Stanford Trauma Service Rev 4-05

Stanford Trauma ServiceHousestaff Manual

Housestaff Trauma ManualEmergency Medicine/Trauma 5/92, revised 11/93, 4/97, 5/01, 5/031

Table of Contents

Goals and Objectives of Stanford Trauma Surgical Rotation.............................................................................2I. Pathophysiology...........................................................................................................................................3II. Blunt Versus Penetrating Trauma................................................................................................................3Ill. General Approach to Trauma Patient...........................................................................................................41. Primary Survey............................................................................................................................................4Fig. 1 – Airway Management Algorithm.....................................................................................................5Fig. 2 Pneumothorax Algorithm..................................................................................................................6Table 1A - Glasgow Coma Scale.................................................................................................................7Table 1B - Modified Glasgow Coma Scale for Infants and Children..........................................................8Table 1C Revised Trauma Score..................................................................................................................82. Resuscitative Phase......................................................................................................................................83. Secondary Survey........................................................................................................................................9Table 2 - Secondary Survey.......................................................................................................................10A. Head Injury…............................................................................................................................................11B. Vertebral and Spinal Cord Injuries.............................................................................................................11Fig. 3 C Spine Algorithm...........................................................................................................................13C. Chest Injury…............................................................................................................................................14Table 3 - Radiographic Signs of Potential Aortic Arch Disruption...........................................................15Fig. 4 – ED Thoracotomy Algorithm.........................................................................................................16Fig. 5 – Cardiac Contusion Algorithm.......................................................................................................17Fig. 6 - Pericardial Fluid by Ultrasound After Blunt Torso Trauma..........................................................18D. Abdominal Injuries....................................................................................................................................18Table 4 - Indications for abdominal/pelvic CT scans.................................................................................19E. Peripheral Vascular Injury.........................................................................................................................20Fig. 7 – Vascular Injury.............................................................................................................................21F. Extremity Injuries......................................................................................................................................21G. Renal / Genitourinary Injury......................................................................................................................22H. Pelvic Injury…...........................................................................................................................................22Fig. 8 – Pelvic Trauma...............................................................................................................................23Table 5 – Radiographic Evaluation of Suspected Fractures.......................................................................24I. Perineal Wounds and Suspected Rectal Traverse Wounds........................................................................24J. Blood Component Therapy........................................................................................................................24K. Medications…............................................................................................................................................24L. Pediatric Trauma: Special Considerations.................................................................................................25Table 6 – Peds vital signs...........................................................................................................................25M. Burns…………..........................................................................................................................................26Fig. 9 - Rule of Nines.................................................................................................................................27 N. Unique and Special Patient Population Considerations:............................................................................28Appendix A Trauma Alert Decision Guidelines...............................................................................................29Appendix B Clinical C-Spine Clearance Guideline..........................................................................................30Appendix C Methylprednisolone Protocol for Acute Spinal Cord Injury........................................................35Appendix D Thoracic and Lumbar Spine Clearance.........................................................................................36Appendix E Guidelines for ED Resuscitative Thoracotomy.............................................................................38Appendix F Predictors of Outcome in Trauma During Pregnancy...................................................................40Appendix G Autopsy Information Form..........................................................................................................48Appendix H Referral Process of All Deaths....................................................................................................49Appendix I Brain Death Protocol.....................................................................................................................50Appendix J Brain Death SHC Administrative Manual....................................................................................51

Housestaff Trauma ManualEmergency Medicine/Trauma 5/92, revised 11/93, 4/97, 5/01, 5/032

Goals and Objectives of Stanford Trauma Surgical RotationPGY IV Resident

By completion of the rotation the resident will be 1) ATLS certified and 2) proficientin the use of diagnostic ultrasound of the abdomen for trauma. The Resident should be skilled at the evaluation,triage and treatment of multiple injured trauma patient. The details of specific organ injuries and their management will be well understood by the Resident at the end of their rotation. The Resident will performoperations on the injured patient. The Resident will increase their knowledge base by independent readings andinteractions on daily hospital rounds. Twice a month the Trauma Resident will be responsible for presenting acase at the combined Trauma/ER conference. In addition, the Resident will present a case each Mondaymorning at the Trauma/ICU conference. It is expected that the Trauma Chief Resident will learn to manage thecomplex trauma patient and deal effectively with multiple consultants, specifically emergency room physicians,neurosurgeons and orthopedists.

PGY I Resident

The PGY I residents rotating on the Trauma service should be ATLS certified prior to initiating their rotation on the Trauma service. They will respond to all Trauma alerts and will be introducedinto the process of evaluation, triage and treatment of the multiple injured patient. They will do this under theguidance of the PGY IV Resident and the Trauma Surgery Attending. They should be fully versed and capableof performing both the primary and secondary surveys on injured patients and developing a treatment plan for those patients. In addition, the first year Resident will be involved primarily in the management of Trauma patients on the surgical ward. They will be supervised by the Trauma Chief Resident and Attending. Traumaintern will be given the opportunity to be introduced to technical skills as they relate to trauma such as arterialline placement, central line placement, chest tube placement, diagnostic peritoneal lavage and placement of immobilizing splints.