1. No category

T R A U M A
H A N D B O O K
These management protocols are
intended to serve as guidelines only.
Individual circumstances need to be
considered, as there may be times when
it is appropriate or desirable to deviate
from these guidelines.
These educational guidelines will be
reviewed and updated periodically.
This handbook provides a quick reference
for some problems but should not be
considered a substitute for a trauma
textbook or current literature.
1
T R A U M A
H A N D B O O K
Contents
GENERAL POLICIES
Trauma Conferences and Clinics .........................................................................1
Trauma Service Policies .......................................................................................2
Service Assignments and Inter-Service Transfer Guidelines................................7
Code Yellow Trauma Team Activation ...............................................................9
Criteria for Triage to Trauma Rooms: Adult ........................................................11
Criteria for Triage to Trauma Rooms: Pediatric ...................................................12
Role of Trauma Team Members: Adult................................................................14
Role of Trauma Team Members: Pediatric ..........................................................16
Routine Trauma Labs ...........................................................................................21
Combined Family Adult and Pediatric Trauma (Mixed Bundles) .......................22
Police Notification of Emergency Department Cases...........................................23
Maintaining the Chain of Evidence in Trauma/Criminal Cases............................24
PRIMARY SURVEY
ED Thoracotomy ..................................................................................................25
Prediction and Management of the Difficult Airway............................................27
Rapid Sequence Induction: Adult ........................................................................29
Rapid Sequence Induction: Pediatric ....................................................................30
Intravenous Access and the Trauma Patient .........................................................32
Resuscitation Guidelines ......................................................................................33
Hypothermia: Pediatric and Adult ........................................................................34
SECONDARY SURVEY / DEFINITIVE CARE
Severe Head Injury (GCS 3-8)..............................................................................36
Pediatric Severe Head Injury ................................................................................38
Reversal of Anticoagulation in Patients with Intracranial or
Spinal Bleeding.....................................................................................................40
C-Spine Evaluations in Adult Trauma Patients.....................................................41
C-Spine Clearance: Pediatric ................................................................................43
Thoracic/Lumbar/Sacral (TLS) Spine Clearance in the Trauma Patient...............45
Standard Neurological Classification of Spinal Cord Injury.................................46
Penetrating Neck Trauma .....................................................................................47
Penetrating Injuries to the Heart ...........................................................................49
Transmediastinal Gunshot Wounds (TMGSW)....................................................51
Vascular Exposures ..............................................................................................52
Truncal Stab Wounds ...........................................................................................54
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T R A U M A
H A N D B O O K
Blunt Cerebrovascular Injuries .............................................................................56
Blunt Aortic Injury (BAI) .....................................................................................58
Blunt Cardiac Injury .............................................................................................60
Rib Fracture Protocol: Adult.................................................................................62
Blunt Abdominal Trauma: Adult ..........................................................................65
Blunt Splenic Trauma: Adult................................................................................66
Renal Trauma .......................................................................................................68
Diagnosis of Blunt Bowel and Mesenteric Injury.................................................70
Rectal Injury .........................................................................................................72
Unstable Pelvic Fractures .....................................................................................73
Mangled Extremity ...............................................................................................75
To Ligate or not to Ligate ....................................................................................77
Trauma Scoring Systems ......................................................................................78
ICU CARE
TICU Sedation/Analgesia ....................................................................................80
Ventilator-Associated Pneumonia ........................................................................82
Severe Sepsis and Septic Shock............................................................................84
DVT/PE Prophylaxis in Adults Following Multiple Trauma................................86
Heparin-Induced Thrombocytopenia ....................................................................88
Antibiotic Usage on the Trauma Service ..............................................................90
SPECIAL ISSUES
Trauma in Pregnancy............................................................................................92
Reporting Child Abuse and Neglect and Referrals to the Child
Protection Program ...............................................................................................95
Speech-Language Pathology Services ..................................................................96
Diagnosis of Brain Death: Adult...........................................................................98
Diagnosis of Brain Death: Pediatric......................................................................80
Informed Consent and the Care of the Trauma Patient ........................................104
Obtaining Consults ...............................................................................................105
End of Life Issues .................................................................................................109
3
T R A U M A
H A N D B O O K
Trauma Conferences and Clinics
The Trauma Surgery Team is expected to attend these as well as other applicable surgical
conferences:
SATURDAY / SUNDAY
Trauma Morning Report
8:00 a.m., 5-ISC Conference Rm #526
THURSDAY
Critical Care Fellow’s Conference
Week 1 – Journal Club
7:00 a.m., 5-ISC Conference Room #526
Critical Care Fellow’s Conference
Week 2 – Journal Club led by SICU
7:00 a.m., 5-ISC Conference Room #526
Critical Care Fellow’s Conference
Week 3 – Protocol Development, PGY-4
7:00 a.m., 5-ISC Conference Room #526
Critical Care Fellow’s Conference
Week 4 – Speaker
7:00 a.m., 5-ISC Conference Room #526
Critical Care Fellow’s Conference
If Week 5 – Open – Ad Hoc
7:00 a.m., 5-ISC Conference Room #526
MONDAY
Trauma Conference
Weeks 1, 2 & 3 (and 4th week if month
has 5 weeks)
7:00-8:00 a.m., George Auditorium
Trauma M&M
Last Week
7:00-8:00 a.m., George Auditorium
Trauma Morning Report
8:00 a.m., 5-ISC Conference Rm #526
Burn Clinic
9:00 –11:00 a.m., Coop 1
Trauma Morning Report
8:00 a.m., 5-ISC Conference Room #526
TUESDAY
Resident Teaching Conference
8:00 a.m., APC 415 Conference Room
Trauma Morning Report
9:00 a.m., 5-ISC Conference Rm #526
Trauma Clinic
9:00 – 12:30 p.m., Coop 1
Pediatric Burn Clinic
3:00 – 5:00 p.m., Pedi Surg Office
WEDNESDAY
ED Trauma Service Conference
Week 1
8:00 a.m., Nursing Arts Room #104
Combined ICU Conference
Weeks 2 & 4
8:00 a.m., APC 415 Conference Room
Trauma Operative Procedures
Conference
Week 3
8:00 a.m., APC 415 Conference Room
Ad-Hoc Conference
If Week 5- Open
8:00 a.m., APC 415 Conference Room
FRIDAY
Ad-Hoc Conference
7:00-8:00 a.m., APC 415 Conference
Room
Trauma Morning Report
8:00 a.m., 5-ISC Conference Room #526
Pediatric Trauma Patient Care
Committee (PTPCC)
Every other week, 7:30- 8:30 a.m.,
Collis Conference Room, Pediatric
Surgery residents must attend.
Trauma Multidisciplinary Meeting
9:00 a.m., APC 415 Conference Room
1
T R A U M A
H A N D B O O K
Trauma Service Policies
To ensure optimal patient care as well as a productive educational experience, Trauma
staff has formulated the following guidelines. These policies cover the roles and goals
for each resident and medical student rotating on the Service, the responsibilities of each
member of the Trauma Team, specific policies regarding patient care, and other issues
essential to the efficient running of the Trauma Service.
Resident/Medical Student Roles
The PGY-5 on the Trauma Service is the Chief Resident of the Trauma Service. This
resident is responsible for the Trauma Service. 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. This resident is responsible for the
coordination of care with consulting services. This resident is also responsible for
organizing the weekly Trauma Conferences.
There is also a PGY-4 Trauma Resident, a PGY-3 Trauma Resident, two PGY-1 Trauma
Residents, and rotating medical students and Emergency Medicine residents. Each day,
there is a senior Trauma Resident (PGY-4 or PGY-3) and a junior resident (PGY-1) in
house. The daily responsibilities of the residents are as follows:
PGY-2 / PGY-3 / PGY-4 Trauma
1. Initial response to all patients triaged to the Trauma Rooms.
2. Management of resuscitation in the Trauma Rooms.
3. Daily management of in-house trauma patients.
4. Overseeing junior residents’ daily activities.
5. Daily Morning Report presentations / sign out.
6. Trauma Conference presentations.
7. Trauma / Critical Care Conference presentations.
PGY-1 Trauma Residents
1. Initial response to all patients triaged to the Trauma Rooms.
2. Assisting in Trauma Room resuscitations.
3. Daily ward patient care.
4. Coordination of discharge planning for all Trauma Service patients.
5. Daily Morning Report presentations / sign out.
PGY-2/3 Emergency Medicine Residents
1. Initial response to all patients triaged to the Trauma Rooms.
2. Assisting in Trauma Room resuscitations.
3. Daily Morning Report presentations / sign out.
PGY-1/PGY-2 Trauma, PGY-1 EM Resident on TICU
1. Patient care in TICU.
2. Daily Morning Report presentations / sign out.
Medical Students
1. Initial response to all patients triaged to the Trauma Rooms.
2. Assisting in daily patient care as dictated by senior Trauma Service Resident.
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T R A U M A
H A N D B O O K
Operative Procedures
A resident from the Trauma Service is expected to scrub on all Trauma Service cases.
A Senior Trauma Resident should scrub on all major trauma cases. This must be
coordinated with the Chief Resident in house.
Trauma Attending Coverage
Monday through Friday, 0800 - 2000 hours — Trauma attending of the week
Monday through Friday, 1700 - 0700 hours — Attending on call
Saturday, Sunday and Holidays 0800 - 2000 hours — Attending on call
The Trauma Attending of the week is available for back-up trauma coverage and for
consultation on established trauma service inpatients.
Attending Notification
1. Immediate (within 15 minutes) Trauma Attending presence is required
for the following:
A. CONFIRMED Blood pressure < 90 at any time in adults and age specific
hypotension for children:
<60 mmHg if 0-2 years old.
<70 mmHg if 3-5 years old.
<80 mmHg if 5 years old.
B. Respiratory compromise/obstruction and/or intubation (excluding
pediatric patients intubated to allow sedation);
C. Transfer patients from other hospitals receiving blood or vasopressors to
maintain vital signs or intubated;
D. Emergency physician’s discretion;
E. Gunshot wound to the abdomen, neck, or chest;
F. GCS < 8 with mechanism attributed to trauma.
G. Burn > 40% total body surface area.
H. Electrical injury involving high-tension wires.
I. Penetrating neck wounds (pediatric)
If any of these criteria are met, Code Yellow Level IA Trauma Team Activation is called. The notification time will be documented on the Trauma History
and Physical and the ED nursing flow sheet. The Trauma Attending must be
present within 15 minutes of notification and this time must be documented on
their progress note in the patient’s medical record and on the nursing flow
sheet.
2. On-call attending must be notified immediately for the following:
a. Stab wounds to the neck, chest or abdomen.
b. Major pelvic fractures.
c. Spinal injuries.
d. Extremity trauma with neurovascular deficit.
e. Major blunt thoracic trauma.
f. All patients going to the operating room regardless of the service.
3. On-call attending must be notified promptly of all admissions. No exceptions.
4. Dr. Harrington is to be notified of all burn patients. If he is not available,
contact the trauma attending.
General Policies
1. A complete and accurate trauma history and physical is required for all
trauma admissions.
3
T R A U M A
2.
3.
4.
4.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
H A N D B O O K
A complete daily Trauma Service note in SOAP format addressing all
problems and containing all test results are required on each patient on the
Trauma Service.
The chief resident in house must be notified of all trauma room admissions.
The entire trauma team is expected to respond to all trauma room admissions.
Dismissal from the trauma room is at the discretion of the senior trauma
resident.
The ED accepts all trauma transfers from outlying hospitals and the communication center immediately notifies the trauma attending to coordinate the
transfer.
A trauma service resident must accompany and stay with a Trauma Service
patient traveling from the ED or special care unit to CT, special procedures,
or the OR. If another service is operating on the patient, a resident from
that service should accompany the patient to the OR. The Trauma Nurse
Practitioner at the discretion of the Chief Trauma Resident may accompany
stable patients.
The Trauma Service will continue to round and document the tertiary survey
after transfer of a patient from the trauma service to a subspecialty service.
Admission to and discharges from a special care unit require notification and
approval of the trauma attending.
Acute ethanol intoxication is a diagnosis and should be provided on the discharge summary when applicable. Consult Substance Abuse Social Worker.
When a patient is transferred from the trauma room to the urgent area of the
ED, the trauma resident must inform the ED attending of the patient’s status
and pending workup, and document the results of his/her evaluation (including
primary and secondary survey).
The senior trauma resident must review and sign all trauma room evaluations
completed by the EM residents or medical students.
Interim discharge summaries are required on all complicated patients and on
any patient on the Trauma Service for more than one week prior to transfer to
another service. A discharge summary should contain a complete and accurate
list of the patient’s diagnoses. Multiple trauma is not a diagnosis.
Discharge planning is the responsibility of the Trauma Service.
A physician and nurse must accompany each patient in the burn shower to
assess wound and skin treatments and monitor the patient.
Level of care must be documented daily on each TICU patient. ICU, stepdown
or border are the accepted levels.
Trauma patients 17 years of age and older are admitted to the adult service.
Any patient >35kg may be admitted to the TICU at the discretion of the trauma
attending.
If any questions arise regarding patients <17 years of age, ask!
Clinical Social Work (CSW) referrals for trauma patients are not automatic.
Request CSW consults for patients, when required, within 24 hours of patient
admission.
All patients should have the tertiary survey form filled out within the first 24
hours. A repeat tertiary survey is warranted in patients upon extubation or
emerging from altered level of consciousness.
Patients transferred from an outside institution should have their x-rays given
to the radiologist with the request that a written report/reading be generated.
Additional films may be ordered as clinically indicated.
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T R A U M A
H A N D B O O K
21. Patients are admitted to the Trauma Attending covering at the time of
admission. They are transferred to the care of the Trauma Attending of the
week at 0800. Weekend admissions are transferred on Monday morning.
22. Discharge Summaries will be dictated in the name of the Trauma Attending
who is covering on the day of discharge.
23. Participates in and assists in enrollment of patients in research.
Universal Precautions in the Trauma Rooms
All employees, students, and observers are required to wear all of the following with all
patients in trauma rooms:
1. Gloves
3. Masks
2. Gowns
4. Eye Coverings
* Non-compliance with Universal Precautions will result in management action. OSHA
standards require compliance.
Transfer Policies for Burn Patients
Burns will be admitted to the burn service under the care of Dr. Harrington. The trauma
residents will decide upon burn transfers on a case-by-case basis after discussion with Dr.
Harrington. If he is not available, consult the burn attending on call list. In the event
inter-facility transfer is necessary, adults will go to MGH (617-726-2000), children to the
Shriners Burns Institute (617-722-3000).
Verification of Person, Procedure, and Site for Surgical Procedures
For procedures performed in the Emergency department, the hospital promotes the
Universal Protocol to Prevent Wrong Site, Wrong Procedure and Wrong Person
Surgery™.
It is expected, to the extent possible and appropriate, the patient and trauma team
members will be involved with site marking and a “time out” immediately before a
procedure to verify the correct patient, procedure and site. Marking and documentation
are always secondary to the patient’s safety in an emergent situation. However, even in
the direst situation, it is suggested that a pause to collaboratively agree on the procedure
and patient identity would be worthwhile and recommended. Any exceptions,
circumstances, etc. precluding the Universal Protocol MUST be documented in the
medical record. The “Time Out” form must be completed and faxed, even if the
procedure was emergent and consent was NOT obtained.
Throughout the hospital, the standard patient identifiers are name and date of birth.
Unknown patients may be banded with the identifying information: “unknown”, gender,
and race. Visual check of the band with chart documents and/or radiographs is required
before treatments or services are rendered.
Site marking is required in cases of laterality and multiple structures or levels. The
unique hospital mark for incision of the skin or insertion of an instrument or foreign
material into the body is identified in the Rhode Island Hospital Perioperative Services,
Operating Room Policy and Procedure Manual located at the following address:
http://intra.lifespan.org/surgsvcsrih/documents/OR%20Policies%2011%2024%202008/Pr
otocols%20Standards%20V/universal-protocol-verification-of.pdf
Verbal call back—actively involving all team members—is used to verify patient ID, the
procedure, and site in a time out just before incision that is documented in the record.
Such a pause is required before all invasive procedures of more than minimal risk to the
patient whether or not sedation or anesthesia is used.
5
T R A U M A
H A N D B O O K
Trauma Service Consultation Policy
Frequently, patients admitted to the trauma service will have complex problems or
issues requiring the assistance of a consultant service, however it is never acceptable
for a consulting service to consult another service. Such a practice is detrimental to
patient care and promotes poor inter-service communication. If a consulting service
feels that they need the assistance of another service in order to treat the problem they
were requested to co-manage, then a discussion must be held with the trauma service
attending of record or trauma chief resident.
In general, it is good medical practice to ask a consulting service to address a specific
patient care question rather than to abdicate all medical care to the consultant service.
For example, Gustilo grade III fractures frequently require free tissue or rotational flaps
in order to allow bone and hardware coverage. Thus, plastic surgery should be consulted
with a specific questions centering on the need for a flap or tissue transfer rather than
the generic “wound management”. Similarly, the concept of “medical clearance” as part
of a pre-operative workup diminishes the central importance of good surgical care such
as avoiding prolonged operative time, excessive blood loss or complex procedures when
a more expedited procedure may suffice with similar outcome and less risk. It is imperative that the services communicate frequently and clearly so that risk stratification,
modification and abatement may ensue.
Thus, it is the policy of the trauma service that all consults on trauma patients be cleared
through the senior trauma resident or chief resident and that in situations where a consultant requires another consultative service, the trauma service attending or trauma chief
resident must be informed and agree with that decision. If conflicts arise, good patient
care is our first and highest priority followed by good communication, resident education,
minimizing medico-legal liability, etc. The chief of trauma should be involved in those
situations identified as ongoing system issues or those situations unable to be resolved in
a simple, timely fashion.
Rev. 6/1/08
6
T R A U M A
H A N D B O O K
Service Assignments and Inter-Service Transfer Guidelines
Adult: To facilitate patient care and to eliminate potential misunderstandings between
various services caring for trauma patients, the Trauma Committee has
established the following guidelines regarding admission to and transfer of
trauma patients between services.
1. Patients with multiple system injuries, hemodynamic instability, or spinal
cord injuries will be admitted to the Trauma Service.
2. Patients with unisystem injuries, without a mechanism for multiple system
injury shall be directly admitted to the appropriate service.
3. Patients with a mechanism for potential multiple system injuries should be
evaluated by the Trauma Service. Patients will be admitted to the Trauma
Service as long as an appropriate evaluation for occult injuries is in
progress. Pre-existing medical conditions such as congestive heart failure,
seizures, arrhythmias, diabetes, or COPD do not constitute reasons to remain on the Trauma Service with a unisystem injury. Once occult injuries
have been ruled out and the patient with unisystem injuries is stable, the
patient may be transferred from the Trauma Service to the appropriate
service. The order activating transfer will be executed by the Trauma
Service (either the attending or the chief resident) with notification of the
attending or chief resident from the receiving service. Once a patient is
transferred from the Trauma Service to another service, Trauma Service
will complete a tertiary survey and follow up as appropriate.
Pediatric: To facilitate patient care and to eliminate potential misunderstandings
between various services caring for trauma patients, the Pediatric Trauma
Patient Care Committee has established the following guidelines regarding
admission to, and transfers of, pediatric trauma patients between services.
Patients with multiple injuries are admitted to the Pediatric Surgery
Service
Patients with isolated injury, but whose mechanism of injury involved multiple trauma (i.e., severe motor vehicle accident), will be
admitted to the Pediatric Surgery Service. Once associated/occult
injuries have been ruled out, these patients can be transferred to the
appropriate service, but only with direct communication between
attendings or chief residents of the involved services. After transfer,
documented follow-up by the Pediatric Surgery Service will continue
at least until after completion of the tertiary survey
Patients with isolated trauma (by mechanism and finding) are
admitted to the appropriate service
Neurosurgical trauma patients admitted to the PICU will be
concomitantly managed by the Pediatric Critical Care Service
The Pediatric Critical Care Service will be actively involved in the
care of the multi-injured patient whenever the active and sustained
involvement of the Neurosurgical Service is required (i.e., more than
a one-time C-spine clearance)
7
T R A U M A
-
H A N D B O O K
As communication is of the utmost importance:
ƒ
All involved Services and their representatives (attendings,
fellows, residents) will be clearly identified in the chart and
at the bedside, to allow seamless continuity of care
ƒ
All multidisciplinary issues will be discussed through direct
physician-to-physician communication
ƒ
Admission orders will be written before a patient is
admitted to the PICU or other in-patient unit
Frequently used telephone numbers:
CT (24/7)
Medicine Clinic
Neuro Surg Clinic
Optho Clinic
Ortho Clinic
Rev. 8/8/07
8
444-6159
444-4741
444-5507
444-5509
444-5662
T R A U M A
H A N D B O O K
Code Yellow Trauma Team Activation
For every Code Yellow Level IA, I or II patient triaged to the trauma rooms, the group
page will be initiated.
The ED attending, charge nurse or triage nurse will receive the information that a surgical
trauma patient will be arriving and he or she communicates to the ED secretary whether it
is a Code Yellow Level IA, I or II patient.
ADULT:
The ED secretary will call the Emergency paging operator at ext. 5111 and will say,
“Please page a Code Yellow Level (IA, I or II) for G 2 (Group page 2).”
Pagers for all Code Yellow Level IA, I and Level II members of the trauma team will
sound for each surgical trauma case arriving. For Code Yellow Level IA cases, the
beeper will display “Code Yellow AAA”, Level I “Code Yellow 111,” and for Level II
“Code Yellow 222.”
When you are paged, do not call the ED or the trauma rooms; just report to trauma
alley for further directions.
The following trauma team members should respond to each page:
Code Yellow Level IA
Trauma Attending on call
Code Yellow Level I
Chief Surgical Resident
Trauma Resident on call (3rd
or 4th yr)
Trauma Resident on call (3rd First-year Trauma Resident
or 4th yr)
on call
First-year Trauma Resident ED Resident rotating on
on call
Trauma
Resident rotating on Trauma Medical Student rotating on
Trauma
Medical Student rotating on Respiratory Therapy
Trauma
Clinical Social Worker
Clinical Social Worker
Respiratory Therapy
Chaplain
Chaplain
Trauma Nurse Practitioner
Trauma Nurse Practitioner
Chief Surgical Resident
Code Yellow Level II
Trauma Resident on call (3rd
or 4th yr)
First-year Trauma Resident
on call
ED Resident rotating on
Trauma
Medical Student rotating on
Trauma
The adult trauma attending pagers will include notification of all Code Yellow Level IA
cases.
During on call hours, the Clinical Social Worker will call the ED for instruction as to
whether to report to the hospital to consult for the trauma case.
PEDIATRIC:
The Hasbro ED secretary will call the emergency paging operator at ext. 5111 and will
say, “Please page a Code Yellow Level (IA, I or II) for Group 8.”
9
T R A U M A
H A N D B O O K
Pagers for all members of the Group Page will display “Code Yellow AAA-4900” for a
Code Yellow Level IA, “Code Yellow 111-4900” for a Code Yellow Level I, and “Code
Yellow 222-4900” for a Code Yellow Level II indicating the arrival of a surgical trauma
patient.
When you are paged, do NOT call the ED or the trauma room; just report to the
Hasbro trauma room.
The following trauma team members should respond to each page:
Code Yellow Level IA
Code Yellow Level I
Code Yellow Level II
Same as the Code Yellow
Same as the Code Yellow
•
Pediatric Surgery
Adult Level IA with the
Adult Level I with the
Resident
addition of:
addition of:
•
Pediatric Surgical
•
Pediatric Surgical
•
Trauma Resident on
Resident
Resident
Call (PGY-3 or 4)
•
Nursing A.D. or
•
First-Year Pediatric
•
Emergency Medicine
C.R.C.
Surgery Resident on
Residents on Trauma
Call
•
Clinical Social Work
•
Nursing A.D. or
•
Radiology
C.R.C.
Technician
•
Clinical Social Work
•
Radiology
Technician
In the event of beeper system failure, the overhead paging system will announce trauma
team activation by stating, “Code Yellow Level IA, I or II Surgical (or Pediatric Surgical)
Team to ED.”
Rev. 7/17/08
10
T R A U M A
H A N D B O O K
Criteria for Triage to Trauma Rooms: Adult
Code Yellow Level I-A (Level I Team + Trauma Attending)
•
Confirmed systolic blood pressure (SBP) < 90 at any time
•
Respiratory compromise/obstruction and/or intubation
•
Transfer patient receiving blood or vasopressors to maintain vital signs
•
Gunshot wound (GSW) to the abdomen, neck, or chest
•
GCS < 8 with mechanism attributed to trauma
•
Burn > 40% total body surface area
•
Electrical injury involving high tension wires
•
Emergency physician’s discretion
Code Yellow Level I (Level I Team)
•
Abnormal vital signs associated with a traumatic mechanism:
SBP (mm Hg)
Heart Rate
Resp. Rate
Temperature
>180
<60 or >110
<10 or >30
< 32oC (90oF)
•
Trauma Score <13
•
Known LOC > 5 minutes
•
Age >70 with significant mechanism
•
Burn >20% BSA or with suspected inhalation injury
•
GSW head or stab wound (SW) head/neck/torso
•
Strangulation/hanging
•
Extremity injury with neurovascular deficit
•
Fatality within the vehicle or ejection from vehicle
•
Pregnant patient when history is suggestive of major trauma
•
Intoxicated patient when history is suggestive of major trauma
•
Pedestrian struck by vehicle >30 mph or thrown >20 ft
•
Fall >30 ft
•
Pelvic instability; open pelvic or femur fracture
•
Significant bleeding; major crush injury
•
Spinal cord injury
•
Depressed skull fracture/scalp avulsion/CSF leak
•
Severe maxillofacial trauma
•
Flail chest; tension pneumothorax; massive subcutaneous emphysema
•
Major amputation (not fingers/toes)
Code Yellow Level II (Level II Team)
•
Blunt trauma with complaints relative to abdomen or thorax
•
Intrusion of space > one foot; extrication time >20 minutes
•
Pedestrian struck 10 – 30 mph
•
Motor vehicle rollover; steering wheel/windshield deformity
•
Fall 10 - 30 feet
•
Penetrating extremity injury without neurovascular deficit
•
Multiple or open long bone fractures
•
Burn <20% but involving face, hands, feet or genitals
Rev. 8/8/07
11
T R A U M A
H A N D B O O K
Criteria for Triage to Trauma Rooms: Pediatric
Code Yellow Level I-A (Level I Team + Trauma Attending)
•
Age specific hypotension for children:
•
0-2 years old <60 mmHg
•
3-5 years old <70 mmHg
•
6 - 8 years old <80 mmHg
•
>8 years old <90 mmHg
•
Respiratory compromise/obstruction and/or intubation (excluding pediatric patients
intubated to allow sedation);
•
GCS<8 with mechanism attributable to trauma;
•
Transfer patients from other hospitals receiving blood or vasopressors to maintain
vital signs;
•
Gunshot wounds to the abdomen, neck, or chest;
•
Penetrating neck wounds;
•
Burns > 40% total body surface area;
•
Electrical injuries involving high tension wires;
•
Emergency physician’s discretion
Code Yellow Level I (Level I Team)
•
Pediatric Trauma Score < 8
•
Known LOC > 5 minutes
•
Core temperature <32° C or <90° F
•
Abnormal vital signs:
Age
Systolic BP
Pulse
Respirations
(mm Hg)
(bpm)
(breaths/min)
0-2
<60
<80 or >180
<15 or >40
3-5
<70
<60 or >170
<10 or >30
>5
<80
<60 or >160
<10 or >25
•
Shock following injury with:
•
Delayed capillary refill
•
Pale, cool, mottled skin
•
Weak, rapid pulse
•
Decreased LOC
•
Rapid, shallow respirations
•
Respiratory distress following injury with:
•
Increased or decreased respiratory rate
•
Cyanosis
•
Grunting
•
Retraction, flaring
•
Airway obstruction
•
Burns associated with suspected inhalation injury
•
Burns (large) involving face, hands, feet or genitals Burns >10% BSA
•
Electrical injuries involving high tension wire or lightning
•
Strangulations/hangings
•
Penetrating wounds of head, neck, torso
•
Penetrating injuries of extremities with neurovascular deficit
•
Steering wheel/windshield deformity
12
T R A U M A
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
H A N D B O O K
Fatality within the vehicle
Ejection from vehicle
Pregnant patients when history is suggestive of major trauma
Intoxicated patients when history is suggestive of major trauma
Pedestrian hit by vehicle moving >20 mph
Unrestrained occupants of motor vehicle involved in crash at >20 mph
Restrained occupants of motor vehicle involved in crash at >40 mph
Thrown from vehicle or into the air >5 feet
Falls >15 feet
C-spine injury
Uncontrolled traumatic hemorrhage
Severe maxillofacial injuries
Unstable chest injuries
Major pelvic injuries (pelvic instability)
Blunt abdominal trauma with hypotension, rigidity or significant tenderness
Penetrating wound or crush injury to the head, neck, chest, abdomen, pelvis
or groin
Neurological injuries producing altered mental status, posturing, seizures,
lateralizing signs of paralysis
Two or more proximal long bone fractures
Tracheal and laryngeal injuries
Code Yellow Level II (Level II Team)
•
Intrusion of space >1 foot
•
Extrication time >20 minutes
•
Rollovers
•
Free falls 8-15 feet
•
Penetrating extremity injury without neurovascular deficits
•
Blunt trauma with complaints relative to abdomen or thorax
•
Single long bone fracture in association with other injury
•
Open fractures
Rev. 8/8/07
13
T R A U M A
H A N D B O O K
Role of Trauma Team Members: Adult
The following guidelines are for the management of severely- or multiply-injured adult
patients. Variations from these guidelines will occasionally occur based on staffing,
clinical situation, and other factors.
General Protocols for Trauma Team Members
Upon examination of a Code Yellow Level II patient, the ED attending or chief surgical
resident may request activation of the full Code Yellow Level I team or transfer the
patient to the urgent area if a trauma room is no longer indicated. If the patient is transferred to the urgent area, the trauma resident is expected to verbally update the ED
attending on the condition of the patient and to leave a progress note with a history and
physical detailing any procedures performed.
Upon arrival of the patient to the Trauma Room, QUIET should be observed by all
team members so that the report from prehospital personnel may be heard by everyone.
Additional personnel who may be allowed to enter the trauma room as observers should
stand in the designated area and remain QUIET throughout the resuscitation. The maximum number of observers allowed in a Trauma Room simultaneously is three. One or
more observers may be asked to step out of the room at any time, as circumstances
require.
Residents from trauma, pediatric surgery, and pediatrics must evaluate pediatric patients.
The trauma resident must remain in attendance until the patient assessment is completed.
The physician Team Leader in charge of the resuscitation should be the only physician
giving verbal orders to the nursing team members. Orders from other physicians should
be passed through the Team Leader. The respective roles of the Trauma Team members
are as follows:
Trauma Surgeon (or, in his/her absence, ED Attending):
•
Assume primary responsibility for and authority over the patient.
•
Work in conjunction with chief surgical resident to provide team leadership
(acting or supervising).
•
Intervene clinically at any level, as necessary.
Chief Surgical Resident
•
Team Leader, responsible for coordination of patient care.
•
Work in conjunction with the ED attending and trauma attending on
patient management.
•
Direct major surgical intervention (DPL, chest tube insertion, venous
cutdown, thoracotomy).
•
Assume management of patient upon definitive transfer from the ED.
•
Notify attending trauma surgeon of required presence and clinical issues
at his/her discretion.
•
Intervene clinically at any level, as necessary.
•
Designate which trauma resident will perform and document physical
exam.
14
T R A U M A
H A N D B O O K
Surgical / EM Residents:
•
Perform and document physical exam.
•
Perform procedures, obtain consultations and perform other tasks as directed.
•
Accompany patient to Radiology, OR, ICU.
•
Complete the medical record.
•
In the event of greater than two simultaneous trauma cases in the trauma
rooms, additional general surgery housestaff may be garnered from other
services to assist with patient evaluation and treatment. (See hospital Disaster
Policy).
Primary Trauma Nurse:
•
Communicate patient's condition, all lab results, and/or response to therapy
to Trauma Team Leader.
•
Accompany patient to CT, Special Procedures, OR, or ICU.
•
Responsible for continuity of care until patient reaches final destination.
•
Give nursing report when patient is transferred.
•
Responsible for all documentation in the absence of a trauma recorder.
•
Assess the need for a secondary nurse and trauma recorder.
•
Responsible for notification of social and pastoral services as needed.
Respiratory Care Practitioner:
•
Assist with airway management.
•
Accompany the patient to CT, Special Procedures, OR, or ICU.
Clinical Social Work and Pastoral Services:
•
Crisis intervention with patient and family members.
•
Liaison between trauma team and family.
•
Assist in next-of-kin notification PRN.
Security:
•
Crowd control or assistance with patient restraint as deemed necessary.
Rev. 7/16/08
15
T R A U M A
H A N D B O O K
Role of Trauma Team Members: Pediatric
The following are guidelines for the management of severely or multiply-injured
pediatric patients (< 17 years of age) for Hasbro Children's Hospital. Variations from
these guidelines will occasionally occur due to staffing, clinical situation, the number
of trauma patients requiring simultaneous attention, and other factors.
Availability of the Pediatric Trauma Team
The Pediatric Trauma Team is available in the hospital at all times. An attending
pediatric trauma surgeon is available on-call. His or her name appears on the call list
located in the Emergency Department. The in-house attending trauma surgeon is
available on page if immediate attending presence is required (Code Yellow level IA).
General Protocols for Pediatric Trauma Team Members
When there has been pre-hospital notification of the arrival of a patient with known or
suspected multiple system trauma, Hasbro Trauma Room activation should be put into
effect so that the Pediatric Trauma Team may be positioned, waiting for the patient.
The Pediatric Trauma Team should also be activated when a patient who warrants their
attention arrives unannounced.
The Code Yellow Level I or Level II Trauma Team may be activated by the Pediatric
Emergency Department Attending or Fellow based on Trauma Triage Criteria (see pages
10-11 for delineation of levels).
Please see the Hasbro Surgical Trauma Group Call policy to review expected team
response to Code Yellow Level I and Level II pages.
Upon arrival of the patient to the Hasbro Trauma Room, QUIET by all team members
should be observed so that everyone can hear report from pre-hospital personnel. This
will save time and lessen the need to repeat information.
Additional personnel who may be allowed to enter the Trauma Room as observers
should stand in the designated area and remain QUIET throughout the resuscitation.
The maximum number of observers allowed in a Trauma Room simultaneously is
three. One or more observers may be asked to step out of the room at any time, as
circumstances require.
The trauma resident and pediatric surgical resident must remain in attendance until
the patient assessment is completed.
The Physician Team Leader in charge of the resuscitation should be the only physician
giving verbal orders to the nursing team members. The Team Leader may delegate
"leadership" roles as necessary (i.e., medications, fluids); however, the team leader
should make this kind of decision clear to the rest of the team, especially the nurse-incharge. Otherwise, orders and suggestions from other physicians should be passed
through the Team Leader.
16
T R A U M A
H A N D B O O K
The Team Leader will be the most senior person present determined by the following list:
1.
2.
3.
4.
5.
Surgical attending physician
Pediatric surgery fellow
Senior surgical resident
Senior pediatric surgical resident
Pediatric surgical/trauma resident in conjunction with pediatric ED attending/fellow
The ultimate responsibility for the pediatric trauma victim lies with the pediatric surgical
attending, when present. If he/she is not present, the ultimate responsibility lays with the
pediatric ED attending or the in-house attending trauma surgeon, when present.
The respective roles of the Pediatric Trauma Team are as follows:
I.
Team Leader
A. Pediatric Surgical Attending/Pediatric Surgical Fellow/Senior Pediatric
Surgical Resident/Chief Surgical Resident
•
Assigns roles.
•
Works in conjunction with the pediatric ED attending on patient
management.
•
Directs major surgical intervention (DPL, chest tube insertion, venous
cutdown, and thoracotomy).
•
Responsible for management of patient upon definitive transfer from
the ED.
•
Contacts surgical attending, if not present, for any patient with a Pediatric
Trauma Score <9 or if surgical input is considered necessary by chief
resident.
•
Designates which resident will perform and document physical exam.
•
In the event of greater than two simultaneous trauma cases in the trauma
rooms, additional general surgery housestaff may be garnered from other
services to assist with patient evaluation and treatment (see Hasbro
Disaster Policy).
B.
Pediatric ED Attending/Fellow
•
Works in conjunction with senior pediatric surgical resident, chief surgical
resident, and/or pediatric surgical attending on-call to provide team
leadership (acting or supervising).
•
Assumes primary responsibility and authority until or unless the attending
pediatric surgeon on-call, the pediatric surgery fellow, or the senior
pediatric surgical resident/chief surgical resident is physically present in
the trauma room.
•
Provides medical direction during full cardiac arrest.
•
Participates in airway management as needed.
•
Maintains ongoing communication with the primary trauma nurse.
•
Obtains consultations as needed.
•
Completes ED record.
•
May downgrade the trauma and move the patient out of the trauma room
for completion of work-up after consulting with the chief surgical resident.
•
Assures that Pediatric Intensive Care Unit is informed of possible
admission(s).
•
Has ultimate responsibility, unless surgical attending is present.
17
T R A U M A
H A N D B O O K
II. Pediatric Trauma Team Members
A.
Resident A (right side of patient) Trauma Resident or Pediatric Surgical
Resident
•
Knows sequences (ATLS) for diagnosis and treatment in the absence of
Chief Surgical resident.
•
Performs procedures on right side of patient, chest tube or pericardiocentesis, as directed by Team Leader.
•
Draws ABGs, perform rectal exam prior to Foley insertion by primary
nurse, insert NG tube.
•
Performs DPL as directed by Team Leader.
•
Accompanies patient to CT, Special Procedures, OR, or ICU.
•
Protects patient’s neck.
B.
Resident B (left side of patient) Pediatric or ED resident
•
Airway /neck management priority.
•
Assists Team Leader with procedures on left side of patient.
•
Establishes second IV access.
•
Inserts left chest tube, assist with thoracotomy or DPL, as directed by
the Team Leader.
•
Assesses all blood specimens drawn.
•
Pushes all medications during medical sequence.
•
Knows ATLS sequences.
C.
Nurse in Charge
•
Records entire trauma event - elicits data from all team members, such as
all infusates, all output, VS q 5 min., sizes of inserted tubes and catheters,
etc.
•
Communicates to Team Leader and other team members - status of vital
signs, pending medication times, trends from data, etc. on a frequent
basis and gives periodic summary reports of fluid infusion, etc.
•
Monitors all nursing activities, patient needs, flow of equipment and
supplies, etc., and anticipates and communicates needs to inpatient staff.
•
Labels all specimens and notes times sent to Laboratory.
•
Co-signs blood slips as necessary.
•
Ensures appropriate paperwork is completed before transfers and that
all necessary forms are ultimately completed (Trauma/Code Sheets,
Chart Plate, Permits and Lab Data, ID Bracelet, Admissions orders).
•
Coordinates release of team members with Team Leader.
•
Ensures that necessary equipment, supplies, and medications and
personnel are ready to transport.
•
Telephones report to receiving unit: patient condition, treatments, etc.
D.
Nurse A (right side of patient)
•
Assists Resident A.
•
Strips patient and talks to patient to explain emergency procedures
(observe c-spine precautions).
•
Turns on monitor and places ECG leads.
•
Assists with IV access/cutdown and secures all right-sided lines, (Stopcock and extension tubing added to IV's of all potential OR patients).
18
T R A U M A
•
•
•
•
•
•
•
E.
H A N D B O O K
Monitors and controls all right-sided infusions, blood products, lavages,
and all right-sided outputs (blood, urine, drainage, vomitus, etc.) and
announces to nurse-in-charge.
Operates trauma table.
Assists with chest/pleurevacs, N-G tube and Foley insertion.
Applies dressing to all open wounds.
Operates warming lamps as needed for patient exposure.
Applies identification bracelet and guarantee patient identification before
transport to other areas.
May accompany patient to X-ray, OR, ICU, etc. as directed by nurse-incharge.
Nurse B (left side of patient)
•
Compresses chest during cardiac arrest until relieved by other personnel.
•
Obtains vital signs (TPR, BP, neurological signs) every 5 minutes x 4 and
announces them.
•
When following criteria met, obtains vital signs every 15 minutes:
•
T: Taken x 1. Repeats every 5 minutes if below or above normal (36 38 C)
•
P: Stable w/in 5 beats (HR less than 130)
•
R: Stable w/in 5 respirations (RR 20-30/min)
•
BP: Stable w/in 5mmHg (all readings may be Dynamap) systolic BP
> 80mmHg
•
Neuro: Until stable
•
Assists with left-sided procedures.
•
Assists with IV access/ blood drawing and secures all left-sided lines,
(Stopcock and extension tubing added to IV's of all potential OR patients).
•
Monitors and controls all left-sided infusions, blood products, lavages, and
all left-sided outputs (blood, urine, drainage, vomitus, etc.) and announces
to nurse-in-charge.
•
Coordinates MAST trousers with Resident B.
•
May accompany the patient to X-ray, OR, ICU, etc. as directed by nursein-charge.
•
Medications
Before patient arrives
•
Bring Rapid Sequence Intubation drugs.
•
Draw up and label 4, 6cc NS flushes.
•
Draw up and label 5 cc NS for Foley catheter (3 cc. for #8 Foleys).
•
Assemble all blood drawing equipment-tubes, labels, etc.
After patient arrives
•
Prepares all medications and infusions as requested.
•
Knows and verbalizes all drug actions, incompatibilities, and
dilutions.
•
Communicates to Resident B the exact dosage of drugs handed to
him (consistently throughout the incident).
•
Places correct amounts of blood in proper tubes to send to lab.
•
Assembles pressure lines and transducers as needed.
•
Draws up medications for transport as needed.
19
T R A U M A
•
•
•
•
•
F.
H A N D B O O K
Assumes other duties and responsibilities as directed by the nursein-charge such as assisting to strip patient, restrain patient, etc.
May accompany patient to ICU, OR, X-ray, etc. as directed by
nurse-in-charge.
Draw ups and labels epinephrine.
Prepares medications according to standard resuscitation protocol
unless otherwise instructed.
Sets up pressure lines, transducers and pumps for Dopamine or
Epinephrine drips.
Radiology Technician
•
Responds with sufficient number of cassettes to perform x-ray series
as directed by Team Leader.
•
Waits in trauma room for urgent procedures to be completed.
•
Develops film and returns immediately with x-rays.
•
Calls for additional help if required.
G. Respiratory Care Practitioner
• Responds immediately to trauma room when paged.
• Assists with bag-valve mask ventilation.
• Suctions patient PRN.
• Provides mechanical ventilation.
• Accompanies the patient to CT, Special Procedures, OR, or ICU.
H. Clinical Social Work and Pastoral Services
• Performs crisis intervention with patient and family members.
• Acts as liaison between trauma team and family.
• Updates family periodically.
• Responds to patient’s religious needs.
I.
Security
•
Available in E.D. waiting room for assessment of need for further
security assistance.
•
On stand-by outside of trauma room for crowd control or assistance
with patient restraint as deemed necessary.
Rev. 8/1/07
20
T R A U M A
H A N D B O O K
Routine Trauma Labs
ADULT:
The following laboratory tests should be ordered for all adult surgical trauma patients
evaluated in the trauma rooms:
Code Yellow Level I, IA
•
CBC
•
Chem 7
•
Blood alcohol level
•
Urine “Drugs of Abuse”
toxicology screen
•
Type and screen. Type and
cross for any patient with SBP
<90, truncal penetrating injury,
or going directly to the OR.
•
Medical Examiner blood
•
PT/PTT
Code Yellow Level II
•
CBC
•
BUN/creatinine
•
Blood alcohol level
•
Urine “Drugs of Abuse”
toxicology screen
•
Urine dip (if positive for blood
or protein, a UA must be sent),
also UCG in female patients of
childbearing age
•
PT-INR on isolated head injury
or spinal injury
•
Chem 7 on isolated head injury
PEDIATRIC:
The following laboratory tests should be ordered for all pediatric surgical trauma patients
evaluated in the trauma rooms:
•
•
CBC with differential
Urine dip (if positive for blood or protein, a UA must be sent), UCG for
females > age 12)
•
Type and screen. Type and cross for patient with SBP <90 (age > 5), SBP <80
(age 3-5), SBP <70 (age < 0-2); Penetrating truncal injury; going directly to the
OR
•
Medical Examiner blood (Code Yellow Level I only)
•
Urine “Drugs of Abuse” toxicology screen (age > 12)
•
Blood alcohol level (age > 12)
The following labs may also be indicated:
•
PT/PTT for any patient with a GCS < 10
Rev. 8/18/07
21
T R A U M A
H A N D B O O K
Combined Family Adult and Pediatric Trauma
(Mixed Bundles)
The goal of this policy is to have pediatric trauma managed at Hasbro and adult trauma
managed at Bridge ED. The policy for adult/child trauma is as follows:
In the case of adult/child trauma arriving in the Bridge ED:
1. It is the responsibility of the ED Attending at Bridge ED to assess the ABCs of
the child. If there is no airway or hemodynamic problems, the Hasbro ED will
be notified immediately and the child will be transported to Hasbro while still on
the ambulance stretcher. No Bridge ED chart will be generated. An ED resident
will accompany the child. Upon arrival at the Hasbro ED, the ED resident will
document on the ED Face Sheet that the child was evaluated and found to have
an intact airway, adequate breathing, and hemodynamic stability, and was transported with or without incident.
2.
If the child is evaluated by the ED Attending at Bridge ED and found to have an airway or breathing problem, or appears to be hemodynamically unstable, the child will
be put in a trauma bay in Bridge ED and the pediatric surgical trauma team and the
Hasbro ED Attending/Fellow will be notified that the patient is located in the Bridge
ED. The child will be admitted to the Bridge ED and a chart will be generated in the
Bridge ED.
In case of adult/child trauma arriving in the Hasbro ED:
1. If an adult/child trauma arrives at the Hasbro ED, it will be the responsibility of the
Hasbro ED Attending/Fellow to assess the ABCs of the adult. If the adult has no
airway or breathing problems or hemodynamic instability, the Bridge ED will be
notified immediately and the adult will be transported while still on the rescue
stretcher to the Bridge ED by the ED or pediatric resident. Upon arrival at the
Bridge ED, the resident will document on the ED Face Sheet that the patient was
evaluated and found to have no airway or breathing problem or hemodynamic
instability and was transported with or without incident to Bridge ED, as the case
indicates.
2.
In the case of an adult trauma patient who is hemodynamically unstable or has an
airway or breathing problem, the adult will be evaluated by the ED Attending/
Fellow and admitted to the Hasbro ED. The Trauma Team and the Bridge ED
Attending will be notified that the patient is in the Hasbro ED and a chart will be
generated through the Hasbro ED.
Rev. 8/1/07
22
T R A U M A
H A N D B O O K
Police Notification of Emergency Department Cases
The appropriate police department is to be notified of all patients received in the
Emergency Department as a result of gunshot wounds, stab wounds, and animal bites.
I.
There are specific reporting instructions for the following:
a. Suspected child abuse — report to Department of Youth, Children and
Families, and police department
b. Deaths from violent acts report to police and medical examiner
a. Elderly abuse — report to Department of Elderly Affairs
b. STDs are reportable to the Health Department
II.
Because of the Patient’s Bill of Rights provision on confidentiality and HIPPA
regulations, all other information will be reported to the appropriate police
department only with the approval or at the request of the patient.
Release of Information to the Police Department:
Information released to the police department will be limited to the following:
a.
b.
c.
d.
e.
f.
g.
h.
Your answer is always “a question of” a fracture, or “a question of” an intraabdominal injury, etc.
Patient admitted
Condition — good, fair, critical
Doctor’s name treating the patient
Whether or not the patient can speak to them
Wounds may be described as lacerations, abrasions or contusions. Never tell the
Police how you think the patient sustained the injury.
The hospital and its personnel are under no obligation to take blood samples from an
unconscious patient at the behest of law enforcement personnel or other officials. If
a patient consents to the taking of a blood sample, when requested by law
enforcement personnel, the appropriate consent form should be completed. If the
patient refuses or is unable or unwilling to consent, no blood sample should be taken
unless, in the opinion of the physician, its acquisition is dictated by sound medical
practice for the purpose of diagnosis.
REMEMBER: The police quote you.
Rev. 8/1/07
23
T R A U M A
H A N D B O O K
Maintaining the Chain of Evidence in Trauma/Criminal
Cases
•
•
•
•
•
Clothing, including shoes, should be placed in a paper bag, labeled with the patient’s
address-o-graph label and given to the investigating police department. Record
name and badge number as well as the department of the officer.
Money and valuables may be given to the family or locked up in the safe unless a
bullet/knife penetrated the money-then it goes to the ME once the case is accepted.
Do not cut through bullet/stab wounds if possible.
Do not cut through bullet or stab holes in clothing.
If a specimen related to an act of violence or criminal investigation (e.g. bullet) is
ever removed on the floor, the doctor is to place the specimen in a labeled plastic
container and then the specimen is to be walked to pathology to maintain the chain
of evidence. This chain of evidence should be documented in the medical record.
Once the patient is pronounced:
1. NO PROCEDURES CAN BE DONE ON THE PATIENT.
2. One to two large sutures may be placed to close large incisions (i.e., open
thoracotomy).
3. Do not remove or reposition any tubes or catheters
4. Do not wash/clean up the patient.
5. Family members may see the patient but may not touch him/her as they may
transfer/effect evidence. They may not be left alone with the body.
6. Clothing and valuables (including money) become the property of the ME’s
office and must be turned over to them. They accompany the body and must
be in a paper bag labeled as above. Weapons such as guns and knives should
be given to the police for Security reasons with documentation as to the police
officer who took them.
7. Call the ME’s office (222-5500) for specific questions.
Rev. 8/1/07
24
T R A U M A
H A N D B O O K
ED Thoracotomy
Emergency department thoracotomy (EDT) was introduced in 1966 as a life-saving
measure for patients with thoracic injuries. Since then, multiple critical analyses of EDT
have prompted a more selective application of the procedure. Survival with intact neurologic status (meaningful survival) should be the goal of EDT.
Selective Approach
In deciding whether to perform EDT, the following variables should be considered:
Mechanism of injury (blunt vs. gunshot vs. stab); vital signs*, and signs of life** at the
scene and on presentation to the ED. The same criteria for performing EDT should apply
to children, as their survival closely parallels that of adults. The elderly may be a special
population group. In several large series of EDT there are no meaningful survivors over
the age of 65. EDT should be used in the over 65 population in only the most favorable
circumstances. EDT is most productive for life-threatening penetrating cardiac wounds,
especially pericardial tamponade. Outcomes for EDT are shown in the following table:
ED:
No sign of life
ED:
Signs of life,
No vital signs
ED:
Vital signs
BLUNT
1%
1%
3%
GSW
1%
3-5%
10-15%
STAB
3-5%
10-15%
30-40%
1/3 of survivors severely
neurologically impaired
< 1/10 of survivors
neurologically impaired
The major goals and potential therapeutic maneuvers of EDT are as follows: release
pericardial tamponade; control cardiac and/or great vessel bleeding; control bronchovenous air embolism; perform open cardiac massage; redistribute blood to myocardium
and brain, and limit sub-diaphragmatic hemorrhage via aortic cross-clamping.
Technique
EDT is performed through a left anterolateral incision at the level of the fifth intercostal
space, or inferior border of the pectoralis major muscle. The skin, subcutaneous tissue,
and chest wall musculature should be incised with one knife pass. The intercostal
muscles and pleura should then be incised with heavy Mayo scissors along the superior
margin of the rib. A rib spreader is inserted with the handle toward the axilla. The
pericardium is opened with a longitudinal incision anterior to the phrenic nerve. Any
blood or clot should be evacuated, and attempts made to control cardiac bleeding with
sutures (pledgets used in the RV). Transsternal extension into the right chest
(“clamshell” incision) may be helpful in exposing the heart for repair. Open cardiac
massage can then be performed. Air embolism or massive bleeding from the lung is
controlled with a clamp across the pulmonary hilum. The thoracic aorta is visualized by
elevating the left lung anteriorly and superiorly. The aorta is differentiated from the
esophagus by palpating the nasogastric tube, and a vascular clamp is placed across the
aorta.
25
T R A U M A
H A N D B O O K
Risks to Trauma Team
ED thoracotomy involves the use of sharp instruments and contact with the patient’s
blood in an often-chaotic atmosphere. In urban trauma populations, the rate of HIV and
hepatitis B and C infection range from ten to twenty times that of the general population.
This rate may be even higher in the population most likely to require ED thoracotomy,
making universal precautions and selective use of the procedure essential.
1.
2.
3.
4.
5.
6.
7.
Baxter BT, Moore EE, Moore JB, et al. Emergency department thoracotomy following injury: critical
determinants of patient salvage. World J. Surg 1988;12:671-675.
Beaver BL, Columbani PM, Buck JR, et al. Efficacy of emergency room thoracotomy in pediatric trauma. J.
Pediatric Surg 1987;22:19-23.
Biffl WL, Moore EE, Johnson JL. Emergency department thoracotomy. In Feliciano, Mattox, Moore (eds),
Trauma, 5th ed., 2004.
Branney SW, Moore EE, Feldhaus KM, et al. Critical analysis of two decades of experience with postinjury
emergency department thoracotomy in a regional trauma center. J Trauma 1998;45:87-94.
Kelen GD, DiGiovanna T, Bisson L, et al. Human immunodeficiency virus infection in emergency
department patients: epidemiology, clinical presentations, and risk to health care workers: the John’s
Hopkins experience. JAMA 1989;262:516-522.
Rothenberg SS, Moore EE, Moore FA, et al. Emergency department thoracotomy in children— a critical
analysis. J Trauma 1989;29:1322-1325.
Sloan EP, McGill BA, Zalenski R, et al. Human immunodeficiency virus and hepatitis virus seroprevalence
in an urban trauma population. J Trauma 1995;38:736-741.
Rev. 8/1/07
26
T R A U M A
H A N D B O O K
Prediction and Management of the Difficult Airway
The incidence of difficult airway has not been clearly delineated in the trauma population; however, up to 1% of trauma patients requiring intubation require a surgical
airway and may require more than one attempt before a successful airway is secured.
It is imperative that the trauma physician be able to identify patients with potentially
difficult airways, and understand how best to manage them.
Assessment: Up to 5% of the population may be difficult to oxygenate via bag valve
mask (BVM) – these patients should undergo rapid sequence induction only when
absolutely necessary. Risk factors that predict that a patient will be “difficult to bag”
include:
•
BMI >26 kg/m2
•
Absent teeth
•
Presence of a beard
•
Age >55 years
Prior to attempting endotracheal intubation, one should examine the patient’s mouth
opening, dentition, thyromental distance, and tongue size. Factors associated with
difficult intubation include:
•
•
•
•
•
•
•
Massive facial or neck trauma
Receding mandible (<3 finger-breadths from mandibular
symphysis to hyoid bone)
Short, thick neck (<3 finger-breadths from sternal notch to
thyroid cartilage)
Narrow mouth opening
Large or immobile tongue
Immobilized cervical spine
Inspiratory stridor suggesting upper airway compromise
Management: Failed intubation in a patient that has also failed BVM requires a prompt
surgical airway. Laryngeal mask airway (LMA), or transtracheal jet ventilation (TTJV)
are temporary measures that may serve as a bridge to creation of a definitive airway.
LMA—Size 4 is used for adults <70kg, and size 5 for >70kg. The LMA rests in the
hypopharynx over the laryngeal opening, and does not require visualization of the
cords. Supraglottic pathology may preclude placement. The LMA does not separate
the respiratory and alimentary tracts, and thus carries a risk of aspiration, particularly in
pregnant or obese patients. LMA is unreliable at delivering high pulmonary pressures,
and ventilation may be compromised.
TTJV—requires placement of a 12-16 gauge catheter through the cricothyroid membrane
and attachment to a high pressure (50psi) oxygen source. One-second inspiratory time
followed by 4 seconds for exhalation should be given.
Cricothyroidotomy—Definitive airway (does not mandate conversion to tracheostomy)
using a 6-mm cuffed ETT or a 4-6 tracheostomy tube. Pediatric patients (<12 years old),
or patients with a laryngeal fracture should undergo tracheostomy.
27
T R A U M A
1.
2.
3.
4.
5.
H A N D B O O K
Blanda M, Gallo UE. Emergency Airway Management. Emerg Med Clin North Am. 2003 Feb; 21(1): 1-26.
Pollack CV. The laryngeal mask airway: a comprehensive review for the emergency physician. J Emerg
Med. 2001 Jan; 20(1): 53-66.
Butler KH, Clyne B. Management of the difficult airway: alternative airway techniques and adjuncts. Emerg
Med Clin North Am. 2003 May; 21(2): 259-89.
Wright MJ, Greenberg DE, Hunt JP, et al. Surgical cricothyroidotomy in trauma patients. South Med J. 2003
May; 96(5): 465-7.
Jagminas L, Auerbach PS, Cioffi WG. Airway management in the trauma patient. In Cameron, Current
Surgical Therapy, ed. 7, St. Louis: Mosby, 2001: 1032-42.
Rev. 8/1/07
28
T R A U M A
H A N D B O O K
Rapid Sequence Induction: Adult
1.
Assemble staff, i.e., ED attending, nurse, and respiratory therapist.
2.
Continuous monitoring of BP, ECG, SaO2.
3.
Consult Anesthesiology if airway problems anticipated (i.e., short neck, facial
trauma, suspicion of c-spine fracture).
Prepare equipment (suction, ETT with syringe, end-tidal CO2 device, stylet,
laryngoscope, ambu bag, mask, oral/nasal airways).
Examine airway, check anatomy (be ready to hand ventilate patient if airway
problem).
Pre-oxygenate patient with 100% O2. Bag mask ventilation PRN.
Consider Lidocaine 1 mg/kg IV push (preferably 1-2 minutes before induction) in
the setting of suspected elevated intracranial pressure.
Inducing agent: Thiopental 2-3 mg/kg IV or Etomidate 0.3 mg/kg IV.
Have 1 mg Atropine at bedside (to reverse bradycardia).
Apply cricoid pressure.
Paralyzing dose of Succinylcholine 1.5 mg/kg IV or Rocuronium 0.9 mg/kg IV (in
patients with suspected head injury).
Wait until full paralysis (60 seconds). Check eyelid/jaw.
Inline cervical immobilization of potential C-spine injury.
Intubate orally.
Confirm ETT position with end tidal CO2 monitor.
Release cricoid pressure after balloon is inflated.
Consult Anesthesiology if airway problems.
Consider long-term paralysis with Pavulon 0.1 mg/kg IV along with longer acting
sedative such as lorazepam (Ativan) 0.5-2 mg/IV.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
*Avoid succinylcholine if > 24 hours post burn, > 7 days post crush, hyperkalemia,
penetrating eye injuries, CVA, rhabdomyolysis, neuromuscular disease, or family
history of malignant hyperthermia.
Rev. 8/1/07
29
T R A U M A
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Rapid Sequence Induction: Pediatric
1.
Assemble staff, i.e., ED attending, nurse, and respiratory therapist.
2.
Continuous monitoring of BP (rapid cycling), EKG, pulse oximetry.
3.
Consult Anesthesiology if airway problems anticipated (i.e., short neck, facial
trauma, high index of C-spine fracture).
4.
Prepare and assemble equipment:
• Tonsil tip/Yankauer suction
• ETT-appropriate suction catheter
• 2 suction systems at head
• Range of ETT sizes and stylet, ETT size = (age in years/4) + 4, and 1 larger
and smaller ETT
• Consider cuffed ETT even in infants
• Laryngoscope and light
• Bag-valve mask and range of mask sizes
• Oral airway (length = angle of mandible to corner of mouth)
• Syringe (to inflate ETT cuff)
• Tape
• End-tidal CO2 device (capnograph or easy cap)
5.
Evaluate airway: Facial, cervical, laryngeal trauma/congenital anomalies. Consult
anesthesiologist and/or surgeon (cricothyroidotomy) PRN.
6.
Pre-oxygenate patient with 100% O2. Assess chest rise. If patient is not breathing
spontaneously: cricoid pressure and bag mask ventilation.
7.
Evaluate and establish intravenous access.
8.
Have Atropine available (to reverse bradycardia).
9.
Maintain in-line C-spine immobilization.
30
T R A U M A
H A N D B O O K
10. Sedation and muscle relaxation: Administer in rapid succession one drug from each
category:
Category
Vagolytic
Drug
Dose
0.02 mg/kg IV
• Atropine
Comments
• Minimum dose: 0.1 mg
• Consider in patients <8
years old to block
laryngoscopy induced
bradycardia
Intracranial
Antihypertensive
• Lidocaine
1 mg/kg IV push • Give when increased
ICP is known or
suspected
Sedative
• Midazolam
0.1-0.4 mg/kg IV • Less CV effects than
thiopental, titrate dose
effect (doses > 0.3 mg/kg
needed for anesthesia)
0.3 mg/kg IV
• Decreases ICP,
essentially no CV effects
1-2 mg/kg IV
• Bronchodilator but
increases ICP, BP and
HR
1-2 mg/kg IV
• Decreases ICP but may
decrease BP and HR
• Etomidate
• Ketamine
• Thiopental
Paralytic
• Rocuronium
1 mg/kg IV
• Succinylcholine 1-2 mg/kg IV
• May have slower onset
of action (30-90 vs 30-60
seconds) and is longer
acting (28-60 vs 3-*12
minutes) than
succinylcholine
• Contraindications:
glaucoma, penetrating
eye injuries,
neuromuscular disease,
FHx malignant
hyperthermia or
pseudocholinesterase
deficiency, patients with
sever burns, crush
injuries, or hyperkalemia
11. Maintain cricoid pressure. Await full paralysis (check eyelid reflex, jaw).
12. Intubate orally. Depth of intubation: age (years) / 2 + 12 or 3 x ETT size.
13. Confirm ETT placement with end-tidal CO2 device (capnograph or easy cap),
auscultation, and if time permits, a CXR.
14. If unsuccessful and O2 saturation <90%, remove ETT and mask ventilate. Return
to #6.
Rev. 8/1/07
31
T R A U M A
H A N D B O O K
Intravenous Access and the Trauma Patient
Attention to detail is the hallmark of excellent surgical care, whether it takes place in the
emergency department (ED), operating room (OR), intensive care unit (ICU), or ward.
This attention to detail extends to seemingly trivial matters including intravenous (IV)
access. 100% of trauma patients undergo placement of an IV catheter, with many
receiving central venous lines. Unfortunately, IV access related complications are
common and by and large are preventable. The following recommendations should be
observed in order to minimize line-related complications and decrease the risk of
superficial thrombophlebitis, cellulitis, catheter-related bloodstream infections, sepsis
and septic shock, DVT/PE and death.
1.
2.
3.
4.
5.
All lines placed in the field, ED or OR are considered suspect and should be
replaced as soon as feasible. Exceptions include central lines placed utilizing
full barrier precautions (see below).
The preferred site of central access in an unstable (hemodynamically abnormal)
trauma patient is the femoral vein, while the preferred site in a stable (hemodynamically normal) patient is the subclavian vein.1-2
a. In the acute setting large-bore IV access above AND below the
diaphragm is desirable. Large-bore (14 or 16 gauge) peripheral IV
cannulas are recommended for upper access.
b. Femoral access should be utilized with caution in unstable patients
with severe pelvic fractures or likely vena caval injuries.
c. Patients with suspected cardiogenic shock or in need of central
venous pressure monitoring should have a subclavian or internal
jugular venous central line placed.
ALL central lines should be placed under “full barrier precautions” defined
as sterile gown and gloves, cap and mask, and FULL draping (3/4 sheet, lap
drape, etc). Chlorhexidine is the preferred prep agent and is available as a
ChloraPrep® stick on most central line kits. Cap and masks are recommended
for those nearby (i.e. bedside RN), while full barrier precautions should be
observed by those assisting.1-3
All TICU patients who have a central line placed should have ALL peripheral
IV cannulas removed in order to decrease the incidence of thrombophlebitis as
well as “save” the veins for IV insertion upon transfer from the TICU so that
central venous access can be discontinued in floor-level care patients.
Central lines should be dressed with clear adhesive dressings unless the site is
bleeding, or the patient is diaphoretic, in which the preferred dressing is sterile
gauze. Chlorhexidine-impregnated disks have been shown to reduce line
infections threefold in a PRCT.3
1. Mermel LA, et al. Am J Med 1991, 91:197S-205S.
2. Goetz AM, et al. Infect Control Hosp Epidemiol 1998, 16:842-5.
3. www.CDC.gov/mmwr/PDF/rr/rr5110.pdf
Rev. 8/1/07
32
T R A U M A
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Resuscitation Guidelines
The traditional endpoints of resuscitation include normal blood pressure, heart rate and urine
output. However, after normalizing these parameters, up to 85% of severely injured trauma
patients still have evidence of inadequate tissue perfusion. This condition is described as
“compensated shock”.1 The initial base deficit (BD) and serum lactate (LA) are reliable
indicators of the need for ongoing resuscitation.2,3 Furthermore, the time to normalization of
these parameters is predictive of multiple organ failure (MOF) and survival. Consequently,
expeditious evaluation of life and limb threatening injuries and early aggressive resuscitation
are warranted. In addition to hemodynamic compromise, other factors that have been identified as independent predictors of MOF are age > 55 years, injury severity score (ISS) >25 and
transfusion of more than 6U of red blood cells in the first 12 hours.4,5 High-risk patients are
defined as follows:
ISS>25
High-Risk
Transfusion >6U in 12 hours
Age>55 and ISS>15
Age>70 and ISS>9
High-risk patients should have an arterial blood gas and lactate level measured early during
their ED course. These high-risk patients should be “fast-tracked” through the ED and brought
up to the TICU as soon as possible. Non-essential imaging should not delay this process.
If patient is not responding to intervention consultation with trauma attending is imperative. Keep in
mind that over-aggressive resuscitation may be associated with morbidity.6
1. Scalea TM, Maltzs, Yelon J, et al. Resuscitation of multiple trauma and head injury: role of crystalloid fluids and
inotropes. Crit Care Med 1994:20:1610-1614.
2. Rutherford EJ, Morris JA, Reed GW, et al. Base deficit stratifies mortality and determines therapy. J Trauma 1992;
33:417-423.
3. Davis JW, Parks SN, Kaups KL, et al. Admission base deficit predicts transfusion requirements and the risk of
complications. J Trauma 1996;41:769-774.
4. Sauaia Am Moore FA, Moore EE, et al. Early predictors of postinjury multiple organ failure. Arch Surg 1994;129:39-45.
5. McKinley BA, Kozar RA, Cocanour CS, et al. Normal versus supranormal oxygen delivery goals in shock resuscitation:
the response is the same. J Trauma 2002;53:825-832.
6. Balogh Z, McKinley BA, Cocanour CS, et al. Supranormal trauma resuscitation causes more cases of abdominal
compartment syndrome. Arch Surg 2003;138:637-643.
Rev. 8/1/07
33
T R A U M A
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Hypothermia: Pediatric and Adult
1.
Hypothermia Protocol
The severity and treatment of hypothermia depends on core body temperature,
cardiac rhythm and associated injuries.
Moderate, severe or extreme hypothermia (≤ 32° C, or 90° F) by rectal or vesical
thermistor bladder catheter, and confirmed esophageally (core temperature); or any
hypothermia with cardiac arrest should prompt activation of hypothermia protocol:
•
•
2.
3.
Definitions of Hypothermia
Mild
32 - 35° C
90 - 95° F
Moderate
Severe
Extreme
82 - 90 ° F
77 - 82° F
< 77° F
28 - 32° C
25 - 28° C
< 25° C
Core Rewarming
a. Indications
•
Moderate hypothermia (28 - 32° C) with any perfusing cardiac rhythm
or
•
Severe hypothermia (25 - 28° C) with stable cardiac rhythm*
b.
4.
Notify Trauma Team/Pediatric Surgery Service (Code Yellow Level I)
ED physician notifies O.R. desk to activate bypass protocol: operating room
set-up, cardiac anesthesiologist, perfusion team and cardiac/bypass surgeon
Initial Management
•
CBC, serum glucose + electrolytes + BUN/Crea + Ammonia, PT/PTT,
Fibrinogen, ABG, T&C for 2 U of PRBC
•
Temperature monitoring by esophageal and bladder thermometers
•
Ambient temperature at 32° C (90° F)
•
Contact rewarming (Bair Hugger® )
•
Warmed humidified oxygen by mask (40° C) or ET tube (40 - 50° C)
•
Intravenous fluids: 40° C by Level l re-warmer
•
Nasogastric tube; lavage with NS at 40° C
•
Bladder catheter; lavage with NS at 40° C
•
Allow dwell times of 5-10 minutes to maximize heat exchange during
lavage
•
If rewarming < 1° C/15 minutes: add (choice and order at discretion of
ED/Trauma team)
•
Peritoneal lavage with NS at 40° C
•
Bilateral tube thoracostomy and pleural lavage with NS at 40° C
Cardiopulmonary Bypass Rewarming
a. Indications
•
Moderate (28 - 32° C) or severe (25 - 28° C) hypothermia, with cardiac
arrest or unstable cardiac rhythm*
•
Extreme hypothermia (< 25° C)
34
T R A U M A
•
H A N D B O O K
Moderate or severe hypothermia, managed with core rewarming, who
develops cardiac arrest or who remains hypothermic and fails to regain
stable cardiac rhythm* and adequate perfusion after 30 minutes of core
rewarming.
b.
Exclusion from Cardiopulmonary Bypass
Only at the discretion of the Trauma team and Bypass team, such as
•
Severe injury not compatible with life
•
Immobile frozen body
c.
Initial Management
•
The treatment of choice in these select patients is cardiac bypass.
•
CPR
•
Do not delay bypass to attempt core rewarming in ED
•
ED rewarming continues until OR is ready for patient
•
Full volume resuscitation
•
CBC, serum glucose + electrolytes + BUN/Crea + Ammonia, PT/PTT,
Fibrinogen, ABG, T&C for 2 U of PRBC
•
Nasogastric tube, bladder catheter
•
Arterial line
•
Temperature monitoring by esophageal and bladder thermometers
•
Transfer to OR/bypass ASAP
•
Full systemic anticoagulation to maintain activated clotting time at 450480 sec, unless absolute contraindication (severe associated trauma) - at
discretion of the bypass team
•
Intravenous antibiotics: e.g., Cefazolin
•
Patient < 20 kg: consider immediate median sternotomy and central
(atrial-aortic) bypass
•
Patient > 20 kg: Cannulation of femoral artery and vein - cannulas
appropriate for patient size
•
Median sternotomy and atrial-aortic bypass if inadequate rewarming or
flow, cardiac arrest, or at discretion of bypass team
•
Rewarming rate: 0.5-1.0° C/minute
.
d.
Bypass termination when:
• Core temp > 37° C and spontaneous-stable cardiac rhythm and weanable
to mechanical respirator
• Severe injury incompatible with life (pronounce dead)
• Failure to wean from bypass (pronounce dead)
*Bradycardia alone does not constitute an unstable cardiac rhythm in hypothermic patients.
Rev. 7/20/07
35
T R A U M A
H A N D B O O K
Severe Head Injury (GCS 3-8)
Trauma causes 150,000 deaths in the United States each year, about half due to fatal
head injuries. Not all neurologic damage occurs at the moment of injury; further injury
can occur over the ensuing hours and days. Early goals of therapy are to evacuate
surgically correctable intracranial mass lesions and avoid secondary brain injury by
protecting brain perfusion by meticulous critical care. Patients should be evaluated,
resuscitated and treated according to ATLS guidelines (1o and 2o survey). A majority
of patients with severe closed head injury can be managed with relatively simple, but
meticulous care. They will be referred to as 1st Tier Therapies (Table). Patients with
more severe injury need more aggressive therapy. This will be called 2nd Tier Therapies.
(Figure) In patients who are not responding to therapy, repeat CT scans early can be
considered to detect delayed/ undiagnosed or evolving injury. Status epilepticus and
need for EEG should also be considered.
Table: 1st Tier Therapy for Closed Head Injury
•
Endotracheal Intubation / Mechanical Ventilation. Target SaO2 > 90%,
PaCO2 35-40 mmHg*
•
Euvolemic Resuscitation – consider CVP / PA Catheter
•
ICP Monitoring – EVD for drainage#
•
Seizure Prophylaxis (Phenytoin 1g load, 300 mg/day x 7 days)
•
Normothermia
•
Euglycemia
•
Stress ulcer, DVT prophylaxis
•
Short-acting sedatives / analgesics
•
Head of bed 30o
* There is no role for prophylactic or prolonged hyperventilation to decrease ICP.
Temporary hyperventilation may be considered in acute neurologic deterioration.
#
Some patients with a GCS < 8 may not need an EVD. Young (age < 40), hemodynamically stable (SBP > 90) patients with normal CT scans on admission can be
observed and followed clinically without an EVD.
36
T R A U M A
H A N D B O O K
Figure: 2nd Tier Therapy
1.
2.
3.
4.
5.
6.
7.
8.
Brain Trauma Foundation, American Association of Neurological Surgeons, Joint Section on Neurotrauma
and Critical Care: Guidelines for the management of severe head injury. J Neurotrauma 1996;13:641-734.
Muizelaar JP, Marmaron A, Ward JD, et al. Adverse effects of prolonged hyperventilation in patients with
severe head injury; a randomized clinical trial. J Neurosurgery 1991;75:731-739.
Temkin NR, Dikmen SS, Wilensky AT, et al. A randomized, double blind study of phenytoin for the
prevention of post-traumatic seizures. N Engl J Med 1990;323:497-502.
Doyle JA, Davis DP, Hoyt DB. The use of hypertonic saline in the treatment of traumatic brain injury. J
Trauma 2001;50:367-383.
Clifton GL, Miller ER, Choi SC. Lack of effect of induction of hypothermia after acute brain injury. N Engl
J Med. 2001;344:556-63.
Rosner MJ, Rosner SD, Johnson AH. Cerebral perfusion pressure: management protocol and clinical results.
J Neurosurg. 1995;83:949-62.
Robertson CS. Management of cerebral perfusion pressure after traumatic brain injury. Anesthesiology
2001;1995:1513-7.
Whitfield PC, Patel H. Bifrontal decompressive craniectomy in the management of posttraumatic intracranial
hypertension. Br J Neurosurg 2001;15:500-7.
Rev. 7/20/07
37
T R A U M A
H A N D B O O K
Pediatric Severe Head Injury
38
T R A U M A
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References
1. Guidelines for the acute medical management of severe traumatic brain injury in infants, children
and adolescents. Chapter 17. Critical pathway for the treatment of established intracranial
hypertension in pediatric traumatic brain injury. J Trauma 2003;54:S300-S302.
Rev. 8/10/07
39
T R A U M A
H A N D B O O K
Reversal of Anticoagulation in Patients with
Intracranial or Spinal Bleeding
In an effort to streamline emergency care of patients with neuro trauma who are on
wafarin (Coumadin®) and antiplatelet agents, the following guidelines should be
followed in the Emergency Department.
1.
2.
3.
4.
Neurosurgery or Spine should be informed of all CT scans demonstrating
intracranial or spinal trauma in patients taking warfarin or antiplatelet agents.
A STAT CBC, type and screen, and coagulation profile should be obtained.
For patients who are taking warfarin (Coumadin®):
a. The blood bank should be contacted and two units of AB FFP should
be requested utilizing the “Trauma AB plasma protocol” and the
Emergency Release Form for Blood and Blood Components should
be completed.
b. The two units of “Trauma” FFP should be available for pick up in
about 15-minutes.
c. Additional type specific FFP should be ordered and transfused at
a dose of 15mL/kg (less the volume of the two Trauma AB units).
This infusion should take no more than 1 hour.
1. Watch for pulmonary edema with the administration
of large volumes of FFP.
d. Vitamin K 10mg i.v. should be administered as soon as possible.
e. At the completion of the FFP infusion, repeat a STAT coagulation
profile and calcium level.
For patients who are on antiplatelet agents:
a. A 5-pack of platelets should be requested from the blood bank and
administered as soon as possible regardless of the measured platelet
count. These agents induce thrombasthenia which is a functional
platelet defect NOT reflected by the platelet count!
b. Due to the long half-life of clopidogrel it may be necessary to give
additional platelets in 1-2 hours for those patients undergoing
invasive procedures.
c. Repeat platelet counts are not helpful but a bleeding time determination may be considered if ongoing platelet dysfunction is
suspected.
n.b. Recombinant Activated Human Factor VII (NovoSeven®) should be considered
for use in the setting of severe coagulopathy and evolving neurological deficits that may
require surgical intervention. Consult with Trauma Attending and Neurosurgery/Spine
service prior to use. NovoSeven® doses of 20-40mcg/kg have been reported in the
literature for the reversal of anticoagulation in patients with neurotrauma1-2.
1.
2.
Sorensen B, Johansen P, Nielsen GL, et al. Blood Coagut Fibrinolysis 2003, 14:469-477
Lin J, Hanigan WC, Tarantino M, et al. J Neurosurg 2003, 98:737-740
Rev. 7/20/07
40
T R A U M A
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C-Spine Evaluations in Adult Trauma Patients
The rate of missed cervical spine injuries with plain films alone is unacceptably high1,
thus the imaging study of choice in blunt trauma patients should be CT imaging.
Initial evaluation of the patient will place the patient in one of three categories:
1) Awake and able to cooperate with physical examination.
Assess for one of the following (NEXUS Criteria2)
a) Examine for midline neck tenderness.
b) Focal neurological deficit.
c) Distracting injury.
d) Intoxication with drugs or alcohol.
e) Central neurological deficit defined as GCS <15.
•
•
•
•
If none of the above is present – Clinical examination is acceptable.
Examine for midline tenderness – If present, obtain CT scan cervical spine.
If patient is non-tender then passive flexion-extension, rotation & axial loading
should be performed. If the patient remains without pain, and without focal
neurological deficit then the cervical spine is deemed cleared and the collar
may be removed. Exam findings, date, and time should be documented in the
medical record.
If any one or more of the above is present – Proceed to CT scan imaging of the
cervical spine.
2) Non-Obtunded but with obvious distracting injury or alteration in cognition
•
A distracting injury has been defined as any injury to the head, neck, chest or
upper extremity, or an injury that is so painful that it requires such doses of
analgesics that the patient is unable to co-operate with a clinical examination3.
•
An alteration in cognition is defined at a GCS <15.
•
In either case – CT of the cervical spine.
3) Obtunded patient
•
CT scan of complete Spine – Cervical, thoracic, lumbar and sacral with
reconstruction.
•
If there is absolutely no evidence of bony injury or mal-alignment of the
cervical spine on CT scan – Remove the collar.
•
If there is any anomaly on the CT scan – Consult spine services.
o If ligamentous injury is suspected, the spine service may request a
cervical MRI or perform passive real-time flexion-extension imaging
at their discretion. The collar should remain in place until the spine
consultant documents that it may be removed.
Note – This is a protocol and deviations from the above including obtaining plain films,
flexion-extension or MRI, may be undertaken at the discretion of the Trauma attending or
spine surgeon.
DISCUSSION
Role of plain film radiography
Plain films are reported to miss 55% of clinically significant cervical spine fractures
when compared with multi-slice CT scan imaging1. Up to one third of patients with an
41
T R A U M A
H A N D B O O K
injury on plain films will have a second cervical spine injury detected by CT scan but
missed by plain films.
CT Versus MRI
The concern for cervical ligamentous injury arose from a finding of cervical spine
instability seen on flexion-extension views in 0.1-0.5% of patients who had normal plain
films4. This was compounded by studies which relied on older generation CT scans. A
multi-slice CT scan with reconstructions that shows no fractures obviates the need for
MRI scanning. In general, the most common ligamentous injury discovered by MRI in
comatose patients with a normal CT scan is a single column posterior ligamentous
complex disruption, which is clinically insignificant and doesn’t require operative
intervention.
Mucha advocated for the use of MRI as the “gold standard”5, however many problems
exist with this study since the meta-analysis included only 5 studies, who were CT
scanned before the advent of multi-slice CT scanning or underwent plain films alone.
Two of the studies were from the same institution with overlapping patients. Thus it is
erroneous to conclude that MRI is the gold standard for trauma patients with a potential
cervical spine injury.
Tomycz6 reported a 4 year experience of 690 CT and MRIs in blunt trauma patients and
found no significant injury by MRI when the CT scan was normal. They concluded that
MRI does not add any clinical value in the setting of a normal CT scan. Schuster also
found that MRI revealed no occult unstable injuries when the CT scan was normal,
including 12 comatose patients who were moving all four extremities on arrival. Hogan
found seven acute injuries on MRI that were missed by CT, however none of the injuries
were deemed unstable7. Most recently, Como reported that C-spine MRI, did not change
management or reveal findings requiring continued collar immobilization in the setting of
a normal cervical CT scan8. Stelfox also reported no missed injuries with a helical CT
scan when compared to MRI and CT scan, as long as the helical CT scan didn’t suggest
an abnormality9. Keeping patients in collars awaiting MRI has been associated with
increased morbidity, including pressure sore from the collar (6.8%) and higher rate of
delirium (49% versus 27% p=0.03).
Soft Collars – There is little role for the use of a soft collars at any time during the
patient’s work-up or treatment, whether an injury has been identified or not.
1. Mathen R, Inaba K, Munera F, et al. Prospective evaluation of multi-slice computed tomography versus plain radiographic cervical spine clearance in trauma patients. Journal of Trauma 2007;62(6):1427-31.
2. Hoffman J, Mower W, Wolfson A, Todd K, Zucker M, NEXUS. Validity of a set of clinical criteria to rule out injury to
the cervical spine in patients with blunt trauma. New England Journal of Medicine 2000;343:94-9.
3. Heffernan D, Schermer C, Lu S. What defines a distracting injury in cervical spine assessment? Journal of Trauma
2005;59(6):1396-9.
4. David J, Kaups K, Cunningham M, et al. Routine evaluation of the cervical spine in head-injured patients with dynamic
fluoroscopy: A reappraisal. Journal of Trauma 2001;50(6):1044-7.
5. Muchow R, Resnick D, Abdel M, Munoz A, Anderson P. Magnetic resonance imaging (MRI) in the clearance of the
cervical spine in blunt trauma: A meta-analysis. Journal of Trauma 2008;64(1):179-89.
6. Tomycz N, Chew B, Chang Y-F, et al. MRI is unnecessary to clear the cervical spine in Obtunded/Comatose trauma
patients: The four year experience of a level 1 trauma center. Journal of Trauma 2008;64(5):1258-63.
7. Hogan G, Mirvis S, Shanmuganathan K, Scalea T. Exclusion of unstable cervical spine injury in obtunded patients with
blunt trauma: Is MR imaging needed when multi-detector row CT findings are normal Radiology;237(1):106-13.
8. Como J, Thompson M, Anderson J, et al. Is magnetic resonance imaging essential in clearing the cervical spine in
obtunded patients with blunt trauma? Journal of Trauma 2007;63(3):544-9.
9. Stelfox H, Velmahos G, Gettings E, Bigatello L, Schmidt U. Computed tomography for early and safe discontinuation of
cervical spine immobilization in obtunded multiply injured patients. Journal of Trauma 2007;63(3):630-6.
Rev. 6/20/08
42
T R A U M A
H A N D B O O K
C-Spine Clearance: Pediatric
During the initial evaluation of an emergency department patient by the treating physician,
he/she will be placed into one of three categories regarding probability of an injury to the
cervical spine. Radiographic evaluation alone is not sufficient to determine if a child has a
cervical spine injury. This categorization will be determined by a careful history and physical
exam rather than whether or not the patient arrives with cervical immobilization. If there is
any question, it is best to err toward the more severe category. Cervical spine risk categorization and ordering of spine x-rays may only be done by a physician. PGY 3, more senior
Surgery resident, ED resident, Surgery Attending or ED Attending must verify placement in
Category III.
Category I
A neck injury sufficient to cause a spinal injury may have occurred.
Example: A patient with impaired consciousness or communication, involved in a motor
vehicle crash or fall, with evident head trauma, multiple injuries, complaints of severe neck
pain, or any neurologic deficit.
Category II
There is a history of neck injury, but with a mechanism unlikely to result in an unstable
cervical spine injury. Some complaints or physical findings may be present.
Example: An alert, cooperative individual with some pain on motion, spasm, and/or
tenderness, but no neurologic findings.
Category III
No history, mechanism of injury or physical finding suggests a cervical spine injury.
Example: The patient is alert, has no complaint of neck pain, no tenderness, no head or facial
injury or other distracting injuries, and demonstrates a full, pain-free range of neck motion.
Procedure
The cervical spine must be evaluated first for all patients.
If the patient falls into Category II or III, the physical exam should be continued to evaluate
the thoracic and lumbar spines before x-rays are obtained. Patients placed in Category I will
have initial cervical spine x-rays taken and will be evaluated before x-ray examination of the
thoracic and lumbar spines. Remember: In children under 2 years of age, physical exam is
unreliable. Therefore, a high index of suspicion is necessary (e.g., mechanism of injury).
Also, incidence of spinal cord injury without radiographic abnormality (“SCIWORA”) is
more common in children than in adults.
Category-Based Radiographic Evaluation of the Cervical Spine in Emergency
Patients
Category I
A supine lateral C-spine (with or without swimmer's view, as required to see the cervicothoracic junction), AP, and open mouth view will each be taken while the patient remains
immobilized for children over 5 years of age. For children 5 years of age and under, an
exaggerated waters view film replaces the open-mouth view film. Trauma oblique views,
flexion/extension views, and/or CT scans of areas in question may be obtained at the
discretion of the radiologist or treating physician.
Category II
Patients who arrive with a cervical collar in place and who have no other injuries that prevent
sitting should have an erect lateral c-spine x-ray taken with the collar on. This film must be
evaluated by the PGY 3 or greater emergency or trauma resident, the ED or Surgical attending,
or the Radiology resident followed by supine AP and open mouth views out of the collar.
If the patient arrives without a collar, place the patient in a collar prior to sending to x-ray.
Trauma oblique views, flexion/extension views, and/or CT scans of areas in question may be
obtained at the discretion of the radiologist or treating physician.
43
T R A U M A
H A N D B O O K
Category III
No x-ray of the cervical spine is indicated.
Management
Initial Treatment of Spine-Injured Patients.
Patients who are categorized as I or II will have their initial x-rays evaluated by the radiologist
and treating physician. The decision to discontinue immobilization will be made by the PGY 3
resident or above or the ED attending physician. It will be documented in the notes. If
positive findings are noted, the Spine Service should be notified immediately.
Only a physician can remove cervical collars on pediatric trauma patients. This will
encourage residents to perform a clinical exam at the time of collar removal and it will
eliminate concerns relating to telephone and verbal orders for collar removal to the nursing
staff.
Consultation of Spine Service
There are two arms to the team — a neurosurgical arm and an orthopaedic arm — involved in
the management of pediatric spine injuries. Either the Trauma Service or the Emergency
Department will consult the Spine Service if there is any suspicion of pediatric spine or spinal
cord injury. Every time a consultation is requested for suspected spine injury, the Neurosurgical Service and the Orthopaedic Service will communicate directly with one another in
all cases. These opinions will be given to the leader of the managing team, which in most
cases will be the Trauma Service. These consultations will be rendered within 2-3 hours of
request and will not be delayed beyond that time. It is our intent that all cervical spines that
can be cleared will be done so within 6 hours of presentation to the Emergency Department or
Trauma Service except in comatose patients. Since static plain radiographs may be negative
and flexion/extension x-rays may not be possible, a soft collar may be requested by the treating
physician until the spine can be cleared with flexion/extension x-rays or MRI.
If Neurosurgical and Orthopaedic opinions concur, the treatment plan will be promptly
instituted. If there is a discrepancy between the two opinions, the Neuro-surgical and Orthopaedics teams will resolve the difference. Both teams will follow their internal chains of
command, although complex decisions will often be made at the highest level of the chain.
Because many of these patients will be admitted to the PIC, the Pediatric Intensive Care Team
involved must also be notified of the Spine Service’s opinion. Therefore, it is the responsibility
of the individual consultant teams to not only document in the chart but also to communicate
directly with the trauma team, as well as the PIC staff, when patients are transferred to that
unit.
The Pediatric Spine Service, depending on the constellation of injuries and the best interest of
the patient, will decide subsequent referral of the patient to the Pediatric Neurosurgical or
Pediatric Orthopaedic Service. Both services will continue to see all patients admitted with
spinal injury throughout the period of admission. If spinal surgery is required on any pediatric
patient, it will be performed utilizing a team approach, again with Neurosurgical or Orthopaedic leadership, depending on the needs of the patient.
This Pediatric Spine Service will be responsible for nursing education regarding the management of pediatric spine injury as well as the education of other involved surgical and medical
services.
Rev. 7/20/07
44
T R A U M A
H A N D B O O K
Thoracic / Lumbar / Sacral (TLS) Spine Clearance in
the Trauma Patient
Thoracic spine fractures occur at about the same rate as cervical spine fractures — 2-5%
of the blunt trauma population. While the majority of these patients present with pain
and tenderness, a significant minority (which can approach 20%) do not have associated
pain and tenderness at presentation. This may be due to a decrease in sensorium or
distracting major injuries, which preclude a reliable physical examination. While the vast
majority of patients with vertebral fractures who develop neurologic deficits will have
them at the time of presentation in the trauma room, a few will develop them in a delayed
manner. The purpose of these guidelines is to increase our detection of subtle TLS
fractures and possibly prevent the development of late-onset neurologic sequelae.
All patients with blunt injury should be suspected of having a cervical or thoracic spine
injury. The cervical spine should be cleared according to our established protocol and the
thoracic spine should be cleared as outlined. All patients should be kept on spine
precautions, which include in-line immobilization of the cervical and upper thoracic spine
during any procedures and logrolling. Only after the patient has had an evaluation as
outlined and is without a TLS fracture should spine precautions be discontinued.
1. Cooper C, Dunham CM, Rodriquez A. Falls and major injuries are risk factors for thoracolumbar fractures: Cognitive
impairment and multiple injuries impede the detection of back pain and tenderness. J Trauma 1995;38:692-696.
2. Meldon SW, Moettus LN. Thoracolumbar spine fractures: Clinical presentation and the effect of altered sensorium and
major injury. J Trauma 1995;39:1110-1114.
3. Reid DC, Henderson R, Saboe L, et al. Etiology and clinical course of missed spine fractures. J Trauma 1987;27:980-6.
4. Samuels LE, Kerstein MD. “Routine” radiologic evaluation of the thoracolumbar spine in blunt trauma patients: A
reappraisal. J Trauma 1993;34:85-89.
Rev. 7/20/07
45
T R A U M A
H A N D B O O K
Standard Neurological Classification of Spinal Cord
Injury
MOTOR
R
L
C2
C3
C4
C5
C6
C7
C8
KEY MUSCLES
Elbow flexors
Wrist extensors
Elbow extensors
Finger flexors (distal phalanx of
middle finger)
Finger abductors (little finger)
T1
T2
T3
T4
0 = total paralysis
1 = palpable or visible
contraction
2 = active movement,
gravity eliminated
T5
T6
T7
T8
T9
T10
T11
T12
L1
L2
L3
L4
L5
`S1
S2
S3
S4-5
3 = active movement,
against gravity
4 = active movement,
against some resistance
5 = 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)
MOTOR SCORE
TOTALS
maximum
+
50
=
50
100
American Spinal Injury Association ©1996
Rev. 7/6/07
46
T R A U M A
H A N D B O O K
Penetrating Neck Trauma
The optimal management of penetrating neck injury has been debated for the past 40
years. Early reports, influenced by military experience, recommended a policy of
mandatory neck exploration. Given the anatomical proximity of critical structures in the
neck and the disastrous potential of innocuous appearing injuries, many surgeons adopted
this approach. On the other hand, the policy was questioned in civilian practice, driven by
economic considerations and resistance to “unnecessary surgery” in 40-60% of patients.
Selective management protocols have become widely accepted. Current debate focuses
on the role of ancillary diagnostic tests in selective management protocols as the vast
majority (>95%) of significant injuries are symptomatic.1-4 The debate continues because
there has not been a definitive study proving that one approach is superior or more cost
effective compared with another. The goal of this management guideline is to encourage
timely exploration in symptomatic patients and to obtain appropriate diagnostic studies in
asymptomatic patients. The critical maneuver in the management of these patients is the
physical examination, as all decisions are made based on physical findings. There are
several principles to bear in mind:
1.
2.
3.
4.
5.
Attending presence is required for GSW to the neck (and pediatric SW).
Attending notification is required for SW to the neck.
Penetrating neck wounds should not be probed.
An adequate surgical exploration involves visualizing the wound tract, exploring the
carotid sheath, and fully mobilizing the trachea and esophagus if there are signs of
aerodigestive injury or if the trajectory of the wound is in proximity of these
structures.
The neck is divided into three anatomic zones:
Zone I - (between the clavicle and the cricoid cartilage)
Zone II - (between the cricoid cartilage and angle of the mandible)
Zone III - (above the angle of the mandible)
PHYSICAL EXAMINATION – “Positive” Findings
Vascular Exam:
Aerodigestive Exam:
Active Bleeding
Hemoptysis/Hematemesis
Hypotension
Air Bubbling
Large or expanding Hematoma
Subcutaneous Emphysema
Pulse Deficits – Carotid, Brachial/Radial
Hoarseness
Bruit
Dysphagia
Neurologic Exam:
Localizing Signs: Pupils, Limbs, CN’s
CN’s:
Facial
Glossopharyngeal –midline position of soft palate
Recurrent Laryngeal – hoarseness, ineffective cough
Accessory – shoulder lift
Hypoglossal –midline position of tongue
Horner’s Syndrome – myosis, ptosis
Brachial Plexus:
Median – fist
Radial – wrist extension
Ulnar – abduction/adduction of fingers
Musculocutaneous – forearm flexion
Axillary – arm abduction
47
T R A U M A
H A N D B O O K
Angiography or CTA
Bronchoscopy
Esophagoscopy
Esophagography
1.
2.
3.
4.
Biffl WL, Moore EE, Rehse DH, et al. Selective Management of Penetrating Neck Trauma Based on
Cervical Level of Injury, Am J Surg 1997;174:678-682.
Demetriades D, Theodorou D, Cornwell E, et al. Evaluation of Penetrating Injuries of the Neck: Prospective
Study of 223 Patients, World J Surg 1997;21:41-48.
Gracias VH, Reilly PM, Philpott J, et al. Computed tomography in the evaluation of penetrating neck
trauma: A preliminary study. Arch Surg 2001;136:1231-1235.
Sekharan J, Dennis JW, Veldenz HC, et al. Continued Experience with Physical Examination Alone for
Evaluation and Management of Penetrating Zone 2 Neck Injuries: Results of 145 Cases. J Vasc Surg
2000;32:483-489.
Rev. 7/27/07
48
T R A U M A
H A N D B O O K
Penetrating Injuries to the Heart
Clinical signs of pericardial tamponade in penetrating cardiac injuries are the exception,
rather than the rule.1 Signs are: hypotension, JVD, muffled heart tones, or pulsus
paradoxus.
Pericardiocentesis is unreliable in the acute setting of trauma with a 20% false positive
and 20% false negative rate. The most sensitive test for post-traumatic tamponade is
(subxiphoid) pericardial window. This requires general anesthesia in the operating
room.3 In patients who do not require general anesthesia for surgery following
penetrating trauma, the best non-invasive test for cardiac or pericardial injury is twodimensional echocardiography. This test is both sensitive and specific in the patients
without hemothorax (100%/89%), yet is less accurate in the setting of hemothorax
(56%/93%).4,5
Penetrating cardiac injuries can occur without entrance or exit wounds in the “box”injuries to the heart can occur from a transmediastinal gunshot wound. A small
retrospective study on gunshot wounds reveal that 40% of these patients present in
extremis with decreased blood pressure and require emergency operation, with 1/3 of
these patients having cardiac injury. Approximately 60% of these patients present in
stable condition, but anywhere from 20-50% of these patients have injuries to the heart,
mediastinal vessels, bronchus or esophagus that will present in a delayed fashion.
Evaluation of these injuries requires workup to include echo/pericardial window,
angiogram, bronchoscopy and esophagoscopy / barium swallow.6
Borders of the box are: the suprasternal notch, the nipples, the costal margin.
X = wounds that produce cardiac injuries (Nagy KK, J Trauma 1995)
Rev. 8/1/07
49
T R A U M A
H A N D B O O K
Penetrating chest trauma
NO
YES
Injury within the
“box” (see figure)
YES
Operating room, or
ED thoracotomy
NO
Patients require surgery
(associated trauma)
YES
NO
Subxiphoid window
Blood Present
NO
Echocardiography**
Positive?
NO‡
YES
YES
Admit & observe
Treat hemo-, pneumothorax
R/O other intrathoracic injuries
Median sternotomy
* SBP > 90 in adults (should be adjusted for age)
** Non-availability of 2-D echo warrants consideration of pericardial window.
‡
A negative 2-D is only 60% sensitive in the presence of a pneumo/hemothorax.
Clinical suspicion of cardiac injury despite initially (-) echo should prompt a repeat
echo or pericardial window.
A cardiology fellow is always available in the ED and should be involved for all formal
echoes.
1. Asensio JA, Stewart BM, Murray J, et al. Penetrating cardiac injuries. Surg Clin N Am 1996; 76:685.
2. Moreno C, Moore EE, Majune JA, et al. Pericardial tamponade. A critical determinant for survival following
penetrating cardiac wounds. J Trauma 1994; 36:229.
3. Trinkle JK, Toon R, Franz JL, et al. Affairs of the wounded heart: Penetrating cardiac wounds. J Trauma 1979;
19:467.
4. Meyer D, Jessene M, Grayburn P. Use of echocardiography to detect occult cardiac injury after penetrating
thoracic trauma: A prospective study. J Trauma 1995; 39:902.
5. Nagy KK, Lohmann C, Kim DO, et al. Role of echocardiography in the diagnosis of occult penetrating cardiac
injury. J Trauma 1995; 38:859.
6. Richardson JD, Flint LM, Small MJ, Gray LA, Trinkle JK. Management of transmediastinal gunshot wounds.
Surgery 1981; 90:671-676.
Rev. 8/1/07
50
T R A U M A
H A N D B O O K
Transmediastinal Gunshot Wounds (TMGSW)
Transmediastinal trajectory of a bullet should be considered in the following situations:
1. Entry and exit wounds on opposite sides of the thorax.
2. Single entry wound with x-ray demonstrating a missile on opposite side of the
thoracic cavity or in close proximity to the mediastinum.
3. Multiple gunshot wounds to the thorax.
The mediastinum contains the heart, great vessels, trachea and esophagus as well as
major venous and neural plexuses. Significant injury – especially to heart or great
vessels – often result in prehospital death or hemodynamic instability. There is little
controversy regarding the management of unstable patients – they should have emergent
thoracotomy. However, stable patients could harbor occult injuries to critical mediastinal
structures (heart, great vessels, trachea, esophagus). Consequently, patients have
routinely been submitted to a battery of invasive diagnostic tests: echocardiography or
subxiphoid pericardial window, arch aortography, bronchoscopy, esophagoscopy and/or
esophagography.1 The latter two have been employed together in order to improve upon
the sensitivity of each individual test. This array of tests can be expensive and time
consuming. Furthermore, only a small percentage of hemodynamically stable,
asymptomatic patients have clinically significant injuries.2
Helical CT of the chest has proven useful in demonstrating the trajectory of missiles in
the thorax. 3,4 In the setting of a potential TMGSW, a CT scan may confirm a trajectory
remote from the mediastinum, obviating further testing. On the other hand, proven
transmediastinal trajectory mandates further evaluation. However, rather than
performing all of the aforementioned tests, the investigations may be tailored to the
specific clinical scenario.
Trajectory near the pericardium warrants echocardiography or pericardial window. If CT
suggests aortic injury, or if the trajectory is superior to the arch, arteriography remains the
gold standard (TEE cannot be considered reliable enough). Bronchoscopy is indicated
for pneumomediastinum, respiratory distress or bronchopleural fistula/massive air leak.
Esophagoscopy has been reported to have 100% sensitivity for thoracic esophageal
injuries. 5,6 In an awake, asymptomatic patient, barium esophagography is easier to
obtain and may be adequate by itself. The cervical esophagus most difficult to reliably
evaluate, and so both studies are warranted.
1.
2.
3.
4.
5.
6.
Richardson JD, et al. Management of transmediastinal gunshot wounds. Surgery 1981;90:671.
Renz BM, et al. Transmediastinal gunshot wounds: A prospective study. J Trauma 2000;48:416.
Grossman MD. Determining anatomic injury with computed tomography in selected torso gunshot wounds.
J Trauma 1998;45:446.
Stassen NA, Reevaluation of diagnostic procedures for transmediastinal gunshot wounds. J Trauma
2002;53:635
White RK, et al. Diagnosis and management of esophageal perforations. Ann Surg 1992;58:112.
Flowers JL, et al. Flexible endoscopy for the diagnosis of esophageal trauma. J Trauma 1996;40:261.
Rev. 8/1/07
51
T R A U M A
H A N D B O O K
Vascular Exposures
Vascular exposures can prove especially challenging in the trauma setting, where proximal and distal control must be rapidly achieved in the face of active hemorrhage.
Fundamental ATLS concepts should be followed, with the caution that normotensive
resuscitation may not be attainable and in fact may increase hemorrhage, if a vascular
injury is uncontrolled.
Thoracic Vascular Injuries
Resuscitative (left anterolateral) thoracotomy is indicated in patients in extremis. Transsternal extension with a right anterolateral thoracotomy (“clam shell” incision) is needed
to control cardiac or right-sided injuries. In unstable patients, incisions are chosen based
on the presumed injury. In stable patients, the incision is based on either the presumed
(clinical exam) or the proven (angiogram) location of the injury. Unstable patients
should be kept in a supine position to allow quick access to other body cavities.
Injured Artery
Ascending Aorta/Arch
Descending Aorta
Innominate
Left Common Carotid
Subclavian
First Portion (Left)
(Right)
Second Portion
Third Portion
Axillary
Incision (Depiction)
Sternotomy (1)
L 5th Interspace Thoracotomy (2)
Sternotomy + R Cervical Extension (1+ 3)
Sternotomy + L Cervical Extension (1+ 3)
L 3rd Interspace Thoracotomy (2) or “Trap Door”
(Partial Sternotomy + L Supraclavicular + L 3rd
Interspace Anterolateral Thoracotomy + Division of
Clavicle) (1 + 2 + 4)
Sternotomy + R Supraclavicular (1+ 3)
Supraclavicular + Infraclavicular (4+ 5)
Infraclavicular + Supraclavicular (5+ 4)
Infraclavicular + Supraclavicular (5+ 4) + Deltopectoral
Groove Extension
The subclavian artery exposure needs special attention because it depends on the location
of the injury. The artery has three segments, each defined by its relationship to the
anterior scalene muscle. The first lies medial, the second posterior, and the third lateral
to this muscle. On angiogram, the first portion is proximal to the vertebral artery, the
second is between the vertebral and transverse scapular arteries and the third is distal to
the transverse scapular artery. The clavicle may be divided and removed if necessary.
52
T R A U M A
H A N D B O O K
Abdominal Vascular Injuries
Inspect the retroperitoneum and act according to the guidelines in the Table and Figures
below. If, at any point, patient’s SBP < 60 mm Hg, either compress the aorta or clamp it
at the diaphragmatic hiatus (retract stomach laterally, divide lesser omentum, dissect hiatus,
apply clamp).
Explore -Zone I, Expanding, or Penetrating Hematomas
Do not explore - Blunt, Non-Expanding Zone II/III Hematomas
The three zones of the retroperitoneum
Zone Ia and II L injuries are exposed
with a left medial visceral rotation
Zone II R and caval injuries are exposed
with a right medial visceral rotation
Zone Ib and III injuries are exposed
with a direct approach
1.
2.
3.
4.
Hoyt DB, et al. Anatomic exposures for vascular injuries. Surg Clin N Am 2001; 81(6): 1299.
Mattox KL, et al. Retroperitoneal vascular injury. Surg Clin N Am 1990; 70(3): 635.
Feliciano DV, et al. Abdominal vascular injury. McGraw-Hill, New York. In: Mattox KL, Feliciano DV,
Moore EE(eds): Trauma, 2000.
Yelin AE, et al. Vascular system: 207-262. Mosby, St Louis. In: Donovan AJ(ed): Trauma surgery:
techniques in thoracic, abdominal and vascular surgery, 1994.
Rev. 8/1/07
53
T R A U M A
H A N D B O O K
Truncal Stab Wounds
The purpose of this algorithm is to guide the management of patients with stab wounds to
the anterior abdomen, thoracoabdominal area, back, and flank.
Back/Flank stab wounds are defined as those between the tips of the scapulae and
posterior iliac crests, posterior to the mid-axillary line. Physical examination alone is
unreliable in this group, and DPL is unable to evaluate the retroperitoneum. Triple
contrast (oral, rectal, and intravenous) CT has a sensitivity of 89-100% and a specificity
of 98-100% in diagnosing intra-abdominal and retroperitoneal injuries.1-4
Thoracoabdominal stab wounds are defined as those between a circumferential line
connecting the nipples and tips of the scapulae superiorly, and the costal margins
inferiorly. Occult diaphragmatic injury is problematic in this patient group.5 We have
selected DPL as the preferred diagnostic modality to exclude diaphragmatic injury, with
a RBC cutoff of 5000/mm3 chosen to balance sensitivity and specificity.6
Anterior abdominal stab wounds are defined as those anterior to the mid-axillary line,
from the xiphoid process to the pubic symphysis. Although optimal management of
stable patients with AASW is debated, we have adopted a protocol of serial clinical
assessments to determine the need for laparotomy. Retrospective review of RIH data
suggests that this is a safe and effective approach in our institution.7
Stab wounds may fall into more than one defined region, thus a combined work-up may
be required. For these type of wounds, or in the setting of multiple stab wounds, exploration may be indicated.
Consider penetrating cardiac injuries with epigastric wounds (see pages 50-51).
1.
Easter DW, Shackford SR, Mattrey RF, et al: A prospective, randomized comparison of computed
tomography with conventional diagnostic methods in the evaluation of penetrating injuries to the back and
flank. Arch Surg 1991;126:1115-9.
2.
Himmelman RG, Martin M, Gilkey S, et al: Triple-contrast CT scans in penetrating back and flank trauma. J
Trauma 1991;31:852-5.
3.
Kirton OC, Wint D, Thrasher B, et al. Stab wounds to the bank and flank in the hemodynamically stable
patient: a decision algorithm based on contrast-enhanced computed tomography with colonic opacification.
Am J Surg 1997;173:189-93.
4.
Albrecht RM, Vigil A, Schermer CR, et al. Stab wounds to the back/flank in hemodynamically stable
patients: evaluation using triple-contrast computed tomography. Am Surg 1999;65:683-7.
5.
Murray JA, Demetriades DD, Cornwell EF, et al: Penetrating left thoracoabdominal trauma: The incidence
and clinical presentation of diaphragm injuries. J Trauma 1997;43:624-626.
6.
Thompson JS, Moore EE. Peritoneal lavage in the evaluation of penetrating abdominal trauma. Surg Gynecol
Obstet 1981;153:861-863.
7.
Tsikitis V, Biffl WL, Majercik S, et al: Selective clinical management of anterior abdominal stab wounds.
Am J Surg 2004;188,807.
8.
Nagy K, Roberts R, Joseph K, et al: Evisceration after abdominal stab wounds: is laparotomy required? J
Trauma 1999;47:622-4.
Rev. 8/1/07
54
T R A U M A
H A N D B O O K
Rev. 8/1/07
55
T R A U M A
H A N D B O O K
Blunt Cerebrovascular Injuries
Blunt cerebrovascular injuries (BCVI) have historically been considered rare, yet
potentially devastating events. Early series reported mortality rates of 28%, with 58%
of survivors suffering permanent severe neurologic sequelae.1 Given the dearth of
experience with BCVI, there is essentially no Class I literature to guide management.
The fundamental mechanisms of internal carotid artery (ICA) injury include: a) cervical
hyperextension/hyperflexion with rotation, stretching the ICA over the lateral articular
processes of C1-C3; b) direct cervical trauma; c) intraoral trauma; and d) basilar skull
fracture involving the carotid canal.1 The vertebral artery is most commonly injured from
C- spine subluxation and fracture, especially of the foramen transversarium and C1-C3.2
Regardless of the mechanism, the final common pathway of BCVI is intimal disruption.
This provokes platelet aggregation with subsequent embolization or thrombosis; it also
allows egress of blood with dissection or pseudo-aneurysm formation.
A latent period between the time of injury and the appearance of cerebral ischemia is
characteristic of BCVI, and relates to the pathophysiology (i.e., platelet plug formation
and subsequent embolization or occlusion). 23-50% of patients first develop signs or
symptoms >12 hours after the traumatic event.1 This has led to the adoption of screening
protocols in many institutions. Screening has dramatically increased the recognized
incidence of BCVI, but benefit in terms of stroke reduction has not been proven.4-7
Existing data does indicate that anticoagulation improves neurologic outcomes among
symptomatic patients, and may prevent stroke in asymptomatic patients.5,8
Arteriography is the gold standard for diagnosis. Duplex ultrasonography is inadequate
for screening.3 We have elected to screen asymptomatic patients for BCVI at RIH. The
screening test will be CTA using the 16-slice scanner in the ED. ANY ABNORMALITY
will be further investigated with 4-vessel cerebral arteriography, unless there is consensus
among clinicians that it is diagnostic. Our screening criteria will be:
SIGNS AND SYMPTOMS OF BCVI:
a) Hemorrhage- from mouth, nose, ears- of potential arterial origin.
b) Large or expanding cervical hematoma (consider surgery).
c) Cervical bruit in a patient <50 years old.
d) Evidence of cerebral infarction on computed tomography (CT) scan.
e) Unexplained or CT incongruous central or lateralizing neurologic deficit, transient
ischemic attack, or Horner’s syndrome.
RISK FACTORS FOR BCVI:
a) “High risk” associated injuries: GCS <6, petrous bone fracture, diffuse axonal brain
injury, LeFort II or III fracture, and cervical spine injury. It should be noted, however,
that at least 20% of patients with BCVI have none of these injuries.3
b) Mechanism compatible with severe cervical hyperextension/rotation or hyperflexion,
particularly if associated with complex facial fractures;
c) Diffuse axonal injury of the brain;
d) Near-hanging, seat belt abrasion, or other soft tissue injury of the anterior neck
resulting in significant cervical swelling;
e) Basilar skull fracture involving the carotid canal;
f) Cervical vertebral body fracture or distraction injury.
56
T R A U M A
H A N D B O O K
Treatment strategies and treatment-related outcomes by injury grade are as
follows:5
Grade I- Intimal Irregularity; Dissection/Hematoma with <25% Stenosis: 7% stroke rate.
57% heal, 8% progress on follow-up arteriogram. No significant difference in healing or
progression whether treated with heparin, anti-platelet therapy, or untreated. Use antiplatelet therapy (ASA 325mg qd) unless there is absolutely NO contraindication to
heparin.
Grade II- Intraluminal Thrombus; Intimal Flap; Dissection/Hematoma with >25%
Stenosis: 26% stroke rate. 8% heal, 43% progress on follow-up arteriogram. Consider
repair, may be complicated by extension to base of skull. Anticoagulation with heparin
recommended. Consider stenting for dissections that threaten to occlude lumen.
Grade III- Pseudo-aneurysm: 26% stroke rate. Rare healing with anticoagulation,
although it may prevent strokes. Repair if surgically accessible. Consider endovascular
therapy for inaccessible lesions, but wait several days for injury to stabilize.
Grade IV- Occlusion: 35% stroke rate (50% in ICA). Rare re-canalization with
anticoagulation, but it may prevent stroke (all strokes were in untreated patients).
Consider repair, but it may be complicated by extension to base of skull.
Grade V- Transection: 100% stroke rate, mortality. Endovascular therapy may be the
only useful intervention.
Therapy should be individualized. Anticoagulation should be held until there is no
presumed risk of intracranial or other life-threatening hemorrhage. Anti-platelet therapy
may be a reasonable alternative to systemic heparin.11 Drugs of choice are heparin (no
bolus; 15 U/kg/hr to target PTT 40-50 sec) or anti-platelet therapy (clopidogrel 75 mg qd
or aspirin 325 mg qd). Anticoagulation should be administered following stenting.
Follow-up arteriography is performed within 7-10 days, to evaluate efficacy of the initial
therapy and plan further interventions.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Biffl WL et al. Blunt cerebrovascular injuries. Curr Prob Surg 1999; 36:507.
Cothren CC et al. Cervical spine fracture patterns predictive of blunt vertebral artery injury. J Trauma 2003;
55:811.
Biffl WL et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg 1999; 178:517.
Kerwin AJ et al. Liberalized screening for blunt carotid and vertebral artery injuries is justified. J Trauma
2001; 51:308.
Biffl WL et al. Treatment-related outcomes from blunt cerebrovascular injuries: Importance of routine
follow-up arteriography. Ann Surg 2002; 235:699.
Miller PR et al. Prospective screening for blunt cerebrovascular injuries: Analysis of diagnostic modalities
and outcomes. Ann Surg 2002; 236:386.
Mayberry JC et al. Blunt carotid artery injury: The futility of aggressive screening and diagnosis. Arch Surg
2004; 139:609.
Fabian TC, et al. Blunt carotid injury: Importance of early diagnosis and anticoagulant therapy. Ann Surg
1996; 223:513.
Biffl WL, et al. Noninvasive diagnosis of blunt cerebrovascular injuries: A preliminary report. J Trauma
2002; 53:850.
Berne JD et al. Helical computed tomographic angiography: An excellent screening test for blunt
cerebrovascular injury. J Trauma 2004; 57:11.
Wahl WL et al. Antiplatelet therapy: An alternative to heparin for blunt carotid injury. J Trauma 2002;
52:896.
Rev. 10/24/07
57
T R A U M A
H A N D B O O K
Blunt Aortic Injury (BAI)
BAI is the second most common cause of death in blunt trauma, following head injury.
Deceleration forces (e.g., high speed MVCs, falls from heights) cause tearing of the aorta at
points of fixation: ligamentum arteriosum (80-85%), diaphragmatic hiatus (10-15%), and
ascending aorta (5-10%). 85% of fatalities occur at the accident scene. Of the remainder,
25% occur within 24 hours and another 25% within one week.
The A-P CXR is a reasonable screening test for BAI. Findings suggestive of BAI (including
widened mediastinum, indistinct aortic knob, depression of left main stem bronchus, deviation
of NG tube, opacification of aortopulmonary window, widening of paratracheal/ paraspinous
stripes, apical capping, scapular fracture or 1st/2nd rib fracture) should prompt chest CT. If
suspicion of BAI is low, a widened mediastinum may be further investigated by upright CXR.
However, if suspicion of BAI is high, as in situations where there has been a severe deceleration
mechanism, chest CT is indicated regardless of CXR findings as the initial CXR may be
interpreted as “normal” in up to 7% of patients with BAI.1, 2 Helical chest CT is a sensitive test
for BAI, and its specificity approaches 100%.2, 3 Suspicious findings warrant arteriography
(the gold standard). If CT is diagnostic of BAI the decision to proceed to aortography vs thoracotomy is the thoracic surgeon’s preference.
Once BAI is diagnosed or strongly suspected, antihypertensive therapy should be instituted with
the goal of SBP <110 and HR <100, to prevent aortic rupture.3 Esmolol is preferred initially. A
loading dose of 0.5 μg/kg over 30 sec is followed by infusion of 50 μg/kg/min (increasing up to
300 μg/kg/min as needed). If necessary, nitroprusside (2-5 μg/kg/min) may be added.
The optimal means of minimizing perioperative morbidity – spinal cord ischemia, mesenteric
and renal insufficiency – is debated. “Clamp-and-sew” techniques can be relatively safe with
cross clamp times <30 minutes.4, 5 However, as the crossclamp time is not always predictable,
and paraplegia rates increase markedly after 30 minutes, many authors recommend some form
of bypass.1 Partial cardiopulmonary bypass with either left atrial-femoral or femoral-femoral
cannulation to maintain distal arterial perfusion, allows for prolonged crossclamping times
without significant untoward effects.6, 7, 8
Multisystem injuries (90%) and brain injuries (50%) are commonly associated with BAI, and
management must be prioritized. Severe brain injury, blunt cardiac injury, or pulmonary injury
may be prohibitive risks to early repair. Nonoperative management (i.e. antihypertensive and
other supportive therapy) should be considered, with potential delayed repair.9, 10 Low-grade
blunt solid organ injuries may still be managed nonoperatively, but higher-grade injures
represent a bleeding risk with heparinized bypass circuits.11 Endovascular stent-grafts may be
considered on an individual basis.
58
T R A U M A
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
H A N D B O O K
Fabian TC, Richardson JD, Croce MA, et al. Prospective study of blunt aortic injury: Multi-center trial
of the American Association for the Surgery of Trauma. J Trauma 1997;42:374-383.
Dyer DS, Moore EE, Ilhe DN, et al. Thoracic aortic injury: How predictive is mechanism and is chest
computed tomography a reliable screening tool? A prospective study of 1561 patients. J Trauma
2000;48:673-683.
Fabian TC, Davis KA, Gavant ML, et al. Prospective study of blunt aortic injury: Helical CT is
diagnostic and antihypertensive therapy reduces rupture. Ann Surg 1998;227:666-677.
Razzouk AJ, Gundry SR, Wang N, et al. Repair of traumatic aortic rupture. A 25 year experience.
Arch Surg 2000;135:913-919.
Sweeney MS, Young DJ, Frazier OH, et al. Traumatic aortic transections: Eight year experience with
the “Clamp & Sew” technique. Ann Thorac Surg 1997;64:384-389.
Hochheiser GM, Clark DE, Morton JR. Operative technique, paraplegia and mortality after blunt
traumatic aortic injury. Arch Surg 2002;137:434-438.
Miller PR, Kortesis BG, McLaughlin CA III, et al. Complex blunt aortic injury or repair: Beneficial
effects of cardiopulmonary bypass use. Ann Surg 2003;237:877-884.
Szwerc MF, Benckart DH, Lin JC, et al. Recent clinical experience with left heart bypass using a
centrifugal pump for repair of traumatic aortic transection. Ann Surg 1999;230:484-492.
Wahl WL, Michaels AJ, Wang SC, et al. Blunt thoracic aortic injury: Delayed or early repair? J
Trauma 1999;47:254-260.
Symbas PN, Sherman AJ, Silver JM, et al. Traumatic rupture of the aorta: immediate or delayed
repair? Ann Surg 2002;235:796.802.
Santanielo JM, Miller PR, Croce MA. Blunt aortic injury with concomitant intra-abdominal solid
organ injury: Treatment priorities revisited. J Trauma 2002;53:442-445.
Rev. 8/1/07
59
T R A U M A
H A N D B O O K
Blunt Cardiac Injury
Blunt cardiac injury (BCI) is a common cause of scene death. Of those who present to
the hospital, the injury can be minor and inconsequential, or may be the cause of inhospital mortality. The term “blunt cardiac injury” is preferable to older terms such as
“myocardial/cardiac contusion or concussion.” Modifiers such as “with ECG or enzyme
changes, -with complex arrhythmia, -with cardiac failure, -with coronary thrombosis, with septal/free wall rupture” may be added.
The goal of this algorithm is not to identify all patients with a BCI: the diagnosis itself is
of secondary importance. Rather, the goal is to identify the patients at risk for complications (dysrhythmia, cardiogenic shock, or structural injury) which may require treatment.
BCI should be suspected in individuals who sustain major chest trauma. The initial
evaluation should include an ECG as part of the secondary survey. Patients with shock
from any cause, ischemic changes on ECG or significant dysrhythmia* are admitted to the
ICU. If angina or ischemic ECG changes are noted, the routine r/o MI protocol should be
followed. Nonspecific ECG findings‡ are rarely associated with significant BCI; patients
may be discharged after 24 hours of cardiac monitoring if no new symptoms occur.
Patients with significant blunt chest trauma who are being admitted for associated injuries
should have cardiac monitoring for 24 hours. While many patients will require admission
for associated injuries, a subset of patients may not require admission. These patients can
be safely discharged from the ED if the ECG at presentation and at 8 hours are normal,
and if a Troponin I level at 8 hours is less than 1.5 ng/mL.
1. Biffl WL, Moore FA, Moore EE, et al. Cardiac enzymes are irrelevant in the patient with
suspected myocardial contusion. Am J Surg. 1994;169:523-528.
2. Mattox KL, Flint LM, Carrico CJ, et al. Blunt cardiac injury. J Trauma. 1992;33:649-50.
3. Pasquale MD, Nagy K, Clarke J, et al. Practice management guidelines for screening of blunt
cardiac injury. http://www.east.org/tpg/chap2.pdf. 1998.
4. Velmahos GC, Karaiskakis M, Salim A, et al. Normal electrocardiography and serum troponin I
levels preclude the presence of clinically significant blunt cardiac injury. J Trauma. 2003;54:4551.
60
T R A U M A
H A N D B O O K
BLUNT CHEST TRAUMA WITH
Substernal chest pain, dysrhythmia on ECG monitor‡, sternal/multiple rib
fractures, pulmonary contusion, thoracic seat belt sign.
dysrhythmia
12-LEAD ECG
ischemic
ANGINA / SHOCK
ICU admission,
R/o MI if angina/ischemia
+/- cardiology consult†
Admission for
associated injury
New angina,
dysrhythmia, shock
Normal
EKG
Tel x 24 hrs
ECG in AM
No new symptoms
Abnormal 8 hr EKG
or
ii
i
No injuries requiring admission
Normal ECG & Troponin at 8 hrs
Discharge
* Ischemic changes: ST elevation, depression, or T wave inversion in ≥ leads dysrhythmia: new
atrial fib, new LBBB/RBBB, frequent PVC’s/PAC’s heart block
†
Echocardiogram may be obtained in selected patients in this group with refractory shock, new
murmur, clinical suspicion of pericardial effusion/tamponade
‡
Anything other than normal sinus rhythm
Rev. 8/1/07
61
T R A U M A
H A N D B O O K
Rib Fracture Protocol: Adult
Multiple rib fractures (more than 4 ribs) in patients > 45 years of age have been associated
with increased morbidity.1 Elderly patients (≥ 65 years) who sustain blunt chest trauma with
2 or more fractured ribs have twice the mortality and thoracic morbidity of younger patients
with similar injuries. For each additional rib fracture in the elderly, mortality increases by
19% and the risk of pneumonia by 27%.2 Data suggests monitoring the respiratory function
of both groups may improve patient outcome.
Pain Assessment:
Once significant accompanying injuries have been ruled out, the cornerstone of rib fracture
management is pain control.3 Treatment of rib fractures should be focused on early and
adequate pain relief to avoid complications from splinting; primarily atelectasis, retained
secretions and pneumonia. Multiple rib fractures may result in flail chest, which in itself can
result in respiratory failure. A review of studies from 1966-2002 comparing systemic opioids,
transcutaneous electrical nerve stimulation and NSAIDS to regional analgesia therapy such as
nerve blocks and epidurals conclude it is difficult to recommend a single method for pain relief
in all clinical situations but demonstrate regional blocks to be more effective than systemic
opioids with less systemic side effects.4 The use of epidural analgesia in one study showed a
decrease in the rate of nosocomial pneumonia and shorter duration of ventilator days with
patients having more than 3 rib fractures.5 It is assumed by most clinicians that once pain is
under control, deep breathing and coughing is assured after patients have been educated on
their importance; evidence shows the contrary. Egbert et al demonstrated that narcotics and
pain may eliminate the sigh mechanism and result in a pattern of monotonous tidal ventilation.6 This data suggests that even in the setting of controlled pain, it is important to be
regimented in coaching the patient on coughing and deep breathing. The patient should not
have a sufficient amount of pain to interfere with the ability to perform a slow vital capacity
(Fig. 1 below) and an effective cough. If so the covering MD should be made aware.
Adequate Slow Vital Capacity (SVC):
Fundamental respiratory principles tell us if patients, especially those who are sedentary, are
unable to take deep breaths and cough; efficiency of ventilation and oxygenation becomes
compromised. Bendixen et. al demonstrated that shallow tidal volumes lead to atelectasis and
increased shunting.7 Figure 1 (below) demonstrates a cause and effect of atelectasis specific to
those on narcotics and/or having thoracic pain.
Figure 1. Pathogenic mechanisms and sequelae of atelectasis. Atelectasis: Physiology and Treatment Bakow
et al. Comprehensive Respiratory Care, 1995; pg. 676
Infection
Narcotics/Pain
Tachypnea/Hypopnea
Monotonous ventilation
Tissue hypoxia
Reduction in FRC
Hypoxemia
Respiratory failure/death
Airway closure
Lung collapse
V/Q mismatch
Sputum retention
Reduced lung compliance
62
T R A U M A
H A N D B O O K
After pain assessment, the clinician should measure a slow vital capacity from the patient.
The incentive spirometer will be used as a surrogate the goal being 10-15ml/kg of ideal body
weight. Patients able to achieve this should continue to be monitored by using at least once a
shift (results documented) with patient being instructed to use the device every 1-2 hours as
well. Attention should be paid to declining (but still in normal range) results.
For individuals who are unable to achieve 10-15 ml/kg, the clinician should identify if the
patient is unable due to pain, technique or respiratory function. For pain, the results should be
referred to the covering MD. For improper technique the clinician may have to resort to using
alternative methods (incentive spirometer with mask) or devices. Alternative devices include
TheraPEP® (see procedure), in which the patient would be instructed to take a deep breath,
then blow out slowly through a mouth piece. The device has a pressure indicator to assure
slow exhalation and adjustable resistance to facilitate customizing the device to the patient’s
ability. Also available is the Acapella® (see procedure). This device also would have the
patient take a deep breath and exhale through adjustable expiratory resistance but with an
added vibratory effect. This effect helps to mobilize secretions. The disadvantage of both the
TheraPEP® and Acapella® devices is that the clinician is blind to what “volumes” the patient is
moving. For this reason it is important that the clinician monitor the exhalation time to assure
it is appropriate (at least 3-4 seconds).
If the patient is unable to use any of the aforementioned devices and/or they demonstrate
sequelae of shallow tidal ventilation, the clinician will utilize a more invasive technique.
EzPAP® (see procedure) is a hand held device that will utilize 0-15 lpm of air or oxygen and a
pressure monitor to facilitate a positive exhalation pressure (10-20 cm/h20). The goal of this
device is to increase the patient’s functional residual capacity (FRC) and thus prevent/treat
atelectasis. If this method of lung recruitment fails with the patient, the clinician will discuss
the use of CPAP/BiPAP with the covering physician. If non-invasive ventilation is to be
utilized, the patient should be transferred to a step down/ICU if appropriate for their clinical
condition. The patient’s ability to maintain a SVC will still be monitored until it improves or
they require mechanical ventilation.
Patient Ambulation:
Ambulation of the patient should be done as soon as possible with all patients. In one study,
delayed ambulation after orthopedic surgery was related to the development of new onset
delirium, pneumonia and an increased hospital stay.8 Ambulation will encourage deep
breathing due to increased activity and also decrease the surface area of gravity dependant
areas in the lung; both important factors in improving ventilatory distribution. As with
breathing, movement should not be inhibited by excessive pain and the inability of ambulation
(not limited by contraindication) should be discussed with the covering physician.
1
Morbidity from Rib Fractures Increases after Age 45. JB Holcomb et al. American College of Surgeons.
Vol. 196, No. 4, April 2003; 549-555
2
Rib Fractures in the Elderly. EM Bulger et al. The Journal of Trauma: Injury, Infection and Critical Care.
Vol. 48, No. 6, June 2000; 1040-47
3,4
Karmakar, MK, Ho, AM. Acute pain management of patients with multiple fractured ribs. J Trauma 2003;
54:615
5
Bulger EM et.al. Epidural analgesia improves outcomes after multiple rib fractures. Surgery 2004,
Aug:136(2):426-30
6
Egbert LD. Effect of morphine on breathing pattern: A possible factor in atelectasis. JAMA 188:485-488, 1964
7
Bendixen H, Hedley-Whyte J, Laver MB. Impaired oxygenation I surgical patients during general anesthesia
with controlled ventilation: A concept of atelectasis. N Engl, J Med 269(19):991-996, 1963
8
Hosamk Kaamel, Mohammad A. Iqbal Ratna Mogallapu, Diana Maas, Raymond G. Hoffman. Time to
ambulation after hip fracture surgery: Relation to hospital outcomes, The Journals of Gerontology Series A:
Biological Sciences and Medical Sciences 58:M1042-M1045 (2003).
Rev. 8/1/07
63
T R A U M A
H A N D B O O K
Multiple Rib Fracture Protocol
For patients 45 and older with 4 or more rib fractures
and patients 65 and older with 2 or more rib fractures
IS=10-15
ml/kg
?
Y
N
Y
IS Monitored by Nursing
(document results)
Effective
?
N
Non-invasive
analgesia protocolB
Pain
?
Anesthesia
Consult 4-5657D
Y
N
N
Poor
Technique
?
Age > 65
or
>3 rib fx?A
Y
Y
Effective
?
Y
®
TheraPEP
®
or Acapella
N
N
EzPAP
®
Y
N
Effective?
(good cough,
improved IS)
Y
IS 10-15
ml/kg
Continue and
document
N
▼ SaO2
▲ PCO2
Retained secretions
Y
Call HO
Consider
CPAP/BiPAP and
ICU transfer
Suctioning may be used as a supplement to this protocol but should not be used to replace it.
64
T R A U M A
H A N D B O O K
Blunt Abdominal Trauma: Adult
Only 5-10% of patients admitted to trauma centers with suspected abdominal injury
(motor vehicle crashes, severe crush injuries, falls from heights >10 feet, or patients
with abdominal tenderness) will have abdominal injury. The rate of abdominal injury is
twice as high in patients with hypotension, severe head injury, or spinal cord injuries.
Approximately half of these abdominal injuries can be managed non-operatively. The
diagnostic challenge is to identify abdominal injuries efficiently and accurately. Physical
examination alone may result in a significant number of missed abdominal injuries, with
10% of patients with no abdominal tenderness or abdominal wall bruising having an
abdominal injury on CT scan. Complicating the evaluation of patients with blunt
abdominal trauma is the presence of EtOH. However, one large study has found that the
presence of EtOH (levels equivalent to legal intoxication) does not appear to affect the
reliability of an abdominal exam until the EtOH causes obtundation (GCS <11). There
are surrogate markers for abdominal injury in the absence of physical findings, such as
chest injury and hematuria. The absence of abdominal tenderness and these two injuries
has a negative predictive value for abdominal injury of >99%.
Ultrasonography is user-dependant. If FAST results are equivocal, pursue alternative
diagnostic maneuvers.
CT Indications
• Spinal cord injury, GCS <9
• Significant abdominal pain or tenderness
• Gross hematuria
• Pelvic fracture
• Significant chest trauma
•
Myocardial or pulmonary contusion
•
Multiple which is greater than 2 unilateral
rib fractures
•
Left lower (8-12) rib fractures
•
First or second rib fracture
•
Scapular fracture
•
Mediastinal hematoma
• Unexplained tachycardia and/or transient
hypotension (with normal ultrasound exams /
DPL)
1.
2.
3.
4.
Grieshop NA, Jacobson LE, Gomez GA, et al.: Selective Use of Computed Tomography and Diagnostic
Peritoneal Lavage in Blunt Abdominal Trauma. J Trauma 1995;38:727-731.
Fernandez L, McKenney MG, McKenney KL, et al. Ultrasound in blunt abdominal trauma. J Trauma
1998;45:841-848.
Healey MA, Simons RK, Winchell RJ, et al. A Prospective Evaluation of Abdominal Ultrasound in Blunt
Trauma Is It Useful? J Trauma 1996;40:875-885.
Livingston DH, Lavery RF, Passannante MR, et al. Admission or Observation Is Not Necessary after a
Negative Abdominal Computed Tomographic Scan in Patients with Suspected Blunt Abdominal Trauma
Results of a Prospective, Multi-institutional Trial. J Trauma 1998;44:273-282.
Rev. 8/1/07
65
T R A U M A
H A N D B O O K
Blunt Splenic Trauma: Adult
Important Points:
•
ANY bout of hypotension (SBP<90), transient or otherwise, in the Emergency
Department is strongly predictive of failure of non-operative management (NOM).
Other predictors of failure of NOM include injury grade and amount of hemoperitoneum.
•
Patients who fail NOM have a longer overall and ICU LOS than patients who are
managed operatively from the start.
•
95% of NOM failures happen within 72 hours of injury, regardless of grade. Thus,
there is little utility to monitoring NOM patients beyond 3-5 days unless they have
another reason to remain hospitalized.
•
NOM for stable patients consists of bedrest, telemetry monitoring, hemoglobin/
hematocrit checks every 6 hours, and frequent abdominal examinations for the
first 24 hours after admission. A decrease in hemoglobin of ≥2g or a significant
change in abdominal exam should prompt a repeat CT scan, unless the patient is
hemodynamically unstable. There is no data to support empirically repeating CT
scans while the patient is in the hospital.
•
Patients with AAST isolated grades I-II injuries may be safely observed on the
trauma ward.
•
Splenic salvage is increased in patients with arterial blush, pseudoaneurysm, or
A-V fistula who undergo angioembolization (EMBO). Some caveats are:
o
A-V fistula, pseudoaneurysm, or large amounts of hemoperitoneum
seen on CT scan or angiogram are highly predictive of failure of NOM
in EMBO patients. Patients with any evidence of post-EMBO bleeding
or hemodynamic instability should have an immediate splenectomy.
o
There is a significant failure rate of patients with AAST grades III-V
injuries who undergo EMBO.
o
A second try at EMBO is never indicated—patients who fail need an
operation.
•
Splenectomized (and those who undergo main splenic artery EMBO) should have
pneumococcal, meningococcal, and Hib vaccines. The optimal time is 14 days post
splenectomy. If there is any concern about the patient not following up, vaccinate
on the day of discharge from the hospital.
•
There is little objective data about when it is safe for patients with NOM splenic
injuries to return to full activity. There is some data that says that 84% of grade
III-V injuries are healed by 37 days. If the patient wants to return to heavy activities
such as contact sports, he should undergo a CT scan at 2 months post injury to
document healing. For an adult who engages in only everyday activities, an empiric
follow-up CT scan is not necessary.
66
T R A U M A
H A N D B O O K
Blunt Abdominal
Trauma
Hemodynamically Stable
Hemodynamically Unstable
CT scan
Laparotomy
Splenic Injury*
No blush or vascular
injury
Blush, pseudoaneurysm, AV
fistula
NOM
EMBO
*Patients with high-grade injury and/or large amounts of hemoperitoneum with
blush or other evidence of vascular injury may be taken directly to the OR at the
discretion of the trauma attending
1. Crawford RS, Tabbara M, Sheridan R, et al. Early discharge after nonoperative management for splenic
injuries: increased patient risk caused by late failure? Surgery. 2007;142:337-41.
2. Haan J, Biffl W, Knudson M, et al. Splenic embolization revisited: a multicenter review. J Trauma.
2004;56:542-7.
3. Haan J, Boswell S, Stein D, Scalea T. Follow-up abdominal CT is not necessary in low-grade splenic injury.
Am Surg. 2007;73:13-18.
4. Haan J, Marmery H, Shanmuganathan K, et al. Experience with splenic main coil embolization and
significance of new or persistent pseudoaneurysm: re-embolize, operate, or observe. J Trauma. 2007;63:615-619.
5. Peitzman A, Heil B, Rivera L, et al. Blunt splenic injury in adults: multi-institutional study of the Eastern
Association for Surgery of Trauma. J Trauma. 2000;49:177-89.
6. Savage SA, Zarzaur BL, Magnotti LJ, et al. The evolution of blunt splenic injury: resolution and progression. J
Trauma. 2008;64: 1085-92.
7. Schurr M, Fabian T, Gavant M, et al. Management of blunt splenic trauma: computed tomographic contrast
blush predicts failure of nonoperative management. J Trauma. 1995;39:507-13.
8. Smith J, Armen S, Cook C, Martin L. Blunt splenic injuries: have we watched long enough? J Trauma.
2008;64:656-665.
9. Smith HE, Biffl WL, Majercik SD, et al. Splenic artery embolization: have we gone too far? J Trauma.
2006;61: 541-5.
10. Watson GA, Rosengart MR, Zenati MS, et al. Nonoperative management of severe blunt splenic injury: are
we getting better? J Trauma. 2006;61:1113-1119.
Rev. 6/4/08
67
T R A U M A
H A N D B O O K
Renal Trauma
Ten percent of patients with blunt abdominal trauma are found to have a urogenital
injury. Renal parenchymal injuries are the most common. Of these injuries, 75–90%
may be classified as minor (Grade I-III) and require no intervention. Work up and
treatment of the remaining “major” renal injuries has been controversial but there has
been increasing interest in non-operative management because of associated decreased
transfusion requirement, shorter ICU stay, and increased salvage rate of the kidney. CT
scan of the abdomen/pelvis is the test of choice for staging renal injury.
Evaluation:
Urine from the first post injury void should be evaluated on all patients with blunt
abdominal trauma. Most patients with major renal trauma present with gross hematuria
or hypotension, only 0.8 – 1.2% of major renal injuries have neither.
Microscopic hematuria (Greater than 5 RBC/HPF): Rarely associated with significant
renal system injury. Patients require observation and repeat UA later in the ER or
hospital to demonstrate resolution, in order to rule out other sources of hematuria such
as malignancy. Children with significant microscopic hematuria (Greater than 50
RBC/HPF) should undergo abdominal/pelvic CT with Cystogram as their risk for
significant renal injury is higher than in adults.
Gross hematuria: Patients require abdominal/pelvic CT with cystogram if hemodynamically stable. A retrograde urethrogram should be performed if there is blood at
the meatus.
Blunt vs. penetrating: Blunt injury and stab wounds may be worked up in a similar
fashion. Gunshot injuries often skip CT scan staging and require exploration because
of hypotension, massive injury and delayed complications secondary to blast effect.
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Management:
Notify Urology Service. Patients with a major renal injury may be candidates for nonoperative management under these conditions: Stable hemodynamics, urine extravasation
contained within Gerota’s fascia, and no ongoing bleeding. Patients should be monitored
in the TICU for the first 24 – 48 hours. Bed rest should continue for 24 hours after the
cessation of hematuria. Other therapeutic interventions are:
Angio-embolization: A two-unit transfusion limit (blood loss thought to be related to
renal injury) will be set as a threshold to consider angiogram for embolization. Bleeding
may manifest as expanding hematoma or persistent hematuria.
Double J Stent: Patients with evidence of urinary extravasation on initial CT scan may
warrant stenting. Plan re-evaluation with CT scan 48 hours post injury. Any patient with
persistent urinary extravasation on repeat CT scan requires stenting. Less than 10% of
patients require surgery for failure of stents to control urine extravasation.
Percutaneous drainage: Urinoma and abscess may be a complication of non-operative
management. Both may be treated with percutaneous drainage.
Operative salvage: Patients taken to the operating room for hypotension before adequate
staging of potential renal injuries may warrant exploration if there is a strong suspicion
for renal injury. Otherwise, postoperative staging CT is recommended. Intra-op IVP has
been used to assess contralateral kidney function yet less than 1% of patients with a
palpable contralateral kidney have a non-functioning kidney. The “one-shot IVP” is not
warranted.
Intra-op considerations: Assess urinary extravasation by injection of methylene blue.
Goals are debridement, homeostasis, watertight closure of the collecting system, reapproximation of the parenchyma, and drainage of the retroperitoneum. Often omentum
is used to wrap the kidney after repair.
Revascularization: Revascularization has been employed for traumatic renal artery
occlusion. Salvage in this situation is rarely successful and should not be undertaken
in the acutely injured patient. Fewer complications are seen if non-operative management is undertaken. However, the patient must be monitored for the development of
renovascular hypertension.
1. Ahn JH, Morey AF, McAninch JW. Workup and Management of Traumatic Hematuria. Emerg Med Clin North
America, 1998;16:146-164.
2. Altman A. Selective Nonoperative Management of Blunt Grade 5 Renal Injury. J Urology, 2000;164;27-31.
3. Haas CA, Dinchman KH, Nasrallah PF, et al. Traumatic Renal Artery Occlusion. J Trauma 1997;45:557-561.
4. Skinner EC, Parisky YR, Skinner DG. Management of Complex Urologic Injuries. Surg Clin North America
1996;76:861-878.
Rev. 8/1/07
69
T R A U M A
H A N D B O O K
Diagnosis of Blunt Bowel and Mesenteric Injury
Blunt injury to the bowel or mesentery (BBMI) is uncommon and can be difficult to
diagnose. While some studies claim that diagnostic delay does not cause morbidity
or mortality,1 a large multicenter series has reported an increased mortality when the
diagnosis is delayed by as little as 8 hours.2 Therefore, it is important to identify
those at risk and make the diagnosis early.
CT scanning is the best noninvasive test for diagnosing BBMI.3,4 Oral contrast does
not need to be routinely administered as it delays the evaluation and does not add to
the specificity or sensitivity of the test.5 CT findings that suggest BBMI include free
fluid in the absence of solid organ injury, bowel wall thickening, mesenteric fat
streaking, mesenteric hematoma, pneumoperitoneum, and extravasation of IV or oral
contrast.
The findings of pneumoperitoneum or contrast extravasation mandate laparotomy.
The other findings are suggestive but not specific for BBMI. Malhotra and
colleagues3 found that in a patient with a single CT finding 35% had BBMI. Two
findings were associated with BBMI in 80%. If more than two findings were present
the rate was 100%. Thus, two or more of these findings mandate laparotomy. A
single finding should prompt further evaluation.
Options for further evaluation include serial physical exams, DPL, and repeat CT
scan. Physical exam has been shown to have variable results in predicting a need for
operation.1 Thus it should be supplemented by serial WBC and a delayed CT scan.
DPL has a high sensitivity and negative predictive value but a positive predictive
value of only 35%. In addition, it is invasive and carries a risk of complications.6
In patients who cannot be reliably examined, DPL should be considered. A positive
DPL is defined as RBC >100,000/mm3, WBC >500/mm3 or the presence of bile,
bacteria or particulate matter. Amylase >20 and Alkaline phosphatase >3 are useful
adjuncts in equivocal tests.7 A low threshold for exploration should be used when
the clinical picture is not improving.
1.
2.
3.
4.
5.
6.
7.
Fang JF, et al. Small Bowel Perforation: Is Urgent Surgery Necessary? J Trauma1999; 47;515-520.
Fakhry SM, et al. Relatively Short Diagnostic Delays (<8 Hours) Produce Morbidity and Mortality in
Blunt Small Bowel Injury: An Analysis of Time to Operative Intervention in 198 Patients from a
Multicenter Experience. J Trauma 2000; 48:408-415.
Malhotra AK, et al. Blunt Bowel and Mesenteric Injuries: The Role of Screening Computed
Tomography. J Trauma 2000; 48:991-1000.
Killeen KL, et al. Helical Computed Tomography of Bowel and Mesenteric Injuries. J Trauma 2001;
51:26-36.
Allen TL, et al. Computed Tomographic Scanning without Oral Contrast Solution for Blunt Bowel
and Mesenteric Injuries in Abdominal Trauma. J Trauma 2004; 56:314-322.
Rodriguez C, et al. Isolated Free Fluid on Computed Tomographic Scan in Blunt Abdominal Trauma:
A Systematic Review of Incidence and Management. J Trauma 2002; 53:79-85.
McAnena OJ, et al. Peritoneal Lavage Enzyme Determinations Following Blunt and Penetrating
Abdominal Trauma. J Trauma 1991; 31:1161-1164.
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71
T R A U M A
H A N D B O O K
Rectal Injury
The management of civilian rectal injuries has evolved from wartime experience.
Fundamental principles included diversion of the fecal stream, debridement and closure
of the rectal injury when possible, distal rectal washout, presacral drainage, and broadspectrum antibiotics. These principles, while reducing morbidity and mortality in high
velocity injuries, have been modified over the past 20 years, as the majority of rectal
injuries sustained in the civilian population occur from low velocity missiles.2
Rectal injuries should be classified as either intraperitoneal or extraperitoneal. Injuries
to the anterior and lateral surfaces of the upper two thirds of the rectum are classified as
intraperitoneal (serosalized), and those of the posterior surface as extraperitoneal (no
serosa). Injuries to the lower one-third are extraperitoneal.2 Rectal injury needs to be
ruled out in all transpelvic gunshot wounds and other penetrating pelvic injuries. Diagnostic modalities should include a digital rectal exam looking for gross blood, and a
proctosigmoidoscopy.
Intraperitoneal rectal injuries should be primarily repaired with or without fecal diversion.1,2 Recent studies have suggested extraperitoneal rectal injuries should be left
untouched and only a diverting colostomy should be performed.2 These authors state
that the primary repair of extraperitoneal rectal injuries is often difficult because of the
confined pelvic space, the adjacent sacral venous plexus and urogenital structures, and
the hypogastric nerve plexus.2 That being said, easily visualized injuries with minimal
dissection should be primarily repaired.2
Distal rectal washout and presacral drainage, mainstay therapy for high velocity rectal
injuries, has not shown any advantage in the management of civilian type rectal injuries
and may be omitted.2,3 Broad spectrum antibiotics covering gram negative bacteria and
anaerobes should be given. Finally, genitourinary tract injuries are among the most
common injuries associated with rectal trauma. Hematuria should raise the level of
suspicion and prompt further workup.2
Healing of rectal wounds may occur in up to 75% of patients ten days after injury.
Some admission colostomy closure may be considered in patients with low grade or
penetrating injuries. Healing should be demonstrated with a contrast enema to exclude
stricture or fistula formation.
1.
2.
3.
Navsaria PH, Edu S, Nicol AJ. Civilian extraperitoneal rectal gunshot wounds: Surgical management made
simpler. World J Surg. 2007 Jun; 31(6):1345-51.
McGrath V, Fabian TC, Croce MA, Minard G, Pritchard FE. Rectal trauma: management based on anatomic
distinctions. Am Surg. 1998 Dec; 64(12):1136-41.
Gonzalez RP, Falimirski ME, Holevar MR. The role of presacral drainage in the management of penetrating
rectal injuries. J Trauma. 1998 Oct; 45(4):656-61.
Rev 6/1/08
72
T R A U M A
H A N D B O O K
Unstable Pelvic Fractures
Hemodynamically compromised patients with pelvic fractures present a complex
challenge to trauma surgeons. Fractured pelvic bones bleed briskly and can lacerate
surrounding soft tissues and disrupt their extensive arterial and venous networks. The
resultant hemorrhage and secondary coagulopathy can be lethal; to confound matters,
the considerable force required to fracture the pelvis typically results in significant
associated extrapelvic injuries. Collectively, these factors account for high rates of
death and complications. From 1997-2001, pelvic fracture patients presenting to RIH
with hypotension had a mortality of 36%; among those requiring laparotomy, it was
58%. Several groups have reinforced the concept of a multi-specialty approach to
patients with pelvic fractures and significant hemorrhage. Although the fundamental
objectives – control of hemorrhage, restoration of hemodynamics, and prompt diagnosis
and treatment of associated injuries – have not changed, the means of achieving these
goals have evolved significantly. 1,2 Maneuvers such as early mechanical pelvic
stabilization3 and arterial hemorrhage control by means of interventional radiologic
techniques4 are now recognized as pivotal components of the management scheme.
Hemodynamically stable patients should undergo CT scanning of the abdomen and
pelvis to detect occult injuries or contrast extravasation.5 The finding of contrast
extravasation in the pelvis is highly suggestive of significant arterial bleeding that
may require angiography and embolization.6,7 Ongoing transfusion requirements also
constitute an indication for arteriography.
The initial approach to hemodynamically compromised patients must be aggressive.
Crystalloid resuscitation and transfusion of packed red blood cells should be instituted
immediately; empiric administration of fresh frozen plasma (1:1) and plate-lets (5:5)
may help prevent coagulopathy. Reduction of the pelvic volume is critical, and is
achieved by prompt wrapping of the pelvis, and taping of the knees and ankles. The
orthopaedic surgery attending is instrumental in determining whether application of
an external fixation device – and what device – is appropriate.8,9
Identification of alternative sites of bleeding is central to the triage of these patients.
Physical examination, chest x-ray, and ultrasonography will identify significant extrapelvic hemorrhage, allowing timely intervention. If ultrasonography is equivocal,
supraumbilical DPL should be performed, and the patient taken to the OR if the
aspirate is grossly positive.
Patients who do not recover with mechanical pelvic stabilization, transfusion, and
treatment of associated injuries have a high likelihood of harboring pelvic arterial
hemorrhage. They should undergo prompt arteriography either in the operating room
or the radiography suite. For this reason, vascular/interventional radiology should be
alerted early in the course of these patients.
73
T R A U M A
1.
2.
3.
4.
5.
6.
7.
8.
9.
H A N D B O O K
Biffl WL, Smith WR, Moore EE, et al. Evolution of a multidisciplinary clinical pathway for the management
of unstable patients with pelvic fractures. Ann Surg 2001;233:843-850.
DiGiacomo JC, Bonadies JA, Cole FJ, et al. Practice management guidelines for hemorrhage in pelvic
fracture. EAST 2001.
Latenser BA, Gentillelo LM, Tarver AA, et al. Improved outcome with early fixation of skeletally unstable
pelvic fractures. J Trauma 1991; 31:28-31.
Agolini SF, Shah K, Jaffe J, et al. Arterial embolization is a rapid and effective technique for controlling
pelvic fracture hemorrhage. J Trauma 1997; 43:395-399.
Ballard RB, Rozycki GS, Newman PG, et al. An algorithm to reduce the incidence of false-negative FAST
examinations in patients at high risk for occult injury. J Am Coll Surg 1999;189:145-151.
Pereira SJ, O’Brien DP, Luchette FA, et al. Dynamic helical computed tomography scans accurately detect
hemorrhage in patients with pelvic fracture. Surgery 2000;128:678-685.
Stephen DJG, Kreder HJ, Day AC, et al. Early detection of arterial bleeding in acute pelvic trauma. J
Trauma 1999;45:638-642.
Buckle R, Browner BD, Morandi M. Emergency reduction for pelvic ring disruptions and control of
associated hemorrhage using the pelvic stabilizer. Tech Ortho 1995;9:258-266.
Tucker MC, Nork SE, Simonian PT, et al. Simple anterior external fixation. J Trauma 2000;49:989-994.
Rev. 8/1/07
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T R A U M A
H A N D B O O K
Mangled Extremity
Severe extremity injuries with significant damage to more than one tissue component
(integument = skin + subcutaneous tissue, muscles, bone, nerves and vasculature) are
often called mangled extremities. They typically require arterial repair to restore limb
viability. Unlike a pure vascular injury, however (such as a knife or gunshot wound), the
prognosis for restoration of function is poor. Particularly for mangled lower extremities,
amputation must be seriously considered as a better alternative to attempted limb salvage,
especially when risk of systemic complications is high or when the salvaged limb will be
less functional than a prosthesis.
The prediction of successful limb salvage in terms of patient morbidity and eventual
acceptable limb function has been limited by the lack of class I data (well powered,
randomized, prospective trial). Additionally, all of the scoring systems currently used
are based on data from lower extremity injuries only. The NISSSA scoring system is
a tool which emphasizes the important factors which impact limb salvage for mangled
extremities: nerve injury, ischemia, soft tissue/contamination, skeletal trauma, presence
of shock, and patient age. Using this scoring system, several retrospective studies have
shown that limb salvage is nearly always possible with acceptable functional results
when the NISSSA is <7 and that few limbs can be or should be salvaged when the
NISSSA >10.
Several surgical services must become involved immediately in the care of a patient with
a mangled extremity. Attending surgeons from the Trauma Service, the Orthopaedic
Service and, as required on an individual basis, Vascular and Plastic Surgery are essential
during evaluation, decision making, and treatment. If the mangled extremity is ischemic,
every effort must be made to expedite immediate operative intervention – nonviable
limbs rarely benefit from arteriography in the Radiology Department, although an OR
arteriogram may be valuable. It is essential that the trauma attending be directly involved
in the care of these patients, to have a direct dialogue with attending surgeons of other
disciplines and to maintain the perspective of the entire patient.
Time is of the essence! Unless adequately perfused, nerve and muscle become
progressively unsalvageable after 4 to 6 hours.
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NISSSA Rating Criteria
Type of injury
N – Nerve Injury
Degree of
Injury
Sensate
Dorsal
Points
Description
No major nerve injury
Peroneal (deep or superficial), femoral
nerve injury a
Plantar partial
2 Tibial nerve injury a
Plantar complete
3 Sciatic nerve injury a
I – Ischemia
None
0 Good to fair pulses, no ischemia
Mild
1b Reduced pulses, perfusion normal
Moderate
2b No pulse(s), È cap refill, Doppler
signals present
Severe
3b Pulseless, cool, ischemic, no Doppler
pulses
S – Soft Tissue (ST) / Low
0 Minimal to no ST contusion, no CON
Contamination (CON) Medium
1 Moderate ST injury, low-velocity
GSW, moderate CON, minimal crush
High
2 Moderate crush, deglove, high velocity
GSW, moderate ST injury,
considerable CON
Severe
3 Massive crush, farm injury, severe
deglove, severe CON, requires softtissue flap
S – Skeletal
Low energy
0 Spiral, oblique fx, no/minimal
displacement
Medium energy
1 Transverse fx, minimal comminution,
small caliber GSW
High energy
2 Moderate displacement, moderate
comminution, high velocity GSW,
butterfly fragment(s)
Severe energy
3 Segmental, severe comminution, bony
loss
S – Shock
Normotensive
0 BP normal, SBP always >90 mm Hg
Transient ÈBP
1 Transient SBP <90 in field or ED
Persistent ÈBP
2 Persistent SBP <90 despite fluids
A – Age
Young
0 <30 years
Middle
1 30-50 years
Old
2 >50 years
TOTAL SCORE (N + I + S + S + S + A) ___________
a
0
1
Nerve injury as assessed primarily in emergency room. bScore doubles with ischemia >6 h.
1.
2.
3.
Bosse MJ, MacKenzie EJ, Kellam JF, et al. A prospective evaluation of the clinical utility of the lowerextremity injury-severity scores. J Bone Joint Surg Am 2001;83:3-14.
Lin CH, Wei FC, Levin LS, Su JI, Yeh WL. The functional outcome of lower-extremity fractures with
vascular injury. J Trauma 1997;43:480-485.
McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: A retrospective
evaluation of the Mangled Extremity Severity Score. J Orthop Trauma 1994;8:81-87.
Rev. 8/1/07
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To Ligate or Not to Ligate
Injury
Best Mode of Action
Infrarenal vena cava
Repair
Can ligate
Suprarenal vena cava
Repair
Cannot ligate - at least 50% mortality)
Internal jugular vein
Repair
Can ligate unilaterally
Brachiocephalic vein
Repair
Can ligate unilaterally
Subclavian vein and artery
Repair
Can ligate
Superior vena cava
Repair
Can ligate in life-threatening situations
Carotid artery
Repair
Can ligate in life-threatening situations
Mesenteric veins
Ligate
Portal vein
Repair
Can ligate if isolated injury, but at least
50% mortality rate secondary to massive
fluid sequestration in splanchnic vascular
bed and bowel necrosis
Right renal vein
Repair
Cannot ligate - fewer collateral than left
renal vein
Popliteal vein
Repair
Cannot ligate
Femoral vein
Repair
Can ligate
Lobar bile duct
Ligate
Celiac artery
Ligate
Left gastric artery
Ligate
Common/proper hepatic
arteries
Ligate
Especially if proximal to gastroduodenal
branch
Right/left hepatic arteries
Ligate
Especially if portal vein is intact
Splenic artery
Ligate
Short gastric a. from left gastroepiploic
Iliac vein - comm/ext
Ligate
Iliac artery - comm/ext
Repair
Femoral/popliteal arteries
Repair
Tibial arteries
Repair
Can ligate but need to ensure patency of
other leg arteries
Brachial artery
Repair
Can ligate if distal to profunda brachia
branch since the elbow has a rich
collateral of blood flow
Radial/ulnar arteries
Repair
Can ligate but need to ensure patency of
other artery
Rev. 8/1/07
77
T R A U M A
H A N D B O O K
Trauma Scoring Systems
Multiple trauma scoring systems have been promulgated over the years. These scores
were developed for trauma triage and others were used to evaluate and predict outcomes:
Revised Trauma Score (1989) uses the initial respiratory rate, systolic blood pressure
and GCS of the patient. The score has good inter-rater reliability. The higher the score is,
the higher the probability of survival. The scores range from 0 to 7.8.
Injury Severity Score (1974) is based on an abbreviated injury score (AIS). Each injury
is assigned an AIS score, ranging from 1(minor) to 6(lethal). The highest AIS within
each of six body regions – head/neck, face, thorax, abdominal/pelvic contents,
extremities, external structures – is identified. The ISS = the sum of the square of the
three highest of these scores. Scores range from 0-75; any AIS of 6 automatically results
in ISS = 75. It does not consider age of physiologic status, and may misrepresent injury
severity when injuries are confined to a single body region (e.g. in penetrating trauma).
Below is an example of an ISS calculation:
ISS BODY REGION
INJURY
AIS CODE HIGHEST AIS AIS2
HEAD/NECK:
Cerebral contusion
140604.3
4
16
ICA: complete transection 320212.4
FACE:
Ear Laceration
210600.1
1
CHEST:
Rib fractures
450220.2
2
left side, ribs 3-4
ABDOMINAL:
Retroperitoneal hematoma 543800.3
3
9
EXTREMITIES:
Fractured femur
851800.3
3
9
EXTERNAL:
Overall abrasions
910200.1
1
ISS=34
NISS (New Injury Severity Score) considers the three highest AIS scores, irrespective
of body region. This improves its predictive power for penetrating injury.
The TRISS Method is a logistic regression equation based on the Revised Trauma
Score, ISS and age, It also allows for the difference between blunt and penetrating injury.
The ASCOT – a severity and characterization of trauma score – is very similar to the
TRISS method in that is uses the components of the Revised Trauma Score but in a
separated manner of Glasgow Coma Scale, systolic blood pressure and respiratory rate
and also uses a different scoring system for injury to the different body regions,
analogous to the ISS, and also includes age. Predicted outcome is also based on
logistical regression analysis.
The APACHE II (Acute Physiology And Chronic Health Evaluation) – is a predictor of
mortality derived from a logistic equation utilizing both acute and chronic conditions.
The acute physiology score includes 12 data points: temperature, mean arterial blood
pressure, heart rate, respiratory rate, paO2, pH, sodium, potassium, creatine, hematocrit,
white count, and Glasgow coma score (the acute score ranges from 0 to 72). The chronic
score accounts for respiratory failure (asthma, COPD, aspiration), heart failure (valvular
dx, CHF, CAD), liver failure, immunosuppression, age and operative status (elective,
emergent, non-operative)
For further details: Trauma Scoring Systems consult: www.trauma.org/scores/index.html
For APACHE II calculation: http://www.sfar.org/scores2/apache22.html
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Rev. 8/1/07
79
Pelvis fx –
substantial
deformation and
displacement
Humerus fx
Femoral a. – lac
Crushed / mangled
extremity
Burn 20-29% TBSA
Inhalation injury
Brachial a. – lac
Radius fx – closed
Scapula fx
Degloving injury
Brachial plexus
injury
High voltage
electrical injury
w/muscle necrosis
Skin/subcutaneous/
muscle – laceration
Burn – <10% TBSA
Extremities / Pelvic
External
Burn 30-40% TBSA
Liver – deep lac
Parenchymal
disruption <75% of
hepatic lobe
Iliac artery lac
Bladder – rupture
Colon – perforation
Spleen – subcapsular
hematoma < 50%
Abdominal wall
contusion
Abdomen
Diaphragm rupture w/
herniation
Myocardial contusion
with shock
LeFort III w/ 20%
blood loss
DAI with GCS <8
ICA: intimal flap
with neurologic
deficit
>3rib fxs, or any
hemo-/ pneumothorax
Bronchus perforation
Pulmonary contusion
Maxilla fx – LeFort III
C-spine fracture
Lac w/ blood loss
>20%
CHI – GCS 9-14
ICA: intimal flap
4
(Severe)
Rib fxs
Brachial plexus injury
Deep tongue lac
Zygoma fx
T-spine fracture
LOC: GCS 15
3
(Serious)
Chest wall contusion
Cornea abrasion
Mandible fx –
subcondylar
Superficial scalp lac
2
(Moderate)
Chest
Face
Head/neck
1
(Minor)
Burn 40-89% TBSA
Pelvic fx w/ shock
Kidney – hilum
avulsion
Liver >75%
destruction of lobe
Aorta transection
Tension
pneumothorax
Cord contusion with
Paraplegia /
quadriplegia or
neurogenic shock
Brain stem – DAI
Penetrating injury
5
(Critical)
The following are the AIS scores from the 1990 revision to give an idea of the scoring system for each involved area:
Burn - >90%
TBSA
Hepatic avulsion
Aortic transection
– ruptured
Decapitation
6
(Nonsurvivable)
T R A U M A
H A N D B O O K
T R A U M A
H A N D B O O K
TICU Sedation/Analgesia
Analgesia and sedation of the critically ill patient is a vital component of critical care.
Unchecked post-traumatic pain and anxiety can provoke a whole host of deleterious
effects including: increased myocardial oxygen demands leading to ischemia, myocardial
infarction and increased systemic oxygen consumption, increased minute ventilation and
need for prolonged mechanical ventilation, increased ICP, and increased catabolism.
Proper administration of analgesics and sedatives can help to lessen the likelihood of
these undesirable events.
A basic understanding of the pharmacologic properties of analgesic and sedative medications will lessen the likelihood of improper use. A brief description of these medications
follows. The summary presented here is intended to function as a framework for selection of medications. The most “correct” regimen is ultimately determined by clinical
acumen, as well as continuous reassessment of the patient. In the near future, the Trauma
Service will draw up a detailed TICU sedation protocol, which will be nursing-driven,
based on the Richmond Agitation and Sedation Scale (RASS). This protocol will strive
for a RASS of -1 to -2 as a target (see next page), which the bedside nurse will achieve
through the titration of appropriate analgesics and sedatives. In the interim, the following
points should be observed:
Analgesia
1. Fentanyl, hydromorphone, and morphine are recommended agents. Fentanyl
has the most rapid onset. Fentanyl and hydromorphone are preferred if
patient is hemodynamically unstable or has renal insufficiency. Fentanyl
may accumulate and cause prolonged effects, especially in the elderly.
2. Scheduled doses or intermittent doses are preferred over continuous infusions.
Sedation
1. The RASS sedation scale is used to assess agitation.
2. Propofol is preferred in the first 24-72 hours after injury if frequent neurologic
assessment is necessary. Beyond 72 hours, intermittent midazolam or lorazepam should be strongly considered. Common adverse effects of propofol
include bradycardia and hypotension and triglyceride levels must be checked
after 2 days of propofol infusion.
3. Midazolam is an excellent agent in the acute setting, but may accumulate in
fatty tissue and cause prolonged effects, especially in the elderly, obese, or
renal failure patient.
4. Benzodiazepines should be used with extreme CAUTION in the elderly and
are to be considered drugs of last resort.
5. Atypical antipsychotics may provide a valuable adjunct to control agitation,
and may decrease the reliance on benzodiazepines.
Paralysis
1. In general, the indications for chemical paralysis are exceedingly rare and
include life-threatening ARDS with ventilator dyssynchrony, to decrease
systemic oxygen consumption in cases of fixed cardiac output, or when patient
or staff safety is compromised by extreme agitation (RASS +5) prior to the
effect of longer acting sedatives/antipsychotics.
2. When using paralytics, the degree of neuromuscular blockade must be
monitored. Check train of four (TOF) in facial muscles every 30 minutes
during induction and once a shift after that. Titrate to 2/4 TOF. For 0/4 TOF,
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T R A U M A
H A N D B O O K
hold drug until 1/4 twitches are visible, then restart drug at a 20% reduction in
rate. For 4/4 twitches, re-bolus and increase infusion rate by 25%.
Atracurium is cleared by Hoffmann elimination; thus, no renal or hepatic
metabolism is required. Doses in excess of the recommended dose may be
necessary. This is the drug of choice if there is any concern about renal or
hepatic function.
3.
Delirium
1. Delirium is an independent risk factor for increased ICU mortality
2. ICU delirium should be treated with an antipsychotic, such as haloperidol
3. In the future, the Confusion Assessment Model (CAM) will be utilized by
the nursing staff to identify delirium.
Richmond Agitation Sedation Scale
Score
Term
Description
+4
Combative
Overly combative or violent. Immediate
danger to staff.
+3
Very Agitated
Pulls/Removes tubes or catheters. Has
aggressive behavior towards staff.
+2
Agitated
Frequent non-purposeful movement. Patientventilator dyssynchrony.
+1
Restless
Anxious or apprehensive but movements not
aggressive or vigorous.
0
Alert & Calm
-1
Drowsy
-2
Light Sedation
Briefly (<10 sec) awakens with eye contact to
voice.
-3
Moderate
Sedation
Any movement (but no eye contact) to voice.
-4
Deep Sedation
No response to voice, but any movement to
physical stimulation.
-5
Unarousable
Not fully alert, but has sustained (>10 sec)
awakening with eye contact, to voice.
No response to voice or physical stimulation.
Adapted from Ely EW, Truman B, Shintani A, et al: Monitoring sedation status over time in ICU patients:
reliability and validity of the Richmond Agitation Sedation Scale (RASS). JAMA, 289:2983-91, 2003.
Rev. 7/15/08
81
T R A U M A
H A N D B O O K
Ventilator-Associated Pneumonia
Ventilator-associated pneumonia (VAP) occurs in up to 68% of mechanically ventilated
patients, with a mortality rate of nearly 50%. The incidence of VAP increases by approximately 1% per day in the intubated patient. VAP “bundles” have been shown to reduce the
incidence of VAP, thus head-of-bed elevation greater than 30 degrees, minimization of
sedation with daily interruptions and early discontinuation of mechanical ventilation as soon
as possible are strategies demonstrated to reduce the rate of VAP.
The diagnosis of VAP is controversial; however bronchoalveolar lavage (BAL) with quantitative culture appears to be the best strategy for diagnosing VAP. Recent prospective cohort
and randomized controlled trials have demonstrated decreased mortality and antibiotic usage
when BAL was used to diagnose VAP.1,2 Since BAL is an invasive procedure, the suspicion
of VAP must warrant the risk of the procedure. Currently, the clinical pulmonary infection
score (CPIS) is used as an indicator of patients with likely VAP and therefore warrant BAL.
Patients with CPIS greater than or equal to 5 and/or clinical suspicion should undergo BAL.
However, CPIS is only intended to be a rough screening tool and some literature suggests
that is may be ineffective in predicting VAP in trauma patients, thus clinical suspicion must
remain high and CPIS should not be used as the sole basis to exclude VAP as a source of
sepsis.3
BAL is performed by wedging the bronchoscope into the affected segment, instilling and
aspirating five 20 ml aliquots of non-bacteriostatic sterile saline. The scope should remain
wedged throughout and the initial aliquot MUST be discarded. The remaining effluent is
pooled and sent for BAL culture. Broad spectrum antibiotic coverage should be initiated
immediately after BAL pending final culture results. Patients who have been in the hospital
for 3 days or more should be started on empiric coverage for MRSA and gram negative rods.
Recent studies have demonstrated that appropriate early empiric antibiotic coverage in patients
with VAP reduces mortality and ICU length of stay.4,5 It is imperative that antibiotics be
focused or discontinued as appropriate at 72 hours based on culture results. Quantitative
cultures should be imminently available at RIH and bacterial counts will be reported as 103
or less versus 104 or more organisms/mL. VAP is defined as a count of 104 or more
organisms/ml. Counts less than this are considered to represent colonization and antibiotics
should be discontinued. MRSA & SPACE bugs (Serratia, Pseudomonas, Acinetobacter,
Citrobacter & Enterobacter) should be treated for 15 days, while 8 days is sufficient for all
others. Discontinuation of antibiotics after 3 days may be considered if CPIS <6 and suspicion
of pneumonia is clinically resolved.6
Modified Clinical Pulmonary Infection Score (CPIS)
Temperature (oF)
> 96.8 & < 101.2
> 101.2 & < 102
> 102.1 or < 96.8
0 points
1 point
2 points
WBC Count
> 4,000 & < 11,000
< 4,000 & > 11,000
(>50% band forms)
0 points
1 point
1 point
Tracheal Secretions
Absent
Nonpurulent
Purulent
0 points
1 point
2 points
Culture
< 105 cfu/ml
> 105 cfu/ml
Gram stain & Cx same
0 points
1 point
1 point
PaO2/FIO2
> 240 or ARDS
< 240 & no ARDS
0 points
2 points
Progression of infiltrate
None
Progression
0 points
2 points
X-ray Infiltrate
None
Diffuse / patchy
Localized
0 points
1 point
2 points
82
T R A U M A
H A N D B O O K
Mechanically Ventilated Patient
Preventative Measures a
No Treatment
Clinical Suspicion of pneumonia
and/or CPIS ≥5
NO
YES
BAL b
Initiate Broad Spectrum Abx c
Stop ABX
<104
CFU/ml
Non-Resistant Organism
De-escalate according to
Sensitivities, Tx for 8 days
Check Culture &
Sensitivities
≥ 104 CFU/ml
SPACE d
De-escalate according to
sensitivities for 15 days.
Double cover pseudomonas
if concomitant bacteremia
Resistant Organism
MRSA
Vancomycin for 15 days
– Goal trough >15-20
(15mg/kg dosing)
Footnotes:
a.
b.
c.
d.
1.
2.
3.
4.
5.
6.
Head of bed elevation at least 30 degrees, minimization of sedation, daily assessment for
spontaneous breathing trial, chlorhexidine oral care.
Discard first 20mL prior to sending pooled effluent for culture.
<3 Days in hospital/Admitted from home – Empiric coverage for community-acquired
pneumonia. > 3 Days in hospital/nursing home patient/recent hospital admission – Empiric
coverage for MRSA/SPACE bugs.
Serratia, Pseudomonas, Acinetobacter, Citrobacter, Enterococcus.
Heyland DK, et al. The clinical utility of invasive diagnostic techniques in the setting of ventilatorassociated pneumonia. Chest. 19999; 115:1076-1084
Fagon JY, et al. Invasive and non invasive strategies for management of suspected ventilator-associated
pneumonia. Ann Int Med. 2000; 132:621-630.
Croce M, et al, The futility of the clinical pulmonary infection score in trauma patients. J Trauma 2006;
60:523-7.
Dupont H, et al, Impact of appropriateness of initial antibiotic therapy on the outcome of ventilator
associated pneumonia. Intensive Care Med. 2001; 27:355-362.
Kollef MH. Antimicrobial therapy of ventilator-associated pneumonia: how to select an appropriate drug
regimen. Chest. 1999; 115:8-11.
Singh N, et al. Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the
intensive care unit. Am J Respir Crit Care Med. 2000; 12:505-5111.
Rev. 10/1/07
83
T R A U M A
H A N D B O O K
Severe Sepsis and Septic Shock
Systemic inflammatory response syndrome (SIRS):
Any patient with two or more of the following four criteria has SIRS:
•
Temperature > 100.4 or < 96.8
•
Heart rate >90
•
Respiratory rate >20 or PaCO2 < 32 mm Hg
•
WBC count >12,000 or < 4,000
Sepsis:
SIRS + Infection
Severe sepsis: Sepsis + Acute Organ Dysfunction
Septic shock: Sepsis with Hypotension (SBP<90 or MAP<60) despite resuscitation
Patients with severe sepsis or septic shock must be treated aggressively to optimize
outcome. Fundamental principles include source control, resuscitation, antimicrobial
therapy and other adjuncts.1
Early goal-directed therapy improves survival in severe sepsis and septic shock. This
approach involves adjustments of cardiac preload, afterload, and contractility to balance
oxygen delivery with oxygen demand within 6 hours.1,2
Vasopressin may be effective in supporting blood pressure in patients with refractory
shock despite adequate fluid resuscitation and high-dose conventional vasopressors.
Low-dose corticosteroid therapy (hydrocortisone 200-300 mg/day x 7 days) should be
considered in patients with septic shock. Patients with severe sepsis should be tested for
adrenal insufficiency; non-responders should receive steroid therapy.3
Hyperglycemia and insulin resistance are common in critically ill patients, even if they
have not previously had diabetes. Tight control of blood glucose (80-110 mg/dl) has
been shown to improve morbidity and mortality4. Emerging evidence supports the use of
a target blood glucose of 150mg/dl, which seems to yield many of the benefits of tighter
control without the adverse effects due to unintended hypoglycemia. The ultimate goal
for target blood glucose remains elusive at present and may change in the near future as
additional data become available.
Activated Protein C should be considered in patients with severe sepsis or septic shock
who have Apache II score > 24 or two-system organ dysfunction.5 Avoid its use in
postoperative patients with single-system organ dysfunction, or those who have not had
source control.
Contraindications are listed at: www.fda.gov/cder/foi/label/2001/droteli112101LB.pdf.
Hold for 2 hours to procedure/surgery; resume 12 hours after major surgery or
immediately after minor surgery.
1.
2.
3.
4.
5.
Dellinger RP, Carlet JM, Masur H, et al. Surviving sepsis campaign guidelines for management of severe
sepsis and septic shock. Crit Care Med 2004; 32:858-73.
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic
shock. N Engl J Med 2001; 345:1368-77.
Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and
fludrocortisone on mortality in patients with septic shock. Jama 2002; 288:862-71.
van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl
J Med 2001; 345:1359-67.
PROWESS study group. Efficacy and Safety of Recombinant Human Activated Protein C for Severe Sepsis.
N Engl J Med 2001; 344: 699-709.
84
T R A U M A
H A N D B O O K
Severe Sepsis / Septic Shock
↓
Initial Evaluation
H&P; CBC, Chem 7, ABG, Lactate
Cultures, UA; Imaging as indicated
↓
Broad Spectrum Antibiotics; Plan for Source Control
Arterial and Central Venous Catheters
↓
Aggressive Resuscitation
Targets:
CVP 8-12 mmHg
MAP > 65 mmHg
UO > 0.5ml/kg/hr
Give Hgb to ≥ 10 g/dl then crystalloid
↓
Reassess
Vital signs, UO, ABG, lactate q 2hrs
Improving / Normal
Worsening
↓
↓
Swan-Ganz Catheter C.C.O.
Glucose Control 80-110 mg/dl
DVT/GI prophylaxis
Semi-recumbent position for ventilated pts
Lung protection ventilation for ARDS/ALI
Consider Activated Protein C
↓
Cardiac Profile
↓
PCWP low → fluid
PCWP > 12, SVR low → α agent (eg. Levo)
↓
PCWP NI, SVR N1/High
C.O. low
↓
Dobutamine
Milrinone
Cosyntropin Stimulation Test
Draw Cortisol (time = 0)
250 meg Cosyntropin IV
Cortisol at 30 and 60 min
Increase ≤ meg/dl = “non-responder”
Consider empiric hydrocortisone or
Dexamethasone if critically unstable
If high dose pressors (eg,
Levo ≥0.2 meg/kg/min)
Glucose Control 80-110 mg/dl
DVT/GI prophylaxis
Semi recumbent position for ventilated pts
Lung protection ventilation for ARDS/ALI
Consider Activated Protein C
Vasopressin 0.04 IU/min
Rev. 10/1/07
85
T R A U M A
H A N D B O O K
DVT/PE Prophylaxis in Adults Following Multiple
Trauma
The National Institute of Health estimates that approximately 20% of multiply-injured
young people develop DVT.1 Accurate assessment of the risk of DVT is critical for
proper prophylaxis (see below). All non-ambulatory trauma patients should be considered for prophylactic anticoagulation. Prior to anticoagulation, however, the relative
risk of DVT must be identified as greater than that of potential bleeding complications.
Absolute contra-indications to anticoagulation include acute neurotrauma (intracranial
or intraspinal bleeding) as well as ongoing coagulopathy or bleeding. However, after
mandatory consultation with spine service or neurosurgery, DVT prophylaxis may
commence as early as 48 hours post injury. When indicated, anti-coagulation should
be immediate and continuous. Duration of therapy is dictated by the period of immobilization. Importantly, therapy should continue through rehabilitation until ambulation is
achieved.
Patients with low risk for DVT/PE should have early ambulation instituted. The
definition of ambulatory status is walks 200 feet 3 times daily. In moderate risk patients,
low molecular weight heparin (LMWH) appears to offer a safer, more effective means
of protecting against DVT than either unfractionated heparin or sequential compression
devices (SCD).2 In this population, if anticoagulation is contraindicated, SCD should be
used.3 Of note, there is currently no proven benefit to the simultaneous use of anticoagulants and SCD. Use of prophylactic IVC filters should be reserved for patients
with multiple risk factors (i.e., high risk patients) for whom an extended period of
immobilization is anticipated, or in the event of failure of or contraindication to anticoagulant therapy.4 If not contraindicated, concomitant use of anticoagulants following
IVC filter insertion should be considered.5
1.
2.
3.
4.
5.
6.
Consensus Conference, National Institutes of Health: Prevention of venous thrombosis and pulmonary
embolism. JAMA 1986;256:744.
Geerts WH, Jay RM, Code KI et al. A comparison of low-dose heparin with low molecular weight heparin
as prophylaxis against venous thromboembolism after major trauma. N Engl J Med 1996;335:701-707.
Knudson MM, Lewis FR, Clinton A, et al. Prevention of venous thromboembolism in trauma patients. J
Trauma 1994;37:480-487.
Greenfield LJ, Proctor MC, Rodriguez JL, et al. Post-trauma thromboembolism prophylaxis. J Trauma
1997;42:100-103.
Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena cava filters in the prevention of
pulmonary embolism in patients with proximal deep vein thrombosis. N Engl J Med 1998;338:409-415.
Greenfield, EAST 1998.
86
T R A U M A
H A N D B O O K
Risk Assessment6
Underlying condition
Morbid obesity
Malignancy
Abnormal coagulation factors at admission
History of DVT
Iatrogenic factors
Femoral line >24 hours
4 or more transfusions in first 24 hours
Surgical repair >2 hours
Repair or ligation of major vascular injury
Injury-related factors
Burn >20% TBSA
AIS score >2 for chest
AIS score >2 for abdomen
AIS score >2 for head, or Coma (GCS <8 for >4 hours)
Complex lower extremity fracture
Pelvic fracture
Spinal cord injury +/- paraplegia or quadriplegia
Age
40-60 years
60-75 years
75 years
4
2
2
4
2
2
2
3
3
2
2
3
4
4
4
2
3
4
DVT/PE Prophylaxis
LOW
Risk < 3
MODERATE
Risk 3 – 5
HIGH
Risk > 5
Early Ambulation
LMWH
Lovenox 30 mg SC q12h
LMWH
Lovenox 30 mg SC q12h
If early ambulation
not possible – SCD
If contraindication for
LMWH – SCD
If contraindication for
LMWH – IVC filter
Rev. 8/4/07
87
T R A U M A
H A N D B O O K
Heparin-Induced Thrombocytopenia
Heparin-Induced Thrombocytopenia (HIT) occurs in up to 5% of patients receiving
therapeutic or prophylactic doses of unfractionated heparin (UH). HIT generally occurs
5 to 12 days after initiation of UH /LMWH, however, patients with previous exposure to
UH/LMWH may develop HIT within 24 hours of exposure to UH/LMWH and are at
particularly high risk for thrombotic complications. Exposure to extremely small
amounts of heparin, such as those used to coat central catheters or flush intravenous lines
has been associated with HIT. The use of low molecular weight heparin (LMWH)
reduces the incidence of HIT by up to 90%1,2.
HIT is a clinical diagnosis that may be confirmed by laboratory testing. The American
Society of Hematology has developed a ‘4T’s’ grading scale to determine the pretest
probability of HIT3,4 (See Table). A score of 0-3 indicates a low risk for HIT (< 0.1%);
4-5 an intermediate risk (.1-10%); 6-8 indicates high risk (>10%). All patients receiving
UH/LMWH should have their risk assessed daily. Patients at low risk (score, 0-3) may
be continued on UH/LMWH with continued daily risk assessment. Patients at intermediate risk (score, 4-5) should have confirmatory ELISA testing. If the ELISA is
negative the patient may continue on UH/LMWH with continued daily risk assessment.
In high-risk patients (score 6,8) or intermediate patients with a positive ELISA all
UH/LMWH must be immediately discontinued (including heparin flushes and heparin
bonded central catheters) and alternative anticoagulation with direct thrombin inhibitors
(DTI) initiated3-5 (See below).
Several DTI’s are available for treatment of HIT. Lepirudin and Argatroban are the only
DTI’s currently approved by the FDA for treatment of HIT although there is growing
experience with Fondaparinux. Lepirudin (0.1 mg/kg/hour) is renally metabolized and is
contraindicated in patients with renal failure. Argatroban (1 mcg/kg/min) is hepatically
metabolized and is the alternate DTI of choice in patients with renal failure. The
incidence of thrombotic complications in patients with HIT who are not on DTI is up to
6% per day.5-7
The timing and duration of oral anticoagulation needed following an episode of HIT is
unclear but currently DTI therapy until the platelet count surpasses 150,000 followed by
6 weeks of Coumadin (5 days of Coumadin/DTI overlap recommended) is recommended.
In patients with a documented thrombotic complication associated with HIT, 6 months of
anticoagulation with Coumadin is recommended.5
Category
Thrombocytopenia
Timing of platelet
count fall
Thrombosis of
other sequelae
2 Points
>50% fall
Days 5-10, or < 1
day if heparin
exposure w/I past
30 days
Proven thrombosis,
skin necrosis, or,
after heparin bolus,
acute systemic
reaction
None evident
Other cause for
thrombocytopenia
* Table adapted from Warkentin et al.8
88
1 Point
30-50% fall
> 10 Days or unclear (but
fits with HIT), or < 1 day
if heparin exposure w/I
past 30-100 days
Progressive, recurrent, or
silent thrombosis;
erythematous skin
lesions
0 Points
<30% fall
<1 day (no
recent
heparin)
Possible
Definite
None
T R A U M A
H A N D B O O K
1.
Aster RH. Heparin-induced thrombocytopenia and thrombosis. N Engl J Med. 1995; 332: 1374-1379.
2.
Martel N, Lee J, Wells PS. Risk for heparin-induced thrombocytopenia with unfractionated and low
molecular weight heparin thromboprophylaxis: A meta-analysis. Blood. 2005; 106: 2710-2715.
3.
Lo GK, Juhl D, Warkentin TE, et al. Evaluation of pretest clinical score (4 T’s) for the diagnosis of heparininduced thrombocytopenia. J Thromb and Hem. 2006; 4: 759-766.
4.
Rice L. Emerging treatment strategies for heparin-induced thrombocytopenia. Semin Hematol. 2005; 42: 1521S.
5.
Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia: Recognition, treatment and prevention:
The seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest. 2004; 126: 311S-337S.
6.
Greinacher A, Eichler P, Lubenow N, et al. Heparin-induced thrombocytopenia with thromboembolic
complications: Meta-analysis of 2 prospective trials to assess the value of parenteral treatment with lepirudin
and its therapeutic aPTT range. Blood. 2000; 96: 846-851.
7.
Lubenow N, Eichler P, Leitz T, et al. The HIT investigators group. Lepirudin in patients with heparininduced thrombocytopenia – results of the third prospective study (HAT-3) and a combined analysis of
HAT-1, HAT-2 and HAT-3. J Thromb Haemost. 2005; 3: 2428-2436.
8.
Wartentin TE, Aird WC, Rand JH. Platelet-endothelial interactions: sepsis, HIT, and antiphospholipid
syndrome. Hematology (Am Soc Hematol Educ Prog). 2003; 497-519.
Rev. 8/7/07
89
T R A U M A
H A N D B O O K
Antibiotic Usage on the Trauma Service
Prophylactic antibiotics are often employed in trauma patients, for a variety of conditions
in order to prevent infections and are frequently recommended by consulting services.
The data to support many of these recommendations is weak or nonexistent, and drugresistant infections attributable to antibiotic overuse are becoming more common and far
more virulent, even resulting in preventable deaths due to Clostridia difficile. The overall
concept is that antibiotics cannot overcome poor wound management and if over-utilized
will promote the emergence of bacterial resistance and super-infections.
Open fractures:
Bacterial wound contamination of open fractures can lead to cellulitis, osteomyelitis
and bony nonunion. Open fractures are best managed by debridement of devitalized
tissue with concomitant antibiotic therapy. Most studies on antibiotic therapy for open
fractures are outdated and/or suffer from serious methodological flaws. There is
adequate data to support the use of a short course of a first generation cephalosporin,
along with appropriate surgical wound care. Currently, there is NOT adequate data to
support coverage of gram-negative bacilli or clostridial species, nor the use of antibiotic
impregnated beads. 1 Thus, all open fractures should be treated with cefazolin for no
more than 48hrs. Closed fractures are treated like any other clean case and should
receive no more than a single perioperative dose.
Traumatic Hemo-pneumothorax requiring Tube Thoracostomy:
carry an associated risk of 1-2% incidence of empyema, mostly dependent on the
insertion conditions and complete evacuation of hemothorax 2 . Strict adherence to full
barrier sterile precautions is an ABSOLUTE MUST. Presumptive antibiotics for the
prevention of empyema and pneumonia are controversial. A recent prospective, randomized trial comparing cefazolin for the duration of tube placement versus cefazolin for 24
hours versus placebo failed to demonstrate a difference in pneumonia or empyema. 3
Although underpowered, this study argues strongly AGAINST the use of antibiotics
in trauma patients who require chest tubes.
EVDs:
Adequate data is not available to support early cessation of antibiotics, however, there are
small studies that suggest that the rate of ventriculitis is unchanged in patients who
receive only pre-procedural antibiotics. 4 Until an adequately powered study is performed
to show that this is indeed the case, patients with EVDs will receive a first generation
cephalosporin for the duration that the drain is in place.
1
Hauser CJ, Adams CA, Eachempati SR: Surgical Infection Society Guideline: Prophylactic antibiotic use in open
fractures: an evidence-based guideline. Surgical Infections, 2006: 7(4): 379-405.
2
Luchette FA, Barrie PS, Oswanski MF, et al: Practice Management Guidelines for Prophylactic Antibiotic Use in
Tube Thoracostomy for Traumatic Hemopneumothorax: the EAST Practice Management Guidelines Work Group.
Eastern Association for Trauma. J Trauma. 2000;48:753-7.
3
Maxwell RA, Campbell DJ, Fabian TC, et al: Use of Presumptive Antibiotics following Tube Thoracostomy for
Traumatic Hemopneumothorax in the Prevention of Empyema and Pneumonia—A multi-center Trial. J Trauma,
2004; 57: 742-9.
4
Alleyne CH, Hassan M, Zabramski JM: The efficacy and cost of prophylactic and periprocedural antibiotics in
patients with external ventricular drains. Neurosurgery, 2000; 47(5): 1124-7.
90
T R A U M A
H A N D B O O K
Facial Fractures:
There is no prospective study demonstrating a decreased incidence of infections after
closed facial fractures in patients who receive empiric antibiotics. There is one
randomized study looking at patients with operatively managed closed facial fractures. 5
This study showed a lower risk of infections in patients who received one dose of
cefazolin pre-operatively, and one dose eight hours later. Thus, it seems reasonable to
give a first generation cephalosporin for no more than 24 hours, including
mandibular fractures.
Traumatic Pneumocephaly:
As an isolated finding, there is no indication for prophylactic antibiotics in traumatic
pneumocephaly. In the presence of a sinus fracture, however, a short course of
antibiotics may be warranted. Again, there is no literature to support this, and is at the
discretion of the trauma attending and neurosurgeons.
Base of skull fractures:
No evidence to support routine antibiotic prophylaxis or empiric therapy in cases without
meningitis. Irrespective of CSF leak.
Vascular Injury:
st
Single dose of 1 generation cephalosporin for 24 hours if synthetic graft used. A single
dose is indicated in endovascular procedures. There is no benefit from graft antibiotic
“bathing”, suction groin wound drainage and preoperative bathing with antiseptic agents.
Burns:
Systemic antibiotic prophylaxis is of no value in controlling burn wound sepsis, and
might even favor the growth of P. aeruginosa in the burn wounds.
Penetrating Abdominal Trauma:
A single preoperative dose of prophylactic antibiotics with cefazolin or ampicillin/
sulbactam is standard of care for trauma patients sustaining penetrating abdominal
wounds. These antibiotics should be given as soon as technically feasible once the
decision to operate has been made. Perioperative antibiotics are intended to prevent
wound infection; they DO NOT prevent intra-abdominal abscess or anastomotic breakdown. In the absence of established peritonitis no further antibiotics are indicated and
antibiotics must be discontinued within 24 hours.
Third generation cephalosporins, quinolones, metronidazole, and aminoglycosides should
be avoided.
Chole RA, Yee J. Antibiotic prophylaxis for facial fractures. A prospective, randomized, clinical trial. Arch
Otolaryngol Head Neck Surg, 1987; 113(10): 1055-7.
5
Rev. 5/30/08
91
T R A U M A
H A N D B O O K
Trauma in Pregnancy
1 in 12 pregnancies is complicated by trauma. Two-thirds are injured in MVCs, with
falls and assaults the next most common. Up to 20% of pregnant women are victims of
domestic violence. Trauma is the leading cause of non-obstetrical maternal death. Life
threatening maternal trauma is associated with 50% fetal loss rate; less severe injuries
still have fetal loss rates of up to 5%.1 Since minor injuries are much more common,
most fetal losses result from relatively minor maternal injuries. Thus, special attention
must be paid to the pregnant trauma patient, with a coordinated effort among emergency
physicians, trauma surgeons, obstetricians, and sometimes neonatologists.2,3
INITIAL MANAGEMENT
The highest priority in a pregnant trauma victim is to evaluate and stabilize the mother:
AIRWAY- Special concerns for a pregnant patient’s airway include the increased risk for
aspiration due to decreased GI motility and upward displacement of the gravid stomach.
BREATHING- The fetal 02-hemoglobin dissociation curve is shifted to the left, so
minimal decreases in maternal SA02 can significantly compromise fetal oxygenation.
CIRCULATION- Physiologic changes in pregnancy (30-50% increase in blood volume,
peripheral vasodilation) may result in delayed manifestation of shock. Supine positioning
may lead to hypotension as the uterus compresses the IVC. This can be avoided by
positioning the mother’s right hip on a pillow or IV bag to displace the uterus to the left.
GESTATIONAL AGE DETERMINATION
Age may be estimated by the uterine fundal height: if it is below the umbilicus, the fetus
is 20 weeks or less and is not viable; if it is above the umbilicus, the distance in cm from
the pubis to the top of the fundus roughly correlates with the gestational age in weeks
(+/- 2 weeks). Ultrasonographic measurement of biparietal skull diameter (BPD),
abdominal circumference, and femur length provides a more accurate determination.
BPD is the best single test, but the others allow estimation of fetal weight.
DETERMINATION OF FETAL VIABILITY
The survival of a neonate delivered at 21 weeks is 0%; at 25 weeks it is 75%. Difficult
decisions must be made between 22 and 25 weeks. Even if the fetus survives, long-term
morbidity is a problem. 50% of surviving newborns delivered at 25 weeks or less have
disabilities in psychomotor development, neuromotor function or sensory/communication
function, with one-quarter having severe deficits at 30 months of life.4 Pre-delivery
decisions about neonatal management may be altered depending on postnatal age assessment, condition of the neonate at birth, and the newborn’s response to resuscitation.
Counseling of parents and documentation of decision-making is CRITICAL!
DIAGNOSTIC TESTING
Exposure of a fetus to extremely large doses of ionizing radiation may have teratogenic,
carcinogenic, or genetic effects. The rate of childhood leukemia increases from 1/3000
(background) to 1/2000 among children exposed in utero to ionizing radiation. The
greatest potential risk of anomalies is during organogenesis in the first trimester.
However, total exposure of less than 5 rads has never been associated with anomalies,
growth restriction, or spontaneous abortions. This allows multiple diagnostic tests
(Table 1).5 ACOG guidelines state that concern about possible effects of radiation
exposure should not prevent medically indicated diagnostic x-rays from being performed
92
T R A U M A
H A N D B O O K
on the mother.6 Shielding is reasonable if practical. There are no documented adverse
fetal effects of MRI, but it is arbitrarily recommended to avoid MRI in the first trimester.
Estimated Fetal Exposure For Various Imaging Methods
Plain Films
Cervical spine
Upper or lower extremity
Chest (2 views)
Abdominal (multiple views)
Thoracic spine
Lumbosacral spine
Pelvis
Hip (single view)
CT scans (slice thickness: 10mm)
Head (10 slices)
Chest (10 slices)
Abdomen (10 slices)
Fetal dose (rads)
0.002
0.001
0.00007
0.245
0.009
0.359
0.040
0.213
Fetal dose (rads)
<0.050
<0.100
2.600
TYPES OF TRAUMA
Blunt trauma may cause fetal death by maternal loss of life or direct fetal injury. More
commonly, the uterus bears the brunt of the injury. Over 50% of fetal losses are due to
placental abruption. Abruption typically occurs within 6 hours of the event. The classic
triad of frequent contractions, bleeding and abdominal pain occurs in fewer than half of
cases, and ultrasound will identify placental clot only 50% of the time. Thus, the only
clues to abruption may be contractions and abnormal fetal heart tracing. Up to 2 L of
blood can be sequestered retroplacentally, so if the mother is hypotensive without a
source, consider abruption. Uterine rupture is not common and also may be hard to
diagnose. The classic presentation is searing pain, abnormal fetal heart rate and
transabdominal palpation of fetal parts. The mother may rapidly deteriorate, and there is
a very high fetal loss rate. Fetal-maternal hemorrhage, defined by the presence of fetal
blood cells in the maternal circulation, can lead to fetal anemia and fetal compromise.
When Rh(+) fetal cells are exchanged with Rh(-) maternal blood, the mother will make
immune globulins against Rh(+) blood cells. In subsequent pregnancies with Rh(+)
children, hemolysis of fetal blood cells can potentially cause fetal death. To avoid these
potential complications, all pregnant trauma patients with Rh(-) blood type should
receive a vial of Rh immune globulin (RhoGAM) within 72 hours of the incident. The
amount of blood exchanged can be estimated by the Kleihauer-Betke test, which is
performed on maternal blood. Although the amount of blood exchange does not
accurately predict fetal prognosis, additional vials of RhoGAM must be administered
when there has been >30 ml hemorrhage.
Penetrating trauma is associated with relatively high fetal loss rates due to umbilical
cord, placental, or fetal trauma. Cesarean section is frequently necessary. The distended
uterus may actually shield the maternal viscera and it displaces the bowels superiorly.
Burns over 40 -50% BSA correlate with very poor fetal survival, prompting some to
recommend Cesarean Section.7,8
Electrical injuries have not been well studied. The link between minor household
electrical shocks and stillbirths is unclear, but fetal mortality is as high as 50-75%
following significant electrical injury such as a lightning strike. Early fetal heart
monitoring should be considered.7,8
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SURGERY ON THE PREGNANT PATIENT
Surgery may be required to treat or stabilize a mother. General anesthesia has not been
linked with any specific problems. It is important to maintain uterine perfusion by
maintaining high maternal SA02, providing fluid resuscitation, operating in the left uterine
displacement position, and avoiding vasopressors when possible. Fetal heart monitoring
can be performed during surgery by placing the monitor in a sterile sleeve.
PERIMORTEM CESAREAN SECTION
Once there is maternal loss of vital signs there should be an immediate consideration for
the performance of a Cesarean section if the fetus is viable. Survival is optimized if
performed within 4 minutes. If the fetus is delivered >15 min after maternal death, fetal
survival is only 5% and most of those survivors have severe neurological sequelae.3
DISPOSITION
If a pregnant patient <22 weeks has been evaluated and treated and is ready for discharge,
she should be instructed to contact her obstetrician within 24 hrs for a follow-up
appointment. She should also be instructed to call if she develops any lower abdominal
pain, bleeding, fluid loss or a decrease in fetal movement.
If a pregnant patient with a viable fetus has been stabilized, she should undergo fetal
monitoring for 4-6 hours for minor trauma, and at least 24 hours for major trauma. If the
mother is stable for discharge from RIH the fetal monitoring can be arranged at W&I.
Prior to discharge every pregnant trauma patient should have a blood type determination
and receive RhoGAM if Rh(-).Tetanus toxoid is safe to administer in pregnancy. Local
anesthetics, acetaminophen, and narcotics can be used when indicated. Nonsteroidal antiinflammatory agents should be avoided. Safe antibiotics include penicillins, erythromycins (excluding EES), cephalosporins, clindamycin and gentamicin Tetracyclines,
chloramphenicol, and quinolones should be avoided.
Mechanism for OB/GYN CONSULTATION
Page the PGY-3 OB-GYN Resident in the ED at Women & Infants’ directly at 2741122 ext 1750 or have the operator page them at 274-1100. If the 3rd year cannot be
located, have the in-house OB/GYN chief resident paged by the operator. If a prompt
response is not achieved the Trauma Service should then page the in-house OB/GYN
attending.
Please provide the following information if it is available: Patient’s name and the
name of their OB-GYN, a brief history, an estimation of the gestational age. At this point
the OB resident will come to RIH to evaluate the patient, and will arrange for fetal
monitoring if necessary.
1.
2.
3.
4.
5.
6.
7.
8.
ACOG Educational Bulletin, Obstetric Aspects of Trauma Management. Number 251, Sept 1998.
D’Amico C. Trauma in Pregnancy. Topics in Emergency Medicine. 2002.
Hanley M and Thomson C. Trauma in Pregnancy: Double Jeopardy. Emergency Medicine Practice, 5(1): 128, 2003.
ACOG Practice Bulletin, Perinatal Care at the Threshold of Viability. Number 38, Sept 2002.
Toppenberg K et all, Safety of Radiographic Imaging During Pregnancy. American Family Physician,
59(7) 1813-1818, April 1999.
ACOG Committee Opinion, Guidelines for Diagnostic Imaging During Pregnancy. Number 158, Sept 1995.
Gatrell C and Schwartz G. Trauma in Pregnancy . Principles and Practice of Emergency Medicine, 1999.
Jagoda, A and Kessler, S, Trauma in Pregnancy. The Clinical Practice of Emergency Medicine. 2001.
Rev. 9/2/07
94
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Reporting Child Abuse and Neglect and Referrals to the
Child Protection Program
All medical personnel in Rhode Island are mandated to report suspected child abuse or
neglect to the Rhode Island Department of Children, Youth and Families (DCYF).
Reports are made by calling 1-800-RICHILD. After calling the DCYF 'hotline', a form
entitled "Physicians Report of Examination" (PRE) is filled out and forwarded to DCYF
documenting the suspected abuse or neglect.
The Child Protection Program (CPP) at HCH provides 24 hour-a-day physician coverage.
The Child Protection physician on call is available for consultation when abuse or neglect
is suspected. In many cases the CPP will take responsibility for reporting child maltreatment to the proper authorities and will coordinate the collection and documentation of
forensic evidence.
The Child Protection Program should be contacted in all of the following pediatric
cases:
1. All unexplained head injuries, especially in children <2 years of age.
2. All unexplained fractures, particularly in nonambulatory children and in children <1
year of age; multiple fractures in the absence of major trauma.
3. All immersion, “pattern” injury, questionable burns in nonambulatory children, and
unexplained burns.
4. All unexplained abdominal injuries.
5. All acute sexual assaults in children and adolescents (within 72 hours) that require
immediate documentation of physical trauma by colposcopy. (Most sexual abuse
cases > 72 hours post-assault can be referred to the Child Safe Clinic).
6. Other:
a) All drowning in children <5 years of age.
b) All cases where the child is suffering from exposure or starvation.
c) All cases of significantly delayed or neglected medical care.
d) Ingestion of drugs or alcohol suspected to be “non-voluntary” or caused by
parental neglect, especially ingestion of illegal drugs in children.
e) All cases of suspected Münchhausen syndrome by proxy.
f) All other cases where injuries have been purposefully inflicted on a child (e.g.,
“pattern” bruising such as slap marks, strap marks, or ligature marks).
g) Chronic failure-to-thrive cases without medical cause.
h) Cases of repeated episodes of infantile apnea where the child has been
previously admitted to the hospital and whose medical work-up was negative.
Also, cases of previously healthy children who experience apnea after nine
months of age.
i) All free falls >3ft. in children <1 year of age.
j) Repeated admissions for trauma in children <2 years of age.
k) All trauma cases where the injury is suspected to have occurred because of
inadequate supervision or because of lack of provision for the child's safety.
In any other case where the medical care provider has questions about whether or not
abuse or neglect occurred, the CPP should be consulted. The CPP can be contacted at
4-3996 from 8:00 a.m. to 4:30 p.m. weekdays and through the page operator at 4-5611
from 4:30 p.m. to 8:00 a.m. and on weekends and holidays.
Rev. 9/2/07
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Speech Language Pathology Services
Patients are referred to the Speech-Language Pathology Department via an order in POM
when there are concerns regarding communication/cognition, feeding/swallowing, and/or
voice.
Patient’s injuries may lead to short or long-term loss of ability to speak/communicate,
therefore referral to a speech-language pathologist (SLP) is indicated to evaluate for
need and type of augmentative communication (communication board or electronic
device), Passy-Muir speaking valve, or speech therapy. Head trauma can also lead to
cognitive impairments (attention, memory) and/or aphasia in which case a speech
pathologist may perform a cognitive/linguistic evaluation. Long term intubation, placement of a tracheostomy tube, and long term use of nasal tubes can all have a negative
affect on swallowing function and therefore these patients should be considered for
referral to Speech Language Pathology as well.
ASSESSMENTS
Speech-Language Pathology/ Feeding/Swallow Evaluation
Clinical Swallow Evaluation:
Patient is seen at bedside. A comprehensive swallowing evaluation is completed which
includes an oromotor examination and administration of food and liquid consistencies.
Based upon this assessment recommendations may be made for treatment and additional
testing.
Communication Evaluation:
Voice, speech and language, and cognition are assessed. Recommendation regarding
type of treatment or any additional assessment, which may include Passy-Muir valve
evaluation, augmentative communication evaluation/treatment, videostroboscopy or
clinical voice evaluation/treatment, will be made.
Modified Barium Swallow (MBS)
Examination is completed in the radiology department(s) along with a radiologist.
Patient is seated upright and administered trials of various consistencies and is viewed
under fluoroscopy. Evaluation is made of the oral phase and pharyngeal phases of the
swallow. The pharyngeal phase of the swallow is assessed with regard to timeliness of
the swallow, residue in the pharynx, symmetry of pooling/residue, premature spillage of
bolus, number of swallows per bolus, presence or absence of laryngeal penetration,
presence or absence of aspiration, patient response to laryngeal penetration or aspiration.
Based on the examination, recommendations are made by the SLP regarding dietary
textures, swallowing strategies, treatment and further testing. MBS is indicated to
objectively assess the oropharyngeal swallowing mechanism and to assess for
aspiration/risk of aspiration.
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
A speech language pathologist completes examination at bedside. A flexible fiberoptic
scope is placed into the patients nose and advanced to the level of the pharynx in order to
assess structure and function. The patient is presented with trial of food and liquid of
various consistencies. The pharyngeal phase of the swallow is assessed with regard to
timeliness of the swallow, residue in the pharynx, symmetry of pooling/residue, premature spillage of bolus, number of swallows per bolus, presence or absence of laryngeal
penetration, presence or absence of aspiration, patient response to laryngeal penetration
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or aspiration. Based on the examination, recommendations are made by the SLP
regarding dietary textures, swallowing strategies, treatment and further testing. FEES
is indicated to assess the pharyngeal swallow phase and to assess for aspiration/risk of
aspiration. FEES may be recommended when positioning in or transport to radiology
may be problematic, for assessment laryngeal competence (post intubation, tracheostomy), or assessment of secretion management. For some patients, both MBS and
FEES may be indicated.
Videostroboscopy/Comprehensive Voice Assessment
A speech language pathologist completes examination in the videostroboscopy room
on COOP-1. The examination is reviewed with an Otolaryngologist. A rigid scope is
placed into the oral cavity to the level of the pharynx. If the patient is unable to tolerate
the rigid scope orally, a flexible scope may be used nasally. The larynx is viewed under
a constant and a stroboscopic light source. A comprehensive assessment of the laryngeal
structures and function is completed. Based on the examination, recommendations are
made by the speech language pathologist and Otolaryngologist regarding further testing
and treatment. The Otolaryngologist may also suggest other medical or surgical intervention as indicated. Videostroboscopy is indicated when there is concern for laryngeal
pathology. Videostroboscopy allows for more detailed evaluation of the anatomy and
physiology of the larynx/vocal folds. Swallowing is not assessed during a videostroboscopy examination.
Treatment/Therapy
Based upon the results of the evaluations that have been completed, treatment goals will
be established by the SLP to address voice, swallowing, communication and cognition/
language as indicated.
RIH/HCH Speech-Language Pathology Department: Phone 444-5485/Fax 444-6212
Contacts:
Anette Rogers, Manager, Speech-Language Pathology 444-4053
Moira McDonnell, Clinical Coordinator, Speech-Language Pathology 444-4047
Rev. 6/17/08
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Diagnosis of Brain Death: Adult
DEFINITION
An individual who has sustained either:
1. IRREVERSIBLE cessation of circulatory and respiratory function, or
2. IRREVERSIBLE cessation of all function of the entire brain, including the
brainstem, is dead.
A determination of death must be made in accordance with accepted medical standards.
The “uniform determination of death act” implicitly states two critical points:
1. CESSATION of function is recognized by appropriate clinical examination.
2. IRREVERSIBILITY is recognized by persistent cessation of function during an
appropriate period of observation and/or trial of therapy.
THE DIAGNOSIS OF BRAIN DEATH CAN BEST BE DETERMINED BY CLINICAL
EXAMINATION ALONE, provided that complicating conditions are not present.
CLINICAL CRITERIA FOR BRAIN DEATH DIAGNOSIS:
Assuming that no complicating factors exist, the examination is as follows:
I. ABSENT CEREBRAL FUNCTION: Includes no response to stimuli above the
neck.
II. ABSENT BRAINSTEM FUNCTION: Examination of brainstem function
requires appropriate and adequate stimulation:
a. ABSENT PUPILLARY LIGHT REFLEX: No atropine within 12
days.
b. ABSENT CORNEAL REFLEXES: Includes bilateral stimulation.
c. ABSENT VESTIBULO-OCULAR REFLEX: Must be tested with
caloric stimulation. Patient should be in supine position with head
elevated 30 degrees to allow for proper positioning of the horizontal
semicircular canal. A minimum of 200 cc ice water instilled into
each external canal with careful observation of the eyes for any
movement
as well as the extremities for presence of any vestibulospinal induced
movement.
d. ABSENT OROPHARYNGEAL REFLEX (gag reflex)
e. APNEA: Appropriate testing for apnea is extremely important. Most
patients with severe brain damage will have been hyperventilated for
a period of time during the course of their therapy. Therefore, an
appropriate period of time is required to allow for elevation of serum
PaCO2. Hypercarbia with serum PaCO2 greater than 60 mmHg for
30 seconds has been determined as “adequate stimulation” for
respiratory drive.
To apnea test a patient, the patient should be ventilated on 100% FiO2 for 10 minutes.
During this period, the minute ventilation should be adjusted so that the PaCO2 is in the
low 40’s. THE ARTERIAL BLOOD GAS (ABG) SHOULD BE DRAWN AT THE
BEGINNING AND THE END OF THE APNEA TEST AND DOCUMENTED IN THE
CHART. At the beginning of the apnea test, the patient should be put on 100% FiO2
blow by. After a period of five (5) to eight (8) minutes without any spontaneous
respiratory effort, a second ABG is drawn and the patient is put back on the ventilatory
assistance. If the patient does not tolerate the apnea test, as indicated by the development
of hypoxia during the procedure (e.g., O2 saturation less than 80%) or hypotension
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(e.g., systolic blood pressure less than 70 mmHg), then the test should be terminated. In
this circumstance it should be medically documented that the patient did not tolerate the
performance of the apnea test and, therefore, requires a supplementary diagnostic study
to confirm the absence of cerebral blood flow or electrical activity.
PERIPHERAL NERVOUS SYSTEM ACTIVITY AND SPINAL REFLEXES MAY
PERSIST AFTER BRAIN DEATH. TRUE DECEREBRATE OR DECORTICATE
POSTURING, OR SEIZURES, ARE NOT CONSISTENT WITH A DIAGNOSIS OF
BRAIN DEATH. IRREVERSIBILITY is recognized when:
1.
2.
3.
The cause of coma is established and is sufficient to account for the loss of
brain function.
The possibility of recovery of any brain function is excluded. No reversible
conditions exist such as sedation, hypothermia, hyper- or hypoglycemia or
natremia, neuromuscular blockade, or presence of serum toxins or drugs.
The cessation of all brain function, as outlined above, persists for an
appropriate period of observation and/or trial of therapy.
EXAM INTERVAL: Identical examination, including apnea test, and documentation
must be performed. NOTIFY THE NEW ENGLAND ORGAN BANK AT 1-800-4466362 WHEN THE FIRST CLINICAL BRAIN DEATH EXAMINATION IS
PERFORMED. An observation period of at least 12 hours is required once an
irreversible condition has been established (see below). The exam interval may be
reduced to 3 hours if a confirmatory test is also obtained. For anoxic brain death, 24
hours is required. If no complicating factors exist and all criteria on exam as outlined
above have been met on two consecutive examinations, the patient is pronounced dead
BEFORE artificial means of support are terminated. The documented time of death is the
second neurological examination, not when cardiac arrest occurs following removal of
ventilatory assistance.
COMPLICATING CONDITIONS
IF ANY OF THE FOLLOWING FACTORS EXIST, THE CLINICAL EXAMINATION
IS INVALID:
I. DRUG AND METABOLIC INTOXICATION: Cessation of brainstem
function secondary to sedatives, anesthetic agents, street drugs, paralysis with
areflexia, or apnea secondary to disease such as peripheral nerve infectious
process, myasthenia gravis, or neuromuscular blockade must be ruled out.
Patients who have been given thiopental for ICP management or Valium for
sedation or who have experienced alcohol overdose must have a negative urine
and serum toxicology screen.
II. ELECTROLYTE IMBALANCE: Hyperosmolar coma secondary to elevated
glucose (>400), hypo (<125) or hyper (>160) natremia must be corrected.
Hepatic encephalopathy with elevated serum ammonia or preterminal uremia
can also cause deep coma.
III. HYPOTHERMIA: Criteria for reliable recognition for brain death are not available for the hypothermic state. Core temperature must be greater than 34° C.
ADDITIONAL DIAGNOSTIC TESTS
THERE IS NO MEDICAL OR LEGAL REQUIREMENT TO PERFORM ANY
SUPPLEMENTARY DIAGNOSTIC TESTS OTHER THAN TWO CONSECUTIVE
EXAMINATIONS AS DESCRIBED ABOVE UNLESS COMPLICATING
CIRCUMSTANCES EXIST.
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While electrocerebral silence verifies irreversible loss of cortical function in the nontoxic,
normothermic patient, technically “flat-line” EEGs (using 2 micro V/mm gain and
interelectrode resistance of 100 to 10,000 ohms) are extremely difficult to obtain in the
ICU setting with a patient on multiple supportive machines. Furthermore, catastrophic
posterior fossa events with massive brainstem destruction will usually not cause loss of
cerebral blood flow and therefore cortical activity will still exist on EEG. Other tests are
available that assess the cerebral circulation, although only in the hemispheres, including
radioisotope bolus cerebral angiography, gamma camera imaging with radioisotope
cerebral angiography, and transcranial Doppler ultrasonography. Absent cerebral blood
flow as measured by these tests, in conjunction with the clinical determination of
cessation of all brain function for at least 3 hours, is diagnostic of brain death.
Complete cessation of cerebral blood flow to the normothermic adult brain for more than
10 minutes is incompatible with survival of brain tissue. Therefore, documentation of
circulatory failure is evidence of brain death. Four-vessel cerebral angiography can be
performed at anytime and used as a single confirmatory test of brain death. At a
minimum, bilateral internal carotid and one vertebral artery must be injected. When
faced with a trauma victim who has received large doses of pentobarbital, the clinical
examination is invalid and the angiography may be necessary. If no flow exists, the
patient can be declared brain dead at the time of angiographic documentation of no flow.
CERTIFYING PHYSICIANS
There shall be two certifying physicians, both licensed to practice medicine in the state of
Rhode Island. The initial physician (Staff Association or House Staff Association
member) will be on the service where the patient is hospitalized. The second physician
will be a Staff Association member of the Department of Neurology or Neurosurgery.
Physicians who are members of a Transplant Service are specifically excluded from
making a determination of brain death.
At anytime, during this evaluation for brain death, the family may elect to withdraw life
support.
Donors without a Heartbeat: Donation after Cardiac Death (DCD)
Kidney transplantation offers patients with end-stage renal disease a significant survival
advantage as compared with dialysis. Despite the success of kidney transplantation,
however, fewer than 9000 cadaveric kidneys are transplanted each year in the United
States (UNOS data). This is due to the limited number of suitable kidneys that become
available each year. Despite concerted efforts to increase the rate of donation, the
number of cadaveric kidney transplants increased by only 10 percent between 1991 and
2000, with most of the increase resulting from the acceptance of organs from donors over
the age of 50. The shortage of suitable kidney donors is a global problem for the
transplantation community.
It is encouraging that in 2003-2004 the number of deceased donors in the United States
increased nearly 10%, due in large part to the Collaborative Efforts promoted by HRSA,
in which Rhode Island Hospital is a key participant.
Using kidneys from donors whose hearts have stopped beating could expand the number
of cadaveric kidneys available for patients who need a kidney transplant. While only 115
DCD were recorded in 2000, the number of DCD transplants has steadily increased and
in 2004 20% of deceased donor kidney transplants in New England were from DCD.
The incidence of delayed graft function (DGF) is double that of standard brain dead
donors, but the long-term outcomes of renal function and allograft survival are identical.
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Early concerns about the diagnosis of death on the basis of the cessation of cardiac
activity (cardiac death) and the logistics of family consent were addressed by the Institute
of Medicine (IOM), which declared that DCD including the declaration of death after a
period of 5 minutes of asystole is “ethically acceptable”. Every day, families consent to
the donation of organs from a family member for patients who need transplants, thus
transforming the personal tragedy of death into a gift of life for others. The successful
transplantation of kidneys from donors without a heartbeat extends that opportunity to
families that make the difficult decision to discontinue life support.
DCD Procedure (Based on RIH Protocol):
1. Patients 4 - 60 years of age with irretrievable loss of brain function and an established
cause of irreversible damage:
Trauma
Intracranial bleed
Ischemic brain injury
Brain tumor
2. Brain death criteria not fulfilled due to patient hemodynamic instability or persistent
brainstem function (absent cortical function)
3. Family or appropriate decision maker and attending physician agree to:
No further treatment
Continued artificial support is unwarranted
No resuscitation upon asystole (ORM order)
4. Family / decision maker and attending physician agree to withdrawal of support:
(Usually in the form of extubation, discontinue vasopressors and IV fluids)
5. Otherwise suitable organ donor:
Creatinine < 2.0 mg/dL or suitable liver function
6. Notification of potential donor to New England Organ Bank (NEOB)
NEOB: (800) 446-6362
Invitation for NEOB to speak with family for donation consent
7. Obtain Medical Examiner’s permission for donation.
8. Consent obtained by NEOB for DCD organ and tissue removal
9. Notification of potential donor to:
NEOB technical staff
Transplant surgeon
O.R. Staff (Nursing)
10. Preparation for cold perfusion upon declaration of death in ICU or operating room
11. Systemic heparinization (30,000 Units I.V.)
12. Extubate the patient (performed by ICU staff, attending physician or designate).
13. Five-minute period of asystole (absence of electrical activity on cardiac monitor).
14. Declaration of death (performed by patient’s physician or designate).
15. Cannulation of the femoral artery and vein for cold perfusion
16. Transport the donor to the operating room (for donors extubated in the ICU or the
ED):
17. Laparotomy and organ procurement
18. Back table flush, evaluation and storage of organs
19. Contact recipients for admission and transplantation
20. If the patient does not progress to asystole in 60 minutes, organ donation is
abandoned and routine comfort measures continue.
Rev. 9/8/07
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Diagnosis of Brain Death: Pediatric
A determination of brain death must be made in accordance with accepted medical
standards. The Guidelines for the Determination of Brain Death in Children implicitly
states:
1.
2.
Cessation of brain function is recognized by appropriate clinical examination.
Irreversibility is recognized by persistent cessation of function during an
appropriate period of observation and/or trial of therapy.
To declare brain death, there must be two certifying physicians, both licensed to practice
medicine in the state of Rhode Island. The initial physician should be the attending
physician of record or his/her designee. The second should be a staff member in the
Department of Neurology. Physician members of a Transplant Service are excluded from
making a determination of brain death. Two clinical examinations are required separated
by an age-dependent interval (refer to Appendix A).
I.
Absent cerebral function — Complete loss of responsiveness, vocalization and
volitional activity
II.
Absent brainstem function
A. Absent pupillary light reflex; no atropine within previous 12 hours
B. Absent corneal and oculocephalic reflexes
C. Absent oculovestibular reflex. Caloric testing is contraindicated in the presence
of hemotympanum or perforated tympanic membrane. In the absence of all
other brainstem function, if a bilateral exam is contraindicated, a unilateral
exam will be considered diagnostic. A minimum of 25cc ice water should be
instilled into each external auditory canal followed by a 5-minute period of
observation for eye movement in each eye.
D. Absent oropharyngeal reflex (gag reflex)
E. Apnea (see Appendix B for definition and procedure)
F. Absence of spontaneous and purposeful movement, excluding segmental
myoclonus
III. Absence of complicating factors
A. Drug and metabolic intoxication. Depression of brainstem function due to
sedatives, anesthetic agents, street drugs, or neuromuscular blocking agents
must be ruled out by serum/urine toxicology screen and peripheral nerve
stimulation.
B. Electrolyte imbalance. Hyperosmolar coma due to elevated glucose (>400
mg/dl), and hypo- (<125 meq/L) or hyper- (>170 meq/L) natremia must be
corrected. Hepatic and uremic encephalopathy can also invalidate the clinical
exam.
C. Hypothermia. Rectal temperature must be >34º C/93º F.
D. Hypotension. An acceptable, stable blood pressure must be present during the
examination interval (refer to Appendix A for exam intervals).
There is no medical requirement to perform any confirmatory diagnostic tests (such as
serial EEGs or cerebral blood flow study) other than two physical examinations, unless
complicating circumstances exist. If any of the conditions described in section III exist,
the clinical examination alone is invalid.
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In the presence of drug and metabolic intoxication, electrolyte imbalance, hypothermia,
or significant blood pressure instability, confirmatory tests are required. One of the
following tests, in conjunction with the clinical suspicion of cessation of all brain
function for at least three hours, is diagnostic of brain death. A cerebral blood flow or
cerebral artery angiographic study is required in patients in pentobarbital coma.
Documentation of body temperature >34o C/93o F is required at the time of the
confirmatory test.
Confirmatory tests include:
1.
2.
3.
Electrocerebral silence on 2 EEGs in a normothermic/non-intoxicated patient
Absence of cerebral blood flow on radionuclide study
Absence of cerebral artery visualization on 4 vessel cerebral artery angiography
Appendix A: Exam Intervals
The exam interval recommended to determine brain death is chronologic age-dependent:
1. Newborn through 60 days
48 hours
2. 61 days through 12 months
24 hours
3. 13 months through 12 years
12 hours
4. 12 years or older
6 hours
Appendix B: Apnea Test
The following conditions must be met prior to performing an apnea test:
1. Absence of spontaneous respiratory muscle activity
2. Rectal or esophageal body temperature above 34º C/93º F
3. No clinical or laboratory evidence of medications that affect the respiratory center
or neuromuscular function (refer to section III A)
4. Endpoint: To confirm arterial pCO2 >60 mm/Hg and/or arterial pH <7.25
To perform an apnea test, the patient should be ventilated on FiO2 1.0 for 10 minutes.
During this time, the minute ventilation should be adjusted so that the PaCO2 is in the
low 40s and/or the pH is normalized. An arterial blood gas should be drawn at the
beginning and end of the apnea test and documented in the medical record. The patient
should be placed on continuous positive airway pressure (CPAP), FiO2 of 1.0 with end
tidal CO2 monitoring. When CPAP is not feasible, the patient should be removed from
the ventilator and a suction catheter providing an FiO2 of 1.0 placed through the endotracheal tube. The catheter delivering oxygen should remain in the trachea during the
period of testing. After five minutes with no spontaneous respiratory effort, a second
ABG should be drawn. If oxygenation and blood pressure remain stable, wait for ABG
results; if unstable, resume mechanical ventilation.
If the patient does not tolerate the apnea test, as indicated by the development of hypoxia
or hypotension, the test should be terminated. In this circumstance, it should be
documented that the patient did not tolerate the performance of the apnea test. The
decision to obtain a confirmatory diagnostic study to confirm the absence of cerebral
blood flow or electrical activity rests with the neurology and ICU attendings.
This was prepared by the Pediatric Committee on Brain Death and finalized on 12/17/97.
Rev. 9/8/07
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Informed Consent and the Care of the Trauma Patient
The care of the injured patient presents many difficult and unusual challenges not limited
to medical issues alone. Legal matters punctuate the care of trauma patients and cover a
wide range of topics from concerns regarding informed consent, to medical futility and
end of life care, to the concept of urgent medical necessity. Medical practitioners may
find themselves in precarious and unfamiliar legal situations that may be stressful for the
physician and ultimately may hinder the delivery of top-notch care. This section will
serve to answer some of the more common questions regarding informed consent.
Remember, it is essential that complex medico-legal decision be made with attending
physician input and if possible, Risk Management as well. A Risk Manager is on-call
24/7 at 350-5274.
Informed Consent:
True informed consent involves a process whereby a medical professional describes a
proposed therapy to a patient in layman’s terms, states the risks and benefits of the
proposed therapy and alternative therapies. The patient’s questions and concerns must
be addressed and the medical professional has an obligation to ensure that the patient has
a good understanding of the situation, and is able to participate in the process. In trauma
patients altered mental status due to head injury, hypotension, shock, pain, alcohol or
other substances frequently preclude informed consent. In these circum-stances and if
time or the situation will allow, the medical professional has an obligation to contact
next-of-kin NOK (including acquaintances) so that informed consent can be obtained as
long as no urgent life-saving intervention is required. It is inappropriate to delay lifesaving interventions in order to contact NOK or obtain informed consent. Rhode
Island law does not define the hierarchy of NOK for medical decision-making, so that a
spouse, adult child, parent, etc. may serve in this capacity. (For more info see
http://intra.lifespan.org/supportsvcs/Administration/Admin%20137.pdf ). Close friends
or acquaintances may also serve as NOK and may be able to offer insight about a
patient’s wishes regarding healthcare.
Informed Consent in the Impaired Patient:
It is not uncommon for trauma patients to have issues that make obtaining informed
consent difficult if not impossible. In general, if a patient has a life-threatening injury
and will not consent to or comply with medical care (let alone consent to care), the
practitioner is not obligated to abide by the patient’s wishes. However, the patient’s
life should not be put at risk while this contact occurs. If NOK are not immediately
available and a life-threatening condition exists, the physician should proceed with
any necessary interventions. This may include the need to “control” the patient with
physical or pharmacological restraints. The interpretation of a “life-threatening” injury
is problematic and there is little guidance in the law as to what this encompasses, nor is it
clear whether only the suspicion of a life-threatening injury would fall into this category.
In situations where urgent action is required, it is imperative that the attending physician
documents the urgency of the situation and that the procedure was done without consent
on the basis “urgent medical necessity”. While an intoxicated individual may seem
sensible as they vehemently refuse an operation, you must assess their capacity to understand the situation. If you have doubts about their capacity, consult with others on the
team, especially the attending physician, and if time allows a Risk Manager.
Rev. 9/29/07
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Obtaining Consults on the Trauma Service
All consults must be cleared by a trauma attending prior to consultation with the
exception of the following:
1. Neurosurgical consultation for head and spinal trauma.
2. Orthopaedic consultation for fractures.
3. Plastic Surgery consultation for facial fractures.
4. Ophthalmologic consultation for ocular trauma.
5. Echocardiography for penetrating trauma in the “box”.
OT/PT Rehabilitation
The Trauma Service will request Occupational/physical therapy consultation for any
patient with:
•
Major neurological deficit: significant brain injury, spinal cord of radicular
injury or injury of the brachial or lumbosacral plexus
•
Amputation proximal to the digits
•
Fractures expected to delay recovery of ambulation or independent activities
of daily living
•
Burns
•
Deconditioning
If recommended by OT/PT, a rehabilitation medicine consultation will be requested by
calling Dr. Mukand’s office at 456-4556 from Monday through Friday, 8:00am - 5:00pm
as soon as possible after the patient’s admission and/or diagnosis. Name, diagnosis, and
patient location will be helpful.
Urgent adult rehabilitation medicine consultations can be requested by paging the
Medical Director of Southern New England Rehabilitation Center, Dr. Mukand through
the hospital paging operator.
Adult patients with anticipated placement problems will have a prompt initial screening
by personnel from the Southern New England Rehab Center with a note indicating how
they do or do not fulfill admission requirements and what additional information needs to
be obtained to make such a determination.
Any questions concerning adult placement issues will be communicated through the
Rehabilitation Community Liaison, Diane Ventrone, beeper 456-4541, to the Rhode
Island Hospital Case Management staff.
Weekend Pediatric PT/OT Coverage
A therapist is available at Hasbro on weekends and holidays for priority patients who
require PT/OT in order to be discharged over the weekend and for wound/burn patients
in need of continuous whirlpool treatments.
The Children’s Rehab therapist may be reached through the pager operator (4-5611) on
Saturdays, Sundays and holidays from 8:am until noon. Please page the therapist during
these hours with new priority referrals to ensure weekend service and discharge.
Weekend faxed (444-4181) referrals will be acted upon on the next weekday unless the
therapist has been paged.
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Speech/Language Pathology
If one or more of these symptoms is present, referral to Speech/Language Pathology for
a swallowing/dysphagia exam is warranted:
1. History of aspiration, aspiration pneumonia, recurrent bronchitis, chronic
pulmonary disease.
2. Feeding refusal and/or poor appetite.
3. Presence of NG tube, G/J tube or NPO status, question of transition from NG,
G/J tube to oral feeding.
4. Presence of dysphonia and/or laryngeal pathology.
5. Choking/coughing during or after meals.
6. Congested breathing post-feeding.
7. Recent intubation/extubation.
8. Decreased cognitive status interfering with PO intake.
9. Weight loss/failure to gain weight.
10. Patient and/or patient’s family complains of swallowing problem.
11. Swallowing difficulties noted with changing from one food consistency to
another (e.g., from liquids to solids).
12. Presence of dysarthria and/or oral motor difficulty.
13. Wet, gurgle voice noted during and/or post-meals.
14. Weak or absent volitional cough.
15. Diagnosis of brainstem CVA.
16. Presence of tracheostomy tube and/or need for ventilatory support/question
of tracheostomy tube weaning.
17. Patient and/or patient’s family report of “lengthy” meal times.
18. Patient avoids certain food consistencies (e.g., stringy, course textures).
Urology
1. The timing of urologic consultation is dependent upon the patient’s overall
status. Pre-operative urologic consultation should be obtained in those patients
who are hemodynamically stable and present with gross hematuria or
microhematuria with an established genital-urinary system injury. Intraoperative consultation should
be obtained for established renal, bladder, urethral, ureteral and genital trauma
if the overall status of the patient permits such consultation.
2. The work-up of blunt trauma patients with suspected GU injury should include
the following:
a) Patients with suspected urethral trauma with blood at the penile meatus, a
high-riding prostate on exam or a significant pelvic fracture should have a
cystourethrogram performed prior to placement of a Foley catheter. Such
studies should be performed in conjunction with the Trauma Service,
Urology Service and Radiology.
b) Patients with suspected bladder rupture who will undergo a CT evaluation
of the abdomen should have a CT bladder protocol followed. If the patient
does not undergo CT scanning of the abdomen and a suspicion for bladder
injury exists, the patient should have a cystogram.
c) Patients with gross hematuria should have renal evaluation by CT
scanning with IV contrast or an IVP. The Trauma and Urology Services
should jointly manage any abnormalities detected on the above studies.
d) The potential need for pelvic arteriography should be assessed prior to
performance of these studies, as pooled contrast may confound attempts to
angioembolization.
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Neuropsychology (Phone 444-4500, Pager 350-4042)
Inpatient Consultation Subacute Cognitive Impairment
•
Evaluate cognitive status after closed head injury including patients with:
- Loss of consciousness > 20 minutes
- GCS <13
- Head CT or MRI ⊕ for skull fracture, contusion, hemorrhage or DAI
- Significant retrograde or anterograde amnesia
•
Evaluate cognitive status – stable but has not returned to baseline (patients
with GCS of 13-15 if they have):
- Persistent concussive symptoms (e.g. headache, dizziness, nausea)
- Any question of cognitive impairment
- Any abnormalities seen on head CT or MRI
- History of previous head trauma
- Over the age of 50
•
Evaluate cognitive rehabilitation needs for discharge planning
•
Provide education to patient and family about recovery from head injury
(especially mild head injury/concussion)
•
Evaluate decision-making capacity
- Chronic, longitudinal, non-urgent
Patients can be examined and/or educated as long as all the following are present:
•
Patient can follow commands
•
Patient can communicate (at least yes/no responses)
•
Patient is not heavily sedated due to severe non-CNS injuries
Outpatient Neuropsychology Referral
•
Non-urgent evaluation of cognitive functioning following head injury of any
severity
•
3-6 months s/p injury can provide recommendations for rehabilitation and
compensation
•
6 months + s/p injury can address residual or persistent cognitive deficits
Clinical Social Work: (Call 4-5711, or the page operator for CSW on-call)
There is a CSW on-site from 8am-midnight, Monday-Thursday and there is 24 hour
on-site coverage from 8am, Friday-11:59pm, Sunday.
Consultation should be considered for:
•
Supportive psychotherapy
- Patients
- Families
•
Crisis intervention
•
Grief/bereavement, anticipatory grief, death and dying
•
Evaluation of coping behavior
•
Initial diagnostic assessment of anxiety and depressive symptoms (SW can
triage case to psychiatry if needed)
•
Adjustment to illness for patient and/or family
•
Vulnerability of patient
- lives alone
- social isolation
- retardation
- poor coping skills
- physical disabilities
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Social Work: (continued)
Consultation should be considered for:
•
Family violence
- child abuse*
- neglect/abandonment*
- domestic violence
- exploitation
- elder abuse
- sexual abuse*
•
Advocacy in hospital or community for patient and/or family
- Cultural differences
- Discrimination
•
Patients HIV + or with AIDS
•
Community violence
- Gang fighting
- Sexual assault
•
Patient geographically distant from support system
•
DCYF involvement*
*In conjunction with the Child Protection Team (CPT) for pediatric patients
Rev. 7/16/08
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End of Life Issues
1.
2.
3.
4.
5.
The Trauma Attending will be notified immediately of all deaths on the trauma
service.
All deaths on the trauma service are to be reported to the medical examiner.
Death certificates are not to be filled out in cases that will be taken by medical
examiner.
The decision to institute comfort measures only (“CMO” status) or to withdraw
support may be made only by the attending surgeon.
In situations in which brain death determination must be made, please refer to the
brain death protocols for pediatric and adult patients.
Is This Patient a Potential Organ Donor?
According to the Centers for Medicare & Medicaid Services’ latest regulations (42
C.F.R., sec 283.45) and hospital policy, you MUST contact the New England Organ
Bank if a patient has died in the hospital or if you answer yes to any of the following:
; Is death imminent following a severe neurological injury?
• Cerebral vascular accident (CVA)?
• Head trauma?
• Intracranial hemorrhage?
• Anoxic encephalopathy?
• Brain tumor (non-metastatic)?
; Does the patient exhibit early signs of brain death?
• Pupils fixed and dilated?
• No corneals?
• No withdrawal to pain?
• No gag? No cough?
; Is the patient ventilator-dependent with the likelihood of death upon extubation?
YES to any of the above questions requires a referral to the:
New England Organ Bank
1-800-446-6362
Rev. 7/11/07
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Notes
Notes