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Trauma Handbook 2007

Trauma Handbook 2007

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Elvis Presley Memorial Trauma Center Department of Surgery Division of Trauma and Surgical Critical Care University of Tennessee Health Science Center Memphis, Tennessee


These policies are intended to serve as guidelines only. Individual circumstances must be considered, and there may be times when it is appropriate or desirable to deviate from these guidelines. They should not be considered to be accepted protocol or policy, nor are they intended to replace clinical judgment or to dictate care of individual patients. These educational guidelines will be reviewed and updated routinely.


GENERAL POLICIES Trauma Service Policies Conferences and Clinics Service Assignments and Transfer Universal Precautions in the Trauma Rooms Criteria for Triage to Trauma Rooms Routine Trauma Labs Consults HEAD/SPINE Cervical Spine Clearance Spinal Cord Injury with Deficit Dermatomes Sensory Levels Classification of Spinal Cord Injury NECK Blunt Cerebrovascular Injury Penetrating Neck Injuries CHEST Blunt Aortic Injury Emergent Thoracotomy Hemothorax ABDOMEN/PELVIS Hemodynamically Unstable Blunt Abdominal Trauma Hemodynamically Stable Blunt Abdominal Trauma Antibiotics for Penetrating Abdominal Trauma Anterior Abdominal Stab Wounds Blunt Liver Injury Blunt Splenic Injury Pancreatic Injury Organ Injury Scales Management of Pelvic Fractures Tile Classification of Pelvic Fractures VASCULAR Ligate vs. Repair Neurovascular Injuries EXTREMITIES Fracture/Dislocations Muscles and Nerves Mangled Extremity Severity Score SURGICAL CRITICAL CARE Diagnosis & Empiric Therapy of VAP Risk Factors & Prophylaxis for DVT Herbal Supplements Ventilator Weaning Management of Hypertension Pharmacologic Agents Alcohol Withdrawal Sedation Stress Ulcer Prophylaxis ICP Management 4 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 37 38 39 40 41 42 43 44 47 48 52 53 54 55 56 58 59


2. The trauma team is expected to respond to all Shock/Trauma room admissions. 3. A complete daily Trauma Service note in SOAP format addressing all problems and containing all laboratories and other studies obtained is required on each patient on the Trauma Service. To ensure optimal patient care as well as a productive educational experience. Dismissal from the trauma room is at the discretion of the senior trauma resident. the following guidelines have been formulated by the Trauma staff.Trauma Service Policies Welcome to the Trauma Service. the responsibilities of each member of the Trauma Team. specific policies regarding patient care. General Policies 1. A complete and accurate trauma history and physical is required for all trauma admissions. There are no exceptions. 4 . and other issues essential to the efficient running of the Trauma Service. These policies cover the roles and goals for each resident and medical student rotating on the Service.

Detailed turnover rounds to the other chiefs when they assume call. Trauma Conference coordination. In order to comply with the work hour restrictions. a PGY-2 Trauma Resident. Management of patients in CCA. Performing bedside procedures on TICU patients in conjunction with the Trauma attending and/or fellow. Overseeing junior residents’ daily activities. 3. 2. two PGY-1 Trauma Residents. 4. all residents are excused after turnover rounds following their night on call. This resident is responsible for the Trauma Service. and rotating medical students. Assisting with resuscitation in the Shock/Trauma Room. Management of resuscitation in the Shock/Trauma Room. 6. 5 . 4. 7. there is also a PGY-3/4 Trauma Resident. 5. Detailed turnover rounds to the other TICU residents when they assume call. 2. Aside from the PGY-5 Trauma Resident. Primary operative responsibility for trauma patients. The daily responsibilities of the resident are as follows: PGY-5 Trauma Resident 1. Initial response to all patients triaged to the Shock/Trauma Room. PGY-3/4 Trauma Resident 1. Daily management of TICU patients. This includes running daily work rounds and the Trauma Clinic. Morning rounds will include a review of the previous night’s work-ups to include radiology studies. There are also two Surgical Critical Care fellows and at least one Nurse Practitioner. 3.Resident/Medical Student Roles The PGY-5 on the Trauma Service is the chief resident of the Trauma Service. Daily management of trauma patients. This resident is responsible for the coordination of care with consulting services. PGY-2 Trauma Resident 1.

and attending.2. 2. Medical Students’ Daily Responsibilities 1. Assisting in care of Shock/Trauma Room patients as dictated by the chief. Assisting in care in CCA as dictated by the CCA Resident. Assist the floor resident with patient management and discharge planning. fellow. Assist the ICU residents in critical care management. Assist the CCA resident as appropriate. 4. Management of CCA patients in conjunction with the CCA resident. 3. 3. 3. Nurse Practitioners 1. Management of patients on the floors in conjunction with the chief. Serve as continuity liason between Trauma service and attendings. Assist the operating surgeon (if appropriate). Assisting in Shock/Trauma Room resuscitations and recording the history and physical exam. Assist the Nurse Practitioner with management of Trauma Step-down patients. 2. 4. PGY-1 Trauma Residents 1. 6. 3. 5. 2. Surgical Critical Care fellows 1. Assisting with resuscitation in the Shock/Trauma Room. Management of Trauma Step-down patients in conjunction with the fellow. 6 . Management of patients on the 4th floor ICUs in conjunction with the fellow and the Nurse Practioner. 2. Assist with management of Shock/Trauma patients. Emergency room consultations. Coordination of discharge planning with the case managers.

Learn the basics of surgical critical care in conjunction with the fellow and attending. Learn initial management of trauma patients to include ATLS. 2. Become proficient in operative management of patients with significant trauma. 7 . 2. 3. Assume the leadership role on the Trauma Service. Become proficient in the care of critically injured ICU patients. 3. 6. tracheostomy. goals and end points. PGY-3/4 1. 5. 5. PGY-5 1. 4. 2.Rotation Goals PGY-1 1. and feeding tube placement. Learn initial management and resuscitation of major trauma patients in conjunction with the Chief Trauma Resident. Learn post-injury patient care and facilitate timely and appropriate patient discharge. Learn how to evaluate surgical patients in the ER. 2. Use appropriate diagnostic modalities commonly employed in the evaluation of trauma patients. 3. placement of pulmonary artery catheter and interpretation of the values. closedtube thoracostomy. central line placement. Become proficient in various procedures to include bedside fiberoptic bronchoscopy. Obtain proficiency in evaluation and management (including operative management) of all trauma patients. arterial cannulation. Obtain proficiency in evaluation and management of all trauma patients. Assist in surgical intervention in trauma patients. Become proficient in various procedures to include diagnostic peritoneal lavage. Become proficient with various vasoactive agents in management of critically injured patients. Learn resuscitation techniques. PGY-2 1. 4. bronchoalveolar lavage.

and other critical care personnel. Create. and analyze research projects. 4. 3. 2. Develop proficiency in the diagnosis and management of critically ill patients.Surgical Critical Care fellows 1. residents in training. design. 8 . implement. Learn to administer and manage a critical care unit with particular emphasis on allocation and utilization or resources and on ethical principles in the delivery of healthcare. to include appropriate interventions and procedures. Expand and develop the ability to teach associates.

All members of the Trauma Service (fellows. and patients in CCA. and Shock/Trauma admissions Second Call Attending Responsible for daily rounds and procedures on the floor.Rounding Schedule For 2005-2006 Main Call Attending Responsible for daily rounds and procedures in the TICU. GICU. This attending will also staff the Trauma Clinic on Tuesday and Thursday. 9 .m. residents and students) are expected to attend. Teaching Rounds Tuesdays at 8:00 a. Trauma Step-down.

– 12:00 p. 9:00 a. 9:00 a. 10 . Thursday.m.m.m.. – 12:00 p. 7:30 a. 8:00 a. TICU Trauma Conference Thursday.m. Radiology Conference Room 2nd Floor Chandler Week 1: Trauma/Critical Care Week 2: Orthopedics Week 3: Neurosurgery (Ground floor Adams) Week 4: Trauma M & M (fellows responsible for case selection) Week 5: Case presentations Trauma Clinic (4th floor MedPlex) Tuesday.m.Conferences and Clinics The Trauma Service is expected to attend these and all other applicable general surgical conferences: Attending Teaching Rounds * ALL Trauma team members are expected to be present * Tuesday.m.

Patients with unisystem injury may be transferred to another service when the following general criteria are met: a. they no longer need central venous access*. • exceptions may be made after agreement with all services 11 . 2. In general. 3. they are deemed ready by the Trauma attending and the other service. or occult injuries still in the process of being ruled out.Service Assignments and Interservice Transfer Guidelines To facilitate patient care and to eliminate potential misunderstandings between various services caring for trauma patients. Patients with multiple system injuries or hemodynamic instability will be admitted to the Trauma Service. 4. the following guidelines have been established regarding admission to and transfer of trauma patients between services. Patients with unisystem injury without a mechanism for potential multiple system injuries may be admitted to the pertinent service if both attendings (Trauma and other service) agree. Reasons to remain on the Trauma Service with unisystem injuries include hemodynamic or respiratory instability. Results of these visits will be documented in the patient's medical record. Trauma Service followup will continue for at least three days post-transfer. they are tolerating a diet and having bowel function. 1. Patients with unisystem injuries with a mechanism for potential multiple system injuries will be admitted to the Trauma Service if evaluation for occult injuries is ongoing. d. patients may be admitted to the Trauma service for a 24 hour observation period prior to transfer. b. they no longer require a Foley catheter*. Once a patient is transferred from the Trauma Service to another service. and the Trauma Service may be consulted to provide the Critical Care services. c.

2. and observers are required to wear all of the following with all patients in trauma rooms: 1. 4.Universal Precautions in the Trauma Rooms • All physicians. 3. Gloves Gowns for procedures Masks Eye Coverings Head covers • Non-compliance with Universal Precautions may result in disciplinary action. employees. identifiable pictures and cell phone pictures are NOT allowed. OSHA standards require compliance. • The patient’s privacy will be respected under all circumstances. pictures taken for medical reasons are allowed. 5. 12 . However. nurses. Therefore. students.

massive Tension pneumothorax Major amputations (not fingers/toes) Multiple long bone deformities 13 . pulse <60 or >120. neck. torso Penetrating injuries of extremities with neurovascular deficit Stab wounds of head.Criteria for Triage to Shock / Trauma Room Physiological Alterations • • • • Trauma Score ≤ 13 Known GCS <14 Core temperature <28° C or <82° F Abnormal vital signs: SBP <90. torso Steering wheel/windshield deformity Fatality within the vehicle Rollovers/ejection from vehicle Pregnant patients when history is suggestive of major trauma Intoxicated patients when history is suggestive of major trauma Blunt trauma with complaints relative to abdomen or thorax Extrication time > 20 minutes Intrusion of space > one foot Falls > 15 feet Pedestrian struck Motorcycle crash Anatomical Alterations • • • • • • • Airway obstruction Pelvic instability Significant bleeding Crush (major) injury CSF leak Flail chest Open long bone fracture • • • • • • • Depressed skull fracture/scalp avulsion Maxillofacial trauma. neck. respirations <10 or >30 Mechanism of Injury (assumes physiological stability) • • • • • • • • • • • • • • • Strangulations/hangings GSW/SGW of head. severe Spinal cord injuries Subcutaneous emphysema.

ALT. • • • • • • • • 14 .also UCG in female patients Type and screen. AST) P-amylase INR Lactate Arterial blood gas UA -.Routine Trauma Labs: Adult The following laboratory tests should be ordered for all adult surgical trauma patients evaluated in the trauma rooms: CBC with differential Trauma BMP (to include total bilirubin. Type and crossmatch only for any patient who receives uncrossmatched blood (“red tag”) for resuscitation in Shock/Trauma. or any patient going directly to the OR from Shock/Trauma.

Consults Facial fractures Alternates weekly  Plastic and Reconstructive surgery  Oral and Maxillofacial surgery  Otolaryngology Hand injuries Alternates weekly • Plastic and Reconstructive surgery • Orthopedic surgery Spine injuries Alternates daily • Orthopedic surgery (patients admitted on odd days) • Neurosurgery (patients admitted on even days) Pregnant patients • Obstetrics – preferably notify prior to arrival 15 .

Lateral. asymptomatic. alert. no distracting injuries. or awake with cervical pain or tenderness. normal films Normal Abnormal MRI of affected area Leave collar on and consult Orthopedics (admission date an odd day) or Neurosurgery (admission date an even day) for evaluation 16 . Odontoid plain films Poorly visualized area or abnormal C-spine cleared (document on chart). NEUROLOGICALLY NORMAL Altered mental status.Cervical Spine Clearance Blunt neck trauma Awake. or multiple system injury. remove collar CT scan C-spine Adequate. or clinical signs of spinal cord injury No neck pain AND No tenderness to palpation AP.

Spinal Cord Injury with Neurologic Deficit
Penetrating Blunt

Bolus methylprednisolone (Solumedrol) 30 mg/kg over 15 min (if within 8 hours from injury)

45 minute steroid free pause

Continuous infusion 5.4mg/kg/hr for 23-47 hours* 23 hours if started 0-4 hours after injury 47 hours if started 4-8 hours after injury

Obtain CT of affected area

Obtain MRI of affected area

Strict log roll Take off backboard Keep in cervical collar if cervical injury or altered sensorium

*In conjunction with Orthopedics/ Neurosurgery

Consultation: Orthopedics on odd admission date, Neurosurgery on even admission date




Sensory Levels


against gravity 4 = active movement.Standard Neurological Classification of Spinal Cord Injury KEY MUSCLES R C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4-5 TOTALS maximum 5 0 MOTOR L Elbow flexors Wrist extensors Elbow extensors Finger flexors (distal phalanx of middle finger) Finger abductors (little finger) 0 = total paralysis 1 = palpable or visible contraction 2 = active movement. against some resistance 5 = active movement. gravity eliminated 3 = active movement. against full resistance NT = Not testable Hip flexors Knee extensors Ankle dorsiflexors Long toe extensors Ankle plantar flexors Voluntary anal contraction (Yes/No) + 50 = 100 MOTOR SCORE NEUROLOGICAL LEVELS The most caudal segment with normal function R L COMPLETE OR INCOMPLETE? Incomplete = Any sensory or motor function in S4-S5 SENSORY MOTOR ASIA IMPAIRMENT SCALE American Spinal Injury Association ©1996 20 .

SENSORY KEY SENSORY POINTS Light Touch R C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4-5 L R Pin Prick L 0 = absent 1 = impaired 2 = normal NT = not testable Any anal sensation (Yes/No) TOTALS { ↓ + 56 ↓ 56 56 + = = PIN PRICK SCORE LIGHT TOUCH SCORE 56 Max: 112 Max: 112 Maximum ZONE OF PARTIAL PRESERVATION Partially innervated segments R L SENSORY MOTOR 21 .

1 value 4 hours after drip started then q8hrs Goal is 1.Blunt Cerebrovascular Injury Appropriate mechanism with • Unexplained neuro deficit (inconsistent with CT) • Horner’s syndrome • LeFort II or III (unilateral or bilateral) • Cervical spine injury. including transverse process fractures C-1 – C-6 • Neck soft tissue injury CT angiogram 4 vessel cerebral angiogram Carotid injury Vertebral injury Neurosurgery consult **In conjunction with Neurosurgery Neurosurgery consult Treatment** Treatment** Heparin** if no contraindication (preferred for carotid & complex vertebral injuries) Start @ 1000 units/hour – NO bolus Aspirin ± Plavix** (ASA only if vertebral occluded with back-fill) Serial PTT.0 x normal st Repeat angiogram in 14 days and/or 6 weeks if necessary Conversion to Coumadin or antiplatelet therapy depending on pathology/clinical course for at least 6 weeks. follow up in Trauma Clinic and with Neurosurgery 22 .5-2.

bronchoscopy. barium swallow Injury No Injury TO OR Observe 23 . +/arch angiogram.Penetrating Neck Injury Hemodynamically unstable Expanding hematoma Excessive bleeding Dysphonia* Dysphagia* Air leak from wound Tracheal deviation Retropharyngeal air* Platysma Violation DO NOT PROBE WOUND! *May benefit from diagnostic test such as plain lateral c-spine X-ray. or laryngoscopy To OR Zone I Zone II Zone III unstable stable unstable stable unstable stable To OR To OR To OR 4 vessel cerebral angio. barium swallow.

Maximum dose is 10 mcg/kg/min.05 mg/kg/min over 4 minutes.5 mg/kg IV loading dose over 1 minute. MCC. decelerating blunt injury). Continuous infusion must be titrated to the desired endpoints. Advantage: blockade of α and β with single agent therapy Disadvantage: half life 5-8 hours Nitroprusside: 0. NEVER use without β−blockade therapy. Obtain ECG prior to β−blockade therapy Medications: Esmolol: 0. Advantage: very short half life (9 minutes) Disadvantage: side effect of hypotension may require cessation of therapy Labetalol: 10-20 mg IV slowly followed by continuous IV infusion of 1-2 mg/min. then titrate to BP goal. Advantage: extremely short half life Disadvantage: can increase dP/dT and cause reflex tachycardia.1 mg/kg/min. fall. Additional bolus dose of 20 mg may be given up to a total of 300 mg. then 0. *BP & HR goals: systolic BP ≤120 mmHg.3 mcg/kg/min initial dose. HR <90. then 0. 24 . titrate to HR <90.Blunt Aortic Injury Appropriate mechanism of injury Chest CT Positive Negative Mediastinal hematoma Control BP & HR Control BP & HR* Continue work-up for other injuries Appropriate sedation Arch aortogram Positive Vascular Surgery and/or Thoracic Surgery consult Negative Stop BP & HR control Appropriate mechanism of injury includes high speed impact injuries (MVC.

Resuscitative thoracotomy for penetrating abdominal wounds without suspicion of cardiac injury is not indicated.Emergent Thoracotomy Mechanism of Injury Blunt Penetrating* No vital signs in route or in Shock/Trauma Loss of vital signs in route or in Shock/Trauma No vital signs or CPR > 20 minutes Loss of vital signs in route or in Shock/Trauma Pronounce Cardiac ultrasound Pronounce Negative Positive Emergent thoracotomy * Only for penetrating wounds to the upper abdomen or chest (“cardiac box”). 25 .

3) Instill mixture into chest tube and flush tube with 50cc of sterile saline. consider stopping infusion) 26 2 TPA Contraindications 1) Active bleeding OR 2) CVA in past 30 days OR 3) Intracranial hemmorhage OR 4) Intracranial Neoplasm OR 5) Coagulopathy OR 6) Pregnancy OR 7) Chest tube with air leak .Hemothorax Management Place Chest Tube Daily Chest X-Rays Yes 48 Hours Clot Resolved No Yes CT Chest Remove Tube Clot Resolved No No 1) Residual clot > 500cc OR 2) Residual clot occupies >1/3 of thoracic cavity OR 3) Unchanged Yes Candidate for VATS? Yes No 2 1 Repeat CT Chest in 48 hours VATS Candidate for TPA infusion per chest tube? Yes No Place Second Chest Tube Clot Resolved Infuse TPA per chest tube q 24 hours x 3 days (check daily Chest x-ray) Daily Chest X-Rays Repeat CT Chest Yes 48 Hours Repeat CT Chest Remove Tube Clot Resolved No Repeat TPA infusion x 3 days (check daily chest x-ray) 1 Clot Resolved Repeat CT Chest VATS Contraindications 1) Coagulopathy 2) Hemodynamic instability 3) Inability to tolerate single lung ventilation TPA Infusion Protocol 1) Obtain HCT. PT. 4) Clamp chest tube for 4 hours (observe patient for 10 minutes for problems with breathing). PTT 1 hour after infusion (if significantly changed from baseline. PT. 5) Mobilize patient. PTT prior to infusion (if abnormal consider not using rTPA) 2) Mix 4mg of rTPA (Reteplase ) in 50cc sterile saline. 6) Check HCT.

>500 cells at least 1 hour after injury 27 .S.Blunt Abdominal Trauma Hemodynamically unstable Physical exam F.000 cells WBC .>100. DPL Large amount of fluid in abdomen Scant/no fluid in abdomen Grossly positive* Microscopically positive for RBC* Microscopically positive for WBC* To OR To OR To OR Consider DPL if unstable Continue search for other sources of hemorrhage *Criteria for positive DPL: Grossly positive .T.>10cc blood RBC .A.

treat other injuries 1 2 If any doubt. admit the patient for at least 23 hours May require DPL or other evaluation depending on findings 28 . distracting injuries Nontender Tender CT scan Observation period Remains nontender CT scan Normal Abnormal2 Normal Discharge1 Admit for 23 hour observation Admit. no distracting injuries Unreliable. alert. follow protocols Admit. awake.Blunt Abdominal Trauma Hemodynamically stable Physical exam Reliable. abnormal mental status.

give ciprofloxacin 400 mg IV every 12 hours (2 total doses for hollow organ injury. only the preop dose for no hollow organ injury) and metronidazole 500 mg every 6 h (4 total doses for hollow organ injury.Antibiotics for Penetrating Abdominal Trauma Penetrating abdominal injury requiring laparoscopy/laparotomy Ertapenem 1 gram IV prior to skin incision No hollow organ injury Hollow organ injury No further antibiotics No further dosing *For patients with penicillin allergy. only the preop dose for no hollow organ injury) 29 .

Anterior Abdominal Stab Wounds Hemodynamically stable. nontender abdominal exam Yes No Local wound exploration To OR Violation of anterior fascia Definitely no violation of anterior fascia Equivocal violation of anterior fascia To OR for laparoscopy/ laparotomy Discharge To OR for laparoscopy/ laparotomy For the cooperative patient. consider awake laparoscopy in Shock / Trauma 30 .

5 Stable OR Admit to floor.perihepatic Moderate. unexplained signs of infection *ICUserial Hct q6h. AM Hct Stable ICU * Abdominal pain.repeat CT 1 month until healed .3 Becomes unstable Grades 4. unchanged DC from ICU Search other sources Quantitation of hemoperitoneum Small.2.Nonoperative Management of Blunt Liver Injury Hemodynamic stability mandatory for nonoperative management CT scan Grades 1. improving CT scan Abdominal fluid collection Consider drainage Improved.2.Small + paracolic gutter Large-Moderate + pelvis Repeat CT 1 month Outpatient management Grade 1. close observation Pseudoaneurysm Angiography for embolization Stable. observe.3 Grade 4. jaundice.5 Repeat CT 1 month if pain or jaundice Ad lib activity 31 healed Not healed Light duty .

2 Grade 3-5 CT if clinically indicated Healed CT in 1 month Not healed Activity ad lib 32 Light duty. close observation Age ≥ 50 CT scan Pseudoaneurysm Becomes unstable Age < 50 Angioembolization Grade 3-5 Grade 1.Nonoperative Management of Blunt Splenic Injury Hemodynamic stability mandatory for nonoperative management *ICUserial Hct q6h. improving F/U CT 24 hours Worse OR ICU* Quantitation of hemoperitoneum: Small – perihepatic/splenic Moderate – small + paracolic gutter Large – moderate + pelvis Floor Stable Unexplained blood loss Consider splenectomy OR Outpatient Management Grade 1. repeat CT in 1 month if indicated . moderate hemoperitoneum Stable.2 ICU* OR Grade 1 Floor Grade 2-5 ICU* Large hemoperitoneum Small.

complete pancreatic transection .Pancreatic Injury Management Pancreatic Injury Proximal to mesenteric vessels (right) Distal to mesenteric vessels (left) Duct injury No Indeterminate Yes Drain Low probability High probability Resection + drainage High probability of ductal injury: .>50% pancreatic laceration .direct ductal visualization .pancreatic fluid leak 33 .severe maceration .

<5 cm in diameter Capsular tear. ruptured subcapsular or parecymal hematoma. intraparenchymal. intraparenchymal hematoma > 5 cm or expanding >3 cm parenchymal depth or involving trabecular vessels Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen) Completely shattered spleen Hilar vascular injury with devascularizes spleen *Advance one grade for multiple injuries up to grade III 34 . 1-3cm parenchymal depth that does not involve a trabecular vessel Subcapsular. 10%-50% surface area. <1cm parenchymal depth Subcapsular. <10% surface area Capsular tear.AAST Spleen Injury Scale Grade* Injury type I II Laceration Hematoma III Laceration IV V Laceration Laceration Vascular Hematoma Laceration Hematoma Description of injury Subcapsular. >50% surface area or expanding.

ie. <1cm parenchymal depth Subcapsular. intraparenchymal hematoma > 10 cm or expanding 3 cm parenchymal depth Parenchymal disruption involving 25% to 75% hepatic lobe or 1-3 Couinaud’s segments Parenchymal disruption involving >75% of hepatic lobe or >3 Couinaud’s segments within a single lobe Juxtahepatic venous injuries. <10% surface area Capsular tear. >50% surface area of ruptured subcapsular or parenchymal hematoma. retrohepatic vena cava/central major hepatic veins Hepatic avulsion *Advance one grade for multiple injuries up to grade III 35 . <10 cm in length Subcapsular.AAST Liver Injury Scale Grade* Type of Injury I II Laceration III IV Hematoma Laceration Laceration Laceration V Vascular VI Vascular Hematoma Laceration Hematoma Description of injury Subcapsular. 10% to 50% surface area: intraparenchymal <10 cm in diameter Capsular tear 1-3 parenchymal depth.

urologic studies normal Subcapsular. medulla.AAST Kidney Injury Scale Grade* Type of Injury Contusion I Hematoma Hematoma II Laceration III IV V Vascular VI Vascular Laceration Laceration Laceration Description of injury Microscopic or gross hematuria. nonexpanding without parenchymal laceration Nonexpanding perirenal hematoma confirmed to renal retroperitoneum <1. and collecting system Completely shattered kidney Main renal artery or vein injury with contained hemorrhage Avulsion of renal hilum which devascularizes kidney *Advance one grade for bilateral injuries up to grade III 36 .0 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravagation Parenchymal laceration exteding through renal cortex.0 cm parenchymal depth of renal cortex without urinary extravagation >1.

S.Pelvic Fracture Management Orthopedics consult Initial assessment & A-P pelvic x-ray Exsanguinating hemorrhage (BP~ <70) Marginal hemodynamic stability (BP~ 90-110) Hemodynamically stable (BP~ >110) Open Closed fracture fracture OR Supraumbilical DPL. F.T Algorithm for stable blunt abdominal trauma Positive Negative Positive Negative T-pod T-pod T-pod T-pod OR CT OR Continued hemodynamic instability Angiography 37 .A.S. F.A.T Supraumbilical DPL.

posteriorly. and vertically unstable C1 C2 C3 Unilateral injury. ileal fracture. sacral fracture Bilateral injury. lateral compression injury Bilateral rotationally unstable injury Type C – Rotationally. iliac wing. but vertically and posteriorly stable B1 B2 B3 External rotation instability. SI disruption. both sides completely unstable 38 . open book injury Internal rotation instability. avulsion injuries Stable. minimal displacement. one side rotationally unstable. one side vertically unstable Bilateral injury.Tile Classification of Pelvic Fractures Type A – Stable fractures A1 A2 A3 Fractures not involving ring. isolated rami Transverse fracture of sacrum Type B – Rotationally unstable.

To Ligate or Not to Ligate Injury Infrarenal vena cava Suprarenal vena cava Internal jugular vein Brachiocephalic vein Subclavian vein and artery Superior vena cava Carotid artery Mesenteric veins Repair Repair Repair Repair Repair Repair Repair Ligate Can ligate if isolated injury.comm/ext Femoral/popliteal arteries Tibial arteries Brachial artery Radial/ulnar arteries Repair Repair Repair Ligate Ligate Ligate Ligate Ligate Ligate Ligate Repair Repair Repair Repair Repair Can ligate but need to ensure patency of other leg arteries Can ligate if distal to profunda brachi branch since the elbow has rich collateral blood flow Can ligate but need to ensure patency of other artery and palmar arch Especially if proximal to gastroduodenal branch Especially if portal vein is intact Short gastric a. from left gastroepiploic Cannot ligate .comm/ext Iliac artery .fewer collaterals than left renal vein Cannot ligate Can ligate Best Mode of Action Can ligate Cannot ligate . but at least 50% Portal vein Repair mortality rate secondary to massive fluid sequestration in splanchnic vascular bed and bowel necrosis Right renal vein Popliteal vein Femoral vein Lobar bile duct Celiac artery Left gastric artery Common/proper hepatic arteries Right/left hepatic arteries Splenic artery Iliac vein .at least 50% mortality) Can ligate unilaterally Can ligate unilaterally Can ligate Can ligate in life-threatening situations Can ligate in life-threatening situations 39 .

axillary artery Radial nerve Brachial artery Median nerve Sciatic nerve Popliteal artery Popliteal artery.Neurovascular Injuries Associated with Fractures or Dislocations Orthopedic Injury Anterior shoulder dislocation Humeral shaft fracture Supracondylar humeral fracture Distal radius fracture Perilunate dislocation Posterior hip dislocation Supracondylar femur fracture Posterior knee dislocation Tibial plateau fracture Proximal fibula fracture Neurovascular Injury Axillary nerve. tibioperoneal trunk Peroneal nerve 40 .

7 Orthopedics consult. reduce injury Orthopedics consult.7 Pulse deficit.Fracture/dislocation of Extremity Equal pulses. reduce injury Pulses still equal Pulses equal Pulse deficit Orthopedics management of injury Angiogram in operating room 41 . ABI < . ABI ≥ .

S1 L4 – L5 L5 – S1 S2 – S4 Suprascapular Axillary Long thoracic Musculocutaneous Musculocutaneous Median Radial Median and Ulnar Femoral Sciatic Superior gluteal Obturator Sciatic Femoral Superficial peroneal and tibial Deep peroneal Deep peroneal Deep peroneal Superficial peroneal Pudenal Nerve Root C1 – C4 C1 – C4 Cranial nerve XI Cranial nerve XI Nerve C7 – C8. trapezius & serratus anterior Biceps Forearm supination Forearm pronation Wrist flexors Wrist extensors Hand intrinsics Hip flexion Hip extension Thigh abduction Thigh adduction Leg flexion Leg extension Foot plantar flexion Foot dorsiflexion Great toe extension Foot inversion Foot eversion Rectal spinchters C4 – C6 C5 – C6 C5 – C7 C5 – C6 C5 – C6 C6 – C7 C6 – C8 C7 – T1 L1 – L3 L4 – S1 L4 – S2 L2 – L4 L4 – S2 L2 – L4 L5 – S1 L4 – L5 L4 – L5. supraspinatus 15 to 90o. T1 Median 42 . deltoid >90o.Chart of Muscle Groups and Nerve and Nerve Root Supply Muscle Cervical flexors Cervical extensors Trapezius Sternocleidomastoid Arm abduction 0 – 15o.

pistol gunshot wound) Medium energy (open or multiple fractures. paresthesias. Outcome is variable for scores 7-10.Mangled Extremity Severity Score Skeletal / soft-tissue injury Low energy (stab. dislocation) High energy (high speed RTA or rifle GSW) Very high energy (high speed trauma + gross contamination) 1 2 3 4 Limb ischemia Pulse reduced or absent but perfusion normal Pulseless. numb 1* 2* 3* Shock Systolic BP always > 90 mm Transient hypotension Persistent hypotension 0 1 2 Age (years) < 30 30-50 > 50 * Score doubled for ischemia > 6 hours 0 1 2 The MESS is the sum of scores from each category. Scores < 7 are associated with limb salvage. Scores > 10 are associated with primary amputation. 43 . insensate. paralyzed. simple fracture. diminished capillary refill Cool.

DO NOT USE SUCTION OR CONNECT SUCTION LINE TO BRONCHOSCOPE. change IMV rate if necessary. Scope should be advanced to the smallest bronchial segment possible to perform BAL. <4. Sedate patient as necessary. Follow up with chest radiograph. Proceed to VAP Pathway for treatment. 8. 4. Fever (temperature > 100. Pharmacologic paralysis is NOT necessary. 7. Inject 20cc then immediately aspirate and pool the effluent for quantitative cultures. 5.000. or >10% bands) Purulent sputum New or changing infiltrate on chest x-ray BRONCHOSCOPY + BAL TECHNIQUE 1.Patient must have at least three of the following: 1.000.Diagnosis of Ventilator Associated Pneumonia Indications for bronchoscopy with bronchoalveolar lavage (FOB + BAL) . Use 100cc sterile nonbacteriostatic saline in 20cc aliquots. 3. 2. 6.5) or hypothermia (T < 96) Abnormal WBC (>10. Advance bronchoscope into affected lung segment (as seen on CXR) or LLL (if bilateral infiltrates). 44 . 4. Increase FiO2 to 100%. Routine suctioning with in-line catheter of the upper airway until clear. 2. 3.

change: Unasyn to Levofloxacin 750 mg IV Q24H. Cefepime to Ciprofloxacin 400 mg IV Q8H.000) Continue empiric antibiotic therapy Discontinue antibiotic therapy** Streamline antibiotic therapy** Final culture results <100.999 cfu/mL) Significant (≥100. dosage adjustment may be necessary based on renal function **Continue to monitor for changes in Final culture results 45 .000 cfu/mL >100.000 cfu/mL Empiric therapy discontinued Definitive antibiotic therapy (see Definitive Therapy Pathway for TICU) † Defined as the appearance of a new or changing infiltrate on chest radiograph and at least 2 of the following: o o −Abnormal temperature (>38 C or <36 C).Trauma ICU Ventilator-Associated Pneumonia Clinical Pathway Diagnosis and Empiric Management Clinical Suspicion of VAP † Fiberoptic Bronchoscopy with BAL Empiric antibiotic therapy based on timing of ICU admission <7 days in ICU Ampicillin/sulbactam (Unasyn®) 3g IV q6h * >7 days in ICU Vancomycin 20mg/kg IV q12h * + Cefepime 2g IV q8h * Preliminary culture results >24 hours No growth to date Insignificant (1-99. −Macroscopically purulent sputum -If severe beta-lactam allergy.000 cells/mm or <4000 cells/mm or the presence of >10% immature bands). 3 3 −Abnormal white blood cell count (>10.

000 cfu/mL? † Yes No Discontinue Antibiotics Continue Antibiotics for 10-14 days * Adequate antibiotic therapy is antibiotic therapy with in vitro activity against the pathogen.Trauma ICU Ventilator-Associated Pneumonia Clinical Pathway Definitive Therapy Early VAP? (≤7 days in ICU) Yes No Continue Antibiotics for 7 full days† Repeat BAL on Day 4 of Adequate Antibiotic Therapy * VAP pathogen(s) <10. Patients extubated or not eligible for repeat BAL should be treated for 7 full days (consider 10-14 days if Pseudomonas or not responding clinically) ** Consider treatment for 10.000 cfu/mL in severely injured patients with Pseudomonas and/or Acinetobacter † Use final culture result. †† Continue antimicrobial therapy in patients with septic shock † Pseudomonas requires a follow-up BAL regardless of being early or late VAP 46 .

et al. Consider serial duplex ultrasound in high-risk patients Primary risk factor present? [A] • • • • • Spinal cord injury Spinal column fractures Long bone fracture Pelvic fracture Sacral fracture • Acetabulum fracture • Traumatic brain injury • Laparotomy • Age > 40 plus major surgery. cancer.000 units sq every 8 hours plus Sequential compression devices (preferred) or A-V foot pumps Enoxaparin 30mg sq every 12 hours plus Sequential compression devices (preferred) or A-V foot pumps Reevaluate all patients for continuation of venous thromboembolism prophylaxis upon ICU discharge [A] Consider Inferior Vena Cava (IVC) filter in: High-risk trauma patients with significant bleeding risk or Patient’s with injury pattern rendering them immobile for prolonged period of time: a) Severe Traumatic brain injury b) Spinal cord injury with para. BMP. et al. – Also available at http://www.chestjournal. or hypercoagulable state Unfractionated heparin 5. 53(1):142-164. Yes Operative acetabulum fracture? 4 N o Enoxaparin 30mg sq every 12 hours plus Sequential compression devices (preferred) or A-V foot pumps Yes Pre-operative > 24 h post-operative Unfractionated heparin 5.east.or quadriplegia c) Complex pelvic fracture with associated long bone fracture(s) d) Multiple long bone fractures Evidence-based references • Geerts WH. J Trauma 2002. history of 3 No VTE.6 • Epidural catheter present (consult anesthesia) • PTT > 60 sec 9 • Platelet count < 50 x 10 cells/L No 2 Yes Sequential compression devices (preferred) or A-V foot pumps. 119: 132S-175S. Chest 2001. PTT.Guideline for the Prevention of Venous Thromboembolism in Critically ill Patients Approved by Pharmacy and Therapeutics Committee May 2004 Baseline CBC.org/tpg/dvt.pdf (accessed 5/14/04) Modified 5/14/04 47 . – Available at http://www. and PT/INR 1 Contraindication to heparin pharmacotherapy? [A] examples include: • Traumatic brain injury with progression on head • Active hemorrhage CT >24h post-injury (consult neurosurgery) • Recent hemorrhagic stroke • Hx of Heparin-induced Thrombocytopenia (HIT) • INR > 1.org/cgi/reprint/119/1_suppl/132S (accessed 5/14/04) • Rogers FB.000 * units sq every 8 hours plus Sequential compression devices (preferred) or A-V foot pumps *Note: May not be indicated in burn patients unless other risk factors are present.

devil’s dung. bladderwrack. Dong quai can potentiate the therapeutic and adverse effects of warfarin and antiplatelet drugs. root of the Holy Ghost) Anticoagulant Antiplatelet Effect Ingredient(s) Responsible Coumarin consitiuents Comments There is some evidence that the related Angelica species can inhibit platelet aggregation and lower prothrombin time when combined with warfarin.5-1 gram of the dried leaf or 50-200 mL of the essential oil.) Theoretically. reduced platelet counts and adhesiveness. cutweed) Anticoagulant 48 . (Typical dose is 0. The coumarin constituents of related Angelica species can inhibit human platelet aggregation in vitro. and fucus can increase the risk of bleeding. has 4050% of the blood anticoagulant activity of heparin. can lower prothrombin time in rabbits when coadministered with warfarin. The isolated fraction. Danggui) Fish Oils (omega-3 fatty acids) Anticoagulant Anticoagulant Antiplatelet Antiplatelet Coumarin constituents Coumarin constituents Docosahexaenoic acid (DHA) Eicosapentaenoic acid (EPA) Fucoidin Fucus (Fucus vesiculosis. excessive use of anise might prolong coagulation. fum. fucoidin. aniseed. due to coumarins contained in anise. The related species. Anise (Pimpinella anisum. The antithrombin activity of fish oil is due to prostacyclin synthesis. Angelica sinensis. increasing PT/INR and test results. Anticoagulant effects have been seen with excessive doses of anise. kelp. Chinese angelica. giant fennel) Dong Quai (Angelica sinensis. sweet cumin) Anticoagulant Coumarin constituents Asafoetida (Ferula assafoetida.Natural Products with Potential to Act as Blood Modifiers Natural Products THOUGHT to have Blood Modifying Effects Herb (other names) Angelica root (Angelica archangelica. Anticoagulant effects have been noted in vivo. vasodilation. black tang. assant. and prolonged bleeding time.

Populi folium) Effect Coagulant Anticoagulant Antiplatelet Ingredient(s) Responsible Vitamin K constituent Coumarin constituents Salicin Comments Excessive doses of agrimony could interfere with anticoagulant therapy.) Excessive doses could increase the risk of bleeding. agromonia. The crude extracts can inhibit platelet aggregation and the neutrophil and platelet secretory activity. This could potentiate the effects of anticoagulant and antiplatelet drugs. Studies show that lectin can have agglutinating activity and could interfere with anticoagulant or coagulant therapy. However. Celery could have anticoagulant effects due to the apiogenin constituent. leopard’s bane. bird’s foot. There is insufficient reliable information to determine if there is enough salicylate present in black cohosh to have significant effects. bromelin) Capsicum (Capsicum frutescen. red sage. bachelor’s button) Ginseng. marsh trefoil. cayenne. chili pepper) Celery (Apium graveolens. (Typical dose is 1-2 mL of the 1:1 liquid extract in 25% alcohol TID or 1-3 grams of the dried leaf TID. bugwort) Bogbean (Menyanthes trifoliata. boldine) Borage Seed Oil (Borago officinalis. jintsam) Goldenseal (Hydrastis canadensis. baneberry. Fenugreek could potentiate the effects of anticoagulant and antiplatelet drugs. black snakeroot. smallage. caryophyllus) Danshen (Salvia miltiorrhiza. Aesculin may increase bleeding time due to antithrombin activity. wolf’s bane. water shamrock) Antiplatelet Salicylate Bleeding risk Unidentified constituent Boldo (Peumus boldus. Greek hay) Feverfew (Tanacetum parthenium. escine. Black cohosh (Cimicifuga racemosa.) Arnica could potentiate the effects of anticoagulant and antiplatelet drugs. devil’s fuge. Excessive doses of bogbean can increase the risk of bleeding due to the hemolytic effects of an unknown constituent.Natural Products with THEORETICAL Potential to Have Blood Modifying Effects Herb (Other names) Agrimony (Agrimonia eupatoria. African pepper.4-dihydroxyphenyllactic acid Lectin Coumarin constituents Crude extracts Coagulant Anticoagulant Antiplatelet Anticoagulant Antiplatelet Coagulant Anticoagulant Active constituents Berberine Aesculin (coumarin) 49 . buckbean. eye balm) Horse Chestnut (Aesculus hippocastanum. Goldenseal could inhibit the anticoagulant effects of heparin. yellow puccoon. cocklebur) Arnica montana. Capsicum has led to increased fibrinolytic activity and could prolong bleeding time. There is one case report of increased international normalization ratio (INR) with concomitant use of danshen and warfarin. burage. which could increase the risk of bleeding when used concomitantly with anticoagulants or antiplatelets. featherfew. starflower) Bromelain (Ananas comosus. Panax (Asian ginseng. salvia root) European Mistletoe (Viscum album. Bromelain could increase the risk of bleeding when used in combination with antiplatelets or anticoagulants. Salicin is a salicylate constituent. in vitro studies provide preliminary data that suggest salicin might not potentiate the effects of anticoagulant drugs. midsummer daisy. Apii fructus) Clove (Syzygium aromaticum. venostat) Anticoagulant Anticoagulant Antiplatelet Antiplatelet Antiplatelet Antiplatelet Antiplatelet Anticoagulant Coumarin constituents Gamma linolenic acid Enzyme constituent Capsaicinoid constituents Apiogenin (coumarin) Eugenol Protocatechualdehyde 3. all-heal. Korean red. Panax ginseng could decrease the effectiveness of warfarin and affect clotting time.) Borage seed oil could prolong bleeding time. (Typical dose is 60-200 mg of the dried leaf TID. (Typical dose is 3 grams/day. drudenfuss) Fenugreek (Trigonella foenum-graecum. Clove contains a volatile oil that consists primarily of eugenol. mountain tobacco) Aspen (Populi cortex.

Tonka bean can contain up to 10% Antiplatelet Unidentified constituent Unidentified constituent Coumarin constituents Papain (Carica papaya) Passionflower (Passiflora incarnata. dropwort) Northern Prickly Ash (Zanthoxylum americanum. There is insufficient reliable information to know if the side effects and toxicity normally associated with salicylates could occur. cow clover. Large amounts of red clover can increase the effects and bleeding risk of anticoagulant drugs or natural products. greater plantain) Poplar (Populus tacamahacca. However.Horseradish (Armoracia rusticana. (Typical dose is 2-4 mL of the 1:1 liquid extract in 25% alcohol TID or 2-4 grams of the dried leaf TID. trefoil. although none have involved thromboembolic complications. Excessive ingestion of northern pickly ash might potentiate anticoagulant therapy. common plantain. balm of Gilead) (Quassia amara. Excessive doses of passionflower could increase the risk of bleeding. nettle) Sweet Clover (Melilotus officinalis. John’s Wort Stinging Nettle (Urtica dioica.25-2 grams of the dried plant. sweet root) Meadowseet (Filipendula ulmaria. Large amounts of sweet vernal grass could potentiate the risk of bleeding with anticoagulant drugs or natural products. mountain radish) Licorice (Glycyrrhiza glabra. sea ash. beebread) Roman chamomile (Chamaemelum nobile. zaffer) Southern Prickly Ash (Zanthoxylum clava-herculis. There is one case report of increased INR associated with the use of warfarin and papaya extract. pepper wood) Onion (Allium cepa) Anticoagulant Coumarin constituents Antiplatelet Anticoagulant Coumarin constituent Salicylates Anticoagulant Coumarin constituents Peroxidase stimulates the synthesis of arachidonic acid metabolites. sweet lucerne) Sweet Vernal Grass (Anthoxanthum odoratum. ipes. apricot vine) Pau D’Arco (Tabebuia impetiginosa. spring grass) Tonka Bean (Dipterux Risk of bleeding Anticoagulant Anticoagulant Coagulant Lapachol Vitamin K Antiplatelet Salicin Anticoagulant Anticoagulant Anticoagulant Coumarin constituents Coumarin constituents Coumarin constituents Anticoagulant Anticoagulant Safflower yellow Coumarin constituents Coagulant Coagulant Anticoagulant Anticoagulant Anticoagulant Vitamin K Dicumarol Coumarin constituent Coumarin constituent 50 . pepperrot. yellow wood) St. garden chamomile.5-1 mL of the 1:1 liquid extract in 25% alchohol TID or 0. Excessive doses of stinging nettle could interfere with anticoagulant therapy. Maypop. taheebo tea. hay flower. bridewort. whig plant) Safflower (Carthamus tinctorius. bitterwood) Red Clover (Trifolium pratense. saffron. Large amounts of safflower could potentiate the risk of bleeding with anticoagulant drugs or natural products. Inhibits platelet aggregation in humans and could increase the risks of bleeding with antiplatelet drugs or natural products. Excessive doses of quassia could increase the risk of bleeding.) Multiple cases of decreased INR have been reported. (Typical dose is 0. English chamomile. Excessive ingestion of southern pickly ash might potentiate anticoagulant therapy.) Pau d’arco may potentiate the effects of anticoagulants and increase bleeding tendency. Large amounts of Roman chamomile could have anticoagulant effects. lapacho) Plantain (Plantago major. (Typical dose is 3-4 mL of the 1:1 liquid extract in 25% alcohol TID. Licorice has shown antiplatelet activity in vitro. common melilot. Excessive doses of plantain could interfere with anticoagulant therapy. in vitro studies provide preliminary data that salicin might not potentiate the effects of anticoagulant drugs. toothache bark. which could potentiate the anticoagulant activity of other drugs or natural products. Large amounts of sweet clover could potentiate the risk of bleeding with anticoagulant drugs or natural products.) Salicin is a salicylate constituent.

ginger. danshen. feverfew. lettuce opium) Willow Bark (Salix alba. arnica. Large amounts of wild lettuce could potentiate the risk of bleeding with anticoagulant drugs or natural products. ginkgo. chamomile. tumeric. Data suggests irreversible inhibition of thrombocytes is unlikely and there might be no increase interaction with blood coagulants. asafoetida. HERBS WITH ANTICOAGULANT/ANTIPLATELET POTENTIAL: Concomitant use of herbs that have coumarin constituents or affect platelet aggregation could theoretically increase the risk of bleeding in some people. white willow. clove. Indian saffron) Wild Carrot (Daucus carota. There is some evidence to suggest that achilleine has decreased clotting time. horseradish. garlic. celery. licorice. wound wort) Antiplatelet Curcumin Anticoagulant Anticoagulant Antiplatelet Coumarin constituents Coumarin constituents Salicylate constituents Coagulant Achilleine coumarin and theoretically potentiate the risk of bleeding associated with anticoagulant drugs or natural products. Panax ginseng. red clover. capsicum. horse chestnut. fenugreek. willow. meadowsweet. and others. wild carrot. papain. green endive. Queen Anne’s lace. These herbs include anise. Large amounts of wild carrot could potentiate the risk of bleeding with anticoagulant drugs or natural products. onion. 51 . turmeric. quassia. prickly ash. boldo. thousand-leaf. torquin bean) Turmeric (Curcuma longa. passionflower. bogbean.odorata. coumarouna. poplar. wild lettuce. silberweide) Yarrow (Achillea millefolium. Curcumin has anti-inflammatory activity and could potentiate the antiplatelet activity of other drugs or natural products. beesnest plant) Wild Lettuce (Lactuca virosa.

Weaning from Mechanical Ventilation Daily screening No Problem for which patient was intubated is controlled Yes SaO2 ≥ 90% FiO2 ≤ 0.5 PEEP ≤ 5 cm H2O Airway reflexes intact No vasopressors or significant sedation Continue mechanical ventilation No Yes Therapist to measure RR/Vt No RR/Vt < 105 breaths/min/L Spontaneous breathing trial Yes RR > 35 breaths/min for more than 5 minutes SaO2 < 90% HR > 140 or ± 20% of baseline Systolic BP > 180 or < 90 mmHg No Increased anxiety or diaphoresis Extubate 52 .

Otherwise use of IV antihypertensives is more easily titratable in ICU patients. also check for other contraindications (bronchospasm) • nimodipine produces cerebral vasodilation.cold.AMI.MANAGEMENT OF HYPERTENSION Diagnosis of Hypertensive Crisis Immediate control to minimize end organ damage (CNS .pain .transducer height etc. Management of Hypertension There are many causes of hypertension in ICU patients.5 to 15 mg slow IVP every 6 hours IVP: 5 to 20 mg slow IVP every 1 to 4 hours Bolus: 5-20 mg IVP Infusion: 0.agitation .hypoxia. max 400 mcg/min) Infusion: 0. effect noticeable in areas of brain with restricted circulation than healthy areas. renal – ARF) is necessary.5 to 4 mg/min (Titrate) Bolus: 250-500 mcg/kg slow IVP Infusion: 25-100 mcg/kg/min (Titrate) Infusion: 5 to 20 mcg/min (Titrate. Treat underlying causes prior to administration of antihypertensives Common intravenous antihypertensive agents: Drug Metoprolol Action β-1 antagonist (min β-2 antagonist) β-1 antagonist (mod β-2 antagonist) α-1 antagonist β-1 antagonist (min β-2 antagonist) Exogenous source of nitric oxide Exogenous source of nitric oxide Direct arterial smooth muscle relaxation ACE Inhibition Effect Negative chronotropy Negative inotropy Negative chronotropy Negative inotropy Vasodilation Dose IVP: 2. BAI. amphetamine etc) • avoid β-blockers in patients with poor LV function. shivering . usually used in patients with vasopasm after subarachnoid hemorrhage • nitrates and nitroprusside can produce cerebral vasodilation and hence should be avoided in patients with intracranial pathology • prolonged nitroprusside administration can lead to acidosis and cyanide toxicity 53 .5:1 No vasodilation Half-life 4 to 6 hours Monitor closely in asthmatic patient (beta2 antagonist) Half-life ~ 15 min No vasodilation Methemoglobinemia Headache Profound hypotension Cyanide toxicity Reflex tachycardia Intrapatient variability Reflex tachycardia Hyperkalemia Acute renal failure Angioedema Labetalol Esmolol Negative chronotropy Negative inotropy Venous vasodilation (min arterial dilation) Arterial and venous vasodilation Arterial dilation Vasodilation (arterial > venous) Nitroglycerin Nitroprusside Hydralazine Enalapril Oral antihypertensives can be used in patients with stable hemodynamics. hypercarbia .increased ICP .withdrawal . cardiac . dissecting aortic aneurysm. Note on choice of antihypertensives: • avoid β-blockers in patients with increased adrenergic activity (pheochromocytoma.hypertensive encephalopathy. Otherwise BP should be lowered slowly and cautiously.1 to 10 mcg/kg/min (Start low and Titrate) IVP: 5 to 20 mg slow IVP every 4 to 6 hours IVP: 0. common causes include: . use of sympathomimetic drugs such as cocaine.underlying hypertension .625 to 1.25 slow IVP every 6 hours Comments Half-life 4 to 6 hours Oral:IV conversion 2.

may use Propofol (generic) continuous infusion1 PLUS Morphine sulfate prn pain/agitation2 REASSESS Pt every shift & as needed REASSESS Pt every shift & as needed 4 Patient w/TBI.Propofol (Diprivan® brand) continuous infusion1 PLUS Morphine sulfate prn pain/agitation 2 OR Alternative . ↑ICP.Fentanyl continuous infusion 2 Titrate to Riker SAS of 4 May consider use of neuromuscular blocker to assist with ventilator compliance 7 Lorazepam prn agitation.1 Mechanically ventilated trauma patient requiring sedation YES 3 2 Patient w/TBI. THEN Lorazepam continuous infusion if dosing requirements are high 4 PLUS Morphine sulfate prn pain/agitation. or requiring frequent neurologic examinations? NO NO 5 Go to 12 YE S 6 Pt expected to require sedation for ≥ 24 hours? YES NO REASSESS Pt every shift & as needed 8 Pt requiring sedation after 24 hours? 9 Preferred – Midazolam prn agitation3 PLUS Morphine sulfate prn pain/agitation2 Alternative . continue Morphine sulfate prn pain (or morphine sulfate 2 continuous infusion) 57 . or requiring frequent neurologic examinations? YES Preferred . ↑ICP. THEN Morphine sulfate continuous infusion if dosing requirements are high2 Titrate to Riker SAS of 4 In refractory cases.Propofol (generic) continuous infusion1 PLUS Morphine sulfate prn pain/agitation2 10 Continued need for sedation past 24 hours? NO YES NO 11 Go to 12 Titrate to Riker SAS of 4 12 D/C Sedation Protocol.

Dosage: 5-10 mg/dose. Excellent amnestic effect. Duration of action: 8-20 hours. Does not have histamine release. Cost: $49. suitable for usage in renal failure. Titrate to affect up to 50 mg/dose.5 hours. therefore. Cost: $15. Dosage (continuous infusion): 0. Dosage (continuous infusion): 2 mg/h.46/100 mg.95/1000 mg.48/5 mg. 24-hour cost (70 kg patient): ~$19.89/40 mg. Does not cause sedation per se. 24-hour cost: $100. Use with caution in elderly.00/day. Half-life: 18 hours. Prepared in lipid carrier.00/day.1 mg/kg/h. Dosage (continuous infusion): 20-200 mcg/kg/min. Does have limited anticholinergic effects.01 mg/kg/h.06-0. 24-hour cost: ~$8. Cost: $11. PROPOFOL Lipid soluble. Mechanism of action is to cause affective dissociation. May cause paradoxical reactions in the elderly. Titrate to 2/4 TOF. Duration of action: 4-5 hours. FENTANYL Short acting opiate. Metabolites accumulate in renal failure. Has sedative as well as analgesic properties.28/1000 mcg. 24-hour cost: ~$90. Cleared in plasma via Hoffman reaction. MIDAZOLAM Short acting benzodiazepine.76/100 mg. IF EITHER RISES. may cause hypotension/respiratory depression. 24-hour cost: ~$28.00/day. Dosage (continuous infusion): 2-4 mg/h. Causes respiratory depression. histamine release. MORPHINE Opiate. Duration of action: 15 minutes.ICU Pharmacologic Agents ATRACURIUM Half life: 20 minutes. Should not be used in patients with hypertriglyceridemia. Exhibits three-compartment redistribution with prolonged use. Cost: $5. Cost: $0.00/day. and hypotension.57-5. Cost: $12. Dosage (continuous infusion): 0.1 mg/kg/h. Clearance adversely affected by renal failure. Much more stable than morphine from cardiovascular standpoint.00/day.57/5 mg. 24-hour cost: $3. Contraindicated in hepatic failure. STOP DIPRIVAN IMMEDIATELTY. Bolus doses may cause hypotension. Duration of action: 2 hours. Cost: $1.79/10 mg. does not cause respiratory or cardiovascular depression. leading to prolongation of action. Should use Cogentin at regularly scheduled intervals.00-6. HALOPERIDOL Butyrophenone/antipsychotic. Rare fatal reactions noted in children.000.00/day. the “gold standard” analgesic in the ICU setting. Lowers ICP.00-1.00/day.70.80-64. PANCURONIUM Half-life: 2 hours. Duration of action: 1-2 hours. Cost: $9. LORAZEPAM Intermediate acting benzodiazepine. Cost per dose: $0. ALL PATIENTS RECEIVING DIPRIVAN MUST HAVE DAILY SERUM LACTATE AND CPK CHECKED. Titrate to 2/4 TOF.39/10 mg. VECURONIUM Half-life: 1. Sedative and analgesic effects. May cause tachycardia. 24-hour cost: $12. Dosage (continuous infusion): 1-5 mcg/kg/min. Easily titratable. Dosage (continuous infusion): 1 mg/h.00/day. Titrate to 2/4 TOF. Prolonged use can lead to prolonged sedation. 54 . 24-hour cost: ~$20. may cause dystonia/tardive dyskinesia. Causes respiratory depression. ultra-short-acting anesthetic. Dosage (continuous infusion): 0. Cost: $1.

albumin 3. Folic acid 1mg once daily PO/IV 3. Thiamine 100mg once daily IV/IM/PO 2. Blood glucose monitoring Provide: 1. BMP.Alcohol Withdrawal Protocol Patient with risk factors for alcohol withdrawal syndrome Obtain: 1. Multivitamin once daily or Cernevit 5ml in minimum 500ml IVF once daily 4. Lorazepam 2-4mg IV every 1 hr until lightly sedated and symptoms resolved. liver function panel. Wean over 3 days. Monitor vital signs and status every hour 55 . Titrate for symptoms of early withdrawal. phosphorus. Adequate hydration High clinical suspicion for withdrawal Active withdrawal Select desired therapy: Lorazepam (preferred) or ethanol drip Note: ethanol is contraindicated in patients with pancreatitis and liver disease Transfer to monitored unit Lorazepam 2-4mg PO/IV/IM q 6 hrs x 4 doses. magnesium. then 12mg PO/IV/IM q 6 hrs 2 8 doses (3 day prophylaxis wean). Monitor vital signs and status q 4-6 hrs. Ethanol 5% in D5W at initial rate of 50 ml/hr. Monitor vital signs and status q 4-6 hrs. INR/PT 2.

Patients with Renal Insufficiency/Failure The preferred agents are lorazepam (Ativan) and hydromorphone (Dilaudid) 0. IF EITHER RISES. up to 5 mg/kg/hr. follows simple commands Calm. Patients with documented allergy to morphine sulfate and/or severe hypotension with morphine sulfate administration. Midazolam (Versed): Standard regimen is 2. propofol should be discontinued if serum triglyceride levels are ≥300.5-5 mcg/kg/hr. alternative regimen is continuous infusion (100 mg/ 100 mL NS): start at 2-4 mg/hr.5 mg/hr. alternative regimen is continuous infusion (20 mg/ 100mL NS): start at 1-2 mg/hr. awakens to verbal stimuli or gentle shaking but drifts off again.5-5 mg IV every 1-2 hours prn sedation. awakens easily. attempting to sit up. Lorazepam (Ativan): Standard regimen is 1-2 mg IV every 1-2 hours prn sedation. striking at staff. may use fentanyl: load with 1-2 mcg/kg. Morphine sulfate: Standard regimen is 1-6 mg IV every 1-2 hours prn pain/agitation. ALL PATIENTS RECEIVING DIPRIVAN MUST HAVE DAILY SERUM LACTATE AND CPK CHECKED. normeperidine and morphine-6glucuronide. AVOID meperidine (Demerol) and morphine sulfate because of increased potential for accumulation of renally excreted metabolites. Patients receiving propofol infusion should have serum triglyceride levels monitored every 4-7 days. (Diprivan): Begin with 0. STOP DIPRIVAN IMMEDIATELTY. Patients with closed head injury being followed by the neurosurgical service may receive Diprivan® brand propofol because it has been shown to decrease intracranial pressure. 4. continuous infusion to start at 0. climbing over bed rail. 3. increase by 0. calms down to verbal instructions Does not calm. then continuous infusion (1 mg/ 50 mL) at 0. trying to remove catheters. biting ET tube 7) Dangerous agitation Pulling at ET tube. follows commands 4) Calm and cooperative: 5) Agitated: 6) Very agitated: Anxious or mildly agitated. may not move spontaneously Difficult to arouse. Riker Sedation-Agitation Scale (SAS) 1) Unarousable: Minimal or no response to noxious stimuli. 2. does not communicate or follow commands 2) Very sedated: 3) Sedated: Arouses to physical stimuli but does not communicate or follow commands.5 mg/kg/hr. thrashing side-to-side 56 . respectively. requires physical restraint.Sedation Protocol 1. despite frequent verbal reminding of limits.5-1 mg IV every 1-4 hours prn pain/sedation.5 mg/kg every 5-10 minutes.

Patient Admitted to MICU/SICU/TICU Stress Ulcer Prophylaxis Yes Evidence of active GI bleed on admission Treat active bleeding *SRMD=Stress Related Mucosal Damage PUD=Peptic Ulcer Disease GERD=Gastroesophageal Reflux No Patient with SRMD.Risk factors for gastrointestinal bleeding in critically ill patients. Robinson NJ et al. Major Surgery/Trauma No Yes IV PROTON PUMP INHIBITOR i. CookD. Individual patients may require different treatments from those specified in this particular guideline.e. Ann Pharmacother. HeylandD.Dig Dis Sci 1997Jun.N Engl J Med. Pantoprazole 40 mg every 24 hours  > 48h Mech.42(6):1255-9 3. or GERD* No Yes MAJOR RISK FACTORS Severe Head Trauma Burns > 30% BSA Prior Organ Transplant Renal Failure Recent PUD (6 weeks)* Hypotension/Shock 1. 2002 Dec. 2. Jung R. Levy MJ. Ventilation OR Coagulopathy No No Prophylaxis Indicated Re-evaluate need for treatment Yes IV H2 BLOCKER i. 58 . PUD. Severe Sepsis 2. This guideline is not a fixed protocol that must be followed.330(6):377-81.e.et al:Risk factors for clinically important UGIB in patients requiring mechanical ventilation. Cook DJ . Fuller HD. While it identifies and describes generally recommended courses of intervention.27:2812–2817 4. Proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients.Comparison of omeprazole and ranitidine for stress ulcer prophylaxis. MacLaren R.Ranitidine 50 mg IV every 8 hours (For Cr Cl < 50) 50 mg IV daily Discontinue Therapy On Transfer/Discharge OR Risk Factors Resolved References 1. it is not presented as a substitute for the advice of a physician or other knowledgeable health care professional or provider. Seelig CB. but is intended for health care professionals and providers to consider. Ranitidine 150mg PO BID (For Cr Cl < 50) 75 mg PO BID OR Oral Proton Pump Inhibitor i. Crit Care Med 1999. Pantoprazole 40 mg IV every 24 hours ORAL H2 BLOCKER Tolerating Tube Feedings or PO intake i.e.36(12):1929-37 *Endoscopic or radiographic evidence of peptic ulcer disease in preceding 6 weeks ** Presence and persistence and severity of risk factors should be reviewed every24h This clinical practice guideline is a systematically developed algorithm intended to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. 1994 Feb 10.Griffith L.e. Guyatt GH et al.

depressed skull fx. GCS < 10. serum Na and osmolarity every 6 hours  No hyperosmolar agents if osmolarity > 320  Goal serum Na 145-155 usually • Cerebral Perfusion Pressure Goals 50-70 mm Hg usually  Neosynephrine preferred pressor if pressors needed  Dopamine in low doses 59 .4 occasionally still done) • Avoid thrombocytopenia • Serial INR (repeat 6-8 hours after injury. Mannitol +/. sz within 24 hours of injury • Avoid symptomatic anemia • Maintain normal ICP and CPP within desired range For elevated ICP (> 20 mm Hg x > 5 minutes): Notify Neurosurgery First Tier Therapies: • Ensure HOB elevated • Ensure no compression from cervical collar and neck in neutral position • Ensure ventriculostomy (if present) patent and functioning • Sedation and analgesia with Diprivan Drip (discontinue if elevation of CPK or lactate) or Fentanyl or Morphine Drip or Intermittent Dosage • Maintain Hyperosmolar Euvolemia  A Catheter. IPH/contusion. for frequent neurological exams  Especially important in first 24 hours  Sedation holiday for nursing neuro check unless otherwise ordered • Convert field collar to Miami J until ligamentous injury can later be ruled out • Insertion of intraparenchymal ICP monitor after coagulopathy (if present) corrected (Normal PTT and INR < 1.2 desireable. penetrating injury. enteral preferred • DVT prophylaxis with TEDs and thigh-high SCDs if possible  Delay subcutaneous heparin until 24-48 hours post-injury  Delay Lovenox until cleared by NSR • Seizure prophylaxis (Dilantin) x 7 days for EDH. <1. then every 24 hours for 48-72 hours) • Rapid evacuation of mass lesions if indicated • Rule out vascular injury/hypoxic or embolic mechanisms of brain injury • Rule out intoxicants as contributors to neurological status • Ensure adequate ventilation and oxygenation and prevent hypercarbia • Elevate HOB to 30 degrees (reverse Trendelenberg if spine not cleared) • Avoid hypothermia • Avoid hyperglycemia and hypoglycemia (Goal Glucose 80-150) • Early nutrition. SDH. hypertonic saline boluses.Lasix.General Management Principles for Severe (GCS 3-8) and Moderate (GCS 9-12) TBI • Use very short-acting sedatives if needed.

these are used in somewhat of a step-wise progression by tier but simultaneously within tiers (and sometimes across tiers). • The third-tier therapies may be used prior to any second tier therapies. • The first tier therapies are used on essentially everyone with a severe TBI. 60 . • The second tier therapies may be used prior to some of the first tier therapies or never at all. The idea is to have standards for all but tailor the therapy to the individual patient's physiology and injury patterns. temporary hyperventilation to pCO2 30-35 • Intermittent paralytics • Intermittent barbiturates Third Tier Therapies: • Decompressive craniotomy • Barbiturate coma • In general.General Management Principles for Severe (GCS 3-8) and Moderate (GCS 9-12) TBI (continued) Second Tier Therapies: • Cerebrospinal fluid drainage/Ventriculostomy • Mild.

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