Beruflich Dokumente
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RESIDENT
HANDBOOK
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.
2
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
3
Trauma Service Policies
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.
4
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:
5
2. Assisting with resuscitation in the Shock/Trauma Room.
3. Emergency room consultations.
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.
6
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.
7
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.
8
Rounding Schedule For 2005-2006
Teaching Rounds
Tuesdays at 8:00 a.m. All members of the Trauma Service (fellows, residents
and students) are expected to attend.
9
Conferences and Clinics
The Trauma Service is expected to attend these and all other applicable general surgical
conferences:
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
10
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
11
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
12
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
13
Routine Trauma Labs: Adult
The following laboratory tests should be ordered for all adult surgical trauma patients evaluated
in the trauma rooms:
14
Consults
Facial fractures
Alternates weekly
Hand injuries
Alternates weekly
Spine injuries
Alternates daily
Pregnant patients
15
Cervical Spine Clearance
No neck pain
AND AP, Lateral,
No tenderness Odontoid plain films
to palpation
Normal Abnormal
MRI of affected
area
16
Spinal Cord Injury with Neurologic Deficit
Penetrating Blunt
Bolus methylprednisolone
(Solumedrol) 30 mg/kg over 15 min
(if within 8 hours from injury)
Consultation:
Orthopedics on odd admission date, Neurosurgery on even admission date
17
Dermatomes
18
Sensory Levels
19
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)
maximum 5 50 100
0
20
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)
ZONE OF PARTIAL R L
PRESERVATION SENSORY
Partially innervated segments
MOTOR
21
Blunt Cerebrovascular Injury
CT angiogram
Neurosurgery Neurosurgery
consult consult
**In conjunction
Treatment** with Neurosurgery Treatment**
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
22
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!
To OR To OR To OR
Injury No Injury
TO OR Observe
23
Blunt Aortic Injury
Chest CT
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.
24
Emergent Thoracotomy
Mechanism of Injury
Blunt Penetrating*
* 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.
25
Hemothorax Management
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
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)
26
Blunt Abdominal Trauma
Hemodynamically unstable
Physical exam
F.A.S.T. DPL
To OR To OR To OR
Consider DPL if
unstable
Continue
search for
other sources
of hemorrhage
27
Blunt Abdominal Trauma
Hemodynamically stable
Physical exam
Nontender Tender
CT scan
Observation CT scan
period
1
If any doubt, admit the patient for at least 23 hours
2
May require DPL or other evaluation depending on findings
28
Antibiotics for
Penetrating Abdominal
Trauma
Penetrating abdominal
injury requiring
laparoscopy/laparotomy
Ertapenem 1 gram IV
prior to skin incision
No further
No further dosing
antibiotics
29
Anterior Abdominal Stab Wounds
Hemodynamically stable,
nontender abdominal exam
Yes No
Local wound To OR
exploration
30
Nonoperative Management of Blunt Liver Injury
CT scan
Stable Stable
OR
31
Nonoperative Management of Blunt Splenic Injury
*ICU-
serial Hct q6h, CT scan Pseudoaneurysm
close observation
Angio-
Age ≥ 50 Becomes Age < 50 embolization
unstable
F/U CT 24
Large Small, moderate hours
hemoperitoneum hemoperitoneum
Stable, Worse
OR ICU* improving
32
Pancreatic Injury Management
Pancreatic Injury
Duct injury
No Indeterminate Yes
Low High
probability probability
Drain
Resection + drainage
33
AAST Spleen Injury Scale
34
AAST Liver Injury Scale
35
AAST Kidney Injury Scale
36
Pelvic Fracture Management
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
38
To Ligate or Not to Ligate
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
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
Limb ischemia
Pulse reduced or absent but perfusion normal 1*
Shock
Systolic BP always > 90 mm 0
Transient hypotension 1
Persistent hypotension 2
Age (years)
< 30 0
30-50 1
> 50 2
The MESS is the sum of scores from each category. Scores < 7 are associated with limb
salvage, Scores > 10 are associated with primary amputation. Outcome is variable for
scores 7-10.
43
Diagnosis of Ventilator Associated Pneumonia
44
Trauma ICU Ventilator-Associated Pneumonia Clinical Pathway
Diagnosis and Empiric Management
†
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
Early VAP?
(≤7 days in ICU)
Yes No
VAP pathogen(s)
<10,000 cfu/mL? †
Yes No
* 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
No
4
Operative
Enoxaparin 30mg sq every 12 hours
plus
acetabulum N Sequential compression devices
fracture? o (preferred) or A-V foot pumps
Yes
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
47
Natural Products with Potential to Act as Blood Modifiers
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
Yes
Continue
mechanical
ventilation
SaO2 ≥ 90%
FiO2 ≤ 0.5
PEEP ≤ 5 cm H2O
Airway reflexes intact
No No vasopressors or significant sedation
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.
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
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
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.
56
Patient Admitted to Stress Ulcer Prophylaxis
MICU/SICU/TICU
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
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
59
General Management Principles for Severe (GCS 3-8) and
Moderate (GCS 9-12) TBI (continued)
60