signals and Managing the unexpected
4. Entropy, or, why it's so hard to get people to follow guide-
lines
5. Transforming clinical operations lessons from firefighting
6. Obtaining proficiency in low frequency high stress
situations
7. Training cognitive practical tactical
8. Saving the patient or saving the resources
9. Safety and risk assessment
10. The ideal medic or medical stuent or nurse of clinician
11. Calling for help
12. Practice makes better
13. Dealing with uncertainty in the middle of the night
14. Medical decision making lecture at Virginia society of
respiratory care
15. Measuring your performance
16. Misperception and clinical
17. Medical Students lecture

HOW TO HANDLE CLINICAL INCIDENTS AND


AVOID ERRORS
1. Minimizing explanations for patients problems
2. Dealing with uncertainty in the middle of the night
3. Case presentations on hemothorax & GI bleed
4. Calling for help
5. Crashing what to do when your patient is suddenly the
sickest patient in the house
6. Kobisyashi Maru wiki it if you dont know what it is
7. Mistakes
8. When the little things can mean something with Tom
Joyce
96 03/15 UVA TRAUMA HANDBOOK
CLINICAL BRAIN TRAINING (cont'd from previous page)

9. Sick or not sick. That is the question


10. Active Shooter MCI Discussion with Tom Joyce and
Tom Berry
11. MCIs and Disasters
12. Clinical Incident Command System

DEALING WITH SPECIFIC CRITICAL CARE ISSUES


1. Abdominal Pain
2. Hypotension
3. Burns
4. Crashing: Hypotension
5. Respiratory failure and mechanical ventilation
6. Crashing: Mental status
7. Hypotension
8. Sepsis
9. Respiratory Failure 2
10. Critical Care: Surveillance is the key

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)

INTRODUCTION TO ICU CARE


1. New paradigm for ICU presentations
2. Presenting patients
3. Securing the airway and other heart stopping procedures
4. Training cognitive: Practical tactical
5. Hypotension 1 & 2
6. Burns
7. Complex airway issues
8. Sepsis
9. Shock
10. Respiratory failure 1 & 2
11. Airway comes first
12. Making logical presentations in the ICU

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)

20. Why 10 Years of quality effort in medicine have so little to


show
21. Hyperurgent hospital communications
22. Handoffs
23. Newest Video from Orange County Fire EMS: Hospice,
and Palliative Care
24. Training: Cognitive, Practical, Tactical
25. Critical Care Airway and Breathing Emergencies
26. The Future of EMS Hospital Integration
27. FDNY Buff Trip
28. Time Travel and Recognition and Primed Decision Making
29. Command in the Field
30. Why There is No Magic in Wizard System
31. Offense and Defense in Clinical Care
32. How to Herd Cats: Youve Got the Job, Now What?
33. How to Herd Cats: Interview with Chief Dan Eggleston,
Albemarle County Fire and Rescue
34. How to Herd Cats Part 1: Leading Clinical Services
35. When the Little Things Can Mean Something with Tom
Joyce
36. After all this work, why arent patients safer?
37. Basic Principles Reinforced
38. Whats the Worst That Can Happen?
39. System Resilience: Where are the points in your system
where a single bad decision by a single person can affect
outcome?
40. Transforming Clinical Operations: Lessons from
Firefighting Part 1 & 2
41. The Future of Paramedicine Part 1 & 2
42. Too much Safety?
43. Obtaining Proficiency in Low Frequency High Stress
Situations
44. Mistakes
45. How do we teach people to function effectively during
emergencies?
UVA TRAUMA HANDBOOK 03/15 99

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.

FOR SPLEEN & HEPATIC INJURIES:


No contact sports
No strenuous exercise

TRANSITIONAL CARE HOSPITAL


The Transitional Care Hospital at the University of Virginia
provides Long Term Acute Care (LTACH) 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 (LTACH) 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 LTACH referral with family
Call Social Work
100 03/15 UVA TRAUMA HANDBOOK

DISCHARGE SUMMARY GUIDELINES


Discharge summaries must be dictated before residents ro-
tate 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 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.

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 pa-
tient 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 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)

PAST MEDICAL HISTORY:


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:


Primary reason for admission such as: rule out head injury, or
treatment of splenic lac. NOT: multi trauma

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.

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.


102 03/15 UVA TRAUMA HANDBOOK

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)

Most of the APS attendings acknowledge that they serve as a


back-up to the in-house overnight team and in certain circum-
stances could be called in to facilitate epidural placement.
B) If epidural catheter placement is not feasible, second-line
alternatives to epidural catheter placement include:
1) Threading an epidural catheter adjacent to an existing
chest tube, for the instillation of up to 20 mL 0.25% bupi-
vacaine 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.
2) Paravertebral blocks and/or catheters may be placed, as
the expertise of the Departmental staff increases
3) Separate intercostal nerve blocks can provide temporary
benefit when only 4-5 levels are involved.

**** Patients with high risk for intra-cranial or epidural bleeding


from head or vertebral injuries (including patients who have
recently undergone spinal fixation) shall receive 5,000u
unfractionated heparin TID approximately 24 hours after
STABLE neurologic exam, low drain output, 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 femur ORIF (not femoral nailing)
SUPERFICIAL VENOUS THROMBOSIS:
Cephalic and saphenous vein thrombosis are NOT deep vein
thrombosis should be followed with ultrasound and NOT anti-
coagulation
For dosing guidelines see Adult Medication References at
back of manual.
104 03/15 UVA TRAUMA HANDBOOK

INJURY SCALES

DIAPHRAGM INJURY SCALE


Grade* Description of Injury 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.


UVA TRAUMA HANDBOOK 03/15 105

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 multi-local 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
106 03/15 UVA TRAUMA HANDBOOK
HEART INJURY SCALE (cont'd from previous page)

Grade* Description of Injury ICD-9 AIS-90


Blunt or penetrating cardiac injury with aortic
mitral valve incompetence
Blunt or penetrating cardiac injury of the right
ventricle, right atrium, or left atrium
IV Blunt or penetrating cardiac injury with proximal
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 multi-


ple chamber involvement. From Moore et al. [3]; with permission.
UVA TRAUMA HANDBOOK 03/15 107

KIDNEY INJURY SCALE


Grade* Injury Type Description of Injury ICD-9 AIS-90
I Contusion
Microscopic or gross hematuria, 866.01 2
urologic studies normal 866.11 2
Hematoma Subcapsular,
nonexpanding without
parenchymal laceration
II Hematoma Nonexpanding perirenal 866.01 2
hematma confirmed to renal 866.11
retroperitoneum
Laceration <1.0 cm parenchymal depth of 866.02 2
renal cortex without urinary 866.12
extravagation
III Laceration <1.0 cm parenchymal depth of 866.02 3
renal cortex without collecting
system rupture or urinary
extravagation
Laceration Parenchymal laceration 866.12 4
extending through renal cortex,
medulla, and collecting system
IV Vascular Main renal artery or vein injury 4
with contained hemorrhage
V Laceration Completely shattered kidney 866.03 5
Vascular Avulsion of renal hilum which
devascularizes kidney 866.13 5

* Advance one grade for bilateral injuries up to grade III

www.aast.org
108 03/15 UVA TRAUMA HANDBOOK

LIVER INJURY SCALE


(1994 REVISION)

Grade* Injury Type Description of Injury ICD-9 AIS-90


I Hematoma Subcapsular, <10% surface area 864.01 2
864.11
Laceration Capsular tear, <1cm 864.02 2
parenchymal depth 864.12
II Hematoma Subcapsular, 10% to 50% 864.01 2
surface area intraparenchymal 864.11
<10 cm in diameter
Laceration Capsular tear 1-3 parenchymal 864.03 2
depth, <10 cm in length 864.13
III Hematoma Subcapsular, >50% surface area 3
of ruptured subcapsular or
parenchymal hematoma;
intraparenchymal hematoma
> 10 cm or expanding
Laceration >3 cm parenchymal depth 864.04 3
864.14
IV Laceration Parenchymal disruption involving 864.04 4
25% to 75% hepatic lobe or 864.14
1-3 Couinauds segments
V Laceration Parenchymal disruption involving 5
>75% of hepatic lobe or >3
Couinauds segments within a
single lobe
Vascular Juxtahepatic venous injuries; 5
ie, retrohepatic vena cava/central
major hepatic veins
VI Vascular Hepatic avulsion 6

* Advance one grade for multiple injuries up to grade III


UVA TRAUMA HANDBOOK 03/15 109

LUNG INJURY SCALE


Grade* Injury Type Description of Injury ICD-9 AIS-90
I Contusion Unilateral, <1 lobe 861.12 3
861.31
II Contusion Unilateral, single lobe 861.20 3
861.30
Laceration Simple pneumothorax 860.0/1 3
III Contusion Unilateral, > 1 lobe 861.20 3
861.30
Laceration Persistent (> 72 hrs) air leak 860.0/1 3-4
from distal airway 860.4/5
862.0
Hematoma Nonexpanding intraparenchymal 861.30
IV Laceration Major (segmental or lobar) 862.21
air leak 861.31 4-5
Hematoma Expanding intraparenchymal 901.40 3-5
Vascular Primary branch intrapulmonary
vessel disruption
V Vascular Hilar vessel disruption 901.41 4
901.42
VI Vascular Total uncontained transection 901.41 4
of pulmonary hilum 901.42

* Advance one grade for bilateral injuries up to grade III.


110 03/15 UVA TRAUMA HANDBOOK

SPLEEN INJURY SCALE


(1994 REVISION)

Grade* Injury Type Description of Injury ICD-9 AIS-90


I Contusion Unilateral, <1 lobe 861.12 3
I Hematoma Subcapsular, <10% surface area 865.01 2
865.11
Laceration Capsular tear, <1cm 865.02 2
parenchymal depth 865.12 2

II Hematoma Subcapsular, 10%-50% surface 865.01 2


area intraparenchymal, 865.11
<5 cm in diameter
Laceration Capsular tear, 1-3cm 865.02 3
parenchymal depth that does not 865.12
involve a trabecular vessel
III Hematoma Subcapsular, >50% surface area
or expanding; ruptured
subcapsular or parecymal
hematoma; intraparenchymal
hematoma > 5 cm or expanding
Laceration >3 cm parenchymal depth or 865.03 3
involving trabecular vessels 865.13
IV Laceration Laceration involving segmental
or hilar vessels producing major
devascularization
(>25% of spleen) 4
V Laceration Completely shattered spleen 865.04 5
Vascular Hilar vascular injury with
devascularizes spleen 865.14 5

* Advance one grade for multiple injuries up to grade III.


UVA TRAUMA HANDBOOK 03/15 111

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

LISTEN TO YOUR GUT, TRUST YOUR INSTINCTS!


CALL EARLY!
112 03/15 UVA TRAUMA HANDBOOK

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 pa-


tient 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 appropri-


ate End-of-Life options for the family. LifeNet will be present, in
general, at the bedside within 90 minutes of notification. They
will page the attending or in-house trauma chief resident before
departure. LifeNet will leave a clinical note with contact infor-
mation in EPIC.

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.

The Lifenet representative will page the (in-house) Trauma


attending or chief resident before departure AND leave a
clinical note with contact information into EPIC after discerning
the patients status and formulating an action plan.

See Medical Center Policy 0098.


UVA TRAUMA HANDBOOK 03/15 113

CATASTROPHIC BRAIN INJURY GUIDELINES


Purpose: to offer management guidelines for the neurolog-
ically 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.

These suggestions must only be instituted when the Attend-


ing 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 rehy-
dration, 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 status may 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 (suction and turn every 2 hrs)
3. Respiratory treatments to prevent bronchospasm
114 03/15 UVA TRAUMA HANDBOOK
CATASTROPHIC BRAIN INJURY GUIDELINES (cont'd from previous page)

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

Source: Organ Donation Breakthrough Collaborative


http://www.organdonationnow.org/
UVA TRAUMA HANDBOOK 03/15 115

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 cu-
rative 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 set-
ting, 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 pri-
mary goal of treatment rather than cure in a person with ad-
vanced 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
116 03/15 UVA TRAUMA HANDBOOK
ASSIGNMENT OF PALLIATIVE CARE CODE (cont'd from previous page)

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.

For example, if a patient has been receiving curative care


and is transferred to another service for Hospice or Pallia-
tive 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 fol-
lowed to substantiate that palliative care was provided, and to
justify the assignment of an ICD-9-CM code V66.7 as a sec-
ondary 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
UVA TRAUMA HANDBOOK 03/15 117

OCCUPATIONAL AND PHYSICAL


THERAPY REFERRALS
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
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)

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 partic-
ipate 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.
UVA TRAUMA HANDBOOK 03/15 119

TRANSITIONAL CARE HOSPITAL


UNIVERSITY OF VIRGINIA
WHAT IS AN LTACH?
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 ad-
mission and continued stay criteria.
LTACHs provide acute services for patients who are medical-
ly complex and require a long hospitalization
LTACHs offer specialized care for a variety of conditions in-
cluding, 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
Patients who are admitted to a long-term acute care hospital
(LTACH) 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 LTACH 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
120 03/15 UVA TRAUMA HANDBOOK

Primary cardiac and /or peripheral vascular disease with co-


morbidities
Wound management requiring interdisciplinary team care
High level orthopedic conditions
Low-tolerance rehabilitation, 1-3 hours daily
Other primary medically complex condition or illness
Malnutrition requiring feeding tube or TPN, and speech therapy
intervention with swallowing techniques
Long Term Acute Care Services include:
Multi-specialty medical and surgical consultations available
Diagnostic services available
Respiratory therapy services on-site 24/ 7
Continuous cardiac monitoring
Weekly interdisciplinary team review
Medical / Surgical services with nurse staffing the same as
short-term acute care
Wound management
Daily physician rounds
LEVEL 1 TRAUMA CENTER

PEDIATRIC GUIDELINES

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
122 03/15 UVA TRAUMA HANDBOOK

PEDIATRIC TRAUMA PROTOCOLS


TABLE OF CONTENTS
PAGE
Sedation Service .................................................................. 123
Brain Injury ....................................................................124-138
Guidelines for the Management of Intercranial
Hypertension in Children with Closed Head Injury ........... 139
I. Standard Therapy for All Children ........................139-140
II. Sequential Treatment of Elevation in Intracranial
Pressure (ICP > 20 mmHg All Ages).....................132-133
III. Severe, Abrupt Elevation in ICP and/or
Manifestation of Impending Herniation ................130-131
IV. Sequential Treatment of Decreased MAP
Decreased CPP....................................................130-131

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.

These guidelines were approved for patients < 18 years of age


who are under the care of pediatric surgeons.

MAJOR CONTRIBUTIONS BY:

John Jane, Jr, MD


Associate Professor of Neurosurgery and Pediatrics

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

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 inten-


sivist 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 qual-
ified 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.
UVA TRAUMA HANDBOOK 03/15 125

BRAIN INJURY
Guidelines for the Management of Intracranial Hypertension
in Children with Closed Head Injury

Please note: These are meant to be guidelines.


No criteria, protocol or guideline can anticipate every clinical
circumstance nor are these meant to substitute for clinical judg-
ment.

COMMUNICATION AND RESPONSIBILITIES


The PICU team will be responsible for ongoing monitoring,
and for safe and expedient transport to CT scan or other im-
aging procedures. The PICU Resident and Fellow, the Trauma
Service Resident (Pediatric Surgery) and Neurosurgery Service
Resident will be responsible for administration of these guide-
lines. Deviation from these guidelines or rapid or unexpected
escalation of therapy will require notification of the Chief Resi-
dent and/or Attending Physician from each of the involved ser-
vices 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 manage-
ment 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. Patients with admission (ED or PICU) GCS < 8
2. Patients with GCS > 8 but who require operative or other
interventions that compromise evaluation of the childs neu-
rological status.
3. Patients with GCS > 8 who require intubation and sedation
for accompanying traumatic injuries and are, thus, unable to
be adequately evaluated neurologically.
126 03/15 UVA TRAUMA HANDBOOK
BRAIN INJURY (cont'd from previous page)

Guidelines for Management of Intracranial Hypertension in


Children with Closed Head Injury

Goals of therapy by age*:


Age MAP2,3 ICP1 CPP
< 2 years > 55 mm Hg < 20 mmHg > 45 mmHg
2-5 years > 60 mm Hg < 20 mmHg > 50 mmHg
>5 years > 65 mm Hg < 20 mmHg > 55 mmHg
Adolescents/ > 70 mm Hg < 20 mmHg > 70 mmHg
Adults
*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 Trende-
lenburg 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 pres-
sure (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 us-
ing Lactated Ringers or Normal Saline solution. Any ad-
ditional IV fluids should be administered in bolus form
and titrated to effect.
6. Monitor serum sodium at least every 6 hours hypo-
natremia must be avoided. Sodium falling by more than
3 mEq/L in 6 hours needs to be investigated and ad-
dressed immediately.
7. Analgesia with an initial fentanyl infusion at 1-2 mcg/kg/
hr, titrated to effect. Avoid oversedation. Additional an-
algesia (fentanyl 1-2 mcg/kg bolus) should be given for
painful procedures (laceration repair, central line place-
ment, ICP monitor placement, etc.)
UVA TRAUMA HANDBOOK 03/15 127
BRAIN INJURY (cont'd from previous page)

8. Sedation with midazolam at 0.05-0.1 mg/kg/dose q1-2


hours prn, a midazolam infusion at 0.05-0.1 mg/kg hr
may be started if prn doses are inadequate. Avoid over-
sedation. Agitation may be a sign of elevated ICP, hypox-
ia, 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 Ac-
tivated Factor VII if initial administration of FFP does not
improve coagulopathy.
12. Temperature control (< 37 C, rectal temp.). Tempera-
tures > 37 C must be brought down within 1 hour. Tem-
perature control may require acetaminophen, a cooling
blanket, fans, decreased ventilator humidifier tempera-
ture, and ice to groins and axillae.
13. Consider the initiation of prophylactic anticonvulsant
medication (Phosphenytoin preferred), especially in chil-
dren < 2 years old with intraparenchymal hemorrhag-
es on admission CT scan.1 Anticonvulsant medication
should be strongly considered for patients requiring pro-
longed neuromuscular blockade.
14. Initiate prophylactic antibiotics (cefazolin or other Staph-
ylococcal 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.
128 03/15 UVA TRAUMA HANDBOOK
BRAIN INJURY (cont'd from previous page)

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 (mid-
azolam 0.05-0.1 mg/Kg) and infusion increased propor-
tionately. 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, con-
sider lidocaine 1mg/kg IV q2 prn. Following consultation
with the PICU Fellow or Attending, may consider barbi-
turates (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 Neuro-
surgical service must be notified prior to EVD manipula-
tion. CSF drainage should be replaced cc:cc with normal
saline IV.
6. Occult seizures must be considered in cases of refrac-
tory or rising ICP. Consider emergent bedside EEG and
Neurology consultation. Consider initiation of antiepilep-
tic medications (Phosphenytoin or Phenobarbital).
7. If ICP elevation is not responsive to the above mea-
sures, give Mannitol 0.25 0.5 grams/Kg IV over 10-20
minutes. A working foley should be in place, urine out-
put 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).
UVA TRAUMA HANDBOOK 03/15 129
BRAIN INJURY (cont'd from previous page)

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, the lowest effec-
tive 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 vecuro-
nium 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 consid-
er mild hyperventilation (PaCO2 30-35) until ICP can be
controlled by other measures. Normocarbia should be
re-established as soon as other measures become ef-
fective.
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, con-
sider additional CSF drainage.
c. Decompressive craniectomy
130 03/15 UVA TRAUMA HANDBOOK
BRAIN INJURY (cont'd from previous page)

i. Can be considered immediately following injury in


severe cases of elevated ICP.
ii. Should be strongly considered for refractory ele-
vation 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
i. Some patients may be candidates for decompres-
sive 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.
ii. If decompressive craniectomy is not performed,
consider EVD placement if not already done.
a. Barbiturate anesthesiamonitor closely for hypoten-
sion and be prepared to intervene (IV fluids, vasoac-
tive 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).
a. 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 main-
tained to prevent shivering consider NMB infu-
sion.
iii. If hypothermia cannot be limited to 24 hours, con-
sider daily blood cultures.
UVA TRAUMA HANDBOOK 03/15 131
BRAIN INJURY (cont'd from previous page)

III. Severe, Abrupt Elevation in ICP and/or Manifestation of


Impending Herniation (unequal pupils, pupillary dilata-
tion or loss of reactivity)
1. Trauma Service, Neurosurgery and PICU Attendings will
be called immediately.
2. Ventilation will be immediately taken over with hand ven-
tilation 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 MAP2,3 ICP1 CPP
< 2 years > 55 mm Hg < 20 mmHg > 45 mmHg
2-5 years > 60 mm Hg < 20 mmHg > 50 mmHg
>5 years > 65 mm Hg < 20 mmHg > 55 mmHg
Adolescents/ > 70 mm Hg < 20 mmHg > 70 mmHg
Adults
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.
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 he-
matomas) is present. May also consider 1 gram/kg of
5% or 25% albumin for volume expansion.
132 03/15 UVA TRAUMA HANDBOOK
BRAIN INJURY (cont'd from previous page)

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, neuro-
muscular blocking agents, barbiturates.
7. Initiate vasoactive medications such as dopamine, vaso-
pressin, or phenylephrine.

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

SEQUENTIAL TREATMENT FOR


ICP > 20 MMHG (ALL AGES)
134 03/15 UVA TRAUMA HANDBOOK

SECOND TIER TREATMENT FOR


ICP > 20 MMHG (ALL AGES)*
UVA TRAUMA HANDBOOK 03/15 135

SEVERE, ABRUPT ELEVATION IN ICP


AND/OR MANIFESTATION OF
IMPENDING HERNIATION*
136 03/15 UVA TRAUMA HANDBOOK

TREATMENT OF DECREASED MAP


DECREASED CPP*
UVA TRAUMA HANDBOOK 03/15 137

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

PEDIATRIC ALERT OR CONSULT


UVA TRAUMA HANDBOOK 03/15 141

PEDIATRIC ALPHA ALERT CRITERIA


(< 16 Y.O.)
I. AIRWAY / BREATHING:
1. All intubated patients transported to UVA directly from
the field.
2. All other patients with ongoing respiratory compromise
(e.g., SAO2 < 90, massive maxillofacial trauma, airway
hemorrhage, stridor, or flail chest)
II. CIRCULATION:
1. Age > 12: SBP < 90 MMHG
2. Age 6-12: SBP < 80 MMHG
3. Age 2-5: SBP < 70 MMHG
4. Age 0-1: SBP < 60 MMHG
5. Pre-hospital cardiac arrest (any mechanism)
6. Patient requires fluid or blood administration to main-
tain blood pressure
7. Absence of peripheral pulses.
III. DISABILITY:
1. GCS < 9 with trauma mechanism
2. New paraplegia or quadriplegia
IV. MECHANISM:
1. GSW to neck, thorax or abdomen, or to extremities
proximal to the elbow or knee
2. Hangings, especially if any of the criteria above are
present
3. GSW or stab wound to neck, chest or abdomen
4. Two or more proximal long- bone fractures
5. Burns > 15% TBSA or inhalation injury
6. Threatened limb or complete/partial amputation proximal
to wrist or ankle
V. EM OR TRAUMA SERVICE PHYSICIAN DISCRETION
142 03/15 UVA TRAUMA HANDBOOK

PEDIATRIC BETA ALERT CRITERIA


(<16 Y.O.)
I. AIRWAY / BREATHING:
1. Intubated inter-facility transfer patients without ongoing
respiratory compromise.
2. Facial burns or singed facial hair with altered phonation
II. CIRCULATION:
1. Initial age specific hypotension stabilized after 20 CC/
KG Isotonic Crystalloid IVF.
III. DISABILITY:
1. GCS 9-13
2. Head injury / LOC with severe persistent headache,
nausea / vomiting
3. Open or depressed skull fracture, GCS > 10
4. Known fracture to a vertebral body from outside
imaging
IV. MECHANISM / INJURY:
1. Falls 10 feet or 2-3 times height of child
2. Pedestrian or bicyclist vs. Car thrown, run over or
significant > 20 MPH impact
3. Stable severe system injury (ie: Known SDH / EDH or
pelvis fracture)
4. Concomitant thermal / multi-system injury
5. Burns with TBSA 10-15% (2nd and 3rd degree burns
only)
6. High voltage electrical burns
V. EM OR TRAUMA SERVICE PHYSICIAN DISCRETION
UVA TRAUMA HANDBOOK 03/15 143

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

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 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)

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 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)

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:
a. 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 cor-
rection, 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
UVA TRAUMA HANDBOOK 03/15 149

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

Examine entire patient


Xray chest and abdomen (mark wounds)
Evaluate spine risk
Blood products
Consent
Family
Antibiotics (1.5-3 g Unasyn IV)
Tetanus
Neuro exam
Foley
NG
ICU bed? STBICU
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

Patient awake and can protect airway?


ABCs
Check pupils and motor exam
Vital signs
IV and supplemental O2
Review current meds (narcs, benzos)
Check glucose
Consider Narcan
Insure reasonable BP (do not overtreat!)
Contact senior resident
New deficits or focal findings CALL
STROKE ALERT and activate MET team
Stat Head CT (intubate if unable to answer
questions and protect airway)
ICU bed
Contact family
High Risk Checklist Fever
Need for fluid bolus to treat BP change
greater than 25% from baseline, or to
increase urine output in last 24 hours?
Increase in NG drainage, change in
character, abdominal pain, or vomiting?
Any mental status change or drop in GCS
more than one point?
Increase in WBC > 25%?
Increase in Cr > 25%?
Decrease in HCO3 > 25%?
LA > 2.5?
Any respiratory distress, increase in
respiratory rate > 25%, decrease in
baseline oxygen saturations < 90%
If so:
Notify Chief resident
Personally examine patient within 60
minutes of notification
Order CT scan (as part of workup) and ABG
Insure all tests are complete within 8 hours
of notification (or call Chief and Attending)
Transfer to monitored bed or ICU (Chief to
discuss with Attending)
High Risk Checklist UO

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

I >=O (<3 liters)


Bolus with 500 cc Saline if no signs of
pulmonary edema
No response
Contact senior resident
Lytes and CBC
UA and SG
CXR
Consider sepsis workup
Trauma Admission:
Routine Non-ICU

Discuss with Chief about plan of care


Discuss with charge nurse re: plan
Put all injuries into database
Review or call consult recs., consultant
plans/interventions
Know activity or spine clearance plan
DVT prophylaxis
Check for Rx home meds
Identify PCP
Speak with Patient and family Plan
Determine if diet possible Surgery plans?
Tertiary survey ASAP
Pain Management