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TRAUMA

RESIDENT
HANDBOOK

Elvis Presley Memorial Trauma Center


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

1
These policies are intended to serve as
guidelines only. Individual
circumstances must be considered, and
there may be times when it is
appropriate or desirable to deviate from
these guidelines. They should not be
considered to be accepted protocol or
policy, nor are they intended to replace
clinical judgment or to dictate care of
individual patients. These educational
guidelines will be reviewed and updated
routinely.

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

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Trauma Service Policies

Welcome to the Trauma Service. To ensure optimal patient care as well as a


productive educational experience, the following guidelines have been formulated by
the Trauma staff. 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.

General Policies

1. A complete and accurate trauma history and physical is required for all trauma
admissions. There are no exceptions.
2. A complete daily Trauma Service note in SOAP format addressing all problems
and containing all laboratories and other studies obtained is required on each
patient on the Trauma Service.
3. The trauma team is expected to respond to all Shock/Trauma room admissions.
Dismissal from the trauma room is at the discretion of the senior trauma resident.

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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. In order to comply with the work hour
restrictions, all residents are excused after turnover rounds following their night on
call.

Aside from the PGY-5 Trauma Resident, there is also a PGY-3/4 Trauma Resident, a
PGY-2 Trauma Resident, two PGY-1 Trauma Residents, and rotating medical
students. There are also two Surgical Critical Care fellows and at least one Nurse
Practitioner. The daily responsibilities of the resident are as follows:

PGY-5 Trauma Resident


1. Initial response to all patients triaged to the Shock/Trauma Room.
2. Management of resuscitation in the Shock/Trauma Room.
3. Daily management of trauma patients.
4. Primary operative responsibility for trauma patients.
5. Overseeing junior residents’ daily activities.
6. Detailed turnover rounds to the other chiefs when they assume call.
7. Trauma Conference coordination.

PGY-3/4 Trauma Resident


1. Daily management of TICU patients.
2. Assisting with resuscitation in the Shock/Trauma Room.
3. Detailed turnover rounds to the other TICU residents when they assume call.
4. Performing bedside procedures on TICU patients in conjunction with the Trauma
attending and/or fellow.

PGY-2 Trauma Resident


1. Management of patients in CCA.

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2. Assisting with resuscitation in the Shock/Trauma Room.
3. Emergency room consultations.

PGY-1 Trauma Residents


1. Management of patients on the 4th floor ICUs in conjunction with the fellow and the
Nurse Practioner.
2. Assisting in Shock/Trauma Room resuscitations and recording the history and physical
exam.
3. Management of patients on the floors in conjunction with the chief.
4. Coordination of discharge planning with the case managers.

Medical Students’ Daily Responsibilities


1. Assisting in care of Shock/Trauma Room patients as dictated by the chief, fellow, and
attending.
2. Assisting in care in CCA as dictated by the CCA Resident.

Surgical Critical Care fellows


1. Assist with management of Shock/Trauma patients.
2. Assist the operating surgeon (if appropriate).
3. Assist the ICU residents in critical care management.
4. Assist the Nurse Practitioner with management of Trauma Step-down patients.
5. Assist the CCA resident as appropriate.
6. Serve as continuity liason between Trauma service and attendings.

Nurse Practitioners
1. Management of CCA patients in conjunction with the CCA resident.
2. Management of Trauma Step-down patients in conjunction with the fellow.
3. Assist the floor resident with patient management and discharge planning.

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Rotation Goals

PGY-1
1. Learn initial management of trauma patients to include ATLS.
2. Learn resuscitation techniques, goals and end points.
3. Use appropriate diagnostic modalities commonly employed in the evaluation of trauma
patients.
4. Become proficient in various procedures to include diagnostic peritoneal lavage, closed-
tube thoracostomy, central line placement, placement of pulmonary artery catheter and
interpretation of the values, tracheostomy, and feeding tube placement.
5. Learn post-injury patient care and facilitate timely and appropriate patient discharge.
6. Learn the basics of surgical critical care in conjunction with the fellow and attending.

PGY-2
1. Learn initial management and resuscitation of major trauma patients in conjunction with
the Chief Trauma Resident.
2. Assist in surgical intervention in trauma patients.
3. Learn how to evaluate surgical patients in the ER.

PGY-3/4
1. Obtain proficiency in evaluation and management of all trauma patients.
2. Become proficient in various procedures to include bedside fiberoptic bronchoscopy,
bronchoalveolar lavage, arterial cannulation.
3. Become proficient in operative management of patients with significant trauma.
4. Become proficient in the care of critically injured ICU patients.
5. Become proficient with various vasoactive agents in management of critically injured
patients.

PGY-5
1. Obtain proficiency in evaluation and management (including operative management) of
all trauma patients.
2. Assume the leadership role on the Trauma Service.

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Surgical Critical Care fellows

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

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Rounding Schedule For 2005-2006

Main Call Attending


Responsible for daily rounds and procedures in the TICU, GICU, and
Shock/Trauma admissions

Second Call Attending


Responsible for daily rounds and procedures on the floor, Trauma Step-down,
and patients in CCA. This attending will also staff the Trauma Clinic on
Tuesday and Thursday.

Teaching Rounds
Tuesdays at 8:00 a.m. All members of the Trauma Service (fellows, residents
and students) are expected to attend.

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Conferences and Clinics

The Trauma Service is expected to attend these and all other applicable general surgical
conferences:

Attending Teaching Rounds


* ALL Trauma team members are expected to be present *
Tuesday, 8:00 a.m., TICU

Trauma Conference
Thursday, 7:30 a.m.
Radiology Conference Room
2nd Floor Chandler
Week 1: Trauma/Critical Care
Week 2: Orthopedics
Week 3: Neurosurgery (Ground floor Adams)
Week 4: Trauma M & M (fellows responsible for case selection)
Week 5: Case presentations

Trauma Clinic (4th floor MedPlex)

Tuesday, 9:00 a.m. – 12:00 p.m.


Thursday, 9:00 a.m. – 12:00 p.m.

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Service Assignments and Interservice Transfer Guidelines
To facilitate patient care and to eliminate potential misunderstandings between various
services caring for trauma patients, the following guidelines have been established
regarding admission to and transfer of trauma patients between services.

1. Patients with multiple system injuries or hemodynamic instability will be admitted to the
Trauma Service.

2. Patients with unisystem injury without a mechanism for potential multiple system injuries
may be admitted to the pertinent service if both attendings (Trauma and other service)
agree, and the Trauma Service may be consulted to provide the Critical Care services. In
general, patients may be admitted to the Trauma service for a 24 hour observation period
prior to transfer.

3. Patients with unisystem injuries with a mechanism for potential multiple system injuries
will be admitted to the Trauma Service if evaluation for occult injuries is ongoing. Reasons
to remain on the Trauma Service with unisystem injuries include hemodynamic or
respiratory instability, or occult injuries still in the process of being ruled out.

4. Patients with unisystem injury may be transferred to another service when the following
general criteria are met:
a. they are tolerating a diet and having bowel function;
b. they no longer need central venous access*;
c. they no longer require a Foley catheter*;
d. they are deemed ready by the Trauma attending and the other service.
Once a patient is transferred from the Trauma Service to another service, Trauma Service
followup will continue for at least three days post-transfer. Results of these visits will be
documented in the patient's medical record.
• exceptions may be made after agreement with all services

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Universal Precautions in the Trauma Rooms
• All physicians, nurses, employees, students, and observers are required to wear all of
the following with all patients in trauma rooms:

1. Gloves
2. Gowns for procedures
3. Masks
4. Eye Coverings
5. Head covers

• Non-compliance with Universal Precautions may result in disciplinary action. OSHA


standards require compliance.

• The patient’s privacy will be respected under all circumstances. Therefore,


identifiable pictures and cell phone pictures are NOT allowed. However, pictures taken for
medical reasons are allowed.

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Criteria for Triage to Shock / Trauma Room

Physiological Alterations
• Trauma Score ≤ 13
• Known GCS <14
• Core temperature <28° C or <82° F
• Abnormal vital signs: SBP <90, pulse <60 or >120, respirations <10 or >30
Mechanism of Injury (assumes physiological stability)
• Strangulations/hangings
• GSW/SGW of head, neck, torso
• Penetrating injuries of extremities with neurovascular deficit
• Stab wounds of head, neck, torso
• Steering wheel/windshield deformity
• Fatality within the vehicle
• Rollovers/ejection from vehicle
• Pregnant patients when history is suggestive of major trauma
• Intoxicated patients when history is suggestive of major trauma
• Blunt trauma with complaints relative to abdomen or thorax
• Extrication time > 20 minutes
• Intrusion of space > one foot
• Falls > 15 feet
• Pedestrian struck
• Motorcycle crash

Anatomical Alterations

• Airway obstruction • Depressed skull fracture/scalp avulsion


• Pelvic instability • Maxillofacial trauma, severe
• Significant bleeding • Spinal cord injuries
• Crush (major) injury • Subcutaneous emphysema, massive
• CSF leak • Tension pneumothorax
• Flail chest • Major amputations (not fingers/toes)
• Open long bone fracture • Multiple long bone deformities

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Routine Trauma Labs: Adult

The following laboratory tests should be ordered for all adult surgical trauma patients evaluated
in the trauma rooms:

• CBC with differential


• Trauma BMP (to include total bilirubin, ALT, AST)
• P-amylase
• INR
• Lactate
• Arterial blood gas
• UA -- also UCG in female patients
• Type and screen. Type and crossmatch only for any patient who receives
uncrossmatched blood (“red tag”) for resuscitation in Shock/Trauma, or any patient going
directly to the OR from Shock/Trauma.

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Consults

Facial fractures
Alternates weekly

 Plastic and Reconstructive surgery


 Oral and Maxillofacial surgery
 Otolaryngology

Hand injuries
Alternates weekly

• Plastic and Reconstructive surgery


• Orthopedic surgery

Spine injuries
Alternates daily

• Orthopedic surgery (patients admitted on odd days)


• Neurosurgery (patients admitted on even days)

Pregnant patients

• Obstetrics – preferably notify prior to arrival

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Cervical Spine Clearance

Blunt neck trauma

Awake, alert, no distracting Altered mental status, or


injuries, asymptomatic, multiple system injury, or
NEUROLOGICALLY NORMAL awake with cervical pain or tenderness, or
clinical signs of spinal cord injury

No neck pain
AND AP, Lateral,
No tenderness Odontoid plain films
to palpation

Poorly visualized area Adequate,


or abnormal normal films
C-spine cleared
(document on chart),
remove collar
CT scan C-spine

Normal Abnormal

MRI of affected
area

Leave collar on and consult Orthopedics (admission date an odd day)


or Neurosurgery (admission date an even day) for evaluation

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Spinal Cord Injury with Neurologic Deficit

Penetrating Blunt

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

45 minute steroid free pause

Continuous infusion 5.4mg/kg/hr for 23-47 hours*


23 hours if started 0-4 hours after injury
47 hours if started 4-8 hours after injury

Obtain CT of affected area Obtain MRI of affected area

Strict log roll


Take off backboard *In conjunction
Keep in cervical collar if cervical with Orthopedics/
injury or altered sensorium Neurosurgery

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

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Dermatomes

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Sensory Levels

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Standard Neurological Classification of Spinal Cord Injury
MOTOR
KEY MUSCLES
R L
C2
C3
C4
C5 Elbow flexors
C6 Wrist extensors
C7 Elbow extensors
C8 Finger flexors (distal phalanx of middle finger)
T1 Finger abductors (little finger)
T2
T3 0 = total paralysis
T4 1 = palpable or visible contraction
T5 2 = active movement,
T6 gravity eliminated
T7 3 = active movement,
T8 against gravity
T9 4 = active movement,
T10 against some resistance
T11 5 = active movement,
T12 against full resistance
L1 NT = Not testable
L2 Hip flexors
L3 Knee extensors
L4 Ankle dorsiflexors
L5 Long toe
extensors
S1 Ankle plantar
flexors
S2
S3
S4-5 Voluntary anal contraction (Yes/No)

TOTALS + = MOTOR SCORE

maximum 5 50 100
0

NEUROLOGICAL R L COMPLETE OR INCOMPLETE?


LEVELS SENSORY Incomplete = Any sensory or motor function
in S4-S5
The most caudal MOTOR
segment with ASIA IMPAIRMENT SCALE
normal function

American Spinal Injury Association ©1996

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SENSORY
KEY SENSORY POINTS

Light Pin
Touch Prick
R L R L
C2 0 = absent
C3 1 = impaired
C4 2 = normal
C5 NT = not testable
C6
C7
C8
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
L2
L3
L4
L5
S1
S2
S3
S4-5 Any anal sensation (Yes/No)

+ = PIN PRICK SCORE Max: 112


TOTALS { ↓ ↓
+ = LIGHT TOUCH SCORE Max: 112
Maximum 56 56 56 56

ZONE OF PARTIAL R L

PRESERVATION SENSORY
Partially innervated segments

MOTOR

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Blunt Cerebrovascular Injury

Appropriate mechanism with


• Unexplained neuro deficit (inconsistent with CT)
• Horner’s syndrome
• LeFort II or III (unilateral or bilateral)
• Cervical spine injury, including transverse process
fractures C-1 – C-6
• Neck soft tissue injury

CT angiogram

4 vessel cerebral angiogram

Carotid injury Vertebral injury

Neurosurgery Neurosurgery
consult consult

**In conjunction
Treatment** with Neurosurgery Treatment**

Heparin** if no contraindication Aspirin ± Plavix**


(preferred for carotid & complex (ASA only if
vertebral injuries) vertebral occluded
Start @ 1000 units/hour – NO bolus with back-fill)

Repeat angiogram in
st
Serial PTT, 1 value 4 14 days and/or 6
hours after drip started weeks if necessary
then q8hrs
Conversion to Coumadin or antiplatelet
Goal is 1.5-2.0 x normal
therapy depending on pathology/clinical
course for at least 6 weeks, follow up in
Trauma Clinic and with Neurosurgery

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Penetrating Neck Injury

Hemodynamically unstable
*May benefit from Expanding hematoma
diagnostic test Excessive bleeding
such as plain lateral Dysphonia* To OR
c-spine X-ray, Dysphagia*
barium swallow, Air leak from wound
bronchoscopy, or Tracheal deviation
laryngoscopy Retropharyngeal air*

Platysma Violation
DO NOT PROBE WOUND!

Zone I Zone II Zone III

unstable stable unstable stable unstable stable

To OR To OR To OR

4 vessel cerebral angio, +/-


arch angiogram, barium
swallow

Injury No Injury

TO OR Observe

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Blunt Aortic Injury

Appropriate mechanism of injury

Chest CT

Positive Negative Mediastinal


hematoma

Control Continue Control


BP & HR* work-up for BP & HR
other injuries

Appropriate
sedation Arch aortogram

Positive Negative

Vascular Surgery
and/or Thoracic Stop BP &
Surgery consult
HR control

Appropriate mechanism of injury includes high speed impact injuries (MVC, MCC, fall, decelerating blunt
injury).
*BP & HR goals: systolic BP ≤120 mmHg, HR <90. Obtain ECG prior to β−blockade therapy
Medications:
Esmolol: 0.5 mg/kg IV loading dose over 1 minute, then 0.05 mg/kg/min over 4 minutes, then 0.1
mg/kg/min; titrate to HR <90.
Advantage: very short half life (9 minutes)
Disadvantage: side effect of hypotension may require cessation of therapy
Labetalol: 10-20 mg IV slowly followed by continuous IV infusion of 1-2 mg/min. Additional bolus dose
of 20 mg may be given up to a total of 300 mg. Continuous infusion must be titrated to the desired
endpoints.
Advantage: blockade of α and β with single agent therapy
Disadvantage: half life 5-8 hours
Nitroprusside: 0.3 mcg/kg/min initial dose, then titrate to BP goal. Maximum dose is 10 mcg/kg/min.
Advantage: extremely short half life
Disadvantage: can increase dP/dT and cause reflex tachycardia. NEVER use without
β−blockade therapy.

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Emergent Thoracotomy

Mechanism of Injury

Blunt Penetrating*

No vital signs in Loss of vital No vital Loss of vital


route or in signs in route or signs or CPR signs in route or
Shock/Trauma in Shock/Trauma > 20 minutes in Shock/Trauma

Pronounce Cardiac Pronounce


ultrasound

Negative Positive Emergent


thoracotomy

* Only for penetrating wounds to the upper abdomen or chest (“cardiac box”).
Resuscitative thoracotomy for penetrating abdominal wounds without suspicion of
cardiac injury is not indicated.

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Hemothorax Management

Place Chest Tube

Daily Chest X-Rays


48 Hours
Yes
Remove Tube Clot Resolved
No
CT Chest
Yes

No 1) Residual clot > 500cc OR


Clot Resolved 2) Residual clot occupies >1/3 of thoracic cavity OR
3) Unchanged
No
Yes
1
Repeat CT Chest in 48 hours Candidate for VATS?

Yes No

2
No
VATS Candidate for TPA infusion per chest tube? Place Second
Chest Tube
Yes
Infuse TPA per chest tube q 24 hours x 3 days
(check daily Chest x-ray)
Clot Resolved
Daily Chest X-Rays
Repeat CT Chest
48 Hours

Yes Repeat CT Chest


Remove Tube Clot Resolved
No

Repeat TPA infusion x 3 days


(check daily chest x-ray) 1
VATS Contraindications
1) Coagulopathy
2) Hemodynamic instability
Clot Resolved Repeat CT Chest 3) Inability to tolerate single
lung ventilation

2
TPA Infusion Protocol TPA Contraindications
1) Obtain HCT, PT, PTT prior to infusion (if abnormal consider not using rTPA) 1) Active bleeding OR
2) Mix 4mg of rTPA (Reteplase ) in 50cc sterile saline. 2) CVA in past 30 days OR
3) Instill mixture into chest tube and flush tube with 50cc of sterile saline. 3) Intracranial hemmorhage OR
4) Clamp chest tube for 4 hours (observe patient for 10 minutes for problems 4) Intracranial Neoplasm OR
with breathing). 5) Coagulopathy OR
5) Mobilize patient. 6) Pregnancy OR
6) Check HCT, PT, PTT 1 hour after infusion (if significantly changed from 7) Chest tube with air leak
baseline, consider stopping infusion)
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Blunt Abdominal Trauma
Hemodynamically unstable

Physical exam

F.A.S.T. DPL

Large amount Scant/no fluid Grossly Microscopically Microscopically


of fluid in in abdomen positive* positive for positive for
abdomen RBC* WBC*

To OR To OR To OR

Consider DPL if
unstable

Continue
search for
other sources
of hemorrhage

*Criteria for positive DPL:


Grossly positive - >10cc blood
RBC - >100,000 cells
WBC - >500 cells at least 1 hour after injury

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Blunt Abdominal Trauma
Hemodynamically stable

Physical exam

Reliable, awake, alert, Unreliable, abnormal


no distracting injuries mental status,
distracting injuries

Nontender Tender

CT scan

Observation CT scan
period

Remains Normal Abnormal2 Normal


nontender

Discharge1 Admit for 23 Admit, Admit,


hour follow treat other
observation protocols injuries

1
If any doubt, admit the patient for at least 23 hours
2
May require DPL or other evaluation depending on findings

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Antibiotics for
Penetrating Abdominal
Trauma

Penetrating abdominal
injury requiring
laparoscopy/laparotomy

Ertapenem 1 gram IV
prior to skin incision

No hollow organ Hollow organ


injury injury

No further
No further dosing
antibiotics

*For patients with penicillin allergy, give ciprofloxacin 400 mg IV every


12 hours (2 total doses for hollow organ injury, only the preop dose
for no hollow organ injury) and metronidazole 500 mg every 6 h (4
total doses for hollow organ injury, only the preop dose for no hollow
organ injury)

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Anterior Abdominal Stab Wounds

Hemodynamically stable,
nontender abdominal exam

Yes No

Local wound To OR
exploration

Violation of Definitely no Equivocal


anterior fascia violation of violation of
anterior fascia anterior fascia

To OR for Discharge To OR for


laparoscopy/ laparoscopy/
laparotomy laparotomy

For the cooperative patient,


consider awake laparoscopy in
Shock / Trauma

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Nonoperative Management of Blunt Liver Injury

Hemodynamic stability mandatory for


nonoperative management

CT scan

Grades 1,2,3 Becomes Grades 4,5


unstable

Stable Stable
OR

Admit to floor, ICU *


observe, AM Hct Abdominal pain,
jaundice,
unexplained signs
Stable,
of infection
*ICU- improving
serial Hct q6h,
close observation
CT scan
DC from
Pseudoaneurysm ICU
Improved,
Abdominal unchanged
fluid collection
Angiography for
embolization Search other sources
Consider
drainage Quantitation of hemoperitoneum
Small- perihepatic
Moderate- Small + paracolic gutter
Outpatient management Large-Moderate + pelvis

Grade 1,2,3 Grade 4,5 Repeat CT 1 month

Repeat CT 1 month if healed Not healed


pain or jaundice

Ad lib activity Light duty - repeat CT


1 month until healed

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Nonoperative Management of Blunt Splenic Injury

Hemodynamic stability mandatory for


nonoperative management

*ICU-
serial Hct q6h, CT scan Pseudoaneurysm
close observation

Angio-
Age ≥ 50 Becomes Age < 50 embolization
unstable

Grade 3-5 Grade 1,2 OR Grade 1 Grade 2-5

ICU* Floor ICU*

F/U CT 24
Large Small, moderate hours
hemoperitoneum hemoperitoneum

Stable, Worse
OR ICU* improving

Quantitation of hemoperitoneum: Floor Stable Unexplained


Small – perihepatic/splenic blood loss
Moderate – small + paracolic gutter
Large – moderate + pelvis
Consider
OR
splenectomy
Outpatient Management

Grade 1,2 Grade 3-5

Healed CT in 1 month Not healed


CT if
clinically
indicated
Activity ad lib Light duty, repeat CT in 1
month if indicated

32
Pancreatic Injury Management

Pancreatic Injury

Proximal to mesenteric Distal to mesenteric


vessels (right) vessels (left)

Duct injury

No Indeterminate Yes

Low High
probability probability
Drain

Resection + drainage

High probability of ductal injury:


- direct ductal visualization
- complete pancreatic transection
- >50% pancreatic laceration
- severe maceration
- pancreatic fluid leak

33
AAST Spleen Injury Scale

Grade* Injury type Description of injury


Hematoma Subcapsular, <10% surface area
I
Laceration Capsular tear, <1cm parenchymal depth
Subcapsular, 10%-50% surface area;
Hematoma
intraparenchymal, <5 cm in diameter
II
Capsular tear, 1-3cm parenchymal depth that
Laceration
does not involve a trabecular vessel
Subcapsular, >50% surface area or expanding;
ruptured subcapsular or parecymal hematoma;
Hematoma
intraparenchymal hematoma > 5 cm or
III
expanding
>3 cm parenchymal depth or involving trabecular
Laceration
vessels
Laceration involving segmental or hilar vessels
IV Laceration producing major devascularization (>25% of
spleen)
Laceration Completely shattered spleen
V
Vascular Hilar vascular injury with devascularizes spleen

*Advance one grade for multiple injuries up to grade III

34
AAST Liver Injury Scale

Grade* Type of Injury Description of injury


Hematoma Subcapsular, <10% surface area
I
Laceration Capsular tear, <1cm parenchymal depth
Subcapsular, 10% to 50% surface area:
Hematoma
intraparenchymal <10 cm in diameter
II
Capsular tear 1-3 parenchymal depth, <10 cm in
Laceration
length
Subcapsular, >50% surface area of ruptured
Hematoma subcapsular or parenchymal hematoma;
III
intraparenchymal hematoma > 10 cm or expanding
Laceration 3 cm parenchymal depth
Parenchymal disruption involving 25% to 75%
IV Laceration
hepatic lobe or 1-3 Couinaud’s segments
Parenchymal disruption involving >75% of hepatic
Laceration lobe or >3 Couinaud’s segments within a single
V lobe
Juxtahepatic venous injuries; ie, retrohepatic vena
Vascular
cava/central major hepatic veins
VI Vascular Hepatic avulsion

*Advance one grade for multiple injuries up to grade III

35
AAST Kidney Injury Scale

Grade* Type of Injury Description of injury


Microscopic or gross hematuria, urologic studies
Contusion
normal
I
Subcapsular, nonexpanding without parenchymal
Hematoma
laceration
Nonexpanding perirenal hematoma confirmed to
Hematoma
renal retroperitoneum
II
<1.0 cm parenchymal depth of renal cortex without
Laceration
urinary extravagation

>1.0 cm parenchymal depth of renal cortex without


III Laceration
collecting system rupture or urinary extravagation

Parenchymal laceration exteding through renal


IV Laceration
cortex, medulla, and collecting system
Laceration Completely shattered kidney
V
Main renal artery or vein injury with contained
Vascular
hemorrhage
Avulsion of renal hilum which devascularizes
VI Vascular
kidney

*Advance one grade for bilateral injuries up to grade III

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Pelvic Fracture Management

Orthopedics Initial assessment & A-P pelvic x-ray


consult

Exsanguinating Marginal Hemodynamically


hemorrhage hemodynamic stability stable
(BP~ <70) (BP~ 90-110) (BP~ >110)

Open Closed fracture Supraumbilical Algorithm for


fracture DPL, F.A.S.T stable blunt
abdominal
OR Supraumbilical trauma
DPL, F.A.S.T
Positive Negative

Positive Negative
T-pod T-pod

T-pod T-pod OR CT

OR

Continued
hemodynamic
instability

Angiography

37
Tile Classification of Pelvic Fractures
Type A – Stable fractures

A1 Fractures not involving ring; avulsion injuries


A2 Stable, minimal displacement; iliac wing, isolated rami
A3 Transverse fracture of sacrum
Type B – Rotationally unstable, but vertically and
posteriorly stable
B1 External rotation instability; open book injury
B2 Internal rotation instability; lateral compression injury
B3 Bilateral rotationally unstable injury
Type C – Rotationally, posteriorly, and vertically
unstable
Unilateral injury; ileal fracture, SI disruption, sacral
C1 fracture
Bilateral injury; one side rotationally unstable, one side
C2 vertically unstable
C3 Bilateral injury; both sides completely unstable

38
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
Can ligate if isolated injury, but at least 50%
mortality rate secondary to massive fluid
Portal vein Repair
sequestration in splanchnic vascular bed and bowel
necrosis
Right renal vein Repair Cannot ligate - fewer collaterals 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
Ligate Especially if proximal to gastroduodenal branch
arteries
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
Can ligate but need to ensure patency of other leg
Tibial arteries Repair
arteries
Can ligate if distal to profunda brachi branch since
Brachial artery Repair
the elbow has rich collateral blood flow
Can ligate but need to ensure patency of other artery
Radial/ulnar arteries Repair
and palmar arch

39
Neurovascular Injuries Associated with Fractures or
Dislocations
Orthopedic Injury Neurovascular Injury
Anterior shoulder dislocation Axillary nerve, axillary artery
Humeral shaft fracture Radial nerve
Supracondylar humeral
Brachial artery
fracture
Distal radius fracture
Median nerve
Perilunate dislocation
Posterior hip dislocation Sciatic nerve
Supracondylar femur fracture
Popliteal artery
Posterior knee dislocation
Popliteal artery, tibioperoneal
Tibial plateau fracture
trunk
Proximal fibula fracture Peroneal nerve

40
Fracture/dislocation of Extremity

Equal pulses, Pulse deficit, ABI


ABI ≥ .7 < .7

Orthopedics consult, Orthopedics consult,


reduce injury reduce injury

Pulses still equal Pulses equal Pulse deficit

Orthopedics Angiogram in
management of operating
injury room

41
Chart of Muscle Groups and Nerve and Nerve Root Supply
Muscle Nerve Root Nerve
Cervical flexors C1 – C4
Cervical extensors C1 – C4
Trapezius Cranial nerve XI
Sternocleidomastoid Cranial nerve XI
Arm abduction
0 – 15o, supraspinatus
C4 – C6 Suprascapular
15 to 90o, deltoid
C5 – C6 Axillary
>90o, trapezius & serratus
C5 – C7 Long thoracic
anterior
Biceps C5 – C6 Musculocutaneous
Forearm supination C5 – C6 Musculocutaneous
Forearm pronation C6 – C7 Median
Wrist flexors C7 – C8, T1 Median
Wrist extensors C6 – C8 Radial
Hand intrinsics C7 – T1 Median and Ulnar
Hip flexion L1 – L3 Femoral
Hip extension L4 – S1 Sciatic
Thigh abduction L4 – S2 Superior gluteal
Thigh adduction L2 – L4 Obturator
Leg flexion L4 – S2 Sciatic
Leg extension L2 – L4 Femoral
Superficial peroneal and
Foot plantar flexion L5 – S1
tibial
Foot dorsiflexion L4 – L5 Deep peroneal
Great toe extension L4 – L5, S1 Deep peroneal
Foot inversion L4 – L5 Deep peroneal
Foot eversion L5 – S1 Superficial peroneal
Rectal spinchters S2 – S4 Pudenal

42
Mangled Extremity Severity Score

Skeletal / soft-tissue injury


Low energy (stab; simple fracture; pistol gunshot wound) 1

Medium energy (open or multiple fractures, dislocation) 2

High energy (high speed RTA or rifle GSW) 3

Very high energy (high speed trauma + gross contamination) 4

Limb ischemia
Pulse reduced or absent but perfusion normal 1*

Pulseless, paresthesias, diminished capillary refill 2*

Cool, paralyzed, insensate, numb 3*

Shock
Systolic BP always > 90 mm 0

Transient hypotension 1

Persistent hypotension 2

Age (years)
< 30 0

30-50 1

> 50 2

* Score doubled for ischemia > 6 hours

The MESS is the sum of scores from each category. Scores < 7 are associated with limb
salvage, Scores > 10 are associated with primary amputation. Outcome is variable for
scores 7-10.

43
Diagnosis of Ventilator Associated Pneumonia

Indications for bronchoscopy with bronchoalveolar lavage (FOB + BAL)

- Patient must have at least three of the following:

1. Fever (temperature > 100.5) or hypothermia (T < 96)


2. Abnormal WBC (>10,000, <4,000, or >10% bands)
3. Purulent sputum
4. New or changing infiltrate on chest x-ray

BRONCHOSCOPY + BAL TECHNIQUE


1. Routine suctioning with in-line catheter of the upper airway until clear.
2. Increase FiO2 to 100%, change IMV rate if necessary.
3. Sedate patient as necessary. Pharmacologic paralysis is NOT necessary.
4. Advance bronchoscope into affected lung segment (as seen on CXR) or
LLL (if bilateral infiltrates). DO NOT USE SUCTION OR CONNECT
SUCTION LINE TO BRONCHOSCOPE.
5. Scope should be advanced to the smallest bronchial segment possible to
perform BAL.
6. Use 100cc sterile nonbacteriostatic saline in 20cc aliquots. Inject 20cc
then immediately aspirate and pool the effluent for quantitative cultures.
7. Follow up with chest radiograph.
8. Proceed to VAP Pathway for treatment.

44
Trauma ICU Ventilator-Associated Pneumonia Clinical Pathway
Diagnosis and Empiric Management

Clinical Suspicion of VAP †

Fiberoptic Bronchoscopy with BAL

Empiric antibiotic therapy based on timing of ICU admission

>7 days in ICU


<7 days in ICU
Vancomycin 20mg/kg IV q12h * +
Ampicillin/sulbactam (Unasyn®) 3g IV q6h *
Cefepime 2g IV q8h *

Preliminary culture results >24 hours

No growth to date Insignificant Significant


(1-99,999 cfu/mL) (≥100,000)

Continue empiric Discontinue antibiotic Streamline antibiotic


antibiotic therapy therapy** therapy**

Final culture results

<100,000 cfu/mL >100,000 cfu/mL

Empiric therapy discontinued Definitive antibiotic therapy


(see Definitive Therapy Pathway for TICU)


Defined as the appearance of a new or changing infiltrate on chest radiograph and at least 2 of
the following:
o o
−Abnormal temperature (>38 C or <36 C);
3 3
−Abnormal white blood cell count (>10,000 cells/mm or <4000 cells/mm or the presence of >10%

immature bands);
−Macroscopically purulent sputum

-If severe beta-lactam allergy, change: Unasyn to Levofloxacin 750 mg IV Q24H, Cefepime to
Ciprofloxacin 400 mg IV Q8H; dosage adjustment may be necessary based on renal function

**Continue to monitor for changes in Final culture results


45
Trauma ICU Ventilator-Associated Pneumonia Clinical Pathway
Definitive Therapy

Early VAP?
(≤7 days in ICU)

Yes No

Continue Antibiotics for 7 full days† Repeat BAL on Day 4 of Adequate


Antibiotic Therapy *

VAP pathogen(s)
<10,000 cfu/mL? †

Yes No

Discontinue Continue Antibiotics


Antibiotics for 10-14 days

* Adequate antibiotic therapy is antibiotic therapy with in vitro activity against the
pathogen. Patients extubated or not eligible for repeat BAL should be treated for 7 full
days (consider 10-14 days if Pseudomonas or not responding clinically)
** Consider treatment for 10,000 cfu/mL in severely injured patients with Pseudomonas
and/or Acinetobacter

Use final culture result.
††
Continue antimicrobial therapy in patients with septic shock
† Pseudomonas requires a follow-up BAL regardless of being early or late VAP

46
Guideline for the Prevention of Venous Thromboembolism in Critically ill Patients
Approved by Pharmacy and Therapeutics Committee May 2004

Baseline CBC, BMP, PTT, and PT/INR


1

Contraindication to heparin pharmacotherapy? [A]


examples include:
2 Sequential compression
• Traumatic brain injury with progression on head devices (preferred) or A-V foot
• Active hemorrhage
• Recent hemorrhagic stroke
CT >24h post-injury (consult neurosurgery) Yes pumps. Consider serial duplex
• Hx of Heparin-induced Thrombocytopenia (HIT) ultrasound in high-risk patients
• INR > 1.6
• Epidural catheter present (consult anesthesia)
• PTT > 60 sec
9
• Platelet count < 50 x 10 cells/L

No

Primary risk factor present? [A]


• Spinal cord injury • Acetabulum fracture
3 Unfractionated heparin 5,000
*
• Spinal column fractures • Traumatic brain injury units sq every 8 hours plus
• Long bone fracture • Laparotomy No Sequential compression
• Pelvic fracture • Age > 40 plus major surgery, cancer, history of devices (preferred) or A-V foot
• Sacral fracture VTE, or hypercoagulable state pumps
*Note: May not be indicated in
burn patients unless other risk
factors are present.
Yes

4
Operative
Enoxaparin 30mg sq every 12 hours
plus
acetabulum N Sequential compression devices
fracture? o (preferred) or A-V foot pumps

Yes

Pre-operative > 24 h post-operative

Unfractionated heparin 5,000 units sq every 8 hours plus Enoxaparin 30mg sq every 12 hours plus
Sequential compression devices (preferred) or A-V foot Sequential compression devices (preferred) or A-V foot
pumps pumps

Reevaluate all patients for continuation of venous thromboembolism prophylaxis upon ICU discharge

[A] Consider Inferior Vena Cava (IVC) filter in:


High-risk trauma patients with significant bleeding risk or
Patient’s with injury pattern rendering them immobile for
prolonged period of time:
a) Severe Traumatic brain injury
b) Spinal cord injury with para- or quadriplegia Evidence-based references
c) Complex pelvic fracture with associated long bone • Geerts WH, et al. Chest 2001; 119: 132S-175S.
fracture(s) – Available at http://www.chestjournal.org/cgi/reprint/119/1_suppl/132S
d) Multiple long bone fractures (accessed 5/14/04)
• Rogers FB, et al. J Trauma 2002; 53(1):142-164.
– Also available at http://www.east.org/tpg/dvt.pdf (accessed 5/14/04)
Modified 5/14/04

47
Natural Products with Potential to Act as Blood Modifiers

Natural Products THOUGHT to have Blood Modifying Effects


Herb Effect Ingredient(s) Comments
(other names) Responsible
Angelica root (Angelica Anticoagulant Coumarin There is some evidence that the
archangelica, root of the Antiplatelet consitiuents related Angelica species can inhibit
Holy Ghost) platelet aggregation and lower
prothrombin time when combined
with warfarin.

The coumarin constituents of related


Angelica species can inhibit human
platelet aggregation in vitro. The
related species, Angelica sinensis,
can lower prothrombin time in rabbits
when coadministered with warfarin.
Anise (Pimpinella anisum, Anticoagulant Coumarin constituents Anticoagulant effects have been seen
aniseed, sweet cumin) with excessive doses of anise. (Typical
dose is 0.5-1 gram of the dried leaf or
50-200 mL of the essential oil.)

Theoretically, excessive use of anise


might prolong coagulation, increasing
PT/INR and test results, due to
coumarins contained in anise.
Asafoetida (Ferula assa- Anticoagulant Coumarin constituents Anticoagulant effects have been noted
foetida, assant, devil’s in vivo.
dung, fum, giant fennel)
Dong Quai (Angelica Anticoagulant Coumarin constituents Dong quai can potentiate the therapeutic
sinensis, Chinese angelica, Antiplatelet and adverse effects of warfarin and
Danggui) antiplatelet drugs.
Fish Oils (omega-3 fatty Antiplatelet Docosahexaenoic acid The antithrombin activity of fish oil is due
acids) (DHA) to prostacyclin synthesis, vasodilation,
Eicosapentaenoic acid reduced platelet counts and
(EPA) adhesiveness, and prolonged bleeding
time.
Fucus (Fucus vesiculosis, Anticoagulant Fucoidin The isolated fraction, fucoidin, has 40-
bladderwrack, kelp, black 50% of the blood anticoagulant activity
tang, cutweed) of heparin, and fucus can increase the
risk of bleeding.

48
Natural Products with THEORETICAL Potential to Have Blood Modifying Effects
Herb (Other names) Effect Ingredient(s) Comments
Responsible
Agrimony (Agrimonia Coagulant Vitamin K constituent Excessive doses of agrimony could
eupatoria, agromonia, interfere with anticoagulant therapy.
cocklebur) (Typical dose is 3 grams/day.)
Arnica montana, leopard’s Anticoagulant Coumarin constituents Arnica could potentiate the effects of
bane, wolf’s bane, mountain anticoagulant and antiplatelet drugs.
tobacco)
Aspen (Populi cortex, Populi Antiplatelet Salicin Salicin is a salicylate constituent.
folium) However, in vitro studies provide
preliminary data that suggest salicin
might not potentiate the effects of
anticoagulant drugs.
Black cohosh (Cimicifuga Antiplatelet Salicylate There is insufficient reliable information
racemosa, baneberry, black to determine if there is enough salicylate
snakeroot, bugwort) present in black cohosh to have
significant effects.
Bogbean (Menyanthes Bleeding risk Unidentified Excessive doses of bogbean can
trifoliata, buckbean, marsh constituent increase the risk of bleeding due to the
trefoil, water shamrock) hemolytic effects of an unknown
constituent. (Typical dose is 1-2 mL of
the 1:1 liquid extract in 25% alcohol TID
or 1-3 grams of the dried leaf TID.)
Boldo (Peumus boldus, Anticoagulant Coumarin constituents Excessive doses could increase the risk
boldine) of bleeding. (Typical dose is 60-200 mg
of the dried leaf TID.)
Borage Seed Oil (Borago Anticoagulant Gamma linolenic acid Borage seed oil could prolong bleeding
officinalis, burage, time.
starflower) Antiplatelet
Bromelain (Ananas Antiplatelet Enzyme constituent Bromelain could increase the risk of
comosus, bromelin) bleeding when used in combination with
antiplatelets or anticoagulants.
Capsicum (Capsicum Antiplatelet Capsaicinoid Capsicum has led to increased
frutescen, African pepper, constituents fibrinolytic activity and could prolong
cayenne, chili pepper) bleeding time.
Celery (Apium graveolens, Antiplatelet Apiogenin (coumarin) Celery could have anticoagulant effects
smallage, Apii fructus) due to the apiogenin constituent.
Clove (Syzygium Antiplatelet Eugenol Clove contains a volatile oil that consists
aromaticum, caryophyllus) primarily of eugenol.
Danshen (Salvia Anticoagulant Protocatechualdehyde There is one case report of increased
miltiorrhiza, red sage, salvia international normalization ratio (INR)
root) 3,4-dihydroxyphenyl- with concomitant use of danshen and
lactic acid warfarin.
European Mistletoe Coagulant Lectin Studies show that lectin can have
(Viscum album, all-heal, agglutinating activity and could interfere
devil’s fuge, drudenfuss) with anticoagulant or coagulant therapy.
Fenugreek (Trigonella Anticoagulant Coumarin constituents Fenugreek could potentiate the effects of
foenum-graecum, bird’s foot, anticoagulant and antiplatelet drugs.
Greek hay)
Feverfew (Tanacetum Antiplatelet Crude extracts The crude extracts can inhibit platelet
parthenium, featherfew, aggregation and the neutrophil and
midsummer daisy, platelet secretory activity. This could
bachelor’s button) potentiate the effects of anticoagulant
and antiplatelet drugs.
Ginseng, Panax (Asian Anticoagulant Active constituents Panax ginseng could decrease the
ginseng, Korean red, Antiplatelet effectiveness of warfarin and affect
jintsam) clotting time.
Goldenseal (Hydrastis Coagulant Berberine Goldenseal could inhibit the
canadensis, yellow puccoon, anticoagulant effects of heparin.
eye balm)
Horse Chestnut (Aesculus Anticoagulant Aesculin (coumarin) Aesculin may increase bleeding time due
hippocastanum, escine, to antithrombin activity, which could
venostat) increase the risk of bleeding when used
concomitantly with anticoagulants or
antiplatelets.

49
Horseradish (Armoracia Anticoagulant Coumarin constituents Peroxidase stimulates the synthesis of
rusticana, pepperrot, arachidonic acid metabolites, which
mountain radish) could potentiate the anticoagulant activity
of other drugs or natural products.
Licorice (Glycyrrhiza glabra, Antiplatelet Coumarin constituent Licorice has shown antiplatelet activity in
sweet root) vitro.
Meadowseet (Filipendula Anticoagulant Salicylates There is insufficient reliable information
ulmaria, bridewort, dropwort) to know if the side effects and toxicity
normally associated with salicylates
could occur.
Northern Prickly Ash Anticoagulant Coumarin constituents Excessive ingestion of northern pickly
(Zanthoxylum americanum, ash might potentiate anticoagulant
toothache bark, pepper therapy.
wood)
Onion (Allium cepa) Antiplatelet Unidentified Inhibits platelet aggregation in humans
constituent and could increase the risks of bleeding
with antiplatelet drugs or natural
products.
Papain (Carica papaya) Risk of Unidentified There is one case report of increased
bleeding constituent INR associated with the use of warfarin
and papaya extract.
Passionflower (Passiflora Anticoagulant Coumarin constituents Excessive doses of passionflower could
incarnata, Maypop, apricot increase the risk of bleeding. (Typical
vine) dose is 0.5-1 mL of the 1:1 liquid extract
in 25% alchohol TID or 0.25-2 grams of
the dried plant.)
Pau D’Arco (Tabebuia Anticoagulant Lapachol Pau d’arco may potentiate the effects of
impetiginosa, taheebo tea, anticoagulants and increase bleeding
ipes, lapacho) tendency.
Plantain (Plantago major, Coagulant Vitamin K Excessive doses of plantain could
common plantain, greater interfere with anticoagulant therapy.
plantain) (Typical dose is 2-4 mL of the 1:1 liquid
extract in 25% alcohol TID or 2-4 grams
of the dried leaf TID.)
Poplar (Populus Antiplatelet Salicin Salicin is a salicylate constituent.
tacamahacca, balm of However, in vitro studies provide
Gilead) preliminary data that salicin might not
potentiate the effects of anticoagulant
drugs.
(Quassia amara, bitterwood) Anticoagulant Coumarin constituents Excessive doses of quassia could
increase the risk of bleeding.
Red Clover (Trifolium Anticoagulant Coumarin constituents Large amounts of red clover can
pratense, cow clover, trefoil, increase the effects and bleeding risk of
beebread) anticoagulant drugs or natural products.
Roman chamomile Anticoagulant Coumarin constituents Large amounts of Roman chamomile
(Chamaemelum nobile, could have anticoagulant effects.
English chamomile, garden
chamomile, whig plant)
Safflower (Carthamus Anticoagulant Safflower yellow Large amounts of safflower could
tinctorius, saffron, zaffer) potentiate the risk of bleeding with
anticoagulant drugs or natural products.
Southern Prickly Ash Anticoagulant Coumarin constituents Excessive ingestion of southern pickly
(Zanthoxylum clava-herculis, ash might potentiate anticoagulant
sea ash, yellow wood) therapy. (Typical dose is 3-4 mL of the
1:1 liquid extract in 25% alcohol TID.)
St. John’s Wort Coagulant Multiple cases of decreased INR have
been reported, although none have
involved thromboembolic complications.
Stinging Nettle (Urtica Coagulant Vitamin K Excessive doses of stinging nettle could
dioica, nettle) interfere with anticoagulant therapy.
Sweet Clover (Melilotus Anticoagulant Dicumarol Large amounts of sweet clover could
officinalis, common melilot, potentiate the risk of bleeding with
hay flower, sweet lucerne) anticoagulant drugs or natural products.
Sweet Vernal Grass Anticoagulant Coumarin constituent Large amounts of sweet vernal grass
(Anthoxanthum odoratum, could potentiate the risk of bleeding with
spring grass) anticoagulant drugs or natural products.
Tonka Bean (Dipterux Anticoagulant Coumarin constituent Tonka bean can contain up to 10%

50
odorata, coumarouna, coumarin and theoretically potentiate the
torquin bean) risk of bleeding associated with
anticoagulant drugs or natural products.
Turmeric (Curcuma longa, Antiplatelet Curcumin Curcumin has anti-inflammatory activity
tumeric, Indian saffron) and could potentiate the antiplatelet
activity of other drugs or natural
products.
Wild Carrot (Daucus carota, Anticoagulant Coumarin constituents Large amounts of wild carrot could
Queen Anne’s lace, potentiate the risk of bleeding with
beesnest plant) anticoagulant drugs or natural products.
Wild Lettuce (Lactuca Anticoagulant Coumarin constituents Large amounts of wild lettuce could
virosa, green endive, lettuce potentiate the risk of bleeding with
opium) anticoagulant drugs or natural products.
Willow Bark (Salix alba, Antiplatelet Salicylate constituents Data suggests irreversible inhibition of
white willow, silberweide) thrombocytes is unlikely and there might
be no increase interaction with blood
coagulants.
Yarrow (Achillea millefolium, Coagulant Achilleine There is some evidence to suggest that
thousand-leaf, wound wort) achilleine has decreased clotting time.

HERBS WITH ANTICOAGULANT/ANTIPLATELET POTENTIAL: Concomitant use of herbs that have coumarin constituents or affect
platelet aggregation could theoretically increase the risk of bleeding in some people. These herbs include anise, arnica, asafoetida,
bogbean, boldo, capsicum, celery, chamomile, clove, danshen, fenugreek, feverfew, garlic, ginger, ginkgo, Panax ginseng, horse
chestnut, horseradish, licorice, meadowsweet, prickly ash, onion, papain, passionflower, poplar, quassia, red clover, turmeric, wild
carrot, wild lettuce, willow, and others.

51
Weaning from Mechanical Ventilation

Daily screening

No Problem for which patient was


intubated is controlled

Yes
Continue
mechanical
ventilation
SaO2 ≥ 90%
FiO2 ≤ 0.5
PEEP ≤ 5 cm H2O
Airway reflexes intact
No No vasopressors or significant sedation

Yes Therapist to measure RR/Vt

No RR/Vt < 105 breaths/min/L

Spontaneous breathing trial

RR > 35 breaths/min for more than 5


Yes minutes
SaO2 < 90%

HR > 140 or ± 20% of baseline


Systolic BP > 180 or < 90 mmHg
Increased anxiety orNo
diaphoresis

Extubate

52
MANAGEMENT OF HYPERTENSION
Diagnosis of Hypertensive Crisis
Immediate control to minimize end organ damage (CNS - hypertensive encephalopathy; cardiac
- AMI, BAI, dissecting aortic aneurysm; renal – ARF) is necessary.
Otherwise BP should be lowered slowly and cautiously.

Management of Hypertension
There are many causes of hypertension in ICU patients, common causes include:
- underlying hypertension - cold, shivering
- agitation - hypoxia, hypercarbia
- pain - increased ICP
- withdrawal - transducer height etc.

Treat underlying causes prior to administration of antihypertensives


Common intravenous antihypertensive agents:
Drug Action Effect Dose Comments
β-1 antagonist Half-life 4 to 6 hours
Negative chronotropy IVP: 2.5 to 15 mg slow IVP every 6
Metoprolol Oral:IV conversion 2.5:1
(min β-2 antagonist) Negative inotropy hours
No vasodilation

β-1 antagonist IVP: 5 to 20 mg slow IVP every 1 to Half-life 4 to 6 hours


Negative chronotropy
4 hours Monitor closely in
Labetalol (mod β-2 antagonist) Negative inotropy
Bolus: 5-20 mg IVP asthmatic patient (beta-
α-1 antagonist Vasodilation
Infusion: 0.5 to 4 mg/min (Titrate) 2 antagonist)

β-1 antagonist Bolus: 250-500 mcg/kg slow IVP


Negative chronotropy Half-life ~ 15 min
Esmolol Infusion: 25-100 mcg/kg/min
(min β-2 antagonist) Negative inotropy No vasodilation
(Titrate)

Exogenous source of Venous vasodilation Infusion: 5 to 20 mcg/min (Titrate; Methemoglobinemia


Nitroglycerin
nitric oxide (min arterial dilation) max 400 mcg/min) Headache

Profound hypotension
Exogenous source of Arterial and venous Infusion: 0.1 to 10 mcg/kg/min
Nitroprusside Cyanide toxicity
nitric oxide vasodilation (Start low and Titrate)
Reflex tachycardia

Direct arterial smooth IVP: 5 to 20 mg slow IVP every 4 Intrapatient variability


Hydralazine Arterial dilation
muscle relaxation to 6 hours Reflex tachycardia

Hyperkalemia
Vasodilation IVP: 0.625 to 1.25 slow IVP every
Enalapril ACE Inhibition Acute renal failure
(arterial > venous) 6 hours
Angioedema
Oral antihypertensives can be used in patients with stable hemodynamics. Otherwise use of IV
antihypertensives is more easily titratable in ICU patients.
Note on choice of antihypertensives:
• avoid β-blockers in patients with increased adrenergic activity (pheochromocytoma, use of
sympathomimetic drugs such as cocaine, amphetamine etc)
• avoid β-blockers in patients with poor LV function, also check for other contraindications
(bronchospasm)
• nimodipine produces cerebral vasodilation, effect noticeable in areas of brain with restricted
circulation than healthy areas, usually used in patients with vasopasm after subarachnoid
hemorrhage
• nitrates and nitroprusside can produce cerebral vasodilation and hence should be avoided in
patients with intracranial pathology
• prolonged nitroprusside administration can lead to acidosis and cyanide toxicity

53
1 YES
Mechanically ventilated trauma
patient requiring sedation
3 REASSESS
Preferred - Propofol (Diprivan® brand) continuous Pt every 4
2 infusion1 PLUS Morphine sulfate prn shift & as Patient w/TBI, ↑ICP,
Patient w/TBI, YES pain/agitation 2 OR needed or requiring
↑ICP, or requiring Alternative - Fentanyl continuous infusion 2
frequent frequent neurologic
Titrate to Riker SAS of 4 examinations?
neurologic
examinations?
May consider use of neuromuscular blocker to
assist with ventilator compliance
NO
7
NO Lorazepam prn agitation, THEN
Lorazepam continuous infusion if dosing 5
requirements are high 4 Go to 12
6 PLUS
Morphine sulfate prn pain/agitation, THEN YE
Pt expected to YES
require sedation Morphine sulfate continuous infusion if dosing S
REASSESS
for ≥ 24 hours? requirements are high2
Pt every
Titrate to Riker SAS of 4 shift & as
In refractory cases, may use 8
needed Pt requiring
NO Propofol (generic) continuous infusion1 PLUS
Morphine sulfate prn pain/agitation2 sedation
after 24
hours?
9 REASSESS
Preferred – Midazolam prn Pt every NO
shift & as 10 YES
agitation3 PLUS Morphine
sulfate prn pain/agitation2 needed Continued need
Alternative - Propofol (generic) for sedation past 11
continuous infusion1 PLUS 24 hours? Go to
Morphine sulfate prn 12
pain/agitation2
NO
Titrate to Riker SAS of 4
12
D/C Sedation Protocol, continue Morphine
sulfate prn pain (or morphine sulfate
2
continuous infusion)

57
ICU Pharmacologic Agents
ATRACURIUM Half life: 20 minutes. Cleared in plasma via Hoffman reaction; therefore, suitable for
usage in renal failure. Titrate to 2/4 TOF. Dosage (continuous infusion): 0.1 mg/kg/h. Cost: $11.46/100 mg.
24-hour cost (70 kg patient): ~$19.00/day.
PANCURONIUM Half-life: 2 hours. May cause tachycardia. Titrate to 2/4 TOF. Dosage (continuous
infusion): 0.06-0.1 mg/kg/h. Cost: $1.79/10 mg. 24-hour cost: ~$28.00/day.
VECURONIUM Half-life: 1.5 hours. Clearance adversely affected by renal failure. Titrate to 2/4 TOF.
Dosage (continuous infusion): 0.01 mg/kg/h. Cost: $12.39/10 mg. 24-hour cost: ~$20.00/day.
MIDAZOLAM Short acting benzodiazepine. Duration of action: 2 hours. Excellent amnestic effect. Use
with caution in elderly; may cause hypotension/respiratory depression. Contraindicated in hepatic failure.
Dosage (continuous infusion): 2 mg/h. Cost: $9.48/5 mg. 24-hour cost: ~$90.00/day.

LORAZEPAM Intermediate acting benzodiazepine. Duration of action: 8-20 hours. May cause
paradoxical reactions in the elderly. Prolonged use can lead to prolonged sedation. Dosage (continuous
infusion): 1 mg/h. Cost: $15.89/40 mg. 24-hour cost: ~$8.00/day.
HALOPERIDOL Butyrophenone/antipsychotic. Does not cause sedation per se; does not cause
respiratory or cardiovascular depression. Mechanism of action is to cause affective dissociation. Does have
limited anticholinergic effects; may cause dystonia/tardive dyskinesia. Should use Cogentin at regularly
scheduled intervals. Half-life: 18 hours. Dosage: 5-10 mg/dose. Titrate to affect up to 50 mg/dose. Cost:
$0.57/5 mg. Cost per dose: $0.57-5.70.
MORPHINE Opiate, the “gold standard” analgesic in the ICU setting. Has sedative as well as analgesic
properties. Metabolites accumulate in renal failure. Duration of action: 4-5 hours. Causes respiratory
depression, histamine release, and hypotension. Dosage (continuous infusion): 2-4 mg/h. Cost: $5.76/100
mg. 24-hour cost: $3.00-6.00/day.
FENTANYL Short acting opiate. Duration of action: 1-2 hours. Sedative and analgesic effects. Causes
respiratory depression. Does not have histamine release. Much more stable than morphine from
cardiovascular standpoint. Dosage (continuous infusion): 1-5 mcg/kg/min. Cost: $1.28/1000 mcg. 24-hour
cost: $12.80-64.00/day.
PROPOFOL Lipid soluble, ultra-short-acting anesthetic. Prepared in lipid carrier. Duration of action: 15
minutes. Easily titratable. Lowers ICP. Should not be used in patients with hypertriglyceridemia. Exhibits
three-compartment redistribution with prolonged use, leading to prolongation of action. Bolus doses may
cause hypotension. Rare fatal reactions noted in children. Dosage (continuous infusion): 20-200
mcg/kg/min. Cost: $49.95/1000 mg. 24-hour cost: $100.00-1,000.00/day. ALL PATIENTS RECEIVING
DIPRIVAN MUST HAVE DAILY SERUM LACTATE AND CPK CHECKED. IF EITHER RISES, STOP
DIPRIVAN IMMEDIATELTY.

54
Alcohol Withdrawal Protocol

Obtain:
1. liver function panel, INR/PT
Patient with risk 2. BMP, magnesium, phosphorus, albumin
factors for alcohol 3. Blood glucose monitoring
withdrawal Provide:
1. Thiamine 100mg once daily IV/IM/PO
syndrome
2. Folic acid 1mg once daily PO/IV
3. Multivitamin once daily or Cernevit 5ml in
minimum 500ml IVF once daily
4. Adequate hydration

High clinical Active


suspicion for withdrawal
withdrawal

Select desired therapy:


Lorazepam (preferred) or ethanol Transfer to
drip monitored
Note: unit
ethanol is contraindicated in patients
with pancreatitis and liver disease

Lorazepam 2-4mg PO/IV/IM Ethanol 5% in D5W at Lorazepam 2-4mg IV


q 6 hrs x 4 doses, then 1- initial rate of 50 ml/hr. every 1 hr until lightly
2mg PO/IV/IM q 6 hrs 2 8 Titrate for symptoms of sedated and
doses (3 day prophylaxis early withdrawal. Wean symptoms resolved.
wean). Monitor vital signs over 3 days. Monitor vital Monitor vital signs and
and status q 4-6 hrs. signs and status q 4-6 hrs. status every hour

55
Sedation Protocol

1. (Diprivan): Begin with 0.5 mg/kg/hr, increase by 0.5 mg/kg every 5-10 minutes, up
to 5 mg/kg/hr. Patients receiving propofol infusion should have serum triglyceride
levels monitored every 4-7 days; propofol should be discontinued if serum
triglyceride levels are ≥300. Patients with closed head injury being followed by the
neurosurgical service may receive Diprivan® brand propofol because it has been
shown to decrease intracranial pressure. ALL PATIENTS RECEIVING DIPRIVAN
MUST HAVE DAILY SERUM LACTATE AND CPK CHECKED. IF EITHER RISES,
STOP DIPRIVAN IMMEDIATELTY.
2. Morphine sulfate: Standard regimen is 1-6 mg IV every 1-2 hours prn
pain/agitation; alternative regimen is continuous infusion (100 mg/ 100 mL NS): start
at 2-4 mg/hr. Patients with documented allergy to morphine sulfate and/or severe
hypotension with morphine sulfate administration, may use fentanyl: load with 1-2
mcg/kg, then continuous infusion (1 mg/ 50 mL) at 0.5-5 mcg/kg/hr.
3. Midazolam (Versed): Standard regimen is 2.5-5 mg IV every 1-2 hours prn
sedation.
4. Lorazepam (Ativan): Standard regimen is 1-2 mg IV every 1-2 hours prn sedation;
alternative regimen is continuous infusion (20 mg/ 100mL NS): start at 1-2 mg/hr.

Patients with Renal Insufficiency/Failure


The preferred agents are lorazepam (Ativan) and hydromorphone (Dilaudid) 0.5-1 mg IV
every 1-4 hours prn pain/sedation; continuous infusion to start at 0.5 mg/hr.
AVOID meperidine (Demerol) and morphine sulfate because of increased potential for
accumulation of renally excreted metabolites, normeperidine and morphine-6-
glucuronide, respectively.

Riker Sedation-Agitation Scale (SAS)


1) Unarousable: Minimal or no response to noxious stimuli, does not
communicate or follow commands

2) Very sedated: Arouses to physical stimuli but does not communicate


or follow commands, may not move spontaneously

3) Sedated: Difficult to arouse, awakens to verbal stimuli or gentle


shaking but drifts off again, follows simple commands

4) Calm and cooperative: Calm, awakens easily, follows commands

5) Agitated: Anxious or mildly agitated, attempting to sit up, calms


down to verbal instructions

6) Very agitated: Does not calm, despite frequent verbal reminding of


limits; requires physical restraint, biting ET tube

7) Dangerous agitation Pulling at ET tube, trying to remove catheters, climbing


over bed rail, striking at staff, thrashing side-to-side

56
Patient Admitted to Stress Ulcer Prophylaxis
MICU/SICU/TICU

Evidence of active Yes


GI bleed Treat active bleeding
on admission
No
*SRMD=Stress Related Mucosal Damage
PUD=Peptic Ulcer Disease
Patient with SRMD, Yes GERD=Gastroesophageal Reflux
PUD, or GERD*

No

MAJOR RISK
FACTORS
Yes
Severe Head Trauma IV PROTON PUMP INHIBITOR
Burns > 30% BSA i.e. Pantoprazole 40 mg IV every
Prior Organ Transplant 24 hours
Renal Failure
Recent PUD (6 weeks)*
Hypotension/Shock
1. Severe Sepsis ORAL H2 BLOCKER
2. Major Surgery/Trauma i.e. Ranitidine 150mg PO BID
Tolerating Tube
(For Cr Cl < 50) 75 mg PO BID
Feedings or PO
intake OR
No Oral Proton Pump Inhibitor
i.e. Pantoprazole 40 mg every
24 hours

 > 48h Mech. Ventilation IV H2 BLOCKER


OR Yes i.e.Ranitidine 50 mg IV every 8 hours
Coagulopathy (For Cr Cl < 50) 50 mg IV daily

No
On Transfer/Discharge
OR
No Prophylaxis Indicated Risk Factors Resolved
Re-evaluate need for Discontinue Therapy
treatment

References
1. Cook DJ , Fuller HD, Guyatt GH et al.Risk factors for gastrointestinal bleeding in critically ill patients.N Engl J Med. 1994 Feb
10;330(6):377-81.
2. Levy MJ, Seelig CB, Robinson NJ et al.Comparison of omeprazole and ranitidine for stress ulcer prophylaxis.Dig Dis Sci
1997Jun;42(6):1255-9
3. CookD, HeylandD,Griffith L,et al:Risk factors for clinically important UGIB in patients requiring mechanical ventilation. Crit
Care Med 1999;27:2812–2817
4. Jung R, MacLaren R. Proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients. Ann Pharmacother. 2002
Dec;36(12):1929-37
*Endoscopic or radiographic evidence of peptic ulcer disease in preceding 6 weeks
** Presence and persistence and severity of risk factors should be reviewed every24h
This clinical practice guideline is a systematically developed algorithm intended to assist practitioner and patient decisions
about appropriate health care for specific clinical circumstances. This guideline is not a fixed protocol that must be followed,
but is intended for health care professionals and providers to consider. While it identifies and describes generally
recommended courses of intervention, it is not presented as a substitute for the advice of a physician or other knowledgeable
health care professional or provider. Individual patients may require different treatments from those specified in this particular
guideline.

58
General Management Principles for Severe (GCS 3-8) and
Moderate (GCS 9-12) TBI

• Use very short-acting sedatives if needed, for frequent neurological exams


 Especially important in first 24 hours
 Sedation holiday for nursing neuro check unless otherwise ordered
• Convert field collar to Miami J until ligamentous injury can later be ruled out
• Insertion of intraparenchymal ICP monitor after coagulopathy (if present)
corrected (Normal PTT and INR < 1.2 desireable, <1.4 occasionally still done)
• Avoid thrombocytopenia
• Serial INR (repeat 6-8 hours after injury, then every 24 hours for 48-72 hours)
• Rapid evacuation of mass lesions if indicated
• Rule out vascular injury/hypoxic or embolic mechanisms of brain injury
• Rule out intoxicants as contributors to neurological status
• Ensure adequate ventilation and oxygenation and prevent hypercarbia
• Elevate HOB to 30 degrees (reverse Trendelenberg if spine not cleared)
• Avoid hypothermia
• Avoid hyperglycemia and hypoglycemia (Goal Glucose 80-150)
• Early nutrition, enteral preferred
• DVT prophylaxis with TEDs and thigh-high SCDs if possible
 Delay subcutaneous heparin until 24-48 hours post-injury
 Delay Lovenox until cleared by NSR
• Seizure prophylaxis (Dilantin) x 7 days for EDH, SDH, IPH/contusion,
depressed skull fx, penetrating injury, GCS < 10, sz within 24 hours of injury
• Avoid symptomatic anemia
• Maintain normal ICP and CPP within desired range

For elevated ICP (> 20 mm Hg x > 5 minutes): Notify Neurosurgery


First Tier Therapies:
• Ensure HOB elevated
• Ensure no compression from cervical collar and neck in neutral position
• Ensure ventriculostomy (if present) patent and functioning
• Sedation and analgesia with Diprivan Drip (discontinue if elevation of CPK or
lactate) or Fentanyl or Morphine Drip or Intermittent Dosage
• Maintain Hyperosmolar Euvolemia
 A Catheter, Mannitol +/- Lasix, hypertonic saline boluses, serum Na and
osmolarity every 6 hours
 No hyperosmolar agents if osmolarity > 320
 Goal serum Na 145-155 usually
• Cerebral Perfusion Pressure Goals 50-70 mm Hg usually
 Neosynephrine preferred pressor if pressors needed
 Dopamine in low doses

59
General Management Principles for Severe (GCS 3-8) and
Moderate (GCS 9-12) TBI (continued)

Second Tier Therapies:


• Cerebrospinal fluid drainage/Ventriculostomy
• Mild, temporary hyperventilation to pCO2 30-35
• Intermittent paralytics
• Intermittent barbiturates

Third Tier Therapies:


• Decompressive craniotomy
• Barbiturate coma

• In general, these are used in somewhat of a step-wise progression by tier but


simultaneously within tiers (and sometimes across tiers). The idea is to have
standards for all but tailor the therapy to the individual patient's physiology
and injury patterns.
• The first tier therapies are used on essentially everyone with a severe TBI.
• The second tier therapies may be used prior to some of the first tier therapies
or never at all.
• The third-tier therapies may be used prior to any second tier therapies.

60

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