Resident Handbook

The Penn State Health Trauma Center

Adult Trauma Program
&
Division of Trauma, Acute Care and
Critical Care Surgery

June 2022
 TABLE OF CONTENTS

MISSION STATEMENT ............................................................................................................. 3

INTRODUCTION ........................................................................................................................ 4

TRAUMA/CRITICAL CARE RESIDENT EDUCATION GOALS/OBJECTIVES............. 5

EMERGENCY GENERAL SURGERY RESIDENT EDUCATION

GOALS/OBJECTIVES ................................................................................................................ 8

DIVISION OF TRAUMA, ACUTE CARE & CRITICAL CARE SURGERY STAFF ...... 10

SERVICE OPERATIONS, STRUCTURE, AND FUNCTION.............................................. 12

TRAUMA AND EMERGENCY GENERAL SURGERY RESIDENT EXPECTATIONS 17

SURGICAL CRITICAL CARE (SCC) RESIDENT EXPECTATIONS .............................. 21

TRAUMA AND EMERGENCY GENERAL SURGERY SERVICE TIPS ......................... 23

TRAUMA PATIENT LIST MAINTENANCE .................................................................................. 23
DISCHARGE SUMMARY TEMPLATE .......................................................................................... 23
OPERATIVE REPORT TEMPLATE ............................................................................................... 24
DISCHARGE FOLLOW-UP APPOINTMENTS ............................................................................. 24

Trauma PERFORMANCE IMPROVEMENT (PI) Program................................................ 25

PENNSYLVANIA TRAUMA SYSTEMS FOUNDATION (PTSF) AUDIT FILTERS ...... 26

PTSF OCCURRENCES ............................................................................................................. 26

TRAUMA TRIAGE CRITERIA ............................................................................................... 28

PROFESSIONAL COURTESY DURING TRAUMA RESUSCITATION ............................. 33

Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 2

TRAUMA/EGS/SCC GUIDELINES, AND ALGORITHMS ................................................ 34

WHEN TO CALL AN ACUTE CARE SURGERY ATTENDING ....................................... 36

Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 3

MISSION STATEMENT

The Division of Trauma, Acute Care and Critical Care Surgery is dedicated to providing the very
best in acute surgical care with the ultimate goal of returning patients to an active quality lifestyle.

To provide the best possible patient care, the service is committed to the education of physicians,
medical students, nurses, allied health professionals, pre-hospital personnel, and the public.

To advance our care to the highest level, we are committed to research and the discovery of new
treatments and methods of providing acute care surgery.

To work collaboratively with area hospitals and trauma centers in order to provide a systematic
approach to trauma and emergency surgery ensuring access and availability to appropriate clinical
services.

As a Level 1 trauma center, the trauma program is committed to function as a clinical and an
educational resource to our region. We are available for consultation, lectures, and tertiary to
quaternary care for any patient in our region. Since most traumas are no accident, the trauma
program is committed to promoting prevention strategies to decrease the amount of injury and
disability in our region.
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 4

INTRODUCTION

Penn State Health Milton S. Hershey Medical Center (HMC) is a state-designated Level 1 Adult
Trauma Center and a Level 1 Pediatric Trauma Center that is accredited by the Pennsylvania
Trauma Systems Foundation (PTSF).

The Centers for Disease Control reports that in the first half of life, more Americans die from
injuries and violence, such as motor vehicle crashes, falls, or homicides than from any other
cause including cancer, HIV, or influenza. Over 200,000 people die from injury every year.1 In
2015, 2.8 million people were hospitalized due to injuries and 27.6 million people were treated in
an emergency department for injuries.2 The economic toll of trauma is astounding with total
costs of injury and violence in the US of $4.2 trillion in 2019.3

HMC currently sees over 3,500 trauma admissions per year (>2,700 adults and >800 pediatric).
The top mechanism of injury is falls, second is motor vehicle crashes, and penetrating injuries
(GSW and SW) account for approximately 7% of our admissions.

In addition to caring for trauma patients, the faculty and staff participate in other aspects of
emergency general surgery and surgical critical care. The 30-bed SAICU admits primarily
emergency general surgery patients from our service but also cares for critically ill transplant,
colorectal, MIS, orthopedic, plastic surgery, OB/GYN, and urology patients. The trauma and
emergency general surgery services maintain an elective general surgery practice as well.

Our primary and secondary catchment areas have a population base of approximately 1.9 million
lives. Hershey Medical Center also owns and operates three helicopters for transporting trauma
and emergency general surgery patients.

1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics
Query and Reporting System (WISQARS) 2015 [cited 2015 01/26/15]. http://www.cdc.gov/injury/wisqars.
2. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics
Query and Reporting System (WISQARS) Nonfatal Injury Data. (2016)
3. Peterson C, Miller G, Barnett Sarah, et al. Economic cost of injury – United States, 2019. MMWR 2021;70(48);1655-1659.
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 5

TRAUMA/CRITICAL CARE RESIDENT EDUCATION GOALS/OBJECTIVES

Goals
The resident will learn the scope and practice of trauma and surgical critical care. The resident
will learn the anatomy, physiology, and pathophysiology of trauma and clinical care to manage
severely injured patients. This will include the ability to manage those problems that are
amenable to surgical intervention.

Knowledge
• Demonstrate understanding of institutional policies for pre-hospital care and trauma
triage.
• Acquire ATLS and ACLS certification.
• Discuss management of traumatic wounds (including tubes and drains) and
musculoskeletal injury (casts, splints, traction, rhabdomyolysis, and compartment
syndrome).
• Describe the pathophysiology, initial evaluation, and management of:
o CNS injury - brain and spinal cord
o Chest trauma - heart, thoracic aorta, chest wall, lungs
o Abdominal injury - spleen, liver, GI tract, and GU system
o Musculoskeletal trauma - axial skeleton, pelvis, long bones
• Describe the basic critical care management principles for:
o Neurologic injury
o Airway and ventilator management
o Cardiovascular support (invasive monitoring, dysrhythmias, inotropes,
vasopressors, etc.)
o Fluid, electrolyte, renal, and nutrition support
o Gastrointestinal problems - pancreatitis, intestinal fistulae, ileus, bowel
obstruction, etc.
o Diagnosis and treatment of infections
o Coagulopathy, DVT prophylaxis and treatment, etc.
• Demonstrate knowledge of pharmacologic agents used to treat trauma surgery
patients.
• Recognize the effects of increasing age and concurrent medical illness on organ
system physiology as it relates to traumatic injury and the management of
elderly patients with injury.
• Identify and treat different forms of shock associated with the injured patient.
Examples include hemorrhagic, neurogenic, cardiogenic and septic shock.
• Understand the indications for, and different types of agents used in prophylactic
and therapeutic antibiotic use.
• Understand appropriate fluid and electrolyte resuscitation.
• Recognize the costs, risks, and expected information obtained from routine laboratory
testing.
• Understand the basic principles in the diagnostic evaluation of single organ system
injury.

• Know their role in the trauma resuscitation team, and be able to perform the
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 6

appropriate tasks of that role.

• Familiarize themselves with trauma protocols.
• Discuss the costs, risks and expected information obtained from non-invasive
diagnostic tests to evaluate the injured patient. Examples include plain films,
ultrasonography, and CT scanning.
• Understand the costs, risks, and expected information obtained from invasive
diagnostic rests to evaluate the injured patient. Examples include wound exploration,
DPL, and arteriography.

Patient Care
• Be aware of limitations and know when to call for help.
• Attend daily check out rounds for the service.
• Assist with resuscitation in trauma patients presenting to the emergency department.
• Assume responsibility for care of all patients on the hospital ward, including
initial assessment, creating a therapeutic plan, evaluation of daily progress, and
initial assessment of new problems.
• Assess patients on the ward when called for cross-coverage. Examples include
evaluation of patients with fever, oliguria, hypotension, respiratory
insufficiency, and intractable pain.
• Assume responsibility for discharging patients, including dictating the discharge
summary, writing prescriptions, and ensuring appropriate follow-up.
• Perform basic operative cases under supervision.

Interpersonal Skill and Communication

• Educate patients and families in post-operative and rehabilitative strategies for the
trauma surgery patients.
• Interact with other team members and attending physicians in the communication of
information pertaining to patient care.
• Interact and communicate properly and professionally with other health care
professionals.

Practice-Based Learning and Improvement

• Successfully pass ATLS.
• The resident should use textbooks, journal articles, Harrell library, and other tools
available to learn about diseases and treatment of the injured patient.
• Residents must attend monthly Trauma/EGS Conferences.
• Residents must attend and participate in the weekly clinics for their service.

System Based Practice

• Participate in the coordination of the rehabilitation of the trauma surgery patient.
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 7

• Demonstrate knowledge of cost-effective trauma surgery care.

• Advocate for trauma surgery patients within the health care system.
• Refer trauma patients to the appropriate practitioners and agencies.
• Facilitate the timely discharge of trauma surgery patients.
• Work with paramedical professionals in the pre-hospital care of trauma patients.

Professionalism
• Develop a sensitivity of the unique stresses placed on families of patients under care for
trauma surgery.
• Demonstrate an unselfish regard for the welfare of trauma surgery patients.
• Demonstrate a commitment to carrying out professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
• Demonstrate firm adherence to a code of moral and ethical values.
• Provide appropriately prompt consultations when requested.
• Demonstrate sensitivity to the individual patient’s profession, life goals, and cultural
background as they apply to his or her trauma/surgical diagnosis.
• Be reliable, punctual, and accountable for own actions in the OR, on rounds and in clinic.
• Effectively deal with dissatisfied patients.
• Understand the benefits and functionality of multidisciplinary health care teams.
• Refer patients to the appropriate practitioners and agencies.
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 8

EMERGENCY GENERAL SURGERY RESIDENT EDUCATION

GOALS/OBJECTIVES

Goals
The resident will learn the scope and practice of acute care surgery (emergency general surgery-
EGS). The resident will learn the anatomy, physiology, and pathophysiology of the diseases in
emergency general surgery, including the ability to manage those problems that are amenable to
surgical intervention.

Knowledge
• Demonstrate knowledge of the anatomy, physiology, and pathophysiology of the
following diseases in emergency general surgery, including the ability to manage those
problems that are amenable to surgical intervention:
o Bleeding and/or Perforated Gastric and Duodenal Ulcers
o Acute Cholecystitis
o Choledocholithiasis
o Acute Necrotizing Pancreatitis
o Diverticulitis
o Perforated Viscous
o Small and Large Bowel Obstruction
o Lower Gastrointestinal Bleeding
o Peritonitis
o Appendicitis
o Soft Tissue Infections
o Incarcerated and Strangulated Hernias
• Describe the etiology and pathophysiology of common general surgical emergencies.
• Select and interpret appropriate laboratory and radiologic evaluations in the work-up of
these diseases.
• Describe the common complications associated with the surgical management of these
diseases and their appropriate management.

Patient Care
• Participate in the evaluation, resuscitation, operative, and ICU management of emergency
surgery patients.
• Perform various bedside procedures under attending supervision:
o Thoracostomy tube
o Central venous catheterization
o Intra-arterial catheterization
o Bronchoscopy
o Tracheostomy-Percutaneous & Open
o UGI Endoscopy/PEG tube
o Incision and drainage
• Apply and remove all types of dressings.
• Evaluate, manage, and treat various surgical wounds.
• Demonstrate proficiency in fundamental surgical techniques (surgical incision,
dissection, wound closure, knot tying, basic laparoscopy, etc.).
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 9

• Assess nutritional needs and initiate necessary parenteral/enteral nutritional support.

• Evaluate critically ill patients and make supervised decisions regarding patient care.
• Demonstrate accuracy and proficiency in documenting patient care (daily progress notes,
operative reports, narrative summaries, etc.).
• Evaluate patients in follow up clinic and develop an outpatient plan of care (with
supervision).

Interpersonal Skill and Communication

• Educate patients and families in pre-operative, post-operative, and rehabilitative
strategies for emergency general surgery patients.
• Provides adequate counseling and informed consent to emergency general surgery
patients.
• Interact and communicate properly and professionally with other health care
professionals.

Practice-Based Learning and Improvement

• The resident should use books, journal articles, internet access, and other tools
available to learn about diseases and treatment of the emergent surgical patient.
• The resident must attend monthly Trauma/EGS Conferences.
• The residents must attend and participate in the weekly clinics for their service.

System Based Practice

• Understand the principles of operating room set-up for emergency general surgery.
• Demonstrate knowledge of cost-effective emergency general surgery care.
• Advocate for emergency general surgery patients within the health care system.
• Refer emergency general surgery patients to the appropriate practitioners and agencies.
• Participate in the coordination of the rehabilitation of the emergency general surgery
patient.
• Facilitate the timely discharge of emergency general surgery patients.

Professionalism
• Develop a sensitivity of the unique stresses placed on families of patients under care for
emergency general surgery.
• Demonstrate an unselfish regard for the welfare of emergency general surgery patients.
• Demonstrate a commitment to carrying out professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
• Demonstrate firm adherence to a code of moral and ethical values.
• Provide appropriately prompt consultations when requested.
• Demonstrate sensitivity to the individual patient’s profession, life goals, and cultural
background as they apply to his or her surgical diagnosis.
• Be reliable, punctual, and accountable for own actions in the OR and clinic.
• Effectively deal with dissatisfied patients.
• Understand the benefits and functionality of multidisciplinary health care teams.
• Refer patients to the appropriate practitioners and agencies.
 Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 10

DIVISION OF TRAUMA, ACUTE CARE & CRITICAL CARE SURGERY STAFF

Faculty Pager # Office # Email Address

Scott B. Armen, MD, FACS, FCCP, FCCM 5086 6066 sarmen@pennstatehealth.psu.edu
Charlene J. Smith Professor of Surgery and Neurosurgery
Surgical Director, Quality & Patient Safety, HMC
Vice Chair for Clinical Affairs
Chief, Division of Trauma, Acute Care and Critical Care
Surgery
Adult Trauma Program Medical Director
Melissa M. Boltz, DO, MBA, FACS 6040 6066 mboltz2@pennstatehealth.psu.edu
Vice Chair for Quality & Patient Safety
Director, Emergency General Surgery
Associate Professor of Surgery
Amanda Cooper, MD, FACS 5863 3563 acooper2@pennstatehealth.psu.edu
Associate Program Director, General Surgery Residency
Associate Professor of Surgery
Dan A. Galvan, MD, FACS 4686 322682 dgalvan@pennstatehealth.psu.edu
Program Director, General Surgery Residency
Associate Professor of Surgery
Joshua S. Gish, MD, FACS 2203 3563 jgish@pennstatehealth.psu.edu
Assistant Professor of Surgery
Joshua P. Hazelton, DO, FACS, FACOS 2738 6066 jhazelton@pennstatehealth.psu.edu
Associate Trauma Program Medical Director
Assistant Professor of Surgery
Lacee Laufenberg, MD 3354 6066 llaufenberg@pennstatehealth.psu.edu
Assistant Professor of Surgery
Melissa Linskey Dougherty, MD 5589 6066 mlinskey@pennstatehealth.psu.edu
Assistant Professor of Surgery
John S. Oh, MD, FACS, FCCM 5446 6066 johnoh1@pennstatehealth.psu.edu
Director, Surgical Critical Care
Program Director, Surgical Critical Care Fellowship
Program Director, Global Surgery
Associate Professor of Surgery
J. Nathaniel Ruhala, DO 5222 3563 jruhala1@pennstatehealth.psu.edu
Assistant Professor of Surgery
Ryan Staszak, MD, FACS 5914 3563 rstaszak@pennstatehealth.psu.edu
Medical Director, Surgical Intermediate Care Unit
Assistant Professor of Surgery

Advanced Practice Providers (APPs) Pager # Office # Email Address

Timothy Baker, PA-C 4751 7161 tbaker1@pennstatehealth.psu.edu
Erin (Maggie) Becker, CRNP 7786 7161 ebecker@pennstatehealth.psu.edu
Leonard Dobson, PA-C 3467 7161 ldobson@pennstatehealth.psu.edu
Cynthia Frost, CRNP 1723 6066 cfrost@pennstatehealth.psu.edu
Lynn Motz, CRNP 4392 7161 lmotz@pennstatehealth.psu.edu
Elizabeth Peitzman, PA-C 6513 6066 epeitzman@pennstatehealth.psu.edu
Melissa Steffen, PA-C 5972 7161 msteffen@pennstatehealth.psu.edu
Chrissy Unton, CRNP 7206 7161 cunton@pennstatehealth.psu.edu
Daniel Watkins, PA-C 2719 7161 dwatkins@pennstatehealth.psu.edu
Jason Wyse, PA-C 5353 7161 jwyse@pennstatehealth.psu.edu
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 11

Trauma Program Manager Pager # Office # Email Address

Justin Heinrich, MSN, RN, TCRN 0301 3563 jheinrich@pennstatehealth.psu.edu

Nurse Care Coordinator Pager # Office # Email Address

Amy Bollinger, BSN, RN, TCRN 5370 7159 abollinger1@pennstatehealth.psu.edu
Patricia Palubinsky, BSN, RN, CCRN 4581 7159 ppalubinsky@pennstatehealth.psu.edu

Injury Prevention & Outreach Coordinator

Kimberly Patil, MA, NREMR 6297 281142 kpatil@pennstatehealth.psu.edu

Administrative Staff Rm # Office # Email Address

Laura Kemble C5520 7161 lkemble@pennstatehealth.psu.edu
Helen Long H5516 6066 hlong@pennstatehealth.psu.edu
Carol Nye C5523 3563 cnye@pennstatehealth.psu.edu

Trauma Registrars Rm # Office # Email Address

Julia Crum H5515 5242 jcrum@pennstatehealth.psu.edu
Antoinette Cuzzolina H5515 5242 acuzzolina@pennstatehealth.psu.edu
Angela Cippola H5515 5242 acippola@pennstateheatlth.psu.edu
Jeannie Schiavo H5515 5242 jschiavo@pennstatehealth.psu.edu

Administrators Rm # Office #
Mona Miliner, Vice President, Operations H1246C 7943 mmiliner@pennstatehealth.psu.edu
Greg Swope, Operations Manager C4622 5529 gswope@pennstatehealth.psu.edu
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 12

SERVICE OPERATIONS, STRUCTURE, AND FUNCTION

TRAUMA AND EMERGENCY GENERAL SURGERY SERVICES

This service consists of two resident teams: a Trauma Team, responsible for the care of injured
patients, and an Emergency General Surgery Team, responsible for emergency and elective
general surgery.

TRAUMA ATTENDING COVERAGE

• The Trauma service attending and Trauma back-up attending are responsible for all
admitted service patients during the week.
• The Trauma attending responds to the Emergency Department for trauma activations and
consultations from 7am to 5pm.
• The on-call Trauma surgeon responds to trauma activations from 5pm to 7am.
• Trauma Clinic is on Thursday from 1pm to 4pm.

EGS ATTENDING COVERAGE

• The EGS service attending and EGS back-up attending are responsible for all Emergency
surgery consults and admissions.
• The EGS attending responds to the Emergency Department for emergency general surgery
consultations from 7am to 5pm. The EGS surgeon on-call is responsible for all consults and
admissions from 5pm to 7am.
• EGS Clinic is on Tuesday from 1pm to 4pm.

RESIDENT INPATIENT COVERAGE

• All residents must maintain ATLS and ACLS certifications to care for trauma patients.
• There will be one PGY-5 and one PGY-4 resident on the Emergency General Surgery
Service and a PGY-3 and PGY-4 resident on the Trauma service.
o The PGY-4 on trauma will be the nighttime trauma chief
o The PGY-3 will respond to Level 2 trauma resuscitations during the day
• The Junior Residents and APPs will be assigned to the following Teams:
o EGS: one PGY-2 surgery resident, one PGY-1 resident and two APPs
o Trauma: one PGY-2 surgery resident, two PGY-1 residents, two APPs, two Nurse
PI Coordinators
• All residents are assigned daily clinical duties by the Chief/Senior Residents and service
attendings.
• Trauma and EGS consultations must be evaluated within 30 minutes of any request.
• Advanced practice providers assist with trauma and emergency general surgery care
management throughout all phases of care.
• Resident coverage for trauma team activations and Emergency Department consultations are
performed by the Trauma Team from 6am to 6pm.
• On call resident cross-coverage is provided for trauma team activations and Emergency
Department consultations from 6pm to 6am.
• A PGY-4 or above surgery resident is expected to attend all Level 1 Trauma Alerts.
• A PGY-3 or above surgery resident is expected to attend all Level 2 Trauma Alerts*
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 13

o *Should the PGY-4 or PGY-5 on service both be in the OR when a Level 1 trauma
is activated during the day, it should be communicated prior to the activation that
they will both be unavailable to respond to Level 1’s and that the PGY-3 surgery
resident will be responding.
o *Should the PGY-4 or PGY-5 be out of the operating room and not directly
involved with patient care or education, they are expected to attend the Level 2
Trauma Alerts to assist as needed.
• Day time coverage of Trauma Alerts on Thursday:
o The role of the PGY-3 will be shared with a PGY-3 surgery resident and a PGY-3
emergency medicine resident on Thursday due to surgery resident education and the
need for emergency medicine residents to gain experience in trauma resuscitations.
• The EGS Team is activated by the Trauma Team during the day when additional assistance is
required for adult trauma patients.
• Residents are to be compliant with the 80-hour workweek. They are expected to log their
hours in New Innovations no later than Sunday of each week. Residents post-call are to leave
no later than 4 hours after their 24-hour call.

ADVANCED PRACTICE PROVIDERS: NURSE PRACTITIONER & PHYSICIAN

ASSISTANT ROLES
• APPs function as an integral part of the team.
• APPs assist in daily rounds and collaborate with the attending physicians regarding the plan
of care.
• APPs have privileges to write orders.
• APPs assist with surgical procedures under direct or general supervision by the attending,
depending on level of medical staff privileges. Such procedures include, but are not limited
to: arterial line insertion, thoracentesis, thoracostomy tube placement, central line
placement, intubations, and PEG tube placement.
• APPs assist in trauma resuscitations when available.
• Trauma PI Nurse Coordinators assist the Trauma Program Manager with all Performance
Improvement (PI)/Quality Assurance monitoring and regulatory documentation for the
Hershey Medical Center. Approximately 50% of their day is allotted to PI
initiatives/lectures and community outreach.
• APPs are expected to assist with Performance Improvement reporting as needed.
• APPs may occasionally be asked to carry the consult pager especially during the residents’
protected education time.
• APPs rotate daily duties of the service along with the residents (i.e. taking pager, doing
discharge summaries etc.).
• APPs report directly to the attending and collaborate with the resident staff.
• APPs are an important resource in providing consistency in trauma clinical management
guidelines and service operations. If there are any general questions regarding service
functions, roles and responsibilities, please do not hesitate to ask them.

TRAUMA ACTIVATION STEPS

• Trauma Alert-Activated when EMS crew is being dispatched to a scene
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 14

• Trauma stand-by > 10 min ETA (Level given)

• Call ext. 7077, check pre-hospital report (if available)
• Get ready to assemble in trauma bay
• Trauma response “STAT” < 5 min ETA
• Assemble STAT to trauma bay
• Crew Resource Management – determine roles and responsibilities before the patient
arrives (lead by the trauma chief and/or trauma attending)
• Stand By/Stat Multiple Casualty pages will be alerted in the event there are multiple
patients arriving simultaneously (ETA and number of patients will be given if known)
• ALWAYS use universal precautions in trauma bay (gown and glove, eyewear, caps/masks,
lead aprons, shoe covers)*
o *All Level 1 and 2 Trauma Activations require the use of N95 and face shield
in addition to standard PPE

GOALS FOR TRAUMA RESUSCITATIONS

• Team is assembled upon patient arrival
• All trauma team members must sign-in
• Crew Resource Management will be utilized prior to the patient’s arrival to review and
discuss responsibilities and assign roles to the trauma team
• Responsibilities are assigned by the Team Leader
o Primary and Secondary Survey: stands to the right of the patient
o H&P documentation
o Any indicated procedures
• General Rules
o Equipment is assembled and ready for use
o Universal Precautions are taken
o ROOM IS QUIET for DeMIST (Demographics, Mechanism, Injuries, Signs and
Treatment instituted) report if patient is stable: The “one minute rule” refers to the
time allocated for EMS personnel to make brief patient presentations before
primary survey begins
o ATLS protocols are followed with C-spine protected
o Threats to life are discovered and treated promptly
o Labs are drawn within 5 minutes and please specify if toxic screen is needed
o Chest and / or pelvic x-rays within 15 minutes after backboard removed
o Temperature, weight, rectal examination within 20 minutes
o CT within 30 minutes unless emergent procedure or ongoing resuscitation is
necessary
o Thoracic and lumbar spine reconstructions are NOT automatically done with any
thoracic/abdominal CT---YOU MUST ASK FOR THEM AND ORDER THEM
IN POWERCHART
o Consider blood products after 1 liter of crystalloid during trauma resuscitations
(Based on ATLS 10th addition)
o Analgesia and sedation as clinically indicated in bolus doses
o Call for SICU bed ASAP when indicated
o Trauma H&P must be COMPLETELY filled out on all trauma resuscitations
before presenting the H&P to the Trauma Attending
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 15

o Orders should be completed ASAP

o Communicate the clinical plan to the trauma team, family, and patient
o You have the authority to upgrade the level of activation during any trauma
resuscitation if you think it is appropriate
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 16

TRAUMA SERVICE PAGER: 2136

TRAUMA CHIEF PAGER: 3447

EGS SERVICE PAGER: 4422

EGS CONSULT PAGER: 3228

To transfer a pager to yourself to cover, do the following on the phone:

1. Dial 4311
2. *2136 or *4422 (respectively for particular service)
3. #11
4. Type in your pager number
5. Listen to verify the pager has been transferred to the correct covering pager

ASCOM Phone Numbers:

Trauma Chief 310151
Trauma Resident 310157
Trauma PA-C 310164
EGS Chief 310172
EGS Consult Resident 310152
EGS Resident 310156
EGS PA-C 310163
Outpatient Clinic CRNP 310260
Float PA-C 310267
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 17

TRAUMA AND EMERGENCY GENERAL SURGERY RESIDENT EXPECTATIONS

MORNING REPORT
• Morning report will occur daily at 7:15am via ZOOM for Trauma and EGS. The
exceptions are Thursday when morning report occurs at 6:30am and following monthly
Trauma/EGS conferences when report occurs directly after conference completion.
Residents of all training levels are required to participate in the daily ZOOM morning
reports—when possible cameras should be turned on during the meeting.
• It is the Chief/Senior resident’s responsibility to ensure the resident team has seen ALL
patients on service, including patients on the consult list, prior to morning report.
• Occasionally, trauma activations, emergent consults, OR cases, and patients with acute
issues may prevent this from happening—this should be the exception.
• Morning report should emphasize ensuring the highest possible quality of patient care as
well as the education of all team members.
• The order of morning report will be:
• Patient presentations with pertinent points rather than minute details (start with room
number and name)
o Acute events: Code/Rapid response and upgrades
o OR Cases
§ TRACS cases with relevant imaging and operative plan
§ Consultant cases: pre-operative concerns
o New patients – admissions and consults
§ Brief HPI
§ Relevant vitals, exam findings, labs, imaging
§ Assessment and Plan
o ICU patients
§ Acute issues by diagnosis with supporting data
§ Relevant imaging/labs
o IMC patients
§ Acute issues by diagnosis with supporting data
§ Relevant imaging/labs
o Floor issues (not all)
§ New/pertinent imaging
§ Tubes, drains, and lines plans
§ Complex patients
o Discharges
§ Disposition (home, SNF, rehab, LTACH)
§ Any lines or tubes patient leaving with
§ Discharge follow-up plan

• Clinic list presentations – plan based

o EGS – Tuesday
• (List to be sent to faculty on Sunday evening for elective case planning)
o Trauma – Wednesday for Thursday clinic
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 18

ADMISSIONS / CONSULTS
• Patients will be admitted to the ICU or Floor. Under rare and special circumstances and
only at the discretion of the attending should patients be admitted to the IMC.
• Direct admissions to the ICU, IMC or Floor must have an initial complete and
comprehensive H&P completed by a member of the admitting service. The Attending
should be called to discuss and/or evaluate the patient after the resident team has seen and
evaluated the patient.
• New consults seen and evaluated by junior residents are expected to be discussed with the
Chief/Senior resident or Fellow prior to discussing the patient with the Attending. When
appropriate the Chief/Senior resident or Fellow should see and evaluate the patient with
the junior resident prior to the junior resident’s presentation to the Attending.
• Final reads/reports on all imaging need to be reviewed by the resident team with the
necessary inpatient or outpatient follow-up arranged for incidental findings.
• The supervising Attending should be notified before procedures are performed to ensure
they are available to provide appropriate supervision. Procedure/operative notes should
be done for all procedures, including VAC and initial tracheostomy changes.
• The Attending should be notified of critical changes in patient status as soon as safely
possible. Critical changes include, but are not limited to, sustained tachycardia,
hypotension, tachypnea, hypoxemia, oliguria, bleeding, acute changes in laboratory
values, and significant changes in history and/or physical exam.
• Serial exams mean documented serial exams. If it’s not documented, it didn’t happen. A
single exam note may be used with the exam date and time added in sequence when the
plan of observation includes serial exams. Exams are to be conducted no less frequently
than every 4 hours.

TRAUMA ACTIVATIONS / SERVICE SPECIFICS

• All members of the Trauma service should respond to the Trauma Bay when STAT
Trauma pages occur, unless the team member is actively engaged in the care of an
unstable patient or involved in a complicated operative case requiring the trauma
resident’s assistance.
• The Trauma H&P Form must be filled out in its entirety, including adding the patient’s
complaints on presentation under the HPI section and ensuring completion of the review
of systems before providing the form to the Attending for review and completion during
Trauma Alert resuscitations.
• The Trauma Tertiary Survey Note must be completed by the resident team on ALL
Trauma Alert patients as soon as possible within 24 hours, and prior to discharge of any
patient from the ED.
• The tertiary survey may be utilized as a daily progress note if the review of systems and
appropriate exam is well documented along with a clear and concise assessment and plan.
Please forward the note to the Attending for their review, edits, and final signature.
• Place the patient in a Miami J collar if cervical collar use is expected for >24 hours.
• All outpatient-related paperwork for trauma patients goes to the trauma office to be
completed (turn-around time is 10 days).
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 19

• Lovenox should be started on trauma patients that have an elevated risk of DVT/PE with
twice daily dosing at 08:00 and 20:00 (See Risk Factor Assessment Tool under guideline
002TPM)
• Patients should be considered for discharge on Coumadin or direct oral anticoagulant
(DOAC) if not ambulating >150 feet, low molecular weight heparin may be considered as
an alternative. Contact Primary Care Physician to follow PT/INR; this MUST be set up
prior to discharge.

EGS NIGHT / HOME-CALL RESPONSIBILITIES

• The in-house trauma chief will be the first call for all overnight consults. After a plan is
developed, the consult resident will staff the consult with the on-call Attending.
• The on-call EGS R5/R4 or in-house trauma chief will scrub all night and weekend OR
cases.
• When appropriate and if in doubt of history and/or physical exam findings relayed by the
consult resident, then the in-house trauma chief or on-call EGS R5/R4 should come in to
see the patient.
• If the on-call Attending requests that the on-call EGS R5/R4 see the patient, then they
must come in to see the patient.
• The in-house trauma chief must see all ICU admissions (either direct admits or via the
ED) and call the on-call Attending with the plan.
• If the in-house trauma chief is attending to traumas, then the on-call EGS R5/R4 should
be contacted for admissions/consults.

PROCEDURES
• Residents are expected to come to the OR prepared for scheduled, non-emergent cases.
• History, imaging, preoperative workup, patient positioning, and technical steps need to be
reviewed ahead of time.
• If the attending thinks the resident is not prepared for the OR, then the resident will be
relieved of operative responsibility to afford them the opportunity to complete sufficient
self-guided education on the procedure prior to returning to the OR.
• All patients undergoing surgery must be appropriately assessed preoperatively. This
includes review/ordering of diet, IV fluids, laboratory data, type and screen if needed,
imaging/studies, antibiotics, and DVT prophylaxis if appropriate.
• All patients undergoing surgery will have a Brief-Op Note completed by the resident
team at the conclusion of the case.
• Post-Op Check Notes should be completed by the resident team at the 2 and 6 hour time
periods suggested by the Department of Surgery.
• The operative dictation may be assigned to the resident at the discretion of the attending.
It must be dictated immediately following the case. Key points of the dictation should be
reviewed with the attending when there is any confusion regarding the technical aspects
of the case.
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 20

CLINIC
• EGS clinic occurs every Tuesday and Trauma Clinic occurs every Thursday; both from
1-4pm at UPC Suite 3100.
• All available residents are expected to attend. The APPs are expected to hold the service
pager and respond to trauma activations or another urgent/emergent patient care issues.
• The Chief/Senior resident will look at the clinic list ahead of time to divide up the
patients among the residents, as well as to develop the clinic plan for each patient.
• The Chief/Senior should present the assignments/plans to the attending and fellow on
Tuesday at morning report for EGS and Wednesday for Trauma. If the Chief/Senior fails
to present the clinic document, then they will lose operating privileges for one day that
same week at the attending’s discretion.
• Clinic notes should be dictated during or immediately after clinic. Please forward the
note for signature to the attending that staffed the clinic.

NOTES
• All patients (including consults) must have a resident note completed daily in a timely
fashion. This also includes the day of discharge. Daily Consult Notes should be
completed first to communicate plans to other services as soon as possible.
• Daily Progress Notes are to be complete. This includes a Review of Systems, and a
Physical Exam covering at least 5 body systems, as well as current labs and imaging.
• Notes should be carefully updated and meticulously edited daily—do not simply
copy/paste the previous day’s note.
• Assessments and plans should be system based with attention to specific problems/plans
listed under their respective system.
• Please forward the note to the attending for their review, edits, and final signature.

EDUCATION / CONFERENCES
• Educational programs provided by the Department of Surgery and GME are highly
valued. Please be on time for M&M, Grand Rounds, and Thursday education
conferences.
• On the Trauma and EGS services, educational points or case reviews will be interspersed
throughout morning report. Oral board style questions may also be presented.
• EGS M&M: 2nd Friday of the month at 6:30am. All team members attend.
• Trauma Peer Review: 3rd Friday of the month at 6:30am. Only the Trauma Chief
Resident and PGY 4/5 EGS residents should attend.
• Trauma Operations Committee: 3rd Friday of the month at 7:30am. The Trauma Chief
Resident is invited to attend.
• Trauma M&M: 4th Friday of the month at 7am. All team members attend.

*Due to the COVID-19 crisis, these meetings will likely be held in a Zoom virtual format. Those
details will be distributed to Trauma/EGS team members as appropriate.
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 21

SURGICAL CRITICAL CARE (SCC) RESIDENT EXPECTATIONS

SCC ROUNDS
• Surgical Critical Care Rounds usually begin at the patient’s bedside at 8:30am.
• Presenting resident/intern/student is expected to present each patient in a systematic,
organized manner.
o Use the SICU Daily Goals/Checklist to ensure all prophylactic measures against
infectious and other complications are in compliance on all patients.
o Expectation is to include the bedside RN, pharmacist, and RTs in rounds.
• Senior SCC resident expectations:
o All SCC patients are seen and examined prior to rounds.
o Ensure all residents are prepared to present patients at the bedside.
o After rounds, prioritize tasks and delegate duties.
o Manage the team and ensure critical tasks are completed.
o Notify critical care attending and critical care fellow of any immediate needs or
concerns.

ICU ADMISSIONS
• Complete evaluation on all patients within one hour of admission.
o Complete evaluation includes, at a minimum the following:
§ Pertinent history and 24-hour events
§ Past medical and surgical history
§ Home and active medication list
§ Review of systems
§ Comprehensive system-based assessment and plan
§ Standard prophylaxis measures
• Thromboembolic prophylaxis
• Stress prophylaxis
• C. difficile prophylaxis if indicated
o Contact critical care attending on all admissions after evaluation UNLESS patient
is unstable, then call immediately.

THE FOLLOWING REQUIRES ATTENDING NOTIFICATION

• Starting vasopressors or inotropes
• Increasing oxygen requirements
• Need for airway or intubation
• Administering blood products
• Hemodynamic instability
• For unstable patients, call for help immediately
o Utilize senior critical care resident, chief resident in house, critical care fellow, or
in house trauma attending after hours
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 22

PATIENTS TRANSPORTED TO AND FROM THE OPERATING ROOM: TIME OUT

FOR SIGN OUT
• This is a mandatory procedure to ensure continuity of critical care between the ICU and
OR.
• All patients are discussed with the anesthesia team before going to the operating room
AND immediately after return from the operating room.
• At a minimum, the resident assigned to the patient must be present for sign out.
• All pertinent medical conditions, medications, need for blood products, resuscitation
concerns, and ventilator mode/concerns are addressed.

PROCEDURES
• All bedside procedures must be appropriately supervised: this includes arterial lines,
central access lines, PA catheter placement, and all airway procedures.
• Notify the attending prior to beginning any bedside procedure.
• Perform a timeout to verify site, equipment, and any potential concerns.
• All procedures must have a procedure note dictated upon completion and forwarded to
the appropriate attending for signature.

NOTES
• All patients must have a resident note completed daily in a timely fashion. This also
includes the day of discharge.
• Daily Progress Notes are to be complete.
• Notes must include a Review of Systems, and a Physical Exam covering at least 8 organ
systems, as well as current labs and imaging.
• Notes should be carefully updated and meticulously edited daily—do not simply
copy/paste the previous day’s note.
• Assessments and plans should be system based with attention to specific problems and
their corresponding plans listed under their respective system.
• Please forward the note to the attending for their review, edits, and final signature when
complete.
• Notes for patients admitted from 17:00 – 23:59 should be forwarded to the on call
Trauma Attending. All notes completed after midnight should be forwarded to the
daytime ICU Attending.

EDUCATION / CONFERENCES
• Each month an educational calendar will be made available.
• Lecture/discussions occur via ZOOM from 1:00pm to 2:00pm on Wednesday. The
senior ICU resident will ensure there is a resident prepared to discuss a patient case for
each case conference. Power point is not required, however pertinent labs and imaging
will be presented.
• ICU ethics discussions and ventilator lectures by respiratory therapy will be included on
the educational calendar and the students and residents are expected to attend; these
sessions are mandatory.
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 23

TRAUMA AND EMERGENCY GENERAL SURGERY SERVICE TIPS

PHONE CALLS
• Please handle all calls promptly, and courteously.
• Collect all important information when a call is received: patient name, date of recent
admission/discharge, injuries, procedures, attending, pertinent ROS, call back telephone
number, make phone note in EMR.
• If the patient is instructed to go to the ED, and the patient lives far away, he/she should go
to the closest ED. Log conversation in EMR.
• Narcotic pain medications CANNOT be refilled or reordered by telephone. They must be
electronically routed to the patient’s pharmacy with an attending or APP signature.
• All communication/actions must be logged in patients EMR.

TRAUMA PATIENT LIST MAINTENANCE

• Access the list by going to:
1. Care Connect: Discern Analytics 2.
2. Enter username and password
3. Select Main Menu, Census list or Physician Handoff.
4. Select group proxy list (a drop-down individually for EGS consults & Trauma consults)
5. Under Med Service, select EGS or Trauma
6. Hit “Execute” button in right hand corner
7. New screen with list appears
8. Select the printer icon in the top left hand corner
9. Print to the appropriate printer

• List must be updated as often as possible

• Sticky Notes must include pertinent information for each patient

DISCHARGE SUMMARY TEMPLATE

• All patients regardless of admission status receive electronic discharge instructions for both
the Trauma and EGS services.
• Discharge instructions/summary are completed using the “Discharge” dynamic workflow in
PowerChart.
• All categories must be completed. Forward to the rounding attending who discharged the
patient for signature.
• Principal Diagnosis
• Complete listing of all other acute diagnoses pertinent to the stay
• Co-morbid Diagnoses
• Procedures/diagnostic studies with dates performed
• History
o Trauma: Age, gender, level of activation, mechanism of injury, transfer from
scene/facility, initial blood pressure, heart rate, Glasgow coma scale
o EGS: Age, gender, transfer from facility, presenting complaint,
location/severity of pain, alleviating/aggravating factors, review of systems
• Hospital Course
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 24

o Admitted to floor or SICU

o Indicate if mechanical ventilation was required (include days on ventilator)
o SICU length of stay, if applicable
o “The patient underwent evaluation, observation, and /or treatment of the
above mentioned diagnosis that were established during the hospital stay”
o “A complete listing of the relevant procedures is mentioned above”
o “The patient’s hospital course was significant for the following
complications:”
• Disposition (Home, LTACH, Rehab, Prison)
• Condition at Discharge
• Discharge Treatment Plan
• Discharge Medications
• Discharge Instructions to the patient
• Follow-up appointments
• Review of the PDMP must be mentioned in all discharge summaries

OPERATIVE REPORT TEMPLATE

All inpatient bedside / outpatient office procedures, initial tracheostomy changes, VAC changes,
and operations should be dictated or written with the following template:

• Preoperative diagnosis
• Postoperative diagnosis
• Procedure
• Surgeon
• Assistant(s)
• Anesthesia
• Findings
• Specimen(s)
• Estimated blood loss
• IVF
• UOP
• Drains
• Complications
• Disposition

DISCHARGE FOLLOW-UP APPOINTMENTS

• When placing the discharge follow-up order in PowerChart be as specific as possible as
to the clinic the patient should attend (Trauma, EGS, or Outpatient APP clinics) with the
date.
• If the patient is to have a telehealth visit you must specify in the discharge follow-up
order under “reason for visit” if it is a TELEPHONIC VISIT (a phone call only) or an
ONDEMAND/AMWELL visit (video visit).
• If discharging a patient who needs radiologic studies during their outpatient visit, please
indicate the study needed in the comments section of the order. This ensures the clinic
schedulers coordinate the study and the follow-up appointment for the same day.
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 25

TRAUMA PERFORMANCE IMPROVEMENT (PI) PROGRAM

All trauma centers are expected to demonstrate a clearly defined PI program and how it is
integrated into the hospital wide program. Modern PI in trauma care is a continuous cycle of
monitoring, assessment, and management. A major objective of PI is to reduce inappropriate
variation in care. The data collection process must be reliable, structured, and consistent to
identify valid opportunities for improvement. The process of analysis should occur at regular
intervals and include multidisciplinary review.

Hershey Medical Center’s Trauma Program utilizes the expertise of consistent trauma clinical
staff to concurrently oversee and evaluate that developed standards of practice are being
followed. (Nurse Practitioners, Trauma Nurse Coordinator, Physician Assistants, Attending
Physicians). Please do not hesitate to ask for guidance from these resources. The
identification of issues is the responsibility of all members of the trauma team. This information
is then entered into POPIMS (state mandated database). The Trauma Program Manager and
Trauma Nurse Coordinators are responsible for entering this information into POPIMS.

Trauma performance improvement will be discussed in multiple hospital forums. Your

assistance in the identification and data collection is critical for trauma PI. Our philosophy is, “if
you see something – say something”. Please communicate any facts, issues, or patient concerns
that impact trauma clinical care or our trauma system/process. This is not a punitive action, but a
focus on appropriate clinical care and process.

The following are examples of issues that are currently tracked and trended by the trauma program:
• All Massive Transfusion Protocols
• All upgrades in care (for example - floor to SICU)
• Under-triage
• SDH / EDH that require operative intervention
• Delayed treatment and / or diagnosis
• Unplanned return to the OR
• Unplanned extubations
• All patients that go directly from the ED to the OR
• Compliance with practice management guidelines
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 26

PENNSYLVANIA TRAUMA SYSTEMS FOUNDATION (PTSF) AUDIT FILTERS

The following are examples of audit filters from the PTSF. The Trauma Program is required to
track and trend this information in order to identify issues and/or concerns with clinical care or
trauma systems.

PAF 3 Patient with admission GCS <14 who does not receive a CT of the head
PAF 4a Absence of sequential neurological documentation on emergency department
record of trauma patient with a diagnosis of skull fracture or intracranial injury
PAF 4b Absence of sequential neurological documentation on emergency department
record of trauma patient with a diagnosis of spinal cord injury
PAF06 Patient left ED with a discharge GCS ≤ 8 and without a definitive airway
PAF08 Any patient sustaining a GSW to the abdomen who is managed non-operatively
PAF10 Patient with epidural or subdural brain hematoma receiving initial craniotomy >4
hours after arrival at ED, excluding those performed for ICP monitoring
PAF14 Unplanned return to the operating room within 48 hours of initial procedure
PAF21 All deaths

PTSF OCCURRENCES
The following are examples of clinical occurrences from the PTSF. These are broken down into
body systems, for example pulmonary, cardiovascular, hematology, renal, hepatic,
infection/sepsis, respiratory / airway, GI, and GU. The Trauma Program is required to track and
trend this information in order to identify issues and/or concerns with clinical care.

PULMONARY
Acute Respiratory Distress Syndrome (ARDS): PaO2 / FIO2 <200: decreased
compliance, diffuse pulmonary infiltrates associated with normal capillary wedge
pressure in an appropriate setting:
1. acute onset
2. PaO2 /FIO2 <200
3. bilateral infiltrates on frontal chest radiograph
4. PAWP <18 mm Hg when measured or no clinical evidence of left atrial
hypertension & Section of Trauma & Critical Care Resident Handbook 25

CARDIOVASCULAR
Deep Vein Thrombosis (DVT): acute occlusive condition documented by one of the
following:
1. doppler
2. duplex ultrasound
3. venogram
4. IPG (impedance plysthmography)
5. autopsy
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 27

HEMATOLOGIC/COAGULOPATHY
Coagulopathy (excluding anticoagulation therapy, coumadin therapy, or
underlying hematologic disorders, e.g. hemophilia): uncontrolled diffuse bleeding in the
presence of coagulation abnormalities, e.g., increased prothrombin time, increased partial
thromboplastin time, decreased platelet count, or disseminated intravascular coagulation
(DIC) requiring treatment, i.e., transfusion of components such as platelets, clotting
factors, FFP.

RENAL
Acute Renal Failure: one of the following:
1. creatinine >3.5 mg/dl, or
2. BUN >100 mg/dl

HEPATIC
Liver Failure: documented by a physician. Increased serum ammonia or decreased
synthetic or metabolic function (e.g. PT, TTP, or fibrinogen).

PROCEDURE RELATED
Organ, Nerve, Vessel: perforation or injury resulting from treatment or intervention.

PHARMACOLOGY
Adverse Drug Reaction: As documented by a physician, plus one of the following:
1. Adversely affects patient care
2. Increases length of stay
3. Increases morbidity and mortality
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 28

TRAUMA TRIAGE CRITERIA

Level I Response: Indicated for patients with physiologic or anatomic abnormalities

that indicate serious life- or limb-threatening injury requiring immediate intervention. A
level I response mobilizes the full Trauma Team, notifies the Operating Room and
Blood Bank, and prioritizes Radiology and Laboratory studies.

Level II Response: Indicated for patients with evidence of significant injury who do
not otherwise meet level I criteria. When clinical assessment warrants, there should be
no hesitation upgrading to Level I response. A Level II response mobilizes the Trauma
Team, including OR and prioritizes Radiology and Laboratory studies.

Consideration for extremes in age (< 12 years and > 65 years) and comorbidities such as
bleeding disorders, currently on anticoagulation or antiplatelet therapy, must be included when
the initial trauma triage level is selected.

Core team members must be physically present in the trauma resuscitation area within 10
minutes from time of notification.

Trauma attending is expected to arrive prior to the patient and no longer than 15 minutes after
the trauma patient has arrived.
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 29

1) Level I Trauma Response criterion:

a) Activation Parameters
i. Physiologic Parameters
1) Prehospital intubation
(Patients intubated in the ED for hemodynamic instability or respiratory failure
will be upgraded to Level I)
2) Compromised respiratory status (e.g. resp rate < 10/min or > 30/min)
3) Systolic BP <90 mm Hg at any time
4) GCS <9 Motor ≤ 5 (unable to follow commands) Deteriorating by 2 or more
points
5) Core temperature < 28°C (82°F)
ii. Anatomic Parameters
1) Airway compromise or any use of an artificial airway by EMS to maintain airway,
or high risk of impending airway compromise such as:
(a) Significant intraoral/airway bleeding
(b) Inhalation injury with respiratory compromise
(c) Hanging/strangulation
(d) Facial burns
(e) Vomiting with altered mental status/combative behavior
(f) Stridor
2) Respiratory compromise or high risk of impending respiratory compromise such
as, but not limited to:
(a) Massive subcutaneous emphysema
(b) Absent or unequal breath sounds
(c) Chest wall instability/flail chest
(d) Intubated patient from the scene
(e) Pre-hospital needle decompression of the chest
3) Burns involving > 25% BSA (2nd and 3rd degree)
4) Penetrating injuries to head, neck, chest, abdomen, or extremity proximal to the
elbow or knee
5) Amputation proximal to wrist or ankle
6) Crushed, de-gloved, mangled or pulseless extremity
Other reported signs or symptoms that suggest an immediate life- or limb-threatening injury

iii. System Logistics

1) Emergency Physician/Trauma Surgeon discretion
2) Transfer patients who meet criteria above or require specific interventions to
prevent deterioration
a. Receiving blood products or vasopressors to maintain
hemodynamics
b. Intubated with ongoing respiratory compromise

b) Level I Response Team

Upon activation of Level I response, Trauma Team members will be alerted by
established notification procedure (policy #71TPM ) and must respond immediately to
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 30

the resuscitation bay in the Emergency Department. The goal of the Level I response is to
be readily available upon the patient's arrival. Core team members must be physically
present in the trauma resuscitation area within ten (10) minutes from time of notification.

*Trauma Surgeon Radiologist

*Emergency Medicine Physician Respiratory Therapist
*Emergency Nurse Trauma Resident IV
(2-Primary/Recording) Emergency Medicine Resident
* Radiologic Technologists *ED/Trauma Tech and ED Clerk OR Personnel
(1)

*Core team members--At bedside for patient's arrival

The Trauma Attending is expected on arrival of trauma activations but no later than 15
minutes of patient’s arrival. This expectation can be fulfilled by a PGY-IV Surgery
Resident to expedite the resuscitation until arrival of the Trauma Surgeon.

2) Level II Trauma Response Criterion:

a) Activation Parameters
i. Physiologic Parameters
1) GCS ≤ 13 with persistent altered mental status
ii. Anatomic Parameters
1) Penetrating extremity injury distal to the knee and elbow with active hemorrhage
2) Pre-hospital application of tourniquet to control hemorrhage
3) 2 or more proximal long bone fractures (humerus or femur)
4) Open long bone fracture (humerus or femur)
5) Open or depressed skull fracture
6) Paralysis of any duration after injury (concern for spinal cord injury)
7) Suspected unstable pelvic fracture
8) Burns 10 to 24% TBSA (2nd or 3rd degree), facial burns without respiratory
compromise, or concern for inhalation injury
9) Pregnancy > than 20 weeks gestation
10) Falls greater than 20 feet or 2 stories
11) High risk automobile crash
Ejection (partial or complete)
Death in the same compartment
Passenger compartment intrusion including the roof
>than 12 inches occupant side
>than 18 inches any site
12) Auto vs pedestrian/bicyclist thrown, run over, or with significant (>20 mph)
impact
13) Motorcycle crash>20 mph
iii. System Logistics
1) Emergency physician/trauma surgeon discretion
2) Transfer patients deemed appropriate by trauma and emergency physicians
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 31

b) Level II Response Team

Upon activation of Level II Trauma Alert the Trauma Response Team is notified by
established procedures and must respond immediately to the trauma bays. Core team
members must be physically present in the trauma resuscitation area within ten (10)
minutes from time of notification.

*Trauma Surgeon Radiologist

*Emergency Physician Respiratory Therapist
*Trauma Resident PGY IV Chaplain
*Emergency Nurses (2) ED Clerk (MOI)
OR Personnel (1) ED Tech

*Core Team--At bedside for patients’ arrival

Team member roles are identical to those described in the Level I Response section.
The Trauma Attending is expected on arrival of trauma activations but no later than 15
minutes after patient’s arrival. This expectation can be fulfilled by a PGY-IV Surgery
Resident to expedite the resuscitation, until arrival of the Trauma Surgeon. There will be
communication between the Trauma Attending and the Surgery Resident/ED Attending
within 30 minutes after arrival of injured patient meeting the Level II response criteria.

3) ED Alert:

Adult trauma patients not meeting Level 1 or Level 2 activation criteria can be activated as a
ED Alert in order to expedite the timing and sequence of clinical care.

This can be based upon multiple factors such as EMS report, pre-hospital vital signs, physical
findings, comorbidities, current medications, and EM physician discretion.

If there is a deterioration in status and/or the EM Attending finds that the patient meets
criterion for Level I or II activation, an immediate upgrade in status will be implemented.

ED Alert Response Team

*Emergency Physician
*Emergency Resident PGY II-III
*Emergency Nurses (1)
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 32

Trauma Labs
Pre-determined laboratory tests have been identified for the various levels of trauma alerts.

Level I Labs:
ABG (Hgb, whole blood)
CBC, Plt
PT/PTT
Na, K, Glucose, Creatinine, Ionized Calcium
Amylase, ALT,
U/A (HCG if female, childbearing age)
Troponin I
Type and Cross (as needed)

Level II Labs:
ABG (Hgb, whole blood)
CBC, Plt
PT/PTT
Na, K, Glucose, Creatinine, Ionized Calcium
Amylase
U/A (HCG if female, childbearing age)
Type and Hold (as needed)

ED Alert Labs:
Determined at the discretion of the Emergency Medicine service.
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 33

PROFESSIONAL COURTESY DURING TRAUMA RESUSCITATION

• Lack of respect for ALL staff in the trauma bay will NOT be tolerated.
• Team Leaders must identify themselves prior to initiating all resuscitation.
• Crew Resource Management in the form of a “Trauma Huddle” is to be utilized before
the arrival of all level I and II trauma alerts. This will be led by the trauma chief resident
and/or the attending trauma surgeon.
• Unless the patient is unstable, please allow EMS personnel up to 1 minute to present their
report (DeMIST protocol) without interruption and before proceeding with the primary
survey.
• Do NOT cut through long board spider straps, ECG cords, etc. when transferring patients
from the EMS stretcher to the trauma bed.
• Keep noise and unnecessary chatter to a minimum in the trauma bay.
• Please return and hang up all lead gowns. Throwing them on the floor damages their
integrity much more quickly.
• Dismiss all non-essential personnel from the trauma bay when it has been determined that
their presence is no longer needed (ex. OR representatives, Anesthesiologists, etc.).
• If a patient has been cleared after a negative trauma work-up, and there is a planned
return back to the ED for further evaluation and management, please be sure to provide a
DETAILED sign-out of this patient to the ED attending.
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 34

TRAUMA/EGS/SCC GUIDELINES, AND ALGORITHMS

Please refer to the Infonet “Policies” section to review all updated current guidelines and
algorithms.
Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 35

TRAUMA: NEUROSURGERY

Generalized Bleeding; No intracranial bleeding suspected:

Crash- 2 trial collaborators: TXA shown to improve outcomes in trauma patients with
significant hemorrhage. Use of tranexamic acid can be considered for trauma patients who
require transfusion of packed red blood cells and can receive tranexamic acid within 8 hours of
injury.

Tranexamic acid - 1000mg IV STAT, ONCE, Loading dose, infuse over 10 min, followed by
maintenance dose
Tranexamic acid - 1000mg IV ONCE, Maintenance dose, infuse over 8 hours following loading
dose.

History of warfarin or rivaroxaban use:

First line:

Prothrombin Complex Concentrate (PCC/Profilnine)

and mild-moderate hemorrhage 25 units/Kg IV, STAT,
ONCE
Prothrombin Complex Concentrate (PCC/Profilinine)
and serious hemorrhage 50 units/Kg IV, STAT,
ONCE

Phytonadione (vitamin k) 10 mg IV ONCE

Second line:
Factor VIIa (NovoSeven)
40 mcg/kg, STAT, ONCE
Followed by FFP; a second dose of Factor VIIa may be appropriate if the coagulopathy is not
adequately corrected and is not felt the patient can tolerate the volume associated with FFP.

History of dabigatran use:

FEIBA 50 units/kg, STAT, ONCE

Second line:
Factor VIIa (NovoSeven) 40 mcg/kg, STAT, ONCE

Uremic bleeding suspected (dialysis dependent)

Desmopressin IV (DDAVP) 0.3 mcg/kg, STAT, ONCE,

infuse over 30 minutes

If aspirin, clopidogrel, prasugel, or ticagrelor use suspected – consider platelets

Penn State Health Division of Trauma, Acute Care and Critical Care Surgery Resident Handbook 36

WHEN TO CALL AN ACUTE CARE SURGERY ATTENDING

General Considerations
• Anything you do not understand and are immediately concerned about.
• If you don’t know what you don’t know
• Death in ICU or Floor.
• New consults or returns from OR.
• Prior to performing ANY invasive procedure.
• Prior to ordering a new/unanticipated CT scan on a patient.
• Complication from procedure done in ICU (i.e. pneumothorax from central line insertion,
esophageal intubation, arterial line complications, etc.)
• Primary team or nursing staff requests that the critical care attending be made aware of a
situation.

Neurological
• Acute, significant change in mental status.
• Acute, significant change in neurological exam.
• Newly diagnosed, sustained intracranial hypertension (ICP > 20)

Cardiovascular
• Cardiac arrest.
• Increasing lactate levels.
• Any new pressor drip.
• Any new inotropic drip.
• New hypotension unresponsive to two physiologic fluid boluses (20mL/kg x 2).
• Any new arrhythmia requiring treatment.

Respiratory
• Any patient requiring intubation.
• Any patient requiring chest tube insertion.
• Significantly increased hypoxemia or worsening PaO2 / FiO2 ratio.

Gastroenterology
• Newly diagnosed intra-abdominal hypertension (bladder pressure > 20).
• GI hemorrhage requiring intervention.
• Concern for peritonitis on exam

Renal
• New oliguria unresponsive to two physiologic fluid boluses (20mL/kg x 2).

Hematological
• New source of acute hemorrhage or acute drop in Hgb or platelets.
• Symptomatic anemia that may require a transfusion.
• Any time you think of transfusing a blood product not already discussed.

** Have an assessment and plan to discuss with the attending, don’t

just relay facts; consult a reference if needed before your phone call
except for emergencies!