P

1
I.
Overview
of the
Service
2
3
Overview of the Service
The trauma service is organized:
Attending Surgeon:
Weekday coverage for the service is weekly.
Call will begin Friday at 12 noon until the
following Friday at 12 noon. Weekend
coverage begins at 12 noon Friday until
5 p.m. Monday. Weekday call begins at
7 a.m. and ends at 5 p.m. Evening call for week-
nights will be equally distributed among the
attending surgeons.
Senior Resident on Trauma (R4):
Call begins at 7 a.m. and ends at
5 p.m., unless deemed otherwise
by the Chief Resident. Night call
will be split up according to the
general surgery call schedule.
Please refer to schedule for ap-
propriate pager number.
Junior Resident on Trauma (R1 or R2):
This resident assists the senior resident with
daily management of the trauma service from
7 a.m.-5 p.m. Night call is as described for the
Senior Resident. Please refer to call schedule for
appropriate pager number at night.
ETSU Trauma Nurse:
The trauma nurse will round with the team
Monday through Friday. Responsibilities in-
clude patient billing, assisting with discharge
planning, updating handheld patientkeeper data,
assistance in trauma clinic, coordinating
4
continuity between attendings and assisting in
research efforts. The nurse will also provide
follow-up letters to transferring facilities.
Discharge Planner:
The discharge planner will accompany the
trauma service on rounds 2-3 times per week.
On other days, the ETSU trauma nurse will
serve as liaison to the discharge planner.
Trauma Nurse Coordinator:
Attend rounds 2-5 days/week, schedule
permitting. This individual will provide feed-
back to ED nursing personnel and physicians,
and provide additional RN support in the trauma
bay when needed.
Other:
When pertinent, nutrition support, physical
therapy, speech therapy, rehab services, or other
ancillary support may attend rounds.
Trauma Review:
Trauma review is conducted once a month (the
fourth Friday each month). All deaths will be
reviewed. Interesting and/or Level I trauma
codes will also be reviewed, as well as cases
that were controversial. The senior resident on
trauma will present cases and a radiologist or
physicians assistant will be present to review
lms. All interested parties (e.g., local, EMS,
Wings, ED personnel, P.A.s) are invited to attend.
Revised: January 2004
ED Charge Nurse:
ED Charge Nurse:
5
II.
General Policies
&
Guidelines
6
7

Noties the ED staff and clerical personnel
II - Section 1
Trauma Alert Policy
The purpose of this policy is to provide the rapid,
efcient, and coordinated care of the severely in-
jured patient. A trauma alert will be activated upon
notication from pre-hospital providers that poten-
tially severely injured trauma patient is coming to
the Trauma Center.
The trauma team will be activated by the Emergency
Department Physician on duty and will consist of
three separate levels:

Trauma Alert
Unstable

Trauma Alert
Stable

Trauma Consult
Preparation
Prior to patient arrival the Emergency Department phy-
sician/ED Charge Nurse will obtain and communicate
the following information received from EMS/Medical
Control:

Estimated time of arrival

Mechanism of traumatic injury

Approximate age

Estimate of injuries

Hemodynamic status

Number of victims, if more than one
8

Instructs clerical personnel to activate the
trauma alert beeper system for Alerts

Assures the trauma bay(s) are cleared to
accept the trauma
Trauma Alert Level I - Unstable:
This will elicit the full trauma team response,
including:
1. Junior resident
2. Senior resident OR attending surgeon
3. Primary RN
4. Secondary RN/paramedic
5. Recording Nurse/Shift Leader
6. Patient Care Partner
7. Radiology Technician
8. Respiratory Therapist
9. Anesthesia and OR will be notied of
incoming patient
Duties of the above ED staff are as outlined
on the wall in the trauma bay. Residents duties
are clearly outlined in the Trauma Handbook.
Trauma Alert - Unstable Includes:
1. Systolic blood pressure < 90 mmHg
2. Penetrating injury to the head, chest,
abdomen, or proximal extremity
3. Glasgow Coma Score of < 12, or a deterio-
rating GCS
4. Traumatic amputation proximal to the
wrist or ankle
5. A patient requiring aggressive intervention
9
for airway maintenance or severe respira-
tory distress
6. Flail chest or multiple rib fractures
7. Combination trauma with burns
8. Open and depressed skull fractures
9. Open long bone fractures
10. Multiple casualties
The attending surgeon will be notied about
the patient PRIOR to arrival whenever pos-
sible and will be present in the ED as soon as
possible.
Trauma Alert Level II - Stable
For patients who are hemodynamically
stable but are potentially (based on mecha-
nism, etc.) seriously injured.
1. Glasgow Coma Score <14
2. Flail chest or multiple rib fractures
3. Two or more proximal long bone fractures
4. Open long bone fractures
5. Pelvic injuries
6. Limb paralysis
7. Injured patients transported by helicopter,
but not meeting level I requirements
8. Any patient transferred from an outlying
facility to the Trauma Service for evalua-
tion
This will elicit the same Trauma Team
Response as listed in Level I, and extra staff
will be released as quickly as is feasible. At
10
any time during this process, a Level II can be
upgraded to a Level I if further services are
required. If support personnel are not avail-
able within the ED, the resident/attending is
to query the Shift Leader for additional help.
If it is not available within the ED, the ED
Manager and/or House Supervisor should be
notied for additional support.
The trauma attending will be notied about
the patient prior to arrival whenever possible
and will be available within 30 minutes time.
Trauma Consult Level III
This is for patients who are injured but stable,
or who are already admitted to the ED and
have been evaluated by other physicians. This
will elicit an evaluation by the junior or senior
resident, with other personnel called in as
needed. Like Level II, this can be upgraded
to the higher level if deemed necessary by the
senior trauma resident/attending. The primary
nurse will be notied of this change and a
trauma alert will be activated.
II - Section 2
Divert Situations
11
On occasion, it is necessary to place the Trauma
Center on full divert or on divert based on consult-
ing service availability. When divert is necessary
because of MD unavailability, the attending surgeon
will notify the house supervisor of divert status,
reason, and expected length of unavailability. If OR
services, ICU beds or in-house beds are not avail-
able, the House Supervisor will notify the trauma
attending of status.
A full copy of the divert policy is available in the trauma ofce.
Reviewed and Approved 6/3/03 by:
Medical Director of Trauma Services Julie Dunn, M.D.
Director of Emergency Services Chris Gillespie, M. D.
Director of Emergency Services Brent Lemonds, R. N.

12
13
II - Section 3
Trauma Team Member Roles
Goal
In order to provide optimal care to trauma victims, it
is necessary to avoid confusion in resuscitative situa-
tions. Therefore, the following protocol will provide
guidelines to govern the roles and responsibilities of
the trauma resuscitation team assuring that the needs
of the trauma victim are met and performed in an or-
derly manner. The goal is assuring efcient and rapid
resuscitation, so that the patients will be delivered to
denitive care in the least amount of time possible,
thereby maximizing outcome.
Upon arrival in the ED, all residents and students
need to sign in at the dry-erase board located outside
the trauma bay. This will minimize confusion and
allow for accurate documentation. It is now required
that name tags be worn at all times. In addition, upon
arrival, if time allows, residents and students should
announce themselves and their role to the Primary
Nurse in charge of resuscitation.
It is also necessary to wear lead aprons during
trauma so as to avoid leaving the trauma bay. Protec-
tive clothing and eyewear should also be worn.
Trauma Team Leader:

Assures proper resuscitation in accordance with
ATLS Standards, performs or supervises perfor-
mance of emergency procedures, i.e., cricothyroid-
otomy, needle chest decompression, tube thora-
costomy, open thoracotomy, central venous line
insertion, peritoneal lavage, etc., and directs the
team members in the performance of their duties.
14
Trauma Team Leader (contd):

Meets EMS or Wings at the door and gets a brief
history while moving the patient to the trauma
bay. This information should include mechanism
of injury, damage to the vehicle, treatment prior
to arrival in the ED, and brief physical exam
with suspected injuries.

Performs the primary survey and reports these
ndings out loud to that the nurse scribing on
the trauma sheet and the person in charge of the
trauma H & P can document the ndings.


Calculates the Glasgow Coma and Revised
Trauma Scores and announces this to the team.


Performs, assists, or directs performance of
necessary lifesaving procedures in conjunction
with the junior resident.


Contacts appropriate consultants as needed.


If the team leader is not the attending surgeon,
contacts the attending surgeon a) prior to or im-
mediately upon arrival if the patient is unstable
or b) in the stable patient, after the initial assess-
ment is complete, including the initial survey
lms (c-spine, chest, pelvis) or c) if a stable
patient develops instability decreased level of
consciousness, increasing heart rate or bradycar-
dia, any hypotension).


Checks admission orders written by junior resi-
dent and signs verbal orders from resuscitation
area prior to patient leaving the unit.


Reviews the patients admission H & P and
assures its proper completion.


Responsible for assuring family notication and
discussing patient situation with family.
15
Junior Resident:

Performs or assists in performance of emergency
procedures on the patient as ordered by the
Trauma Team Leader, i.e., cricothyroidotomy,
needle chest decompression, tube thoracostomy,
assist with open thoracotomy, and central venous
line insertion.

Obtains blood by femoral venous stick if periph-
eral venous site is not available for phlebotomy.

Inserts orogastric or nasogastric tube. Informs
recording RN of site and size.

Inserts foley catheter after completing the rectal
exam. Informs recording RN of foley size.
(May defer to RN if he/she has completed other
responsibilities.)

When performed, assists with peritoneal
lavage or other invasive procedures at direction
of team leader.

Responsible for closure of lacerations.
Performs secondary survey and assures proper
completion of the H & P. Announces ndings so
that the recording RN may complete the trauma
ow sheet. Accompanies patient to OR, ICU, or
XRAY until life-threatening injuries are exclud-
ed and patient is hemodynamically stable.

Writes admission orders and reviews them with
the Team Leader.

Assists x-ray tech with C-spine lms if no other
help is available. Takes lms to radiologist
for review and documents the ndings on the
Trauma H & P.

Documents all radiological ndings on the
Trauma H & P preferably prior to the patient
16
Junior Resident (contd):
leaving the ED for the oor. The H & P
MUST be completed prior to the next shift
taking over the patients care.
Medical Student:
The Johnson City Medical Center is a teaching
institution, and as such medical students will
participate in the care of the trauma patient at the
Team Leaders discretion and guidance. Name
badge is to be worn at all times.
Responsibilities include:

Documenting the primary and secondary
survey as announced by the team leader and
junior resident on the trauma H & P form.

Assists or peforms placement of the orogastric
tube or nasogastric tube and foley.


May assist in drawing
femoral
venous blood
under the direc-
tion of the senior
or junior resident.

Accompanies the
patient to the OR,
ICU, xray with the
junior resident.

Assists in closing lacerations.


May help the PCP remove clothing.


Helps the PCP obtain and place warm blan-
kets.
17
Trauma Nursing Protocol
Primary Nurse:


RN assigned to Trauma 1-2.


Responsible for the patient when they arrive
in the ED until transferred out of the ED.

Remains with patient during diagnostic work-
up.

Ensures the room is stocked with medica-
tions, full oxygen tank, BP cuffs, transport
monitor, and other needed equipment and
supplies.

Establishes left arm IV if not established
PTA.

Shares tasks and responsibilities with second-
ary nurse/paramedic to ensure all procedures
are accomplished efciently.

Continuously monitors and is knowledgeable
about O2 saturations, vital signs, and IV uid
intake.

Assists with infusion of blood products as
needed.

Prepares patient for transport to CT, OR, etc,
as soon as possible.

Continuously assesses patient per ED
guidelines.

Maintains communication with patients
family.

Ensures completeness of ED record, trauma
assessment, and property record.

Ensures trauma room is restocked and ready
for the next patient.
18
Secondary Nurse/Paramedic:

Assigned by Shift Leader (preferably at the
beginning of the shift).

Support role until resuscitation and prelimi-
nary procedures are completed.

Connects patient to the cardiac monitor and
pulse oximeter.

Obtains vital signs including manual BP,
respirations, and capillary rell.

Verbalizes all readings/measurements to
recorder, but not to entire room.

Delegates removal of clothing (Medical Stu-
dent okay).

Establishes right arm IV if not established
PTA.

Obtains blood for trauma prole.

Assists with infusion of blood products.
Recording Nurse/Shift Leader:

Ensures ID bracelet is applied.

Assigns patient to trauma room and ensures
staff and room readiness.

Records data as verbalized by primary nurse
and trauma physicians on trauma ow sheet.

At end of resuscitation, asks for information
not audibly reported previously.

Manages crash cart if needed.

Is available for assistance.

Serves as the family liaison and accompanies
trauma physician when communicating with
family if requested to do so.
19

Ensures that House
Supervisor has been noti-
ed of possible trauma
admission.

Takes verbal order from
physician for admission
to specied unit and
ensures that clerk faxes
this to admitting.
Patient Care Partner:

Responsible for removing clothing if not done
by medical student.

Ensures clothing and valuables are managed
appropriately.

Labels and transports blood samples to tube
system and sends to lab.

Available to gather equipment or perform
delegated procedures. Leaves the room when
tasks are complete.
Emergency Department Attending:
Initiates the trauma alert as per established guide-
lines. Monitor resuscitation for appropriateness and
efciency of care, providing guidance as required in
physical absence of trauma attending from trauma
resuscitation area, communicating with trauma
attending as needed.
Code Delta:
This is a situation in which multiple injured patients
present to the ED and cannot be handled by the
Trauma Team alone.
20
Code Delta (contd.):
In this situation:
1. All surgical residents are to be paged to
report to the ED.
2. This should be announced overhead on
the intercom as well as pages placed to
individual residents to assure that the
message is received.
3. All attending trauma surgeons should be
notied by pager. In this situation, the
ED Physicians will also assist the triage
and care of patients.

Revised: January 2004
21
II - Section 4
Additional Resident Duties
All residents rotating on the trauma service will
be asked to abstract 5-10 charts for the National
TRACS data base. This will provide the resident an
understanding of the data essential for collection for
the state and federal government. It is requested that
this process be undertaken within the rst week of
arriving on the trauma service.
Discharge Summaries will contain the following
components:
1. Discharge Diagnoses
2. Operations Performed
3. Consultants
4. Brief Admitting Hx to include mechanism
of injury, stability upon arrival to ED, any
major resuscitative efforts undertaken.
5. Hospital Course
6. Discharge Disposition
7. Copies of the D/C summary should be
sent to all consultants and the primary care
physician, if identied.
Trauma Codes resulting in a death in the ED will be
dictated by the Senior Resident or Trauma Attend-
ing.
Deaths or Discharges from the ICU will be dictated
by the Senior Resident.
22
23
II - Section 5
Consulting Other Services
For stable traumas, the consulting services (e.g.,
neurosurgery, orthopedic surgery, OMF, etc.), will
be contacted after the primary and secondary assess-
ment is complete and lms pertaining to the injured
area are complete. When notifying these services a
1-2 sentence brief history, followed by a complete
description of the injury will be given to the consul-
tant (see below for details).
When a new junior resident is on the service, the in-
formation is best conveyed by the senior resident. As
experience evolves, the junior resident may call, but
should be supervised initially. Be sure that patients
are placed on the consultants list at the time of admit-
ting.
a.) Orthopedic Essentials:
AP and lateral lms of the injured area and
the joint above and below should be x-rayed.
Description to the consultant should include the
limb injured, location of injury (proximal, mid,
or distal shaft), type (comminuted, displaced),
open or closed, quality of distal pulses, and
nerve exam (motor and sensory). Be certain to
PALPATE the entire body to look for less obvi-
ous bony injuries. If the trauma is unstable, it
is not always possible to complete a radiologic
bony survey.
If the patient is going directly to the operating
room and there is not time for lms, it is advis-
able to notify the attending orthopedic surgeon
about joint dislocations, open fractures, or
vascular compromise.
24
b.) Neurosurgery:
In the case of a head
injury, describe location
of injury on the CT scan,
any accompanying frac-
tures, presenting and
current GCS (if dif-
ferent), and any focal
decits.
For spinal cord injuries,
describe highest level of motor and sensory
function and rectal exam.
(See appendix for motor and sensory exam.)
c.) Oral Maxillofacial:
The face should be palpated carefully for
underlying fractures. All lacerations near the
eye should be carefully screened for associated
penetrating trauma to the globe, and visual
elds checked. Deep lacerations to the cheek,
especially posteriorly, should be suspected of
involving the parotid duct and/or branches of
the facial nerve

inspected face for assym-

etry.
25
ASK-
In unclear or
equivocal situ-
ations, clarify
with Trauma
Attending.
}
II - Section 6
Trauma Alert Lab Guidelines
1. CBC
2. Chem 7
3. UA with micro
4. PT/INR
5. P.T.T.
6. ABG when applicable
7. Serum pregnancy when applicable
8. Urine drug screen
9. Blood alcohol
10. LFTs (ALT, AST, ALK, PHOS)
11. Type and Cross
all unstable patients
for 4 units
12. Type and Screen
all stable patients
26
27
II - Section 7
Use of Uncross-Matched Blood
The safest type of blood is fully cross-matched.
Unfortunately this can take up to 30-45 minutes or
longer, so often is not rapidly available.
If time is critical, O-negative blood can be adminis-
tered until blood can be typed. O-negative is mini-
mal risk, however, it does contain some antibodies
and can cause a minor transfusion reaction if given
in large quantities.
OBTAIN BLOOD FOR CROSS-MATCH PRIOR
TO TRANSFUSING O-NEGATIVE BLOOD.
If > 4 units of O-negative blood is given to a patient
with a different blood type admixture can occur
and complicate cross-matching.
In an unstable patient, type-specic blood should be
administered as soon as it is available (usually within
10-15 minutes). Type specic blood is generally safe
and preferable to giving O-negative uncross-matched
blood.
REF: Handbook of Trauma: Pitfalls on Pearls.
Ed. Robt F. Wilson Lippincott Williams. Wilkins.
Philadelphia. 1999.
28
29
III.
Clinical
Guidelines
30
31
32
III - Section 1
Prevention of Hypothermia
Due to the nature of their injury, most trauma victims
are hypothermic and are passive responders to the
ambient temperature and physics of heat loss. Nor-
mothermic injured patients have a better chance of
survival.
Discharge Summaries will contain the following
components:
1. All trauma patients are to have their
temperature assessed and recorded as a
component of their initial vital signs. If the
patient is hypothermic, (core temperature
< 97 F), warming methods are to be initi-
ated per below procedures. Temperature on
all patients is to be assessed hourly. The
trauma resident is to be informed of the
patients initial temperature, and subse-
quent deviations from the norm.
2. When a seriously injured patient is ex-
pected, the ambient temperature in the
trauma bay should be set at > 85 F or
better. This should be regulated by the
wall-mounted thermostat when the trauma
team is alerted. The primary nurse caring
for the patient should ensure that this is
performed.
3. All patients are to be fully exposed and
any wet clothing is to be removed. They
are to be covered in warm blankets and
warm IV uids are to be infused. Care
should be taken to recover them quickly
following an exam or procedure.
33
4. If the patient is hypothermic, in addition
to the above measures, the BAIR Hugger
TM
is applied after initial assessment.
a.) The BAIR Hugger blaket is placed
directly on the patient and covered
with one sheet.
b.) The BAIR Hugger blanket setting
should be per the nurses judge-
ment.
c.) The BAIR Hugger should accom-
pany the patient to CT scan.
d.) Temperature should be assessed
every 30 minutes.
5. If the patient remains hypothermic and
is ventilated, the use of the respiratory
warming coil should be considered. If
the patient requires much IV uid, use of
the Level One
TM
should be considered.
The ambient room temperature should
be set to maximum. Diagnostic perito-
neal lavage should be performed with
warm uid. All blood infused should be
warmed through the Level One infuser.
6. If the patient is going to the OR, alert
them to warm their room to maximum
ambient temperature.

34
III - Section 2
Blunt Traumatic Arrest
Did patient have signs
of life at the scene?
Signs of Life:
1. Detectable BP
2. Palpable Pulse
3. Pupillary Action
4. Respiratory Effort

Yes
Declare
Patient
Dead
Vital Signs
on
Arrival?
Total Time
in arrest
> 20 minutes

No

No Yes

Continue
Resuscitation
and Diagnostic
Evaluation

Yes
Establish Airway
Assure Air Exchange
Consider insertion of chest tube(s)
Initiate Volume resuscitation
(2 liters uid wide open)
Did signs of life return?

No
No
Consider Emegent Thoracotomy: Note that survivors of this
procedure in this situation are extremely rare and costs
extremely high. Perform this only if it is believed that there is a
reasonable possibility of successful resuscitation.
Yes
35
36
III - Section 3
Rapid Sequence Intubation
RSI/oral intubation may be performed on patients
with potential or actual airway compromise due to
depressed sensorium (GCS of 8 or less) or whose
combativeness threatens the airway, spinal cord
stability, patient or team safety. RSI/oral intubation
is also indicated in patients who demonstrate a high
probability of airway compromise during transport
for diagnostic evaluation (i.e., smoke inhalation,
severe facial trauma with bleeding) and patients who
need ventilatory assistance or airway protection.
Procedure:
1. If head injury is suspected, administer
lidocaine 1 mg per kg IV.
2. Apply cricoid pressure and hold until
placement is conrmed and cuff inated.
3. Premedicate with Etomidate 0.3 mg per
kg IV (if 10 years or older) or midazolam
(Versed) 0.1 mg per kg up to 4 mg IV.
4. Premedicate children < 10 years of age
with Atropine 0.01 mg per kg IV.
5. Administer succinylcholine (Anechine)
1.0 mg per kg over 30 seconds if no
contradictions (i.e., penetrating eye injury,
renal failure, hyperkalemia) and wait until
fasciculations stop, then perform intuba-
tion. If unable to intubate during rst 20
seconds, STOP and ventilate with BVM
for 30-60 seconds and re-attempt intuba-
tion.
37
6. If succinylcholine is contraindicated,
administer Nimbex 0.1 - 0.2 mg per kg
IV and proceed as in step 5.
7. If unable to intubate, consider cricothy-
rotomy (patients > 5 years of age).
8. Conrm tube placement by listening to
breath sounds a.) bilaterally b.) over the
epigastrium and/or CO2 end detector.
9. Secure the tube in place and obtain PCXR
to verify proper location.
10. Treat bradycardia during intubation by
temporarily halting intubation attempt
and hyperventilating patient. Consider
Atropine 0.5mg IV (adult) or 0.01 mg/kg
(pediatric).
11. Consider use of Nimbex (cisatracurium)
0.1 to 0.2 mg/kg for prolonged paralysis.
Try to time this to allow adequate neuro-
surgical evaluation of any decits.
12. Maintenance doses of sedatives and pain
relievers should be used during paralysis.
38
III - Section 4
Blunt Cardiac Injury
39
40
III - Section 5
Penetrating Abdominal Trauma
*

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41
42
III - Section 6
Blunt Abdominal Trauma
43
44
III - Section 7
Pelvic Fractures
45
46
III - Section 8
Cervical Spine Evaluation
47
48
III - Section 9
Thoracic and Lumbar Spine Injuries
49
50
III - Section 10
Urologic/Hematoria Evaluation
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c
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51
52
III - Section 11
Penetrating Neck Injuries
H
e
m
o
r
r
h
a
g
e
H
e
m
o
d
y
n
a
m
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a
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o
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d

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r
a
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l
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y
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m
a
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t
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53
54
III - Section 12
Penetrating Extremity Injuries
Hemodynamic
Instabilty
Hemorrhage
OR
Stat
STAB
WOUND
SHOT
GUN
Proximty to
Major
Vessels?
Suspicion or Development
of Compartment
Syndrome?
Admit for Obs vs
d/c w/ Clinic F/U
Local Wound Care
Measure
Compartment
Pressure
>40 mmHg?
Admit for Obs
Repair pressure
assessment as
needed
To OR for
Fasciotomy
Gunshot or other
penetrating object
Note entrance/exit sites
Obtain AP lateral x rays
Fracture?
Signs of
Vascular
Injury?*
Consult /
Admit to
Ortho
Angiography
Treat as appropriate
*Hard signs of vascular injury:
1. Distal ischemia & pain, pallor, pulselessness, paralysis, paresthesia
2. Audible bruit and/or palpable thrill
3. Lg expanding or pulsetile hematoma
4. Active bleeding
No Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
55
56
III - Section 13
Burns
1. Minor Burns:
outpatient management will
generally sufce

Second-degree burns
of less than 15% of the
body surface area in
adults.

Second-degree burns
of less than 10% of the
body surface area in
children.

Third-degree burns of 2% or less, if they do
not involve the eyes, ears, face, hands, feet
or genitalia. (See additional pages for esti-
mating percent and degree of burns.)
2. Moderate Uncomplicated Burns:
generally require hospital admission

Second-degree burns of less than 15-20% of
the body surface area in adults and 10-20%
in children.

Third-degree burns of two to 10% of the
body surface area if they do not involve the
eyes, ears, face hands, feet or perineum.
3. Major Burns:
consider referral to a burn unit

Second-degree burns of more than 25% or
more of the body surface area.

All third-degree burns involving 10% or
more of body surface area.
57

All burns that involve the hands, face, eyes
ears, feet or perineum.

All inhalation injuries.

Electrical burns.

All burns to poor-risk patients, such as those
with cardiovascular disease, chronic renal
disease, hepatic disease, alcoholism, in-
sulin-dependent diabetes, cerebrovascular
accidents with residual decits, head injuries
associated with a loss of consciousness,
severe psychiatric disabilities and enclosed
space injuries.

Patients with sickle cell disease may develop
a sickle cell crisis following a major burn.
Treatment of Burns:
1. Minor burn wounds should be cleansed and
debrided in the Emeregency Department under
the supervision of a private staff physician or
the Emergency Department physician. These
can be treated in an open or closed fashion,
with or without topical agents.
2. Factors to be considered include the area of
the body to be dressed, the depth and extent,
the home or work situation, the patients abil-
ity to care for the wound and the availability of
health care personnel to help in the home.
3. The Emergency Department physician, family
physician or surgeon can treat most minor
burns on an outpatient basis with close follow-
up.
4. Admission should be considered for any pa-
tient who, for any reason, might not be able to
cooperate with frequent follow-up visits.
58
5. Tetanus prophylaxis will be administered as
per tetanus prophylaxis protocol.
6. All patients treated as an outpatient will
receive written instructions telling them how
to care for the burn wound and when and
where they are to follow-up. (Usually with
24-48 hours.) Pain medication prescriptions as
well as prescriptions for topical agents will be
given to them at discharge as well as general
information about the signs and symptoms of
infection.
Treatment of Moderate and Major Burns:
1. Major trauma room will be set up with sterile
burn pack.
2. Personnel will wear masks, gloves, gowns and
practice universal precautions.
3. Trauma surgeon on call will be notied at the
discretion of the Emergency Department
physician.
4. The physcian will assess patency of upper
airway paying particular attention to facial
burns, singeing of the eyebrows and nasal hair,
carbon deposits and acute inammatory
changes in the oropharynx, carbonaceous
sputum and/or history of impaired mentation
and/or connement in a burning environment.
Endotracheal intubation will be accomplished
on all inhalation injuries. All others will
receive supplemental oxygen as per the Emer-
gency Department physicians orders. Equip-
ment for emergency endotracheal intubation/
tracheostomy will be immediately available.
Other indications for early intubation include
> 30% BSA.
59
5. The Emergency Department nurses will
remove all clothing and jewelry from the
patient (see Care of Patients Valuables
Policy), if not done prior to arrival in the
Emergency Department.
6. Cover burned area with clean, dry, sterile sheet
(burn pack.)
7. Place patient on cardiac monitor.
8. Initiate two large bore IVs. Avoid insertion
through burned tissue if possible. The
following guide to adequate resuscitation is as
follows: (Parkland Formula).

2-4 cc Lactated Ringers x wt (kg) x body

surface area burned = Total Amount of uid
Half of this amount is given the rst eight
hours from the onset of the burn. The
remainder is given over the ensuing 16
hours.
This is only a guide - UPOP is the ulti-
mate determinant of adequate resuscita-
tion (at least 30-60 cc/hour).
Fluid should be warmed.
9. Nurses will record and monitor patients intake
and output and record on ow sheet.
10. The physician will do a complete head-to-toe
physical exam on patient looking for any as-
sociated injuries. The physician will then com-
plete the burn estimate table and all three burn
diagrams (body, face, hands: see appendix #1).
If the face or hands are not burned, so note on
these diagrams.

The original of this document will stay with
the patients chart. A copy of the diagrams
and burn estimate table accompany the
patient to the Burn Facility along with a
60
copy of the Trauma History and Physical.
11. Nurses will record vital signs at least every 15
minutes until stable, then every hour. Howev-
er, body temperature should be recorded every
15 minutes until transfer.
12. All extremities will be evaluated for distal
circulation and escharotomy performed as
indicated. (See appendix for guidelines.)

Check for delayed capillary rell, paresthe-
sias or unrelenting pain. Doppler is the most
reliable means to evaluate distal circulation
and should be measured on an hourly basis.
13. Lab work as ordered by physician, but at least
CBC with differential, ABGs, electrolytes,
creatinine, glucose, blood urea nitrogen, blood
type and crossmatch, PT/PTT, arterial car-
boxyhemoglobin and urinalysis.
14. Twelve-lead EKG is done if indicated.
15. Consider insertion of NG tube, Foley, CVP
line and/or arterial line.
16. Chemical powders should be brushed away
before irrigation. Irrigate with continuous
water or saline for at least 20-30 minutes.
Alkali burns are generally worse than acid
burns because of deeper tissue penetration.
17. Patients with electrical burns:
Major electrical burns - These can be classied
into three categories: low voltage (< 380V)
high voltage and super-high voltage (lighten-
ing). The patient should be evaluated and for
urine myoglobin and uid administered to
maintain urine output at 100 ml/hr. If myoglo-
binuria is suspected, mix 1 (one) amp of bicar-
bonate into each liter of uid. Check urine pH
to be certain it is 7.0 or greater.
61
An EKG should be performed or patient kept
on monitor for 24 hours or until disappearance
of any dysrhythmia.
18. Cleaning and prophylaxis of wounds

Cleaning is critical: mild soap and water
generally sufce.

Tar and asphalt residues should never be
debrided. These can be removed with a mix-
ture of cool water and mineral oil.

Applying copious amounts of Polyspo-
rin over several days should emulsify and
remove residual tar.

To minimize infection, necrotic tissue from
partial full thickness burns should be re-
moved manually or with whirlpool.

Ruptured blisters should be removed.

Unroof blisters if uid is cloudy or rupture
imminent.

Management of clear intact blisters is con-
troversial.

Tetanus should be updated in patients with
2 wounds or greater.

Burns 2 or greater should receive topical
prophylaxis.
a) Silvadene should never be used

On the face.

On patients with sulfonamide sensitivity

In pregnant women, newborns or nurs-
ing mothers with infants less than two
months of age because of the risk of
sulfonamide kernicterus
b) Bacitracin should always be used around
mucus membranes.
R
62
Pain Control:
1. For non-intubated patients awaiting transfer,
Morphine 2-10 mg IV q 1 hour prn for pain
and Midazolam 1-2 mg IV q 1 hour prn and
anxiety should be administered.
2. For intubated patients awaiting transfer,
Morphine drip should be instituted at 2-12 mg/
hour accompanied by 2-12 Midazolam drip at
1 mg/hour (tilrated to decrease anxiety).
Lacrilube should be applied to the eyes.
3. For pediatric patients a waiting transfer that
might take a prolonged period of time (greater
than 1 hour) admission to PICU is an option
until transfer is completed.
Transfer of Burn Patients:
1. The decision to transfer a burn from JCMC
Emergency Department to a burn unit is made
by the physician managing the patients care.
2. American Burn Association guidelines for
consideration include patients with burns that
involve more than 25% BSA; 20% BSA in
children under 10 years of age and adults over
40 years of age; third-degree burns involving
more than 10% BSA; all burns of the face,
eyes, ears, hands, feet, fractures or other major
injury; high voltage electrical burns; inhalation
injury and signicant burns about the face, and
lesser burns in patients with signicant, pre-
existing disease.
3. Transfer will only be accomplished after the
patient has been sufciently stabilized to with-
stand the transfer (including escharotomy).
4. Record transfer in transfer log. Obtain consent
to transfer from patient or patients family.
63
5. Transfer will be coordinated with the burn unit
physician.
6. Transfer will be accomplished with appropri-
ate nursing/physician/ambulance personnel to
accompany patient.
7. All pertinent information regarding tests, tem-
perature, pulse, uids administered and urinary
output will be recorded on the burn/trauma
ow sheet and sent with the aptient as well
as the trauma history and physical. Any other
information deemed important by the referring
and receiving physician would also be sent
with the patient.
8. A list of burn units and phone numbers in this
region may be found in the Transfer Policy of
the Emergency Department.
General Guidelines for Transfer Arrangements:
1. Patients from Ten-
nessee should rst be
transferred to Chat-
tanooga or Vander-
bilt. This generally
requires xed wing
transport.
2. Transfer of North
Carolina patients
will be arranged rst
to Bowman-Gray.
This is generally
done via WINGS.
3. Transfer of pediatric patients can be arranged
to Vanderbilt or Shriners Hospital in Cincin-
natti.
64
4. At times, time from stabilization to transfer
can be lengthy while xed-wing transportation
is being arranged. In the interim, the patient
may be admitted to PICU for close monitor-
ing.

Revised: January, 2004
65
66
III - Section 14
Management of Head Injuries
1 Injury:

Produced directly by the original mechanical
force.
2 Injury:

Occurs after the original trauma and is caused
by ischemia, hypoxia or both.

Hypotension, hypoxemia, even if present for
only briey, can double the mortality.

Hyperglycemia-hyperthermia.

Magnesium deciency.

Hct < 30 can worsen ischemia.
Cerebral Blood Flow (CBF):
Regulated by PaCO
2
, PaO
2
, Blood Pressure a Cerebro-
vascular resistance

PaCO
2
< 20-25 mmHg can decrease blood
ow by half. Hyperventilation is no longer
indicated!!!

Hypoxia has little effect until PaO
2
< 50
mmHg.
Cerebral Perfusion Pressure (CPP):
CPP = Mean Art Press (MAP) - intracerebral press
(ICP) Want to maintain a CPP > 70 mmHg

Normal ICP: 5-10 mmHg; 10-20 requires
careful observation; 20-25 requires urgent
treatment.

Prognosis is poor when ICP is > 30-35.

Regardless of the cause, inability to lower ICP
promptly to < 20mmHg is a general indicator
67
of poor prognosis.

Maintain P0
2
> 80 mmHg; PC0
2
35-40 mmHg.

Keep head of bed elevated to 30.

When intubating a head injured patient,
lidocaine 1.5 mg 1kg IV 2-3 min. prior to
intubation can prevent a rise in ICP and may
be benecial to the injured brain. (See RSI
protocol).

These patients need to be adequately sedated.
Recommendation includes fentanyl drip at
50-100 mcg/hr IV (inexpensive, reversable and
decreases oxygen consumption.) An alterna-
tive is diprivan although this is more expen-
sive.

Tx for increased ICP is deferred to the attend-
ing neurosurgeon, but some intervals are listed
below:


Isotrope interventions to increase MAP


Dopamine


Neosynephrine (if tachycardic)


Norepirephrine (if bradycardic)

To lower ICP, mannitol can be given


0.25 mg per kg every 6 rprn (ICP > 20
AND CPP < 80 AND adequet lling
pressures)

For other intervention, defer to neurosurgeon.

Barbiturate coma for ICP refractory to ALL
else with neurosurgeon.

Obtain EARLY OT consults for evaluation and
splinting.

Obtain PT/ST consults when cognition im-
proves to aid in early R.O.M., mobility and
speech therapy.
68
III - Section 15
Management of Amputated Parts
Patient Selection:
Candidates for replantation include victims of amputa-
tion of the scalp, hand, digit, penis, and selected
portions of distal-most extremities. In general, the
younger the patient is, the more potential lifetime
benet replantation has to offer. The patient should
be in sufciently good health to undergo a prolonged
operation and extensive rehabilitation.
Strong Indication for Replantation
of Digits:

A clean guillotine amputation

Amputations through the middle phalanx of
the digit

Bilateral amputations of the hand

Amputations of multiple digits

Amputations of the dominant hand

Amputation of the thumb

Additional circumstances, such as occupation
or associated disability (such as contralateral
paralysis)
Contraindications to Replantation:

Severe crushing injury

Avulsion

Multiple level amputations of the same
extremity
69
Initial Care of the Patient:

It is important to examine the patient for as-
sociated injuries that may be of higher priority.
Hemostasis must be ensured, and the possibil-
ity of shock must be noted, especially with
more proximal extremity amputations. Intrave-
nous uids should be initiated and the need for
tetanus prophylaxis assessed.

Direct pressure and evaluation of the affected
extremity are the best methods for controlling
hemorrhage. If possible, a tourniquet should
be avoided. Blind clamping is to be avoided
due to the possibility of nerve injury.

In the case of incomplete amputation, splint
the entire digit in a physiologic position.

In the case of incomplete amputation, splint
the entire digit in a physiologic position.

The proximal stump may be gently examined,
but a thorough cleansing should be accom-
plished in the operating room, where high
magnication, lighting, tourniquet control and
anesthesia are optimal.
70
Preservation of the Amputated Part:

Do
3
The amputated part is gently examined and
physically cleaned of gross debris by gentle
rinsing with lactated Ringers solution.
3
Wrap the part(s) in sterile gauze moistened
with lactated Ringers solution and place in a
plastic bag or container.
3
Transport the bag or container in an outer
container lled with crushed ice. Be sure
to label the container and send it with the
patient.


Dont
5
Never freeze the part by placing it directly
on the ice or by adding any other coolant,
such as dry ice, which could irreversibly
damage the tissue.
5
Do not attempt debridement or exploration
of the part in the emergency room. This
procedure should be accomplished in the
operating room by the replantation team.
71
The Time Factor:

Cooling may increase the prospect of the suc-
cessful replantation, because it decreases the
metabolic rate and inhibits bacterial growth.

Immediate institution of hypothermia can
extend the ischemic period to 24 hours or
more.

The more proximal the amputation, the more
critical the ischemic interval, because the
larger muscle mass begins degenerating imme-
diately, accounting for the decreased success
of replantation in these cases.
Later Care of the Patient:
Replantation of an amputated digit often involves long
and complex operations that require a surgical team
experienced in replantation.
72
73
III - Section 17
Solid Organ Injury Management:
Liver and Spleen
Pending
74
III - Section 18
Tertiary Survey
It is widely recognized that not every injury is identi-
ed at the time of presentation. Several studies 1,2
indicate that missed injuries occur in 6-14 % of all
traumas. Although not frequently life threatening, these
may result in signicant long-term disability, over-
shadow the heroic efforts made by the trauma team, are
embarrassing to the institution and surgeon, and can be
a source of litigation. Remember, no matter how trivial
an injury might seem to the trauma surgeon, the patient
may feel quite differently. The goal of the tertiary
survey is to minimize this problem. Some of the most
widely recognized factors contributing to a missed
injury are:
1. Urgent treatment priorities abbreviate the
initial assessment (e.g. immediate operative
intervention);
2. Altered sensorium precludes a meaningful
secondary survey (e.g. CHI, alcohol, or drug
intoxication);
3. Clinicians miss or under-appreciate physical
ndings; and
4. Radiologic studies are not performed, are
inadequate, or are misinterpreted.
Protocol
1. The tertiary survey will be performed on all
patients 24 hours after admission.
2. The tertiary survey will be repeated on all
patients after they regain consciousness and/or
become ambulatory.
75
3. The original survey form will be stamped and
kept by the MEAC trauma nurse for the ofce
records.
4. Any abnormalities or new ndings will be
noted in the chart in the progress notes and
appropriate diagnostic studies ordered if nec-
essary.
1 Enderson BL, Maull KL1.Missed injuries: the trauma
surgeons nemesis. Surg clin of North Am. 1991;399-418
2Bif WL,Harrington DT, Ciof WG. Implementation of a
tertiary survey decrease missed injuries. J of Trauma.
2003,54:38-44
Jan. 2004
76
77
78
III - Section 19
Spinal Cord Injuries
Facts:

15% of patients with injuries above the
clavicle have a c-spine injury:

55% of all spine injuries are of the cervical

15% occur in the T spine

15% of the thoracolumbar junction

25% of all patients with spine injury have at
least a mild head injury

5% of all patients experience deterioration in
neurological status AFTER arriving in the
ED
3 Spinal Tracts to be evaluated clinically (all paired):
1. Corticospinal: Posterolateral segment,
voluntary movement of muscle on the
same side.
2. Spinothalamic- anterolateral- pain,
temperature on opposite side of body. Check
pinprick, light touch.
3. Posterior columns- proprioception, same side
of body, check position sense of ngers,
toes.
Examination
It is essential that both motor and sensory response
be tested (see Trauma H&P for dermatome chart).
If any sensory or motor response is spared, there is
an incomplete injury and prognosis is signicantly
better.
Check the perianal area, if there is sacral sparing it is
the sign of an incomplete injury.
79
Syndromes
Central Cord Syndrome - greater loss of power
in upper vs. lower extremities. Seen primar-
ily with hyperextension injuries with canal
stenosis.
Anterior Cord Syndrome Paraplegia, loss of
pain and temperature sensation. Usually
secondary to infarct.
Brown-Sequard Syndrome Hemisection of
the cord rare. Ipsilateral motor loss with
contralateral sensation loss.
Motor Exam Chart
Cervical Level
Diaphragm C2,3,4
Raise elbow to shoulder level C5
Bend elbow (biceps) C6
Straighten elbow (triceps) C7
Flex wrist C8
Spread ngers T1
Lumbosacral Level
Flex leg at hip/ raise knee to chest L1, L2
Extend Leg/ straighten, lock knee L3, L4
Dorsiexion L5
Plantarexion S1
Anal sphincter S2,3,4
80
PEDIATRIC GUIDELINES
81
Normal Vital Signs
Blood Pressure Age Heart
Rate
Respiratory
Rate
Systolic Diastolic
Infant to 1
yr.
100-
160
30-60 70-105 50-66
Toddler 80-110 24-40 75-105 50-66
Preschooler 70-110 22-34 80-112 50-71
School Age 65-110 18-30 85-112 50-71
Adolescent 60-90 12-16 90-128 60-80
Lowest acceptable systolic blood pressure =
70 + (age in years x 2)
________________________________________________________
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82
Pediatric Coma Score
Eye Opening
Score >1 Year <1 Year
4 spontaneously spontaneously
3 to verbal stimuli to verbal stimuli
2 to pain only to pain only
1 no response no response
Verbal Response
Score >1 Year <1 Year
5 oriented/appropriate coos & babble
4 confused irritable and cries
3 inappropriate words cries to pain
2 incomprehensible moans to pain
1 no response no response
Motor Response
Score >1 Year <1 Year
6 obeys commands moves spontaneously
5 localizes painful stimuli localizes painful stimuli
4 withdraws to pain withdraws to pain
3 decorticate decorticate
2 decerebrate decerebrate
1 no response no response
Treatment For Hyperkalemia
Mild to Moderate (K + = 6 7)
Kayexelate given by mouth or per rectum 1 gram/kg every 6 hours
Severe (K + > 7)
A) Mix Regular Insulin 0.1 units/kg IV with D 25W 2 ml/kg IV
over 30 min. Repeat dose in 30-60 min. or begin infusion of D
25W at 1-2 ml/kg/hr with Regular Insulin 0.1 unit/kg/hr. Monitor
gluecose hourly.
B) NaHCO, 1-2 mEq/kg IV or IO given over 5-10 min.
C) With ECG changes, urgent treatment is required. Give Calcium
Gluconate (10%) 1 ml/kg over 3-5 min. May repeat in 10 min.
(does not lower serum K+ concentration).
Note that Calcium is not compatible with NaCHO3. Flush lines
between infusions.
D) Dialysis is recommended if these measures are unsuccessful.
83
Pediatric Trauma Score
Component +2 +1 -1
Weight >20kg 10-20kg <10kg
Airway Normal 02 Adjunct:
Mask, Cannula,
Or Oral/Nasal
Airways
Assisted
Ventilations/
Intubated
Level of
Consciousness
Awake History of LOC
or
Altered
Consciousness
Coma/
Unresponsive
Circulation SBP>90
mmHg
SBP 50-90
mmHg
SBP
<50mmHg
Fracture Not Seen
or
Suspected
Single Closed
Fracture
Any Open or
Multiple
Fractures
Cutaneous No
Visible
injury
Contusion,
Abrasion or
Laceration
<7cm; not
through fascia
Tissue has
laceration >
7cm; any
penetrating
injury through
fascia
Transport children to a pediatric trauma center
IMMEDIATLEY if:
Trauma score < 8
2
nd
or 3
rd
degree burns involving > 10% of TBSA
Paralysis or suspected spinal cord injury
Drowning or near drowning with injury
Falls greater than 10 feet
Altered mental status
Information for Transplant/Referral
Childs name, age, weight
Medical history and allergies
Vital signs and assessment of ABCs
Present condition
Medical, nursing and EMS notes
Laboratory results, x-rays
Registration information and transfer document
84
Resuscitation Medications
Drug
Adenosine
(Adenocard)
Dose
0.1 mg/kg IV or IO
Maximum 1
st
dose: 6mg
May double and repeat dose once
Maximum 2
nd
dose: 12mg
Comments
Give rapidly.
Follow immediately with
10cc NS flush.
Atropine 0.02 mg/kg IV, IO or ETT
Minimum dose: 0.1mg
Maximum dose for child: 0.5mg
Maximum dose for adolescent:
1mg May repeat once
Use for symptomatic
bradycardia
Amiodarone
(Cordarone)
5mg/kg IV or IO
Dilute with at least 20cc of D5W
May cause hypertension.
Do not routinely give
amiodarone and
procainamide together
Calcium
Chloride
20mg/kg IV or IO
May be repeated in 10 minutes if
necessary
Give slowly.
Do not mix with sodium
bicarbonate. Indicated for
hypocalcemia,
hyperkalemia,
hypermagnesemia and
calcium channel blocker
overdose
Epinephrine IV or IO: 0.01mg/kg of 1:10,000
solution ETT:0.1mg/kg of
1:1000 solution May repeat dose
every 3-5 minutes
Lidocaine
(Xylocaine)
1mg/kg IV, IO or ETT
May be repeated every 5 minutes
x 3, followed by 20-50 mcg/kg/
minute continuous infusion
Magnesium
Sulfate
25-50mg/kg IV or IO
Maximum dose: 2 GM
May cause hypotension
With rapid bolus. Use for
documented
hypomagnesmia or torsades
de pointes.
Sodium
Bicarbonate
1 mEq/kg IV or IO Infuse slowly and only if
ventilation is adequate. Do
not mix with calcium
Defibrillation & Cardioversion
Defibrillation 1
st
dose: 2 J/kg
Subsequent doses: 4 J/kg
Use for pulseless rhythms
Cardioversion
(synchronized)
1
st
dose: 0.5 I J/kg
Subsequent doses: 1-2
J/kg
Use for unstable SVT and
rhythms with pulses
85
86
Treatment Medications
Drug
Albuterol
Dose
Nebulizer: 1 unit dose or 0.5 ml
of 0.5% solution in
3 ml NS
Comments
May be repeated every 20
minutes for severe distress
Diazepam (Valium)
Sedative, Anticonvulsant
0.1-0.2 mg/kg IV Maximum
Dose: 4 mg Rectal Dose: 0.5
mg/kg/dose
May cause respitory depression
and hypotension
Diphenhydramine
(Benadryl) Antihistimine
1.25 mg/kg IV
Maximum Single Dose 50 mg
Give over 5 minutes
Epinephrine, Racemic
(Vaponefrin)
Bronchospasm, Croup
Nebulizer: 0.5 ml diluted in 3 ml
NS
May be repeated every 20
minutes for severe distress.
Transient relief of subglottic
edema and croup.
Etomidate Non-
Barbiturate, Sedative-
Hypnotic
0.3 mg/kg IV Very short acting. No analgesic
properties. Decreases ICP.
Fentanyl (Sublimaze)
Analgesic
1-2 mcg/kg IV or Im May cause respitory depression,
hypotension and elevated ICP
Flumazenil
(Romazicon)
Benzodiazepine
Antidote
0.01 mg/kg
Maximum Single Dose 0.5 mg
May give doses every 1 minute
to a total cumulative dose of 1
mg
Short half-life, may need repeat
dosages.
Furosemide (Lasix)
Diuretic
0.5 1 mg/kg IV
Maximum Rate of Infusion:
0.5 mg/kg/minute
Hydralazine
(Apresoline)
Antihypertensive
0.1-0.2 mg/kg IV or IM
Maximum Dose
20 mg
IV Onset: 5 20 minutes
Insulin (Regular) Maintenance infusion of 0.05
0.1 units/kg/hr in DKA
Too rapid decrease of serum
glucose may lead to cerebral
edema. Optimum rate of serum
glucose decrease is 80-100
mg/dl./hr.
Ketamine (Ketalar)
Dissociative Anesthetic
1 mg/kg IV
1-3 mg/kg IM
May increase ICP and BP.
Possible hallucinations and
emergence reactions
Lorazepam (Ativan)
Sedative, Anticonvulsant
Anxiety/Sedation: 0.05 0.1
mg/kg
IV q 4 8 hours
Status Epilepticus: 0.1 mg/kg IV
Give slowly.
May cause respitory depression.
Mannitol
Reduction of increased ICP
associated with cerebral
edema
0.25 1 gm/kg IV over 20-30
minutes
Use a filter when administering.
Methylprednisolone
(Solumedrol)
Antiinflammatory
Status asthmaticus: 1 -2 mg/kg
IV loading dose
Infuse over 5 15 minutes. For
spinal cord injury, consult with
neurosurgeon
Midazolam (Versed)
Sedative, Anticonvulsant
0.1 0.2 mg/kg IV
87
Treatment Medications
Drug
Naloxone
(Narcan)
Narcotics
Antagonist
Dose
0.1 mg/kg IV, IM, SC or
ETT
Maximum Dose 2 mg
May repeat every 3-5
minutes
Comments
If total reversal of narcotic
effect is not desired, 0.01
mg/kg may be used. May
precipitate abrupt
withdrawal symptoms in
patients addicted to oplates.
Phenytoin
(Dilantin)
Anticonvulsant
Loading Dose: 15-20
mg/kg IV
Give loading dose over 20
minutes, not to exceed 0.5
1 mg/kg/min. May cause
cardiac conduction block.
Fosphenytoin (cerebyx)
preferred if available.
Rucuronium
(Zemuron)
Neuromuscular
Blocking Agent
0.6 1.2 mg/kg IV Nondepolarizing agent.
Rapid onset of action.
Minimal cardiovascular
side effects.
Succinylcholine
(Anectine)
Neuromuscular
Blocking Agent
Children 1 1.5 mg/kg
IV
Infants: 2mg/kg IV
Depolarizing muscle
relaxant. Rapid onset &
short duration of action.
Avoid in renal failure,
burns hyperkalemic states
or neuromuscular disorders.
Do NOT use for
maintenance of paralysis.
Thiopental
(Pentothal)
Sedative
2 -4 mg/kg IV Ultra short acting.
Decreases ICP. No
analgesic properties.
Potentiates respiratory
depressive effects of
narcotics and
benzodizepines.
Vecuronium
(Norcuron)
Neuromusclar
Blocking Agent
0.1 mg/kg IV Nondepolarizing agent.
Onset of action 2 -3
minutes.
88
Airway Management
Endotracheal Tube Size: 16 + (age in years)
4
Depth of ETT Insertion: 3 x tube size = cm at lip line
Confirmation of ETT Placement:
Auscultation of Bilateral Breath Sounds
Visualization of Chest Rise and Fall
Colorimetric CO2 Detection
Chest X-Ray
Resuscitation Fluid Requirments
20cc/kg of Normal Saline or Lactated Ringers
Maintenance Fluid Requirments
Infants < 10kg---------------4 ml/kg/hr
Children 10-20--------------40 ml/hr
Plus 2 ml/kg/hr for each kg> 10kg
Children > 20kg----------- -60 ml/hr
Plus 1 ml/kg/hr for each kg> 20kg
89
90
91
92
93
94
V.
Pharmacology
&
ICU Guidelines
95
96
IV- Section 1
Splenic Vaccination Guideline
Indications:

All patients who are post-splenectomy.

All patients with less than 50% of their
spleen intact and/or with absence of the
major vascular supply.
Guideline:

Pneumovax 0.5 cc s.c.

Hemophilus u vaccine (Hib) 0.5 cc IM

Meningococcal vaccine 0.5 cc s.c.
Vaccinations should be administered within 48 hours
of splenectomy or splenic injury, unless the patient
is on pressors (but must be done prior to discharge).
There is no evidence to support delaying vaccination
because of immunosuppression following splenec-
tomy.
All patients should be revaccinated with pneumo-
coccal vaccine at least every 6 years. There are no
recommendations for revaccination for hemophilus
or meningococcal vaccines.
References
Horton J, Ogden M, Williams S, Coln D: The importance of splenic
blood ow in clearing pneumococcal organisms. Ann Surg 1982;
195:172-176; Update on adult immunizations: Recommendations
of the immunization practices advisory committee (ACIP) MMWR
1991;40:40-44; Van Wyck D, Wittre M, Wittre Clhies A: Critical
splenic mass for survival from experimental pneumococcemia. J
Surg Res 1980;28:14-17.
97
98
IV- Section 2
Tetanus Prophylaxis Guideline
99
100
DVT after traumatic injury has been exhaustively studied with
inconsistent ndings. The Eastern Association for the Surgery
of Trauma convened a workgroup and performed an extensive
literature search and meta-analyses. Below is a compilation of
their ndings and recommendations.
Risk Factors:
The only Consistent statistically signicant risk factors for
development of DVT were spinal fractures and spinal cord
injuries. Older age is also considered a risk factor, but it was not
clear at which exact age the risk increases.
Recommendations:
Sequential compression devices/ AV foot pumps:
All patients admitted to the trauma service will have sequential
compression devices (SCDs) ordered. While there were insuf-
cient data to support a standard, there is almost no risk to using
these devices. AV foot pumps may be used as a substitute for
SCDs in patients who cannot wear SCDs (e.g., external xators
or casts).
Low Molecular Weight Heparin (LMWH)
This will be used on:
All pelvic fractures requiring xation or prolonged bed rest
(> 5days)
Complex lower extremity injuries requiring operative bed rest
(> 5 days)
It should be continued for several weeks in patients at high
risk, e.g., elderly pelvic fractures, bed rest greater than 5 days,
prolonged hospital or rehabilitation stay.
Filters:
Reserved for those who cannot receive anticoagulation second-
ary to increased risk of bleeding (e.g., ICH, ocular injury, solid
organ abdominal injury, retroperitoneal hematoma requiring
transfusion) or have the following injury patterns:
GCS<8
SCI
Complex pelvis and long bone fractures
Multiple long bone fractures
Revised June 2004
IV- Section 3
DVT Prophylaxis
101
102
IV Section 4
High Dose Methylprednisolone Therapy
In Blunt Spinal Cord Trauma
In 2005 the AANS stated that the risk
outweigh benets in Solu-nedrol proto
col for spinal cord injury.
103
104
IV Section 5
Recombinant Factor VII (RF VII)
The use of RF VII was rst reported in 1999 when used on a patient with
intractable bleeding after an abdominal gunshot wound. Following
this, in more critically ill, coagulopathic, multi-transfused trauma patients
in whom conventional surgical and medical hemostatic treatment modalities
failed, were given RF VII. All patients suffered uncontrolled bleeding de-
spite surgical efforts and massive replacement therapy. There was no clini-
cal evidence of venous or arterial thromboembolic complications observed.
THIS IN NO WAY IS INTENDED TO REPLACE CURRENT STRATE-
GIES, BUT IS TO SERVE AS AN ADJUNCT IN AN ATTEMPT TO
REDUCE THE EFFECTS OF MASSIVE BLEEDING IN ORDER TO
GAIN CONTROL INTRAOPERATIVELY OR GIVE TIME FOR INTER-
VENTIONAL RADIOLOGICAL PROCEDURES.
Controlled, randomized studies are ongoing.
Recommended dosages:
First dose:
60mcg/kg
Second dose:
120mcg/kg
given one hour later
105
106
Propofol (DIPRIVAN) *Anesthetic/Sedative
Rx-Anesthesia: 2-2.5 mg/kg IV over 1 minute until onset of
anesthesia. Maintenance: 100-200 g/kg/min.
Reduce dose for elderly, debilitated, or neurosurgical Pt .
Rx-Sedation: 100-150 g/kg/min for 3-5 min.
followed by maintenance infusion of 25-75 g/kg/min .
Rx-ICU Sedation in the intubated Pt: 5 g/kg/min., for at least
5 min. May increase by 5 10 g/kg/min., q5 10 minutes
until desired level of sedation.
Maintenance infusion: 5 50 g/kg/min may be required.
Max dose: 150 g/kg/min (some may require higher dose).
Contra: ICP, impaired cerebral circulation, lipid metabolism
disorders, resp., renal, circulatory, or hepatic disease.
SE: apnea, hypotension, N&V, pain at IV site, jerking, H/A,
bradycardia, HTN, fever. Reduce dose it patient has received
large doses of narcotics.
Use 100 l vial (10 mg/ml) & run at:
Patient weight in kg
g/kg/min.
35 40 45 50 55 60 65 70 75 80 90 100
5g 1.05 1.2 1.35 1.5 1.65 1.8 1.95 2.1 2.25 2.4 2.7 3
10g 2.1 2.4 2.7 3 3.3 3.6 3.9 4.2 4.5 4.8 5.4 6
20g 4.2 4.8 5.4 6 6.6 7.2 7.8 8.4 9 9.6 10.8 12
30g 6.3 7.2 8.1 9 9.9 10.8 11.7 12.6 13.5 14.4 16.2 18
40g 8.4 9.6 10.8 12 13.2 14.4 15.6 16.8 18 19.2 21.6 24
50g 10.5 12 13.5 15 16.5 18 19.5 21 22.5 24 27 30
60g 12.6 14.4 16.2 18 19.8 21.6 23.4 25.2 27 28.8 32.4 36
70g 14.7 16.8 18.9 21 23.1 25.2 27.3 29.4 31.5 33.6 37.8 42
80g 16.8 19.2 21.6 24 26.4 28.8 31.2 33.6 36 38.4 43.2 48
90g 18.9 21.6 24.3 27 29.7 32.4 35.1 37.8 40.5 43.2 48.6 54
100g 21 24 27 30 33 36 39 42 45 48 54 60
150g 31.5 36 40.5 45 49.5 54 58.5 63 67.5 72 81 90
200g 42 48 54 60 66 72 78 84 90 96 108 120
250g 52.5 60 67.5 75 82.5 90 97.5 105 113 120 135 150
300g 63 72 81 90 99 108 117 126 135 144 162 180
Microdrops per minute (or ml/hr)
Peds: 1-2.5 mg/kg IV over 1-2 min. Drip: 100-300 ug/kg/min.
107
108
109
Appendix
110
111
Burn Diagrams
APPENDIX APPENDIX APPENDIX APPENDIX
112
APPENDIX APPENDIX APPENDIX APPENDIX
113
Burn Estimate Sheet
APPENDIX APPENDIX APPENDIX APPENDIX
114
Escharotomy Guidelines
Escharotomy can be
done at the bedside
and does not require
anesthesia because
incisions are placed
in insensate,
full-thickness burns.
Electroctrocautery is
preferred and can be
obtained emergently
from the OR. The
eschar should be
incised only to the
level of the supercial
subcutaneous fat.
Current Therapy of Trauma
Fourth Edition
Mosby: Trunkey, M.D.,
F.A.C.S.; Lewis, M.D.
APPENDIX APPENDIX APPENDIX APPENDIX
115
APPENDIX APPENDIX APPENDIX APPENDIX
How to use the Level I Transfuser
Purpose
The Emergency Department nurses and paramedics
are responsible for the operation of the Level I Fluid
Warmer and Pressure Infusion System which is used
for rapid warming and delivery of IV uids and blood
administered to patients.
Policy
An Operations Manual and set up instrucstions are at-
tached to the system for reference. Biomedical Engi-
neering performs semi-annual and as needed safety and
maintenance checks.
Procedure
The water is changed every 30 days as recommended.
Procedure for changing the water is in the set up
instructions attached to the Fluid Warmer. Reference
Level I and Pressure Infusions System Operations
Service Manual.
1. Push bottom end of heat exchanger fully into
bottom socket #1. Aluminum tube should disap-
pear into socket.
2. Pull side lock to unlock #2 top socket. Slide
socket up. Snap heat exchanger into guide.
Slide top socket down over heat exchanger
until latch clicks.
3. Snap lter with gas vent into #3 holder.
4. When the set is correctly installed, and the
uid warmer power switch is turned on, a
green system operational light will illuminate
on the display panel.
116
5. Close clamp A & B above the Y-connector.
6. Spike bag and squeeze drip chamber so it is
1/2 full.
7. Remove male luer cap and open the clamp to
the bag.
8. Close roller clmp D when patient line is
primed. The lter with gas vent will self-
prime.
9. Tap lter with gas vent against cabinet to
release all trapped air. Priming is complete.
(Replace the lter with gas vent every three
hours or when the lter becomes clogged or
air is slowly vented.)

APPENDIX APPENDIX APPENDIX APPENDIX
117
APPENDIX APPENDIX APPENDIX APPENDIX
118
5. Protocol for 1-Shot IVP

Be certain that no items are under the patient that
might obstruct a good quality radiograph (e.g.,
K-pad).

Shoot a scout lm if time permits.

Inject 100 cc of optiray 320 or 350.

Wait 5 minutes.

Shoot radiograph.
6. Retrograde Urethrogram

Place an 8 French cathetar into the urethral orce
and hold in place.

Gently inject 15-20 ml. of contrast medium and obtain
an oblique lm of the pelvis or uoroscysy.

If extravasation is seen of the penile urethra,
suprapublic catheter drainage of the bladder is
required. Consult urology.
7. Cystogram

Instill 300-400 ml of contrast medium into the
bladder.

Clamp the catheter.

Obtain on AP plain.

Empty bladder and obtain post-void lm. (This
better denes extraperitoneol ruptures.)

Abdominal CT has generally replaced this modal-
ity and differentiates between intra- and retro-
peritoneal injuries. It also better evaluates renal
perfusion and parenchymal injuries.

Performing of CT requires hemodynamic stability.
APPENDIX APPENDIX APPENDIX APPENDIX
8. Adult Emergency Interosseus Infusion F.A.S.T. 1
The failure rate for attempting peripheral IV access in patients
with circulatory shock is 10-40 %. Delay in obtaining IV access
con compromise effective resuscitation. Currently, WINGS Air
119
APPENDIX APPENDIX APPENDIX APPENDIX
Rescue and Washington County/Johnson City EMS have guide-
lines for the use of FAST 1, an interossues device placed into the
sternum for rapid infusion. The catheter is a rigid tube placed at
a 90 degree angle to the manubrium. It has a collar at the end to
keep it in place in the sternum. A special device is required to
remove the catheter, otherwise the tip will remain in the sternum
leading to the potential for infection/foreign body reaction. This
removal device should accompany this person to the ED. Use
of this device should be documented on the Trauma H&P. Once
the patient arrives in the ED, peripheral/central access should
be obtained. Under NO circumstances should the patient leave
the ED without removal of the sternal device. This must be
documented.
What can be given through the FAST 1?
5-10% Dextrose
Saline Antibiotics Sodium Bicarb
Lactated Ringers Anticonvulsants Digitalis
Plasma Catecholamines Insulin
Packed Red Cells Atropine Calcium
Colloids Lidocaine Muscle Relaxants
Precautions

Trauma to skin or manubrium at site of entry

Suspected fracture of sternum

Previous Sternotomy

Severe osteoporosis or bone softening conditions

An extremely small adult
Complications

Subcutaneous inltration secondary to incorrect
placement

Subperiosteal inltration of uid from puncture site

Cellulitis and subcutaneous abscesses
(reported in 0.07% or cases)

Bone marrow necrosis if improper medications/uids
infused

Infection/foreign body reaction to tip if not properly
removed
120
APPENDIX APPENDIX APPENDIX APPENDIX
9. Standard Admit Orders
121
APPENDIX APPENDIX APPENDIX APPENDIX
122
APPENDIX APPENDIX APPENDIX APPENDIX
10. AFTERWORD
This continues to be a work in progress. Please
do not hesitate to make suggestions or question
what might be inaccuracies. For future addi-
tions, look for information regarding:
Future Clinical Guidelines:

Helmut Removal

Cricothyroidotomy

Trauma in pregnancy

Pediatric issues
Pharmacology Guidelines:

Use of neuromuscular blocking agents

Alcohol withdrawal prophylaxis

Prevention and treatment of DVT/PE

Surgical antimicrobial prophylaxis in trauma

Early presumptive treatment for fungal infections

Management of anxiety and agitation in the ICU

Glycemic control in critically ill patients
Appendix:

Abbreviated injury score

Organ injury scales (liver& spleen)
123
Layout & Design:
Biomedical Communications
Quillen College of Medicine, 1/05
This Trauma Service Protocol Manual
is a work in progress.
Updates and additions
continue to evolve.
Dr. Julie Dunn
Department of Surgery
James H. Quillen College of Medicine