Trauma Handbook

T R A U M A H A N D B O O K
This handbook and the management protocols

it contains are to serve as guidelines.
There will be many times when it is

appropriate or desirable to deviate from
these guidelines based on the clinical scenario.
The rationale for such deviation must be
logical and should be documented in the
medical record.
Although these educational guidelines have

been reviewed and updated, it is impossible for
any handbook to reflect the continual advances
and evolution of care of the trauma patient.
This handbook provides a quick reference for

common problems but is not a substitute for
a textbook or the current literature.
Printed version may not reflect current/updated practice
and is merely a convenience. If time allows, please refer
to the on-line version.
Version 14.21.1 - Page 1

Adult Contents
GENERAL POLICIES
Trauma Conferences and Clinics ........................................................... 1
Trauma Service Policies ........................................................................ 2
Service Assignments .............................................................................. 6
Combined Adult and Pediatric Trauma (Mixed Bundles) ..................... 7
Team Activation: Adult ......................................................................... 8
Criteria for Triage to Trauma Rooms .................................................... 9
Informed Consent and the Care of the Trauma Patient ........................ 11
Obtaining Consults on the Trauma Service .......................................... 12
Routine Trauma Labs ........................................................................... 13
Tertiary Survey ..................................................................................... 14
PRIMARY SURVEY
ED Thoracotomy .................................................................................. 15
Intravenous Access and the Trauma Patient ......................................... 18
Massive Transfusion/Damage Control Resuscitation Strategy ............. 19
Hypothermia Protocol ........................................................................... 21
SECONDARY SURVEY / DEFINITIVE CARE

Traumatic Brain Injury ......................................................................... 24
Reversal of Anticoagulation in Patients with Intracranial,
Spinal Bleeding or Other Sources ......................................................... 27
C-Spine Evaluations in Adult Trauma Patients .................................... 30
Thoracic/Lumbar/Sacral (TLS) Spine Clearance in Trauma Patients ... 32
Standard Neurological Classification of Spinal Cord Injury ................ 33
Penetrating Neck Trauma ..................................................................... 34
Penetrating Injuries to the Heart .......................................................... 36
Transmediastinal Gunshot Wounds (TMGSW) .................................... 37
Vascular Exposures .............................................................................. 38
Truncal Stab Wounds ........................................................................... 40
Blunt Cerebrovascular Injury................................................................ 42
Blunt Aortic Injury (BAI) ..................................................................... 44
Blunt Cardiac Injury ............................................................................. 46
Management of Thoracic Trauma ......................................................... 48

Blunt Abdominal Trauma ..................................................................... 54

Blunt Splenic Trauma ........................................................................... 56
Renal and Other Genitourinary Trauma ............................................... 58
Blunt Bowel and Mesenteric Injury ...................................................... 61
Management of Colon Injury ................................................................ 63
Rectal Injury ......................................................................................... 64
Unstable Pelvic Fractures .................................................................... 65
The Open Abdomen .............................................................................. 66
Threatened Limb ................................................................................... 69
To Ligate or Not to Ligate .................................................................... 71
ICU CARE
Analgesia, Sedation, and Delirium Protocols ....................................... 72
Infections and Antibiotics in the ICU ................................................... 75
DVT/PE Prophylaxis in Adults Following Multiple Trauma ............... 79
Enteral Access and Nutrition Policy in the ICU ................................... 80
ICU Electrolyte Protocol ...................................................................... 82
Alcohol Withdrawal.............................................................................. 84
Rhabdomyolysis, Crush Injury and Compartment Syndrome .............. 87
TICU Bedside Surgery Protocol ........................................................... 90
SPECIAL ISSUES
Geriatric Trauma ................................................................................... 92
Trauma in Pregnancy ............................................................................ 94
Diagnosis of Brain Death: Adult and Pediatric ..................................... 97
Speech-Language Pathology Services .................................................. 98
Reporting Abuse and Neglect ............................................................. 100
Law Enforcement and the Trauma Patient.......................................... 102
Maintaining the Chain of Evidence in Trauma/Criminal Cases ......... 104
APPENDIX
AAST Liver Injury Scale .................................................................... 105
AAST Small Bowel Injury Scale ........................................................ 105
AAST Spleen Injury Scale.................................................................. 106
Gustilo Open Fracture Classification .................................................. 106
Burgess & Young Pelvic Fracture Grading ........................................ 107

Pediatric Contents
Pediatric Service Assignments............................................................ 109
Role of Trauma Team Members: Pediatric Trauma Team
Resuscitations ..................................................................................... 111
Trauma Team Activation: Pediatric .................................................... 116
Routine Trauma Labs ......................................................................... 118
Substance Use Screening Tool (CRAFFT) ......................................... 119
PRIMARY SURVEY
Rapid Sequence Induction: Pediatric .................................................. 120
Damage Control Resuscitation Protocol: Pediatric ............................. 121
TEG: Thromboelastography and Anticoagulation Reversal
Protocol............................................................................................... 123
SECONDARY SURVEY / DEFINITIVE CARE

Pediatric TBI Clinical Pathway .......................................................... 126
Traumatic Brain Injury ED Management: Pediatric ........................... 129
Guidelines for Pediatric Head Trauma Patient Admissions ................ 130
C-Spine Evaluation in Pediatric Trauma Patients ............................... 131
C-Spine Flow Chart for Pediatric Trauma Patients ............................ 134
C-Spine Clearance: ED Dot Phrase .................................................... 135
Pediatric Spinal Cord Injury Mean Arterial Pressure (SCI-MAP)
Guidelines ........................................................................................... 136
Pediatric Blunt Abdominal Trauma Management Pathway (Part I) ... 138
SPECIAL ISSUES
Child Maltreatment Screening and Evaluation ................................... 139
Reporting Child Abuse/Neglect – CPP Referrals ............................... 141
Pediatric Compartment Syndrome Consult Pathway .......................... 143
Pediatric Microsurgery Protocol for PICU ......................................... 144
Pediatric Venous Thrombosis Prophylaxis Guideline ........................ 147

Trauma Conferences and Clinics

The Trauma Surgery Team is expected to attend these as well as other
applicable surgical conferences. Many conferences can and will be made
virtual as needed.
SATURDAY / SUNDAY THURSDAY

Trauma Morning Report Trauma Morning Report
8:00 a.m. 8:00 a.m.
Trauma Clinic
MONDAY 9:00 – 12:30 p.m., Coop 1
Trauma Care Center
Trauma Conference/Trauma M&M
9:15 a.m.- 12 p.m., MOC 4th fl.
7:00-8:00 a.m.
Trauma Morning Report
FRIDAY
8:00 a.m.
Burn Clinic Critical Care Fellows Conference/
9:00 –11:00 a.m., Coop 1 Acute Care Conference
7:15-8:00 a.m.
TUESDAY Trauma Morning Report
8:00 a.m.
Resident Teaching Conference
Pediatric Trauma Committee
8:00 a.m.
Meeting (PTC)
Trauma Morning Report Week 1
9:00 a.m. 7:00- 8:00 a.m.
Trauma Care Center
9:15 a.m.-12 p.m., MOC 4th fl. *Trauma Program Operational
Process Performance Meetings are
scheduled quarterly*
WEDNESDAY
ED Trauma Service Conference
Week 1
8:15 a.m.
Combined ICU Conference
Weeks 2 & 4
8:00 a.m.
Trauma Operative Procedures
Conference
Week 3
8:00 a.m., APC 415 Conference Room
If Week 5- Open, Faculty Meeting
8:00 a.m., APC 415 Conference Room

Trauma Service Policies

To ensure optimal patient care as well as a productive educational experience, the trauma
staff has formulated the following guidelines. These policies cover the roles, responsibili-
ties, and expectations for each resident and medical student rotating on the service. It also
includes specific policies regarding patient care, and other issues essential to the efficient
running of the Trauma Service. In general, the philosophy of the Trauma Service is that
residents should actively manage patients and the expectation is that the resident will be
able to defend their clinical decisions based on their fund of knowledge and clinical
judgment. Sins of commission are always preferable to sins of omission!
Resident/Medical Student Roles:

Trauma Chief Resident
1. The leader of the Trauma Team; ultimately responsible for all aspects of trauma
patient care and resident team leadership.
2. Respond to all Level A & B trauma Activations, assign resident clinical tasks in
the Trauma Rooms, must “control” the room AND utilize the communication
script.
3. Oversee daily work rounds and management of all admitted trauma patients.
4. Leads the Trauma Clinic.
5. Oversee all junior residents, reviews all Level C workups, assigns operative
cases, bedside procedures, etc.
6. Ensure completion of all Trauma essential documentation (H&Ps, Tertiaries).
This is crucial to our verification.
7. Responsible for Trauma Conference and Trauma M&M content.
8. May be responsible for presentations at the monthly joint ED Trauma Service
Conference. Topics must be approved by Trauma Medical Director prior to
presentation.
9. Trauma Operative Conference planning. Inform Chief of Service or TICU
attending of topic 1-2 days prior to conference.
10. Coordinate patient care with all consulting services.
11. Ensure resident compliance with duty hours and educational mandates.
12. Communicate and inform the Chief of Trauma of problems adversely affecting
trauma patient care on an as needed basis.
13. The responsible trauma attending must be notified of all trauma admissions
(including those to off-services).
14. Attend the Operations meeting, dates to be determined.
Trauma Senior Resident
1. Initial response to all trauma activations. Coordinate resuscitation and oversee
complete workup of all trauma activations.
2. Ensure completion of Trauma H&P (consult) for all patients with trauma activations.
3. Present all Level B activations to the floor attending (7am-5pm) or the on-call
attending (5pm-7am) within 30 minutes of patient arrival
4. Daily management of in-house trauma patients.
5. The in-house chief trauma resident and the responsible trauma attending must be
notified of all trauma admissions (including those to off-services).
6. Daily Morning Report presentations/sign out.

7. Trauma Conference presentations.

8. Assist and educate junior residents.
9. Responsible for adhering to all resident duty hours and educational mandates.
Trauma Intern
1. Initial response to Level A and Level B trauma activations.
2. The in-house chief trauma resident and the responsible trauma attending must be
notified of all trauma admissions (including those to off-services).
3. Ensure completion of Trauma H&P for all patients with trauma activations.
4. Daily management of in-house trauma patients.
5. Coordination of discharge planning for all Trauma Service patients.
7. Responsible for adhering to resident duty hours and educational mandates.
8. Attend and participate in all clinics.
TICU Residents
1. Patient care in TICU.
3. Complete Trauma Tertiary documentation for all TICU patients.
Medical Students
1. Respond to all Trauma activations.
2. Assist in daily patient care as dictated by senior Trauma Service Residents.
3. Presentation of his/her patients at Morning Report.
Trauma Resident Operative Procedure Responsibilities

1. A resident from the Trauma Service should scrub on all Trauma Service cases.
2. A Senior Trauma Resident should scrub on all major trauma cases, but this must be
coordinated with the Chief Resident in house at night.
3. If manpower and the clinical situation permit, the senior resident should assume a
teaching role to junior residents in the OR.
4. Trauma patients going to the OR with other services should be checked on periodically
in accordance with acuity of the patient and nature of the case.
5. All bedside procedures MUST be communicated to the responsible Trauma
Attending beforehand. This includes all TICU procedures.
Trauma Attending Coverage

Monday through Friday 0700-1700 (Contact TICU Attending for ICU patients and
Level A, Trauma Floor Attending for floor-level patients, level B, level C and off
service admissions)
Monday through Friday 1700-0700 - On-call Attending
When the TICU or floor attending are post-call, the Wildcard attending will take over for
him/her at noon.
Saturday, Sunday, and Holidays 24-hour coverage 0800-0800 - On-call Attending
Refer to the published back-up call schedule for nighttime Trauma Attending Back-up.
The decision to call in the back-up attending is solely the responsibility of the in-house
Trauma Attending.

Trauma Attending Notifications

1. Level A Activations: Pre-notification or arrival page
The Trauma Attending must be present within 15 minutes of patient arrival and their
arrival time MUST be documented in the Trauma Narrator by the Primary Trauma
Nurse. Attendings will remind documenting nurse to “sign them in”.
2. Trauma Attending DOES NOT receive Level B and Level C pages.
Present and discuss all Level B activations with responsible Trauma Attending within
30 minutes of arrival. Level C activations should be staffed in accordance with
department policy.
3. The responsible Trauma Attending MUST be promptly notified of all admissions
without exception (including those to off-services). Attending notification requires some
judgement; low acuity overnight admissions must be communicated by 7:00am.
4. The post-call service attending (TICU or Floor) is relieved of clinical responsibilities at
Noon on their post-call day by the “Wildcard” attending.
5. Notify the on-call Burn Attending of all burn patients. Trauma attending is back-up.
General Policies
1. Documentation Requirements:
• A complete and accurate Trauma History and Physical (H&P) is required for all
trauma admissions to trauma service. Consults are required for all activations.
• A complete daily Progress Note addressing all problems and a plan of care is
required for each patient on the Trauma Service.
• All patients should have the Tertiary exam performed. See page 14. Significant
findings should be directly communicated (verbally and written) to the Primary
Service for patients NOT admitted to trauma.
• Discharge Summaries on all patients must be dictated in the name of the Trauma
Attending who is covering on the day of discharge. The Discharge Summary
MUST have a complete and accurate list of the patient’s diagnoses. “Multiple
Trauma” is NOT a diagnosis.
• All trauma patients should have a complete Problem List on admission.
• All trauma service deaths need a Death Note documented, even if they were in the
hospital <24 hours.
2. Trauma team members are expected to arrive in the emergency room per trauma
activation response team algorithm, (see Adult – page 7, Pediatric - page 116).
Dismissal from the trauma room is at the discretion of the senior trauma resident.
3. The ED accepts all trauma transfers from outlying hospitals and Express Care (4-3000)
notifies the TICU or on-call attending of Level A transfers.
4. Admissions and discharges from the TICU (or other intermediary care unit) must be
communicated to the responsible Trauma Attending and Chief Resident.
5. Acute ethanol intoxication is a diagnosis and should be documented in the EMR (Epic).
All admitted patients must have a Brief Screening and Intervention (SBI) done for
alcohol abuse. Audit-C (adult) and CRAFFT (Pediatric >11 years old). Consult
Substance Abuse Social Worker for all positive Audit-C or CRAFFT assessments.
6. Discharge planning BEGINS upon admission to the Hospital.
7. Clinical Social Work (CSW) referrals for trauma patients are not automatic. Request
CSW consults for patients, when required, within 24 hours of patient admission.

8. The final read of all initial radiographic studies is an important part of the Tertiary
form and must be reviewed and documented. It is important for residents to review the
actual images as well. This is critical to preventing missed injuries. Communication of
all new findings is mandatory.
Universal Precautions in the Trauma Rooms

All employees, students, and observers are required to wear personal Protective Equipment
(PPE) while in the trauma rooms. OSHA, Rhode Island DOH, and Joint Commission
mandate this. The following items must be worn in the trauma rooms with NO
EXCEPTIONS:
1. Gloves 3. Masks
2. Gowns 4. Eye Coverings
NOTE: A higher degree of PPE may be required. Refer to Lifespan Infection Control
Policy/updates, (e.g., N95 respirator for COVID patients).
Verification of Person, Procedure, and Site for Surgical Procedures

Procedures performed in the Operating Rooms (OR) adhere to the Universal Protocol which
ensures that the right procedure is being performed on the right location on the right patient.
The Universal Protocol empowers everyone in the OR to speak up to ensure that the patient
(and surgeon) is fully protected from the wrong procedure. Procedures done at the bedside
or in locations outside of the OR need to be approached with the same caution and
adherence to the Universal Protocol to ensure that medical errors are prevented. Refer to
Lifespan Universal Protocol Policy; “Universal Protocol for Procedures Performed Outside
of the Operating Room (OR): Verification of Patient Identity, Procedure, and Site/Side”.
ANY time you are encountering a new patient be sure to verify their name, DOB and
medical record number to ensure you are examining the correct patient. DO NOT rely on
the patient’s response to you using their name since language barriers, intoxicants, and
brain injury may cloud their sensorium.

Service Assignments
To facilitate patient care and to eliminate potential misunderstandings between various
services caring for trauma patients, the Trauma Committee has established the following
guidelines regarding admission to and transfer of trauma patients between services.
1. Patients with single system injuries requiring admission shall be directly admitted
to the appropriate service. There is no need for an initial “24-hour” admission to the
Trauma Service.
Patients will be admitted to the Trauma Service if an appropriate evaluation for occult
injuries is in progress. Pre-existing medical conditions such as congestive heart failure,
seizures, arrhythmias, diabetes, or COPD do not constitute reasons to remain on the
Trauma Service with a single system injury. Once occult injuries have been ruled out
and the patient with single system injury is stable, the patient may be transferred from
the Trauma Service to the appropriate service. The order activating transfer will be
executed by the Trauma Service (attending or chief resident) with notification of the
attending or chief resident from the receiving service.
2. Patients with “isolated” head trauma, including concussions, requiring admission are to
be admitted to Neurosurgery. If a patient’s overwhelming care issue centers on head
trauma, they should also be admitted to the Neurosurgical service, even in the presence
of other minor associated injuries. Patients with significant poly-system trauma should
always be admitted to the Trauma Service.
As communication is of the utmost importance:

• All involved Services and their representatives (attendings, fellows, residents) will
be clearly identified in the chart and at the bedside, to allow seamless continuity of
care.
• All multidisciplinary issues will be discussed through direct physician-to-physician
communication

Combined Adult and Pediatric Trauma Transports

(Mixed Bundles)
The goal of this policy is to have pediatric trauma managed at Hasbro and adult trauma
managed at Anderson. The policy for adult/child trauma is as follows:
• EMS agencies are encouraged to use separate ambulances for injured patients when
possible. When both an adult and child must be transported together, both patients
will go to the age-appropriate facility for the most injured patient.
• ED staff at either ED will welcome both patients, take report from EMS, manage the
patient whose age matches the facility, and perform a Primary Survey on the other
patient:
o Stable patients will then be transferred to their appropriate facility, unstable
patients will remain and receive care where they arrive.
o The given trauma team will be notified of their patient’s disposition. The
involved attending surgeons will communicate directly.
• In the case of a mixed bundle where the parent refuses to be separated from the
child, all efforts will be made to convince the parent that the best place for an
injured child is at Hasbro and for an injured adult is in Anderson – and that parent
and child will be reunited as soon as possible. If a parent cannot be reasoned with
and would otherwise represent a significant disruption or safety risk they can remain
together, and the awaiting trauma team will be notified.
Refer to Lifespan Policy: Combined Family and Pediatric Mixed Bundles Admin-272

Trauma Team Activation: Adult

The Medical Communication Center (Med Comm) is responsible for activating the
appropriate triage level as determined by the triage nurse based on the outlined trauma
triage criteria.
It is the expectation that a pre-notification page be sent for all Level A patients immediately
upon notification by EMS. In addition, a page is sent once the Level A patient arrives in
the ED. On occasion, a Level A will arrive to the ED without pre-notification resulting in
an arrival page only
Level A page information should include age, mechanism, vital signs, GCS, estimated time
of arrival, and critical care room location. Level B and C trauma pages may or may not
have a pre-notification page but will have an arrival page.
When you are paged, do not call the ED or the trauma room; just report to the
Critical Care Rooms. Level A and B activations require immediate response by the
residents. Level C activations require response within 30 minutes of patient arrival/
upgrade in accordance with hospital policy.
For Level A activations, the Trauma Attending MUST report to the Trauma Room
within 15 minutes of patient arrival, even if the patient is pronounced or “down-
graded” in order to comply with ACS requirements.
If the Trauma Attending does not respond to a Level A activation within 15 minutes:
• Telephone the Trauma Attending on-call room (4-8116)
• If no response, call the operator and ask for the Trauma Attending cellphone to
be called.

Criteria for Triage to Trauma Rooms: Adult
LEVEL A
Physiologic / Anatomic Criteria
AIRWAY / • Respiratory Compromise or Obstruction
BREATHING • Intubation in the field/ED
• Trauma transfer with respiratory compromise, despite
intubation
CIRCULATION • Systolic blood pressure <90 at any time field/ED
• Requiring blood products to maintain vital signs
• Age >75 and systolic blood pressure <100 at any time
CENTRAL • GCS 3-8 with signs of trauma or plausible high-risk
NERVOUS trauma mechanism
SYSTEM • Spinal cord injury/paralysis
EXTREMITIES • Amputation proximal to wrist or ankle
• Extremity trauma with neurovascular deficit as
demonstrated by abnormal ABI or absence of signals
(i.e., Threatened Limb)
Mechanism Criteria / Other
BURNS • >40% TBSA second and third degree combined
• High voltage electrical injury >600 volts
HYPOTHERMITY • <32oC or < 90oF with cardiac arrest
/ EXPOSURE
GUNSHOT • GSW to head, neck, chest, or abdomen
WOUND
OTHER • ED Attending or ED nurse’s discretion
LEVEL B
AIRWAY / • Intubated trauma transfer without respiratory
BREATHING compromise
CIRCULATION • Uncontrolled hemorrhage
CENTRAL • GCS 9-12 with signs of trauma or plausible high risk
SYSTEM • Open or depressed skull fracture
CHEST • Chest wall deformity
• Unilateral absent breath sounds
• Needle decompression
• Trauma transfer with known PTX or HTX without a
chest tube

LEVEL B (Continued)
PREGNANCY • Fundus at/above the umbilicus with abdominal
tenderness/pain
EXTREMITIES • Proximal long bone fractures in multiple limbs
(humerus/femur)
FALL • Fall >15 feet
PENETRATING • Head, neck, chest, abdomen, pelvis, or groin (non-
WOUND GSW)
• GSW to extremities, proximal to knees and elbows
BURNS • Burn in enclosed space with second or third degree
facial burns
• Burn ≥20% TBSA
FROSTBITE • Presents with frozen tissue or <24 hours of rewarming
LEVEL C
CENTRAL • GCS 13-14 with signs of trauma or plausible high risk
SYSTEM • Trauma transfer with known traumatic intracranial
hemorrhage
CHEST • Trauma transfer with a chest tube
PREGNANCY • Fundus below the umbilicus with abdominal
tenderness/pain
EXTREMITIES • Open long bone fractures
FALLS • Chest, abdominal, or pelvic pain/tenderness
MVC • Seatbelt marks
BURNS • >10% TBSA second and third degree combined
• Circumferential second or third degree
• >1% TBSA to face, hands, feet, or perineum

Informed Consent and the Care of the Trauma Patient

The care of the injured patient presents many difficult and unusual challenges, not limited
to medical issues alone. Legal matters punctuate the care of trauma patients and cover a
wide range of topics from concerns regarding informed consent, to medical futility and
end of life care, to the concept of urgent medical necessity. Medical practitioners may
find themselves in precarious and unfamiliar legal situations that may be stressful for the
physician and ultimately may hinder the delivery of top-notch care. This section will serve
to answer some of the more common questions regarding informed consent. Remember,
it is essential that complex medico-legal decisions be made with attending physician
input and if possible, Risk Management as well. A Risk Manager is on-call 24/7 at pager
350-5274.
Informed Consent
True informed consent involves a process whereby a medical professional describes a
proposed therapy to a patient in layman’s terms, states the risks and benefits of the
proposed therapy and alternative therapies. The patient’s questions and concerns must be
addressed, and the medical professional has an obligation to ensure that the patient has a
good understanding of the situation and is able to participate in the process. In trauma
patients altered mental status due to head injury, hypotension, shock, pain, alcohol, or other
substances frequently preclude informed consent. In these circumstances and if time or
the situation will allow, the medical professional has an obligation to contact next-of-kin
(NOK), including acquaintances, so that informed consent can be obtained as long as no
urgent life-saving intervention is required. It is inappropriate to delay life-saving
interventions in order to contact NOK or obtain informed consent. Rhode Island law
does not define the hierarchy of NOK for medical decision-making, so that a spouse, adult
child, parent, etc. may serve in this capacity. Close friends or acquaintances may also serve
as NOK and may be able to offer insight about a patient’s wishes regarding healthcare.
Informed Consent in the Impaired Patient

It is not uncommon for trauma patients to have issues that make obtaining informed
consent difficult if not impossible. In general, if a patient has a life-threatening injury and
will not consent to or comply with medical care (let alone consent to care), the practitioner
is not obligated to abide by the patient’s wishes. Attempts should be made to contact next
of kin (NOK), however the patient’s life should not be put at risk while this contact occurs.
If NOK are not immediately available and a life-threatening condition exists, the physician
should proceed with any necessary interventions. This may include the need to “control”
the patient with physical or pharmacological restraints. The interpretation of a “life-
threatening” injury is problematic, and there is little guidance in the law as to what this
encompasses. Nor is it clear whether only the suspicion of a life-threatening injury would
fall into this category. In situations where urgent action is required, it is imperative that the
attending physician documents the urgency of the situation and that the procedure was
done without consent on the basis “urgent medical necessity”. While an intoxicated
individual may seem sensible as they vehemently refuse an operation, you must assess
their capacity to understand the situation. If you have doubts about their capacity, consult
with others on the team, especially the attending physician, and if time allows a Risk
Manager.

Obtaining Consults on the Trauma Service

All consults must be cleared by a Trauma Attending and/or Trauma Chief Resident prior
to consultation. Consulting services CANNOT call consults on a trauma patient. Patients
who sustain significant injuries require the efforts of many services to aid in their full
rehabilitation. Coordinated communication between these services is essential. An excep-
tion to this policy is the Trauma Geriatrician who may be consulted as needed for all
geriatric trauma patients. To optimize the care of the patient, it is important to ask the
consultant a specific question. Examples could include “would you place a monitor in this
patient with a TBI and GCS of 8” from a neurosurgeon or “can you provide coverage of
this complex wound with a rotational flap” from a plastic surgeon. In addition, “medical
clearance” should not be the reason for the consult as it diminishes the importance of
quality surgical care: such as avoiding prolonged operative time or excessive blood loss.
Here are some consults to consider:

Occupational Therapy / Physical Therapy Rehabilitation
Early consideration of the PT and OT needs of the patient should facilitate patient care and
ultimate disposition.
Adult patients with anticipated placement problems should be brought to the case managers
as soon as possible and this contact should be documented in the medical record. Obstacles
to patient discharge should be addressed in Trauma Morning Report as well as during ward
rounds. REMEMBER, discharge planning begins the moment the patient is admitted!
Psychiatry
Urgent Issues - Acute psychosis, acute agitation, suicidality/suicide attempt, homicidal
behavior
Routine Issues - Anxiety symptoms, depressive symptoms, adjustment to illness/non-
compliance, post-trauma symptoms, dysfunctional coping behavior/acting out
Substance Abuse/Addiction Medicine

Substance abuse-referral to detox outpatient counseling, residential treatment facility
Pain management in patients on outpatient medication assisted treatment for opiate use
Neuropsychology
Inpatient Consultation Subacute Cognitive Impairment
Evaluate cognitive rehabilitation needs for discharge planning
Geriatric Trauma Consult

Any patients over the age of 65 with comorbidities
Palliative Care
Early consultation in patients who may progress to comfort measures only or will be
discharged to hospice. In addition, can help with patients who have chronic pain issues
Anesthesia
Can provide acute pain services such as an epidural for rib fractures

Routine Trauma Labs
The following laboratory tests should be ordered for all adult surgical trauma patients
evaluated in the trauma rooms.
Please note: Level A/B and Level C order sets are in the Order Set section of
LifeChart to allow for correct and timely ordering of labs. Trauma resident should
ensure utilization of Trauma Order Set, not the Routine Surgical Order Set.
Level A and B Order Set Level C Order Set

• CBC with differential • CBC with differential
• Chem 7 • Chem 7
• PT/PTT/INR • PT/PTT/INR
• Lactic Acid • Blood alcohol level
• Blood alcohol level • Urine “Drugs of Abuse”
• Urine “Drugs of Abuse” toxicology toxicology screen
screen • Urinalysis
• Urinalysis • UCG in female patients of
• UCG in female patients of childbearing age
childbearing age • Type and screen
• Type and screen. Type and cross for
any patient with SBP <90, truncal
penetrating injury, or going directly
to the OR.

Tertiary Survey
Missed injuries are considered an important issue in trauma patients and can lead to
significant morbidity and even mortality. It has been shown that the standard primary
and secondary surveys, recommended by the Advanced Trauma Life Support (ATLS)
guidelines1, are associated with missed injuries. Trauma Tertiary Survey (TTS) is defined
by the ACS as a patient evaluation that identifies and catalogues all injuries after the initial
resuscitation and operative intervention thus decreasing the number of missed injuries in
trauma patients2,3. TTS should ideally be performed in patients 24 hours after admission,
once radiologic studies have been finalized. In unconscious patients (intubated, TBI,
intoxication), TTS should be performed once patients are extubated and/or sober. For
those patients who do not resolve within 48 hours, a limited TTS can be performed. The
spirit of the TTS is lost if it is performed 4 hours after initial evaluation in an intubated
patient and should not be performed at this time. The TTS can be found in LifeChart.
1. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support 8th Ed. 2008.
2. www.trauma.org/archive/nurse/tertiarysurvey
3. Hajibandeh S et al. Meta-analysis of the effect of tertiary survey on missed injury rate in trauma patients. Injury.
2015 Dec;46(12):2474-82.

ED Thoracotomy
Wilson and Bassett’s 1966 JAMA review of 200 patients with penetrating cardiac injuries
introduced the principles of lifesaving thoracotomy and cardiorrhaphy. In the period
following their publication, emergency department thoracotomy (EDT) came to be widely
used to address other life-threatening injuries, however, multiple critical analyses of out-
comes have resulted in a selective use of the procedure. Performing this procedure for
unindicated reasons increases the safety risk of health care providers and resource utili-
zation costs. The goal of EDT is always survival with intact neurologic outcome while
minimizing risk to the healthcare team.
Selective Approach
The decision to perform EDT should be based on “signs of life” (pupillary activity,
spontaneous respirations, narrow complex PEA, pulse, blood pressure, movement) on
EMS arrival and duration of arrest prior to ED arrival. Cardiac activity on U/S is NOT
considered a sign of life; conversely an absence of cardiac activity or pericardial fluid
does not correlate with survival.
EDT Survival
ED: ED:
ED:
No signs of life, Signs of life,
Vital signs present
No vital signs No vital signs
BLUNT 1% 1% 3%
GSW 1% 3-5% 10-15%
STAB 3-5% 10-15% 30-40%
>1/3 of survivors severely < 1/10 of survivors
neurologically impaired neurologically impaired
Procedural Goals of EDT

The goals of EDT are as follows: release pericardial tamponade, control cardiac and/or
great vessel bleeding, control bronchovenous embolism, perform open cardiac massage,
redistribute blood flow to the brain and myocardium, and limit sub-diaphragmatic
hemorrhage by aortic cross clamping.
EDT Technique
A left anterolateral thoracotomy is done at the level of the fifth intercostal space (below
the nipple in males or the infra-mammary crease in females) with the patient in the supine
position and the left arm abducted.
The knife blade should pass through the skin, sub-cutaneous tissue, and chest wall
musculature in one pass and then the intercostal muscles and pleura should be incised with
heavy Mayo scissors along the superior margin of the rib. A rib spreader should then be
placed in a way such that the spreader does not impede trans-sternal extension (clamshell
thoracotomy). Maximal cardiac and great vessel exposure and “clearance” of the right chest
is obtained via clam-shell thoracotomy by dividing the sternum. The right chest must be
“cleared” thus a right tube thoracostomy should be inserted if clam-shelling is not
performed.

The pericardium is opened with a longitudinal incision anterior to the phrenic nerve and
any blood or clot should be evacuated. If a cardiac injury is encountered, attempts to
control it are best done with digital pressure or a skin stapler followed by 3-0 Prolene or
silk (± pledgets). Foley catheters should NOT be used to control cardiac injuries since they
typically result in a bigger cardiac wound. If the patient has return of vitals (SBP >50
mmHg), then they should be emergently brought to the operating room. Remember, only
LIVE patients can be brought to the OR.
Air embolism or massive bleeding from the lung can be controlled by cross clamping the
pulmonary hilum or 180 lung torsion. The thoracic aorta is visualized by dividing the
inferior pulmonary ligament and lifting the left lung antero-superiorly and opening the
mediastinal pleura. The aorta can be manually differentiated from the esophagus by
palpating for the NG tube (ask to have one placed if difficulty with differentiating).
Clamping the thoracic aorta is easier the closer one gets to the diaphragmatic hiatus.
Risks to Healthcare Providers

The rate of HIV, hepatitis B, and hepatitis C in urban trauma populations are many times
higher than that of the general population. ED thoracotomy involves the use of sharp
instruments and the potential to be in contact with large amounts of the patient’s blood in
a chaotic setting. In addition, compliance of trauma team members with universal pre-
cautions is notoriously poor with observational data showing a “major break” (absence
of a mask, gown, gloves, or eye protection) from precautions noted in 1/3 of those perfor-
ming procedures on trauma patients in the ED. EDT should never be performed by anyone
not observing all aspects of universal precautions. Commotion in the room and by-
standers place the patient AND the trauma team at increased risk for injury, the
room should be cleared of all extraneous personnel.
UNIVERSAL PRECAUTIONS ARE MANDATORY FOR EVERYONE IN THE

TRAUMA ROOM. ANYONE NOT ADHERING TO THIS SHOULD BE ORDERED
OUT OF THE ROOM BY THE TRAUMA LEADER.
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

The use of this endovascular device is being considered as an alternative to EDT,
especially for bleeding due to extra-thoracic injury. Early data does lend some support
to show that hemorrhage is controlled enough for transport from ED to OR. Overall
outcomes are being determined.
SBP ≤ 50
Mechanism
Blunt Penetrating
Vital Signs in ED?* Signs of Life in ED?**
NO YES YES NO
Pronounce DEAD ED Pronounce DEAD

No Further Action Thoracotomy No Further Action
* Vital signs: palpable pulse or obtainable BP

** Signs of life: pupillary activity, respiratory effort, or narrow complex QRS

1. Moore EE, Knudson MM, Burlew CC, et al. Defining the limits of resuscitative emergency department
thoracotomy: a contemporary Western Trauma Association perspective. J Trauma. 2011 Feb; 70:334-9
2. Beall AC Jr, Diethrich EB, Cooley DA, et al. Surgical management of penetrating cardiovascular trauma. South
Med J. 1967; 60:698–704
3. Hofbauer M, Hüpfl M, Figl M, et al, Retrospective analysis of emergency room thoracotomy in pediatric severe
trauma patients. Resuscitation. 2011 Feb; 82:185-9
4. Moriwaki Y, Sugiyama M, Yamamoto T, et al. Outcomes from prehospital cardiac arrest in blunt trauma
patients. World J Surg. 2011 Jan;35(1):34-42.
5. Wilson RF, Bassett JS, Penetrating wounds of the pericardium or its contents. JAMA. 1966 Feb 14; 195:513-8
6. Rhee PM, Acosta J, Bridgeman A, et al. Survival after emergency department thoracotomy: review of published
data from the past 25 years. J Am Coll Surg. 2000 Mar;190(3):288-98
7. Evanoff B, Kim L, Mutha S, et al, Compliance with universal precautions among emergency department
personnel caring for trauma patients. Ann Emerg Med. 1999 Feb;33(2):160-5
8. Sloan EP, McGill BA, Zalenski R, et al. Human immunodeficiency virus and hepatitis B virus seroprevalence in
an urban trauma population. J Trauma. 1995 May;38(5):736-41
9. Frezza EE and Mexghebe H. Is 30 minutes the golden period to perform emergency room thoracotomy (ERT) in
penetrating chest injuries? J Cardiovasc Surg. 1999; 40: 147-151
10. Mollberg NM, Tabachnick D, Lin FJ, et al. Age-associated impact on presentation and outcome for penetrating
thoracic trauma in the adult and pediatric patient populations. J Trauma 2014 Feb. 76 (2): 273-278
11. Cureton EL, Yeung LY, Kwan RO, et al. The heart of the matter: Utility of ultrasound of cardiac activity during
traumatic arrest. J Trauma. 2012 July; 73 (1): 102-110
12. Seamon MJ, Haut E, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency
department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of
Trauma. J Trauma. 2015 July; 79 (1): 159-173
13. Inaba, K, Chouliaras K, Zakaluzny S, et al. FAST Ultrasound Examination as a predictor of Outcomes after
resuscitative thoracotomy: A prospective evaluation. Surgery. 2015 Sept; 262 (3): 512-518
14. Moore LJ, Brenner M, Kozar RA, et al. Implementation of resuscitative endovascular balloon occlusion of the
aorta as an alternative to resuscitative thoracotomy for non-compressible truncal hemorrhage. J Trauma. 2015
Oct. 79 (4): 523-532

Intravenous Access and the Trauma Patient

All trauma patients require intravenous access. Ideally, this access is established with 2
large-bore (14-16 ga.) peripheral IVs. Flow rates through 2 large peripheral IVs is better
than flow through a triple lumen catheter. If central access is needed for aggressive fluid
resuscitation, an introducer (Cordis) should be placed as flow through this catheter is
superior to other IV access. A triple lumen catheter is not a “volume” line.
Identifying Size of Peripheral IV’s

Orange 14 gauge
Gray 16 gauge
Green 18 gauge
Pink 20 gauge
Blue 22 gauge
Cather-related bloodstream infection and other complications have been decreased by strict
adherence to appropriate protocols. The following recommendations should be followed to
minimize line-related complications.
1. All lines placed in field, ED, or OR should be removed as soon as possible.
2. Preferred site of central access in an unstable patient is the femoral vein. The preferred
site in a stable patient is the subclavian vein. Use femoral access with caution in patients
with severe pelvic fractures or suspected vena cava injuries.
3. The central line checklist should be completed by the bedside RN for the insertion of all
central lines.
• ALL central lines should be placed under “full barrier precautions” defined as
sterile gown, gloves, cap, mask, and FULL draping (3/4 sheet, lap drape, etc.) for
all participants. Cap and mask is required for those nearby (e.g., bedside RN)1-3.
ChloraPrep® is the preferred prep agent and is available in the central line kits.
• Central lines should be dressed with clear adhesive dressing unless the site is
bleeding, or the patient is diaphoretic. Chlorhexidine-impregnated (Bio-Patch®)
disks have been shown to reduce line infections threefold and should always be
used, blue side up.3
• The need for central access should be accessed daily.
4. Once central access is obtained, peripheral IVs should be removed to prevent thrombo-
phlebitis and to “save” for use later.
5. Although interosseus (IO) catheters are becoming more prevalent, they are problematic
in the care of trauma patients. Blood may be transfused through an IO but are not
effective for massive transfusion protocols and must be removed within 6 hours of
placement. Thus, the use of IO catheters in trauma patients is reserved for the direst
indications. They are contraindicated in tibial fractures. They are associated with joint
infections, osteomyelitis, cellulitis, and compartment syndrome if placed incorrectly.

Massive Transfusion/Damage Control Resuscitation

(DCR) Strategy
Coagulopathy rapidly develops in severely injured trauma patients for several reasons,
including consumption and dilution of clotting factors, acidosis, hypothermia, fibrinolysis,
and hypocalcemia. The combination of bleeding, acidosis and coagulopathy is termed the
lethal triad. While patients with significant traumatic hemorrhage may require surgical
control of their hemorrhage, it is still important to minimize the ongoing blood loss from
coagulopathy. The avoidance of crystalloid in bleeding patients along with whole blood
and a balanced approach to blood product resuscitation has reduced mortality. However,
exsanguination remains the leading cause of death of trauma patients, especially in the first
24 hours after injury.
We define massive transfusion as transfusion of 10 units of PRBC in the first 6 hours after
injury. A strategy utilizing a balanced ratio of blood products in this setting is termed
“Damage Control Resuscitation” (DCR). Whole blood is one important way to start a
balanced blood product resuscitation. Whole blood and DCR should be considered in any
patient suspicious for ongoing hemorrhage and hemodynamic instability despite transfusion
of PRBCs. A thromboelastography (TEG) should be sent (if possible) at initiation of DCR
and Tranexamic acid (TXA) should be given.
Key Aspects of Whole Blood Transfusion:

• Whole blood is in the ED “smart” refrigerator and can only be transfused by a
Trauma Attending’s order.
• Whole blood is currently only being given to male patients and postpartum female
patients.
Benefits of Whole Blood:

• Decreased total transfused volume with whole blood compared to components
• Possibly decreased incidence of ARDS
• Possibly decreased duration of mechanical ventilation
• Easier to maintain product balance early on in a trauma when surgeon needs to
concentrate on determining whether/how to establish surgical control of
hemorrhage*
Still unclear if whole blood decreased mortality or total transfusions, more studies
needed
Enacting and stopping the DCR:

• The DCR can be activated in LifeChart or by contacting the Blood Bank at 4-5295.
Communication between the Trauma Team and Blood Bank cannot be overstated
especially as patients move through the hospital with ongoing transfusion require-
ments. In order to minimize waste, inform the Blood Bank to STOP the DCR when
blood products are no longer needed since they will be continually sent to the
patient’s location while the DCR is active.
• “Smart” refrigerators are located in the ER and OR which are electronically linked
to the Blood Bank and continually monitored. These are stocked with O- (color-
coded pink for female patients) and O+ (color-coded blue for males) units of
PRBCs, and FFP. Access to the Smart Refrigerator is by RN’s badge access.
• The initial “round” of FFP and PRBC or whole blood at the start of the DCR are
obtained from the smart refrigerator. Emergency platelets are also available.

Benefits of the DCR:

• Increased survival rates with balanced PRBC, FFP and platelet ratios.
• Decreased ICU length of stay.
• Improved end organ perfusion.
• Decreased overall blood product usage.
Utility of TXA:
• Inhibits fibrinolysis by blocking plasminogen.
• CRASH-2 trial in 2013 showed:
o Reduced risk of all-cause mortality and bleeding death with early TXA
o Cost effective
o Not supported if >3 hours post injury so DO NOT give TXA in these
circumstances
Dosing of TXA: 1g IV over 10 minutes, then infusion of 1g over 8 hours
Role of TEG:
• Initiate TEG early in the course of a DCR by contacting the Blood Bank
• Repeat TEG when patient in TICU for comparison
• Goal-Directed Hemostatic Resuscitation of Trauma-Induced Coagulopathy Trial:
improved mortality, decreased blood products, decreased ICU days, ventilator days
(more studies pending)
Other Guidelines:
• ATLS 9th edition: blood products in hemodynamically unstable patients after 1 liter of
crystalloid.
• Consider cryoprecipitate 10 units for every 10 units of PRBC, FFP given. This should be
requested with the 3rd cooler of DCR.
1. Anticipate use of greater than 4 units of PRBC based on injury pattern, (e.g., pelvic
fracture, liver laceration, major vascular injury). It is preferable to keep blood product
numbers balanced early with FFP and platelets.
2. Add cryoprecipitate by the third cooler.
1. de Biasi AR, Stansbury LG, Dutton RP, et al. Blood product use in trauma resuscitation: plasma deficit versus
plasma ratio as predictors of mortality in trauma. Transfusion. 2011 Feb 18.
2. Duchesne JC, Kimonis K, Marr AB, et al. Damage control resuscitation in combination with damage control
laparotomy: a survival advantage. J Trauma. 2010 Jul; 69(1):46-52.
3. Morrison JJ, Dubose JJ, Rasmussen TE, et al. Military Application of Tranexamic Acid in Trauma Emergency
Resuscitation (MATTERs) Study. Arch Surg. 2012 Feb; 147(2):113-9.
4. Roberts I, Shakur H, Coats T, et al. The CRASH-2 trial: a randomized controlled trial and economic
evaluation of the effects of Tranexamic acid on death, vascular occlusive events and transfusion
requirement in bleeding trauma patients. Health Technol Assess. 2013 Mar; 17(10):1-79.
5. Cotton BA, Podbielski J, Camp E, et al. A randomized controlled pilot trial of modified whole blood
versus component therapy in severely injured patients requiring large volume transfusions. Ann Surg
2013;258:527e532; discussion 532e523
6. Duchesne J, Smith A, Lawicki S, Hunt J, Houghton A, Taghavi S, Schroll R, Jackson-Weaver O,
Guidry C, Tatum D. Single Institution Trial Comparing Whole Blood vs Balanced Component
Therapy: 50 Years Later. J Am Coll Surg. 2020 Dec 19:S1072-7515(20)32534.
7. Gonzalez E, Moore EE, Moore HB, Chapman MP, Chin TL, Ghasabyan A, Wohlauer MV, Barnett
CC, Bensard DD, Biffl WL, Burlew CC, Johnson JL, Pieracci FM, Jurkovich GJ, Banerjee A,
Silliman CC, Sauaia A. Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a
pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation
assays. Ann Surg 2016;263:1051–9.

Hypothermia Protocol
The severity and treatment of hypothermia depends on core body temperature, cardiac
rhythm, and associated injuries. Moderate, severe, or extreme hypothermia (see below) is
determined by a core temperature obtained by thermistor, rectal, bladder, or esophageal
measurement. Hypothermia with cardiac arrest is a Level A trauma activation and should
trigger the Hypothermia Protocol. It is important to note that patients presenting with
hypothermia frequently have associated injuries and require an appropriate trauma workup.
Extracorporeal life support/extracorporeal membrane oxygenation (ECLS/ECMO) can

provide life-saving rewarming for patients with hypothermia. ECLS/ECMO replaced the
use of cardiac bypass. ECLS/ECMO is indicated for patients with moderate/severe
hypothermia with cardiac arrest or an unstable cardiac rhythm. Studies have shown
successful outcomes in young patients with hypothermia when there is minimal to no
preceding hypoxia, even with long CPR times. Contraindications to ECLS/ECMO are age
greater than 65 y/o, potassium >12, and hypoxic arrest.
Definitions of Hypothermia
MILD 32 - 35° C 90 - 95° F

MODERATE 28 - 32° C 82 - 90 ° F
SEVEVE 25 - 28° C 77 - 82° F
EXTREME < 25° C < 77° F
Core Rewarming
A. Indications
• Moderate hypothermia (28 - 32° C) with any perfusing cardiac rhythm
OR
• Severe hypothermia (25 - 28° C) with stable cardiac rhythm (Bradycardia alone does
NOT constitute an unstable cardiac rhythm)
B. Initial Management
• Core temperature monitoring (esophagus, rectal probes or via urinary catheter)
• Raise ambient room temperature to ≥32° C (90° F), close the room door!
• Labs per Trauma Activation panel, add Fibrinogen and ABG
• Place Contact Re-warmer (Bair Hugger®). These are meant to be used alone, not
with additional blankets.
• Warmed humidified oxygen by mask (40° C) or ET tube (40 - 50° C)
(An active heating/humidifying unit should be ordered from respiratory therapy for
ventilators. HMEs are inadequate.)
• Intravenous fluids: 40° C by Level l infuser or Hot-Line
• Nasogastric tube AND bladder catheter; lavage with 500cc NS at 40° C.
• Obtain fluid warmer from the OR. Pre-warmed fluid can also be obtained from the
OR, get both 4-5657
• Allow dwell times of 5-10 minutes to maximize heat exchange during lavage

• If rewarming <1° C/15 minutes, then only at the discretion of the Trauma Team
Leader consider the following:
a. Peritoneal lavage with 1L NS at 40° C.
b. Bilateral tube thoracostomy and pleural lavage with 1L NS at 40° C.
c. Venovenous (VV) ECLS via percutaneous single site Right Internal Jugular
(RIJ) access with double lumen Origin® cannula. Proper placement requires
fluoroscopy.
ECLS/ECMO Rewarming
A. Indications
• Moderate (28 - 32° C) or severe (25 - 28° C) hypothermia, with cardiac arrest or
unstable cardiac rhythm.
• Extreme hypothermia (<25° C), moderate or severe hypothermia, managed with
core rewarming, who develops cardiac arrest or who remains hypothermic and fails
to regain stable cardiac rhythm* and adequate perfusion after 30 minutes of core
rewarming.
• Rationale:
a. The shortest time from discovery of the victim to femoral arterial and venous
cannulation will improve chances for survival with minimal sequelae. The
initiation of VA ECLS allows for cardiovascular support while a stepwise,
swift, controlled increase in the patient’s body temperature can be carried out
utilizing the circuit heat exchanger.
b. Studies showing successful outcome were in centers with organized rescue
teams, a young patient population with minimal comorbidities, minimal to
no preceding asphyxia, and deep hypothermia, <28°C.
B. Exclusion from ECLS/ECMO

• At the discretion of the Trauma and ECLS teams
• Severe injury not compatible with life
• Immobile frozen body
• Age greater than 65 years old
Patients with findings incompatible with life are to be pronounced, there is no need to
warm them to do so.
C. Initial Management
• Continue ED rewarming modalities until the OR is ready
• Continue CPR
• ECLS/ECMO will be performed in the operating room for all hypothermic patients,
even those undergoing active CPR. Call OR (4-5657) for emergent transport to the
OR
• Call for ECLS/ECMO consult (Respiratory Supervisor 401-255-3520) and call the
operator to alert the ECMO attending on call
• The treatment of choice in these select patients is Femoral-Femoral Veno-arterial
(VA) ECLS
a. Open incision to expose femoral vessels
b. Seldinger access of both femoral artery (FA) and vein (FV). Consult ECLS
Director for cannula size and configuration for Adult and Pediatric patients
who require ECLS rewarming

• Full systemic anticoagulation to maintain activated clotting time at 450-480 sec,

unless an absolute contraindication (severe associated trauma)
• Intravenous antibiotics (e.g., Cefazolin)
D. Bypass termination when:
• Core temp >37° C and spontaneous-stable cardiac rhythm. Admit to MICU.
• Discovery of severe injury incompatible with life (pronounce Dead).
• Failure to wean from bypass (pronounce Dead).
1. Walpoth et al. Outcome of survivors of accidental deep hypothermia and circulatory arrest treated with
extracorporeal blood warming. NEJM 1997;337:1500-5.
2. Dunne et al. Extracorporeal-Assisted Rewarming in the management of deep hypothermic cardiac arrest. A
systematic review of the literature. Heart, Lung, and Circulation 2014;23:1029-1035.
3. Brown et al. Accidental hypothermia. NEJM 2012;367:1930-8.

Management of Traumatic Brain Injury (TBI)

Mild Head Injury - GCS 13-15
• Q15 min Neuro exam and Vital signs for 1st hour then hourly if remains stable
• If LOC, confusion, memory loss, disorientation → non-contrast HEAD CT
***Any patient with GCS ≤13 needs a head CT in <30 minutes***

Moderate Head Injury - GCS 9-12
• Q15 min Neuro exam and Vital signs for 1st hour then hourly if remains stable
• Non-contrast HEAD CT
• Consider Hypertonic Saline (23%)
Severe Head Injury - GCS 3-8

1st Level of Therapy for Severe Head Injury
• Endotracheal Intubation / Mechanical Ventilation. Target SaO2 >90%, PaCO2 35-
40mmHg*
(Quick Neuro exam to evaluate for paralysis, aphasia, visual impairment, pupillary
exam prior to intubation meds)
• Mannitol - .25-1.0g/kg; IV bolus x 1 dose (or 50-100g). In patients with SBP
<100, a single dose of 23.4% Hypertonic Saline (30cc via central line
preferred), may be used instead of Mannitol. However, if a patient shows
evidence of herniation mannitol should be given without delay.
• Sedation/analgesia with Propofol / Fentanyl
If hypotension is a concern, then use Versed over Propofol.
• Extra-ventricular Drain placement – preferred over a Bolt. Bolt is not placed into
the ventricle.
• Non-contrast HEAD CT
• Q15 min Neuro exam and Vital signs until patient makes it to the ICU.
• Head of Bed ≥30 degrees if no spinal injuries.
• Central line placement
• Seizure Prophylaxis – Phenytoin 1g load (300mg/day x 7 days) or Keppra
• Normothermia
• Reverse coagulopathy
2nd Level of Therapy for Severe Head Injury

Patient should be headed towards either the TICU or NCCU.
• Mannitol: intermittent boluses of mannitol should be administered. Maintain a
serum OSM <320mOsm or Osmolar gap <20. Mannitol may be held if there is
evidence of hypovolemia.
• Hypertonic Saline: boluses of 35 sodium chloride solution (250cc over 1.2 hour) or
other concentrations (i.e., 23.4% - 30cc) may be used. Serum sodium and
osmolarity must be assessed q6hr. Hold if serum Sodium exceeds 160mEq/L.
• PCO2 goal 30-35mHg, as long as brain hypoxia is not encountered.
• Placement of Arterial Line
• Neuromuscular paralysis may be considered.

3rd level of Therapy for Severe Head Injury

Patients belong in ICU at this point.
• All mass lesions causing shift should be considered for craniectomy.
• Decompressive hemi-craniectomy should be strongly considered if 1st and 2nd
levels of therapy are failing.
• Barbiturate coma: an induced coma is an option for those patients who have failed
to respond to aggressive measures to control malignant intracranial hypertension.
Hypotension is a frequent side effect of high dose therapy. Therefore, meticulous
volume resuscitation should be insured. Vasopressors may be required.
• If a traumatic brain injury is deemed non-survivable, both a Trauma and
Neurosurgery attending must be notified. If possible, these attendings should have
a conversation.

Adult Protocol for Scheduled Repeat Head CT (SRHCT) in Traumatic

Intracranial Hemorrhage
Traumatic ICH
GCS <= 13 GCS >= 14
SRHCT
Other Traumatic ICH Isolated Traumatic SAH*
No RHCT
Coagulopathic+ Not Coagulopathic
SRHCT
Isolated, <2mm EDH, Multiple Contusions or IPH > 2mm

Supratentorial SDH, or Infratentorial Hemorrhage
Contusion, Small IVH
SRHCT
To OR++ No OR
RHCT Monitor
Clinically
p
*Any discrepancy regarding type of hemorrhage should be reviewed with Neuroradiology or Neurosurgery Team
+Coagulopathy includes any patient on anticoagulation medication or having abnormal coagulation or platelet values
on laboratory studies
++ If patient is going to the OR for any procedure, Neurosurgery must be notified
Ongoing management of elevated ICP
1. America College of Surgeons, Trauma Quality Improvement Program (TQIP) Best Practices in the Management
of Traumatic Brain Injury, January 2015.
2. Guidelines for the Management of Severe Traumatic Brain Injury 4th Edition. Brain Trauma Foundation,
September 2016.

Reversal of Anticoagulation in Patients with

Intracranial, Spinal Bleeding, or Other Sources
There is a rapidly growing elderly population in the United States and in Rhode Island.
Approximately 13 percent of those over 65 years of age are on an anticoagulant, most commonly
for nonvalvular atrial fibrillation.1 Over the last decade use of direct oral anticoagulants
(DOACs) such as dabigatran, rivaroxaban, apixaban has risen significantly. Anticoagulant use is
associated with worse outcomes after injury to any body region but especially with intracranial
hemorrhage (ICH) and traumatic brain injury (TBI). Decisions regarding reversal need to be
made promptly in cases of ICH and spinal bleeding as these are not easily accessible and are non-
expansile regions where bleeding can cause long lasting or permanent deficits.
In the early stages of DOAC use, trauma surgeons and emergency medicine providers were
concerned about the lack of reversal agents, and it was assumed that trauma morbidity and
mortality would be increased compared to warfarin. However, a recent retrospective review of
injured elderly patients did not show differences in mortality, blood transfusion requirements, or
length of stay when DOACs were compared to warfarin. 2 In patients over 65 years of age with
ICH from low level falls there was no difference in mortality, but lower rates of transfusion and
shorter ICU length of stay with DOACs compared to warfarin. 3 Unlike warfarin, patients may not
become supra-therapeutic on DOACs due to their fixed dosing.
Dosing Recommendations for Reversal of Anticoagulation:

Anticoagulant Reversal Agent Monitoring Considerations
Warfarin • PCC (KCentra ) ®
• Baseline STAT • Administer PCC at
(Coumadin®) dosing: INR prior to PCC a rate not to exceed
o < 45 kg: 1000 units administration 8.4 mL/minute
IV once • Repeat INR 30 • ALL patients
o 45-100 kg: 1500 minutes, 6 hr., 12 receiving PCC
units IV once hr., and 24 hr. should receive
o > 100 kg or initial after concomitant
INR > 5: 2000 units administration of vitamin K 10 mg
IV once PCC IV to prevent
• If repeat INR returns rebound elevation
at > 1.5 or if patient is of INR
experiencing ongoing
clinically significant
bleeding, may give an
additional PCC 500
units IV once
Dabigatran • Preferred: • Monitor for • Two vials must be
(Pradaxa®) Idarucizumab hypersensitivity administered
(Praxbind®) reactions consecutively for
o 5 grams IV once • Elevated PTT may total 5 gram dose
o Can redose with indicate drug of Praxbind®
additional 5 grams presence • Line must be
IV if no improve- flushed prior to
ment within 12 hrs infusion of
• Alternate: PCC Praxbind®
(KCentra®) 50 • Repeat dosing of
units/kg IV once PCC has not been
studied and is not
recommended

Apixaban • PCC (KCentra®) 50 • Elevated PT may • Repeat dosing of

(Eliquis®) units/kg IV once indicate presence PCC has not been
Edoxaban of rivaroxaban studied and is not
(Savaysa®) • Normal PT does recommended
Rivaroxaban not rule out
(Xarelto®) presence of
Apixaban
or Edoxaban
Guidelines
1. The neurosurgery or spine service should be notified of all patients with intracranial
hemorrhage or spinal trauma.
2. A STAT CBC, type and screen, and coagulation profile should be obtained.
3. For patients who are taking anticoagulants and have ICH on initial CT head or have a
declining GCS:
a. For warfarin, administer 25 units/kg of KCentra (4 factor) Prothrombin
Complex Concentrate (PCC) once. Do not exceed infusion rate of 10ml/min.
b. For dabigatran give Idarucizumab (Pradaxa®) - 5g provided as two separate
vials each containing 2.5g/50 mL
c. For rivaroxaban (Xarelto®) give 50 units PCC/kg once.
d. For apixaban (Eliquis®) give 50 units PCC/kg once.
(All patients should also receive Vitamin K 10 mg IV.)
4. Patients with suspected ICH known to be on anticoagulation should not await labs or
CT scan results to receive PCC.
5. FFP is no longer part of the protocol for urgent anticoagulant reversal.
6. For patients on antiplatelet agents such as aspirin, cilostazol, clopidogrel, prasugrel,
ticagrelor, vorapaxar
Duration and Half-Life of Antiplatelet Agents

Drug Onset IPA* Duration Half-life
Aspirin 20-60 minutes 10-20% IPA up to 10 1-2 hours (chew)
days 3-4 hours
(enteric coated)
Cilostazol 2-4 weeks (up to --- Usually, dual 11-13 hours
12 weeks) therapy
Clopidogrel 2 hours (loading 30-40% IPA ~5 days 6 hours (parent)
dose & 30 min (active
2 days metabolite)
(maintenance dose)
Prasugrel < 30 minutes 60-70% IPA ~5-9 days 30-90 minutes
Ticagrelor 30 minutes 60-70% IPA ~3 days 7-9 hours
Vorapaxar 1 week ~80% IPA ~4 weeks 3-13 days
IPA = inhibition of platelet aggregation (platelets blocked are affected for the rest of their life
span until new platelets are released) *reported IPA for maintenance dosing
a. A 5-pack of platelets should be given regardless of the measured platelet count.

These agents create a functional platelet defect not a quantitative issue.
b. Due to the long half-life of clopidogrel it may be necessary to give additional
platelets in 1-2 hours for those patients undergoing invasive procedures.

7. There are several other injuries that may merit reversal of anticoagulant or antiplatelet
medications, especially in elderly patients with limited physiologic reserve who may
not tolerate significant bleeding or operative therapy, including:
- Hemothorax
- Pelvic fractures with hematoma, including pubic rami fractures
- Intra-abdominal solid organ injury
- Extremity, abdominal wall, chest wall, gluteal hematoma per discretion
of trauma team
_______________________________________________________
1. Honickel M, Akman N, Grottke O. The reversal of direct oral anticoagulants in animal models. Shock 2017
Aug;48(2):144-58.
2. Tomaselli GF, Mahaffey KW, Cuker A, et al. 2017 ACC expert consensus decision pathway on management of
bleeding in patients on oral anticoagulants: a report of the American College of Cardiology task force on expert
consensus decision pathways. J Am Coll Cardiol 2017 Dec 19;70(24):3042-67.
3. Dossett LA, Riesel JN, Griffin MR, Cotton BA. Prevalence and implications of preinjury warfarin use: an analysis
of the national trauma databank. Arch Surg. 2011;146(5):565-70.
4. Barletta JF, Hall S, Sucher JF et al. The impact of pre-injury direct oral anticoagulants compared to warfarin in
geriatric G-60 trauma patients. Eur J Trauma Emerg Surg. 2017 Aug;43(4):445-449.
5. Batey M, Hecht J, Callahan C, Wahl W. Direct oral anticoagulants do not worsen traumatic brain injury after low-
level falls in the elderly. Surgery. 2018 Oct;164(4):814-819.
6. Arachchillage DRJ, Alavian S, Griffin J et al. Efficacy and safety of prothrombin complex concentrate in patients
treated with rivaroxaban or apixaban compared to warfarin presenting with major bleeding. Br J Haematol. 2019
Mar;184(5):808-816.
7. Jaben EA, Mulay SB, Stubbs JR. Reversing the effects of antiplatelet agents in the setting of intracranial
hemorrhage: a look at the literature. J Intensive Care Med. 2015 Jan;30(1):3-7
8. Levi M, Eerenberg E, Kamphuisen PW. Bleeding risk and reversal strategies for old and new anticoagulants and
antiplatelet agents. J Thromb Haemost 2011;9(9):1705-12.
9. Frontera JA, Lewin JJ, Rabinstein AA, et al. Guideline for reversal of antithrombotics in intracranial hemorrhage –
a statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine.
Neurocrit Care 2016;24:6-46.

C-Spine Evaluations in Adult Trauma Patients

CT scan of the cervical spine is the imaging study of choice for cervical spine evaluation in
blunt trauma patients. Plain films of the cervical spine should not be used due to high rate of
missed injuries1.
Initial evaluation of the patient will place the patient in one of three categories:
1. Awake and able to cooperate with physical examination.
Assess for one of the following (NEXUS Criteria2)
1. Midline neck tenderness
2. Focal neurological deficit
3. Distracting injury
4. Intoxication with drugs or alcohol*
5. Central neurological deficit defined as GCS <15.
Canadian C-Spine rules are not followed due to the highly subjective nature of
mechanistic criteria.
a. Examine for midline tenderness – If present, obtain CT cervical spine.
b. If patient is non-tender, then Physical Exam (passive flexion-extension, rotation, and
axial loading) should be performed. If the patient remains without pain and/or focal
neurological deficit then the cervical spine is deemed “cleared” and the collar may
be removed. Exam findings, date, time, and clinical clearance of the cervical spine
should be documented in the medical record.
c. If any one or more of the above is present → CT cervical spine.
d. Cervical CT scanning should be liberalized in patients with high-risk mechanism,
the elderly or confounding conditions despite lack of physical exam findings.
2. Non-Obtunded but with obvious distracting injury or alteration in cognition
a. A distracting injury has been defined as any injury to the head, neck, chest or upper
extremity, or an injury that is so painful that it requires such doses of analgesics that
the patient is unable to co-operate with a clinical examination3.
b. An alteration in cognition is defined at a GCS <15.
c. In either case → CT cervical spine.
3. Obtunded patient
a. Cervical spine injury is three times more common in obtunded patients than in the
alert and reliable patient.
b. CT scan of complete Spine - Cervical, thoracic, lumbar, and sacral with recon-
struction.
c. If there is absolutely no evidence of bony or soft tissue injury or mal-alignment of
the cervical spine on CT scan - Remove the collar and document this.
d. If there is any anomaly on the CT scan - Consult spine services.
• If ligamentous injury is suspected, the spine service may request a cervical
MRI or perform passive real-time flexion-extension imaging at their
discretion. The collar should remain in place until the spine consultant
documents that it may be removed.

Note: This is a protocol and deviations from the above including obtaining plain films,
flexion-extension, or MRI, may be undertaken at the discretion of the Trauma attending
or spine surgeon.
Only a physician or advanced practitioner can remove cervical collars on trauma

patients so that a clinical exam at the time of collar removal is performed and
eliminates concerns relating to telephone/verbal orders for collar removal to the
nursing staff.
When the cervical spine is cleared, the removal of the cervical collar must be documented
in the medical record and include the following information:
• Clinical exam findings
• Attending Radiology read
• Who removed the collar?
• Date and time it was removed
CT Versus MRI
The most common ligamentous injury discovered by MRI in comatose patients with a
normal CT scan is a single column posterior ligamentous complex disruption, which is
clinically insignificant and does not require operative intervention. Keeping patients in
collars awaiting MRI has been associated with increased morbidity, including pressure
ulcers from the collar (6.8%), swallowing difficulties and aspiration and a higher rate of
delirium. MRI is indicated in symptomatic patient with neurologic deficits.
Soft Collars
There is no role for the use of a soft collars during the patient’s work-up and has little if any
role in the treatment of an injury, except on a rare case by case basis.
 Intoxication spans a continuum from coma to asymptomatic alcohol ingestion and the
determination of “intoxicated” or “altered” outside of a blood alcohol level is fraught with
ambiguity and does not lend itself well to a strict definition. While NEXUS criteria suggests
patients with a GCS < 15 should be scanned, there are some patients with GCS <15 who
can be clinically assessed, especially if the clinical scenario will allow for time for the
intoxicant to clear. For practical purposes we will assume that a patient may be adequately
examined in the presence of an intoxicant if the provider feels there is a medically
reasonable determination that their exam is “valid” AND the mechanism involved is low
energy, or low probability of an occult spine injury. When in doubt it is far safer to scan
than to miss an injury.
1. Mathen R, Inaba K, Munera F, et al. Prospective evaluation of multi-slice computed tomography versus plain
radio-graphic cervical spine clearance in trauma patients. Journal of Trauma 2007; 62(6):1427-31.
2. Hoffman J, Mower W, Wolfson A, Todd K, Zucker M, NEXUS. Validity of a Set of Clinical Criteria to Rule
Out Injury to the Cervical Spine in Patients with Blunt Trauma New England Journal of Medicine 2000; 343: 94-9.
3. Heffernan D, Schermer C, Lu S. What defines a distracting injury in cervical spine assessment? Journal of Trauma
2005; 59(6):1396-9.
4. Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries
following trauma: update from the eastern association for the surgery of trauma practice management guidelines
committee. J Trauma. 2009 Sep;67(3):651-9

Thoracic/Lumbar/Sacral (TLS) Spine Evaluation in

the Trauma Patient
TLS spine fractures are the most common fractures of the spinal column, especially the
thoracolumbar junction (T10 –L2.) A significant portion of these patients could be
asymptomatic or without a reliable physical examination (approx. 20%). Most of the
patients who develop neurologic deficits have them at the time of presentation, but a few
will develop them in a delayed manner. A high threshold of suspicion for spinal injury
should be used in all patients with a significant blunt mechanism.
Awake, alert (non-intoxicated) patients without distracting injuries and a normal
physical exam can be cleared clinical.
CT scan is the imaging modality of choice for the TLS spine. Similar to cervical spine,
there is no role for plain film imaging to rule out TLS spine fractures. All patients
undergoing CT of the chest/abdomen/pelvis should have TLS spine reformats
performed. Patients who need TLS spine CT scanning based on physical exam findings
should undergo a CT of the chest/abdomen/pelvis with TLS Recons. Isolated CT scanning
of the TLS spine should NEVER BE DONE since it exposes the patient to large doses of
radiation for a fraction of the available imaging data. Plain CXR can NOT be used to clear
the Thoracic spine.
Until the spine evaluation has been completed and the spine “cleared”, patients should be
kept on spine precautions, which includes in-line immobilization of the cervical and upper
thoracic spine during any procedures and logrolling, but do not need to stay on a rigid long
board.
1. Diaz JJ, et al. Practice Management Guidelines for the Screening of Thoracolumbar Spine Fracture. J Trauma
2001; 63:709-18
2. Wood KB, Li W, Lebl DR, Ploumis A. Management of thoracolumbar spine fractures. Spine J. 2014 Jan;
14(1):145-64

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
T8 against gravity
T10 against some resistance
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 50 50 100
American Spinal Injury Association ©1996
ASIA (American Spinal Injury Association) Impairment Scale

Grade A Complete No motor or sensory function below injury
Grade B Sensory Incomplete Some sensation below injury (including anal)
Grade C Motor incomplete (some) Some muscle movement is spared below injury
Grade D Motor incomplete (most) Most muscle (>50%) movement below injury
Grade E Normal Return of all neurologic functions

Penetrating Neck Trauma

The vast majority (95%) of significant injuries are symptomatic; therefore, physical
examination is critical in making decisions regarding operative plans.
Patients with any of the following HARD SIGNS after penetrating trauma to the neck
should be explored in OR, 97% will have injuries.
HARD SIGNS
Vascular Aero-digestive Neurological
Active bleeding Hemoptysis/Hematemesis Localizing CN or brachial
Hypotension Air bubbling plexus deficit
Large or expanding hematoma Subcutaneous emphysema Horner’s Syndrome
Pulse deficit (Carotid, Brachial) Hoarseness Pupil asymmetry
Bruit Dysphagia/odynophagia Deficit in limb movement
For CN: VII droop, IX midline soft palate, X hoarseness, ineffective cough, XI shoulder shrug,
XII midline tongue
For Brachial Plexus: Median fist, Radial wrist extension, Ulnar abduction/adduction of fingers,
Musculocutaneous forearm flexion, Axillary arm abduction
Regarding decision making, the neck is divided to three zones:

Zones Anatomical Boundaries Potential Injured Structures
Zone I Clavicle to cricoid cartilage Great vessels, esophagus, trachea, vagus
& phrenic nerves
Zone II Cricoid cartilage to the angle of Carotid and vertebral arteries, internal
mandible jugular, esophagus, airway
Zone III Angle of mandible to the base of Carotid and vertebral arteries, oropharynx
the skull
Important points:
1. Penetrating neck wounds should NOT be probed.
2. If there is clearly no penetration of the platysma, no workup is needed.
3. Formal angiography and CTA Neck have comparable accuracy in evaluating major
vessels, but CTA Neck is readily available and is Study of Choice.
4. Clinically significant cervical spine (CS) injuries as a result of penetrating trauma are
very rare, unless there is an associated blunt trauma. Tangential gunshots may cause
unstable CS fractures if two columns are involved; stab wounds do not cause CS
injuries. If a screening Cervical CT Angiogram (CTA Neck) is being obtained the CS
should be cleared radiographically. Otherwise Attending judgment should weigh the
benefits of immobilization versus operative exposure.
5. Esophagoscopy and contrast fluoroscopy have comparable sensitivities. The combi-
nation of these tests increases the sensitivity of detecting esophageal injury. Evaluation
of the esophagus should be prompt due to high morbidity of delayed diagnosis.
6. An adequate surgical exploration (via an anterior sternocleidomastoid incision or
cervical collar incision) involves visualizing of the wound tract, exploring the carotid
sheath, and fully mobilizing the trachea and esophagus if there are signs of aero-
digestive injury or if the trajectory of the wound is in proximity of these structures.

Algorithm for Evaluation of Penetrating Wounds to the Neck:
The decision to perform an invasive procedure (operative, endoscopic, etc.) should be

guided by the CTA Neck findings, considering the proximity, trajectory and
anticipated/suspected injuries of the missile or penetrating wound.
1. Gracias VH, Reilly PM, Philpott J, et al. Computed tomography in the evaluation of penetrating neck trauma: A
preliminary study. Arch Surg 2001; 136: 1231-1235.
2. Sekharan J, Dennis JW, Veldenz HC, et al. Continued Experience with Physical Examination Alone for Evaluation
and Management of Penetrating Zone 2 Neck Injuries: Results of 145 Cases. J Vasc Surg 2000; 32: 483-489.
3. Sperry JL, Moore EE, Coimbra R, et al. Western Trauma Association critical decisions in trauma: penetrating neck
trauma. J Trauma Acute Care Surg. 2013 Dec;75(6):936-40.

Penetrating Injuries to the Heart

Patients with penetrating injuries to the heart die more from hemorrhage than from tam-
ponade. Clinical signs of tamponade are hypotension, JVD, muffled heart tones, or pulsus
paradoxus. These signs are usually difficult to assess in the trauma bay and tamponade
physiology can occur with small volume hemopericardium. The most sensitive test for post-
traumatic tamponade is (subxiphoid) pericardial window, which requires general anesthesia
in the operating room. The best non-invasive test for cardiac or pericardial injury is two-
dimensional echocardiograph. This test is both sensitive (100%) and specific (89%) in the
patients without hemothorax but is less accurate (56% sensitive) in the setting of hemo-
thorax, especially on the left sided.
Penetrating injuries to the “box” have high risk of cardiac injuries. Cardiac injuries from
wounds outside the “box” have higher mortality, due to diagnostic delays. A small retro-
spective study on chest gunshot wounds reveal that 40% of these patients present in
extremis with shock and require emergency operation. A cardiac injury will be present in
about 1/3 of these patients. Of the remaining 60% of patients, up to 50% will have injuries
to the heart, mediastinal vessels, bronchus, or esophagus that will present in a delayed
fashion.
Algorithm for Management of Penetrating Cardiac Injuries:
No
* Non-availability of 2-D echo warrants consideration of pericardial window.

** A negative 2-D is only 60% sensitive in the presence of PTX/HTX and could be a pitfall for missing occult cardiac
injuries. Clinical suspicion of cardiac injury despite a (-) echo should prompt repeat Echo or operative intervention
- Borders of the box are the suprasternal notch, the nipples, and the costal margin1
- Cardiology should perform an echo if FAST echo is equivocal or if clinical suspicion for injury remains high.
1. Nagy KK, Lohmann C, Kim DO, et al. Role of echocardiography in the diagnosis of occult penetrating cardiac
injury. J Trauma 1995; 38: 859.
2. Karmey-Jones R, Namias N, Coimbra R. Western Trauma Association critical decisions in trauma: penetrating
chest trauma. J Trauma Acute Care Surg. 2014; 77(6): 994-1002

Transmediastinal Gunshot Wounds (TMGSW)

Transmediastinal trajectory of a bullet should be considered in the following situations:
1. Ballistic wounds on opposite sides of the thorax.
2. Single entry wound with x-ray demonstrating a missile on opposite side of the thoracic
cavity or in close proximity to the mediastinum.
3. Multiple gunshot wounds to the thorax.
The mediastinum contains the heart, great vessels, trachea, and esophagus as well as major
venous and neural plexuses. Significant injury - especially to heart or great vessels - often
results in prehospital death or hemodynamic instability. CT of the chest (in stable patients)
has proven useful in demonstrating the trajectory of missiles in the thorax. Proven trans-
mediastinal trajectory mandates further evaluation with investigations tailored to the
specific clinical scenario. A small percentage of asymptomatic patients have clinically
significant injuries. CTA has supplanted angiography as the gold standard (TEE cannot be
considered reliable enough) for aortic injuries. Esophagoscopy has been reported to have
100% sensitivity for thoracic esophageal injuries. In non-intubated patients, barium
esophagography is easier to obtain and should be performed to increase the sensitivity for
detecting injuries.
1. Stassen NA, Reevaluation of diagnostic procedures for transmediastinal gunshot wounds. J Trauma 2002;53:635
2. White RK, et al. Diagnosis and management of esophageal perforations. Ann Surg. 1992; 58: 112.
3. Flowers JL, et al. Flexible endoscopy for the diagnosis of esophageal trauma. J Trauma 1996; 40: 261.
4. Obi OT, et al. Transmediastinal gunshot wounds in a mature trauma center: Changing perspectives. Injury
2013;44:1198

Vascular Exposures
Vascular exposures can prove especially challenging in the trauma setting, where proximal
and distal control must be rapidly achieved in the face of active hemorrhage. Fundamental
ATLS concepts should be followed, with the caution that normotensive resuscitation may
not be attainable, and in fact may increase hemorrhage if a vascular injury is uncontrolled.
Thoracic Vascular Injuries

Resuscitative (left anterolateral) thoracotomy is indicated in patients in extremis. Trans-
sternal extension with a right anterolateral thoracotomy (“clam-shell” incision) is needed
to control cardiac or right-sided injuries. In unstable patients, incisions are chosen based
on the presumed injury. In stable patients, the incision is based on either the presumed
(clinical exam) or the proven (radiographic imaging) location of the injury. Unstable
patients should be kept in a supine position to allow quick access to other body cavities.
Injured Artery Incision (Depiction)

Ascending Aorta/Arch Sternotomy (1)
Descending Aorta L 5th Interspace Thoracotomy (6)
Innominate Sternotomy + R Cervical Extension (1+ 3)
Left Common Carotid Sternotomy + L Cervical Extension (1+ 3)
Subclavian
First Portion (Left) L 3rd Interspace Thoracotomy (2) or “Trap Door”
(Partial Sternotomy + L Supraclavicular + L 3rd
Interspace Anterolateral Thoracotomy + Division of
Clavicle) (1 + 2 + 4)
(Right) Sternotomy + R Supraclavicular (1+ 3)
Second Portion Supraclavicular + Infraclavicular (4+ 5)
Third Portion Infraclavicular + Supraclavicular (5+ 4)
Axillary Infraclavicular + Supraclavicular (5+ 4) + Deltopectoral
Groove Extension
The subclavian artery exposure needs special attention because it depends on the location
of the injury. The artery has three segments, each defined by its relationship to the anterior
scalene muscle. The first lies medial, the second posterior, and the third lateral to this
muscle. On angiogram, the first portion is proximal to the vertebral artery, the second is
between the vertebral and transverse scapular arteries and the third is distal to the transverse
scapular artery. The clavicle may be divided and removed if necessary. Subclavian artery
injuries are typically associated with concomitant vein injury and are exceptionally lethal.

Abdominal Vascular Injuries

Inspect the retroperitoneum and act according to the guidelines in the Table and Figures
below. At any point, if patient’s SBP < 60 mm Hg, either compress the aorta or clamp it
at the diaphragmatic hiatus (supra-celiac aortic control)
Explore -All Zone I, Expanding, or Penetrating Hematomas

Do not explore - Blunt, Non-expanding Zone II/III Hematomas
The three zones of the retroperitoneum Zone Ia and II L injuries are exposed with
a left medial visceral rotation
Zone II R and caval injuries are exposed Zone Ib and III injuries are exposed with a
with a right medial visceral rotation direct approach
1. Hoyt DB, et al. Anatomic exposures for vascular injuries. Surg. Clin. N Am 2001; 81(6): 1299.
2. Mattox KL, et al. Retroperitoneal vascular injury. Surg. Clin. N Am 1990; 70(3): 635.
3. Feliciano DV, et al. Abdominal Vascular Injury, McGraw-Hill, New York. In: Mattox KL, Feliciano DV, Moore
EE (eds): Trauma, 2000.
4. Yelin AE, et al. Vascular system: 207-262. Mosby, St Louis. In: Donovan AJ (ed.): Trauma surgery: techniques
in thoracic, abdominal, and vascular surgery, 1994.

Truncal Stab Wounds

The purpose of this algorithm is to guide the management of patients with stab wounds to
the anterior abdomen, thoracoabdominal area, back, and flank. Patients with hemorrhagic
shock, peritonitis or GSW to the abdomen need operative exploration and no further
workup is indicated.
Back stab wounds are defined as those between the tips of the scapulae and posterior iliac
crests, between the posterior-axillary lines. Physical examination alone is unreliable in this
group, and DPL is unable to evaluate the retroperitoneum.
Flank stab wounds are defined as those between the anterior and posterior axillary lines.
Triple contrast (oral, rectal, and intravenous) CT has a sensitivity of 89-100% and a
specificity of 98-100% in diagnosing intra-abdominal and retroperitoneal injuries and is
the diagnostic study of choice for all Flank and Back stab wounds.1-3 Prompt scanning,
following the administration of oral contrast, is indicted since its sole purpose is
opacification of the duodenum, not the small bowel.
Thoracoabdominal stab wounds are defined as those between a circumferential line
connecting the nipples and tips of the scapulae superiorly, and the costal margins inferiorly.
Occult diaphragmatic injury is problematic in this patient group.5 We have selected DPL
as the preferred diagnostic modality to exclude diaphragmatic injury on the LEFT side of
the abdomen only, with a RBC cutoff of 5000/mm3 chosen to balance sensitivity and
specificity.6 Alternatively, diagnostic laparoscopy may be performed in lieu of a DPL.
Anterior abdominal stab wounds (AASW) are defined as those anterior to the anterior
axillary line, from the xiphoid process to the pubic symphysis. Although optimal manage-
ment of stable patients with AASW is debated, we have adopted a protocol of serial clinical
assessments to determine the need for laparotomy. Retrospective review of RIH data
suggests that this is a safe and effective approach in our institution. The yield of serial
physical examinations is highest when it is performed by a senior resident and by the same
provider. There is NO ROLE for FAST in the evaluation of truncal stab wounds.
Stab wounds may fall into more than one defined region, thus a combined work-up may
be required. Obtain triple contrast CT scans BEFORE performing a DPL for combined left
flank and thoracoabdominal stab wounds. If the patient has multiple stab wounds in several
different zones, exploration may be indicated as determined by the Trauma attending.
N.B. Consider penetrating cardiac injuries with epigastric wounds.
1. Easter DW, Shackford SR, Mattrey RF, et al: A prospective, randomized comparison of computed tomography
with conventional diagnostic methods in the evaluation of penetrating injuries to the back and flank. Arch Surg
1991; 126: 1115-9.
2. Kirton OC, Wint D, Thrasher B, et al. Stab wounds to the bank and flank in the hemodynamically stable patient: a
decision algorithm based on contrast-enhanced computed tomography with colonic opacification. Am J Surg 1997;
173: 189-93.
3. Albrecht RM, Vigil A, Schermer CR, et al. Stab wounds to the back/flank in hemodynamically stable patients:
evaluation using triple-contrast computed tomography. Am Surg 1999; 65: 683-7.
4. Murray JA, Demetriades DD, Cornwell EF, et al: Penetrating left thoracoabdominal trauma: The incidence and
clinical presentation of diaphragm injuries. J Trauma 1997; 43: 624-626.
5. Thompson JS, Moore EE. Peritoneal lavage in the evaluation of penetrating abdominal trauma. Surg
Gynecological Obstetrics 1981; 153: 861-863.
6. Tsikitis V, Biffl WL, Majercik S, et al: Selective clinical management of anterior abdominal stab wounds. Am J
Surg 2004; 188, 807.

Algorithm for management of abdominal stab wounds:

Blunt Cerebrovascular Injury

Blunt cerebrovascular injuries (BCVI) can occur to either the carotid or vertebral systems
and usually result from mechanisms such as MVCs, MCC or falls from height. While the
classic report is of a direct blow or sudden extension of the neck, BCVI is possible with
several mechanism vectors and often patients are not able to report events. In a recent
review of more than 28,000 blunt trauma patients, BCVI was present in just over 1% and of
those with BCVI almost two-thirds had multisystem injuries.1 BCVI rates after blunt trauma
with recent expansion of imaging criteria was found to be up to 3% in a 2016 series. 2
Patients with TBI, spinal cord injury(SCI), and solid organ injury(SOI) require careful
decision making. A recent review noted similar rates of stroke (~10%) and bleeding events
in those with isolated BCVI (mean time to start of anti-thrombotic treatment~30h) and
BCVI with TBI, SCI, or SOI (mean time~60h).1 BCVI are diagnosed more frequently with
greater use of CT scanning or “pan-scans” and improved resolution of the imaging.
Approach to imaging
While BCVI occurs uncommonly, the ramifications of the injuries are so significant,
including possible stroke and long-term or permanent disability, that criteria to obtain CTA
imaging should be fairly liberal so that prognosis can be established, and early treatment
can be started. When all grades of injury are considered, CVA occurs in ~10%. With higher
grade injuries such as Grade IV, CVA occurs in ~70%.3
Previously decisions for cervical CTA were based on signs on initial exam or imaging such
as skull base fracture, cervical spine injury, displaced facial fracture, mandible fracture,
Glasgow Coma Scale score ≤ 8, flexion/extension mechanism, hard signs of neck vascular
injury, or focal neurologic deficits. Now however CTA with contrast should be done in all
patients who are going for a pan-scan with intravenous contrast dosed from the circle of
Willis through the pelvis. Sensitivity and specificity of CTA are nearly 98% and 100%
respectively for BCVI.4
Grading
Grade I – intimal irregularity, < 25% luminal narrowing
Grade II – dissection or intramural hematoma, > 25% luminal narrowing
Grade III – pseudoaneurysm or >50% luminal narrowing
Grade IV – occlusion
Grade V – transection and extravasation
Treatment
Anti-thrombotic therapy lowers the CVA risk in patients with BCVI to < 1%.
CVA risk and BCVI healing appears to be similar whether daily aspirin or heparin infusion
is used so generally aspirin is going to be the more appropriate and lower risk choice,
especially for those presenting with ICH, spinal injuries.5
Carotid injuries Grade I-III – aspirin 81 mg daily
Carotid injuries Grade IV-V – heparin infusion vs aspirin 81 mg daily
Vertebral injuries – aspirin 81 mg daily
In patients with ICH wait 48 hours after the last stable CT head to start anti-thrombotic
therapy. It is likely safe to start ATT immediately after BCVI diagnosis in patients with
concerning high grade and solid organ injuries. No increase in need for delayed operative
treatment of these patients in a small series.6 Attending discretion, case by case basis.

Occasional carotid injuries need surgical intervention. Carotid stenting is no longer

supported by evidence and increases risk of CVA. This does not require formal Vascular
Surgery consult unless requested by the Trauma attending.
Follow up plans and imaging

Many BCVIs, especially grades I-III, will heal and fully recanalize in a short period of time.
Re-imaging with CTA at 7-10 days may reveal resolution of BCVI so that anti-thrombotic
therapy can be discontinued. If BCVI is not resolved, anti-thrombotic therapy should be
continued for 3-6 months, and re-imaging done at that time.
1. McNutt MK, Kale AC, Kitagawa RS, et al. Management of blunt cerebrovascular injury (BCVI) in the
multisystem injury patient with contraindications to immediate anti-thrombotic therapy. Injury 2018; 49:67.
2. Geddes AE, Burlew CC, Wagenaar AE, et al. Expanded screening criteria for blunt cerebrovascular injury: a
bigger impact than anticipated. Am J Surg. 2016 Dec;212(6):1167-1174.
3. Lauerman MH, Feeney T, Sliker CW, et al. Lethal now or lethal later: The natural history of Grade 4 blunt
cerebrovascular injury. J Trauma Acute Care Surg 2015; 78:1071.
4. Malhotra A, Wu X, Seifert K. Blunt Cerebrovascular Injuries: Advances in Screening, Imaging, and Management
Trends. AJNR Am J Neuroradiol. 2018 Sep;39(9):E103.
5. Cothren CC, Biffl WL, Moore EE et al. Treatment for blunt cerebrovascular injuries: equivalence of
anticoagulation and antiplatelet agents. Arch Surg. 2009 Jul;144(7):685-90.
6. Shahan CP, Magnotti LJ, McBeth PB, et al. Early antithrombotic therapy is safe and effective in patients with blunt
cerebrovascular injury and solid organ injury or traumatic brain injury. J Trauma Acute Care Surg 2016; 81:173.

Blunt Aortic Injury (BAI)

Blunt aortic injury (BAI) is the second most common cause of death in blunt trauma,
following head injury. 85% of fatalities occur at the accident scene. Of the remainder,
25% occur within 24 hours and another 25% within one week. Deceleration forces (i.e.,
high speed MVCs, falls from heights) cause tearing of the aorta at points of fixation:
ligamentum arteriosum (80-85%), diaphragmatic hiatus (10-15%), and ascending aorta
(5-10%). Patients frequently have major associated injuries (TBI, abdominal injury, other
chest injuries). In the abdomen the most common site of BAI is in the infrarenal area and
is associated with lumbar fracture, bowel injury, solid organ injury, and pelvic fracture.
There is also more BAI diagnosed now from lower impact mechanisms, <40 mph, and
risk factors include age >60 years and lateral impacts.
With the improvement in CT scan technology, we are seeing more cases of minimal aortic
injury (MAI): intimal flaps, intraluminal thrombus, and intramural hematomas. MAI may
also require operative intervention, often able to be treated endovascularly.
Anterior mediastinal hematomas are often a source of confusion noted incidentally on

CT scans. The scan should be reviewed carefully with a radiologist for BAI or other
great vessel injury. If there is no BAI or great vessel injury, these hematomas are usually
the result of tearing of mediastinal veins.
Grade of Injury
I – intimal tear or flap
II – intramural hematoma without changes in external aortic contour
III – contained pseudoaneurysm
IV – full thickness with contrast extravasation
Evaluation of BAI
If there is clinical suspicion, a significant deceleration mechanism, or findings on initial
CXR then a gated CT scan with IV contrast should be performed. A compilation of three
studies from last decade showed CT sensitivity to be approaching 100%.
The initial CXR may be interpreted as “normal” in up to 7% of patients with BAI.
CXR findings suggestive of BAI:
- Indistinct aortic knob (more specific)
- Widened mediastinum > 8 cm (more sensitive)
- Depression of left main stem bronchus
- Deviation of NG tube to the right
- Opacification of aortopulmonary window
- Widening of paratracheal/ paraspinous stripes
- Apical capping especially on the left
- Scapular fracture or 1st/2nd rib fracture. (Formally indicative of BAI but now much
less so due to advances in imaging technology.)

Injury Locations
A recent review characterized BAI as proximal (within 5 cm of the left subclavian origin)
or distal. Features of proximal injuries:
- less often associated with thoracic spine fractures
- more often high-grade injuries (III, IV)
- much more likely to require operative repair
- more common in men
Decision Making, Timing of Repair
Delayed repair is now acceptable based on a significant body of literature showing
extremely low rates of in-hospital rupture of BAI. Delay can be necessary due to need for
emergent laparotomy, craniotomy, or patient being not fit for an operation on presentation.
Once BAI is diagnosed antihypertensive therapy should be instituted, if possible, with goal
SBP <110 and HR <80 to reduce wall stress and prevent aortic rupture. Thoracic endo-
vascular repair (TEVAR) is now considered standard of care unless certain technical
aspects of the injury make it unfeasible.
1. Sastry P, Field M, Cuerden R, et al. Low-impact scenarios may account for two-thirds of blunt traumatic aortic
rupture. Emerg Med J. 2010 May;27(5):341-4.
2. Fox N, Schwartz D, Salazar JH, et al. Evaluation and management of blunt traumatic aortic injury: a practice
management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2015;
78:136.
3. Sabra MJ, Dennis JW, Allmon JC, et al. Identification of unique characteristics and the management of blunt
traumatic aortic injuries occurring at unusual locations in the descending thoracic aorta. J Vasc Surg 2019; 69:40.
4. Scalea TM, Feliciano DV, DuBose JJ, et al. Blunt Thoracic Aortic Injury: Endovascular Repair Is Now the
Standard. J Am Coll Surg 2019; 228:605.

Blunt Cardiac Injury

Blunt cardiac injuries (BCI) range from clinically inconsequential to catastrophic atrial or
ventricular ruptures that are usually fatal at the scene. There are also a set of BCIs that
require ICU admission, monitoring, and management that will be the focus here. The most
important aspect of BCI care is identifying these patients early in their course. However
there remains no formal definition of BCI nor standard of testing.
We no longer use the vague term “cardiac contusion” and instead describe the actual
significant clinical entities associated with the BCI:
- arrhythmia – i.e., sinus tachycardia, atrial fibrillation, PACs, PVCs etc.
- cardiac dysfunction – i.e., decreased LV, RV contractility, local wall motion
abnormality
- structural injury – septal rupture, valvular tear
Work-up
Suspect BCI in patients with substernal pain or a mechanism consistent with a significant
blow to the chest such as a fall from height, high-energy front impact motor vehicle
collision, pedestrian struck, blast injury. Patients with multiple rib fractures, sternal fracture,
pulmonary contusions and/or seat belt signs are at increased risk of BCI. Initially obtain an
EKG and compare this to prior EKGs if available. If the EKG is normal, NO further
work up is necessary. If there are no other reasons for admission, patient should be
discharged home from the ED.
If the EKG is abnormal, the patient is to be admitted either to a ward with telemetry or to
the TICU depending on the severity of injuries. All patients with hemodynamic instability,
ischemic changes on EKG, angina and/or shock should be admitted to the TICU.
A negative troponin has a negative predictive value of almost 100%. Note that elevations in
troponin can also be attributed to significant non-thoracic trauma or myocardial ischemia
not related to trauma.

Ischemic changes: ST elevation, depression, or T wave inversion in ≥2 leads

Dysrhythmia: new atrial fib, new LBBB/RBBB, frequent PVC’s/PAC’s heart block
Echocardiogram may be obtained in selected patients with refractory shock, new murmur, or clinical
suspicion of pericardial effusion/tamponade. Routine Echo is discouraged.
CT findings
CT findings of severe chest trauma that are indirect evidence of BCI include:
- anterior rib fractures (73% of BCI cases in recent series)
- pulmonary contusions (64%)
- sternal fracture (36%)
Myocardial hypo-enhancement is poorly sensitive for BCI.
1. Hanschen M, Kanz KG, Kirchhoff C, et al. Blunt Cardiac Injury in the Severely Injured - A Retrospective
Multicentre Study. PLoS One 2015; 10:e0131362.
2. Keith C, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury: An Eastern Association for the
Surgery of Trauma practice management guideline. J Trauma 2012; 73:S301-S306.
3. Hammer MM, Raptis DA, Cummings KW, et al. Imaging in blunt cardiac injury: Computed tomographic findings
in cardiac contusion and associated injuries. Injury 2016; 47:1025.
4. https://rebelem.com/blunt-cardiac-injury-bci/ Accessed August 13, 2019.

Management of Thoracic Trauma

Rib Fracture Protocol:
Blunt chest trauma, specifically rib fractures from falls and motor vehicle collisions, are
among the most common traumatic injuries. More than 4 rib fractures in patients older than
age 45 are associated with increased morbidity and elderly patients with 2 or more rib
fractures have twice the mortality and morbidity of younger patients with similar injuries,
thus these are some of the criteria for ICU admission. Elderly patients have reduced bone
density and cardiopulmonary reserve and thus are much more likely to suffer these injuries
and have complications. There is an increased mortality with increased number of fractured
ribs and older age. N.B. Discuss Code Status (intubation) with the patient/family at the
time of admission and document this discussion in the medical record!
Pain Control
Patients with rib fractures need to be assessed in the emergency room for pain control so
that a medication plan can be initiated in order to avoid shallow breathing, ineffective
cough, and pooling of secretions. PIC score assesses patient’s pain control, inspiratory
effort, and cough strength. Initial PIC score should be assessed and repeated frequently. A
PIC score of 4 or less should trigger a re-evaluation and possibly higher level of care. The
objective measure used is incentive spirometry (IS) with goal volumes of 10-15mL/kg
based on ideal body weight. This is a surrogate measure of vital capacity. Weaning oxygen
support in the elderly and debilitated can be difficult due to limited pulmonary reserve.
● Narcotics: morphine and hydromorphone via PCA and oral oxycodone are first line
agents, but optimal treatment involves use of several adjuncts
● IV or oral acetaminophen: add as standing orders. The IV form has been shown to
have efficacy and safety in the elderly after orthopedic procedures however data is
lacking specifically for rib fractures.
● Ketorolac IV: added standing for 2-3 days but caution taken in those over 65 with
lower creatinine clearance (CrCl <40). Dose can be reduced from 15 to 7.5mg for
borderline CrCl. Avoid in super-elderly.
● Diazepam: Can be helpful in those with spasm-like pain but has not been adequately
studied.
● Epidurals: If in the first few hours following admission the patient's pain control is
not improving or if they are de-recruiting or manifesting progressive respiratory
failure, anesthesia should be consulted for epidural placement (decreased PNA rates,
duration of mechanical ventilation in rib fracture patients)
● Additional adjuncts (not supported by evidence to reduce PNA rates or narcotic
usage) include lidocaine patches, rib blocks, agents for neuropathic pain (e.g.,
Gabapentin, and Ketamine, or Dexmedetomidine drips).
Triage and Reassessment

● Patients over 65 with 2 or more rib fractures or 45 with 4 or more rib fractures should
be admitted to the TICU.
● Patients with concurrent TBI, history of COPD or other significant cardiopulmonary
disease should also be admitted to the TICU.
o The goal is to prevent hypoventilation, poor secretion clearance and loss of
functional residual capacity (FRC).

● Patients should be transferred to the TICU if they are found to have progressive
respiratory failure.
● Frequent reassessment should be done to gauge the patient's pain control, cough
strength and volume on IS. Most of these assessments are more subjective than
objective but they should be documented.
o Be sure to include the bedside RN for their assessment and help in managing
pain and pulmonary toilet. IS should be assessed every shift with focused
attention on patients with declining performance.
o Patients should be reminded to use the device several times per hour (i.e.,
each commercial break).
● Elderly patients, and those unable to successfully use the IS should have an order for
a positive expiratory pressure device (i.e., Acapella) to mobilize secretions. Resis-
tance can be adjusted but volumes cannot be measured.
Non-invasive positive pressure ventilation including BiPAP, and CPAP should also be
considered in those who have escalating needs for support but do not appear to need
intubation imminently. Heterogeneous data (few RCTs) supports the use of these modalities
to avoid intubation, reduce risk of PNA, and decrease ICU length of stay in patients with
blunt chest trauma. Intermittent BiPAP can be very helpful in cognitively impaired and
geriatric patients to maintain FRC. Patients failing BiPAP should prompt an urgent
Family Meeting to discuss goals of care, intubation, tracheostomy, feeding tubes and
long-term care PRIOR to intubating the patient.
Early mobilization and physical therapy (PT)

PT should be consulted for ALL patients over age 65 with multiple rib fractures. Patients
should have backrest elevation while in bed and be out of bed (OOB) as soon as possible.
Early ambulation also helps maintain FRC and avoid progressive respiratory failure.

1. Holcomb JB et al. Morbidity from Rib Fractures Increases after Age 45. JACS 2003; 196: 549-555
2. Bulger EM. Rib Fractures in the Elderly. J Trauma 2000; 48: 1040-47
3. Bulger EM et al. Epidural analgesia improves outcomes after multiple rib fractures. Surgery 2004; 136: 426-30
4. Jahr JS, Breitmeyer JB, Pan C, et al. Safety and efficacy of intravenous acetaminophen in the elderly after major
orthopedic surgery: subset data analysis from 3, randomized, placebo-controlled trials. Am J Ther. 2012
Mar;19(2):66-75.
5. Duggal A, Perez P, Golan E, et al. Safety and efficacy of noninvasive ventilation in patients with blunt chest
trauma: a systematic review. Crit Care. 2013 Jul 22;17(4):R142.
6. Leinicke JA, Elmore L, Freeman BD, et al. Operative management of rib fractures in the setting of flail chest: a
systematic review and meta-analysis. Ann Surg. 2013 Dec;258(6):914-21.
7. Witt CE, Bulger EM Comprehensive approach to the management of the patient with multiple rib fractures: a
review and introduction of a bundled rib fracture management protocol, Trauma Surgery & Acute Care Open
2017;2:e000064

Rib Plating
Surgical fixation of rib fractures has been a controversial treatment that has recently
gained support in certain clinical circumstances1. Studies show improved PFTs as well
as shortened LOS and days in ICU in patients with surgical fixation of rib fractures2, 3.
Patients with significant blunt chest trauma should have a 3D reconstruction performed
utilizing the initial chest CT. Although, this is an order in EPIC, it is important that this
request is communicated to the CT technicians. This can be done up to 36-48 hours after
the original CT chest has been completed.
Surgical fixation of rib fractures should be considered as the primary treatment in the
following patients without severe head injury or ongoing shock
● Flail chest segment (3 or more contiguous ribs)
● Estimated 30% loss of thoracic volume or thoracic contour as measured by CT 1, 4
● Symptomatic fractures refractory to multi-modal pain control efforts (See page 48).
● Aligned fractures in 3 or more consecutive ribs
● Severe displacement of rib fractures (inner cortex of one fracture fragment beyond
the outer cortex of the other fracture fragment)
Special considerations regarding rib fixation procedure:

● Double lumen endotracheal tube if possibly VATS, otherwise regular ETT
● Consider pre-op epidural catheter. This can be placed in the preoperative area or
in the OR by anesthesiology.
1. Lube MW, Cheatham ML. Surgical Critical Care Evidence-Based Medicine Guidelines Committee. February 6,
2013.
2. Granetzny et al. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact
Cardiovasic Thorac Surg 2005;4:583-7.
3. Solberg et al. Treatment of chest wall implosion injuries without thoracotomy: technique and clinical outcomes. J
Trauma 2009; 67:8-13.
4. Pieracci F, et al. Surgical stabilization of severe rib fractures. J Trauma 2015, 78:883-887.
Thoracic Trauma
Although thoracic trauma is common, most of these injuries can be managed non-
operatively. Tube thoracostomy effectively treats about 85%* of thoracic injuries and
while this procedure may be a straightforward bedside procedure, its complications can
lead to significant morbidity. Therefore, successful management of thoracic trauma
mandates careful assessment and meticulous adherence to management protocols and
sterile technique.
Primary Survey
Assessment of breathing is performed in the primary survey after ensuring an adequate
airway. Significant hemo/pneumothoraces (HTX/PTX) should be diagnosed during the
primary survey. Absence of breath sounds, crepitus, open (sucking) chest wound, or
evidence of tension physiology (tracheal deviation, hypotension, jugular venous distension)
should all prompt immediate evacuation without waiting for a chest X-ray (CXR),
especially in cases of penetrating trauma. While ultrasound (U/S) may detect a PTX, it is
by and large unable to quantify the size of the PTX and may lead to unnecessary tube
thoracostomies. U/S CAN NOT be used in lieu of a CXR.

Hemo/Pneumothorax
If no suspicion for HTX/PTX on primary survey, the presence of HTX/ PTX on CXR still
warrants placement of a chest tube.
Technique of chest tube placement

The incidence of complications (infection, iatrogenic injuries, tube malposition) due to
chest tube placement is significant, with reported rates of empyema as high as 25%.
Meticulous preparation and technique most be followed in order to minimize complications.
A good video demonstration of chest tube insertion can be found through the NEJM videos
in clinical medicine series (http://www.nejm.org/doi/full/10.1056/NEJMvcm071974). The
most important technical aspects will be highlighted below.
1. Large bore angiocath decompression of a suspected tension PTX should be
performed immediately and allows time for proper tube insertion, by converting
an emergent tube to an urgent one.
2. Prophylactic antibiotics (Cefazolin) should be given prior to elective or semi-
urgent chest tube insertions. There is no need to administer prophylactic
antibiotics in cases of emergent thoracostomy.
3. Sterile technique should be followed at all times. Chloraprep® should be used for
skin preparation, and full body draping should always be employed. All involved
must wear cap, gown, mask, gloves and eye protection.
4. Be cognizant of contamination of the field! Do not turn your back on the patient.
5. Adequate local anesthetic dramatically improves patient comfort and adherence
to sterile technique. The maximum dose of lidocaine is 4.5 mg/kg/dose. Use 1%
lidocaine instead of 2% to allow a larger volume to be spread over a larger area.
A1% lidocaine solution contains 10mg/ml.
Occult pneumothorax
An occult PTX is defined as a PTX that is only seen on CT scan, but not on CXR. The
management of occult PTX is managed with observation in almost all cases, even in
patients requiring positive pressure ventilation. Patients with occult PTX should undergo a
repeat CXR 6 hours after initial imaging to ensure that a PTX has not progressed. If there is
progression, then a tube thoracostomy should be performed. Subcutaneous emphysema
without overt PTX on CXR, on physical exam or CXR, IS NOT equivalent to an occult
PTX and typically warrants tube thoracostomy. If a patient, clinically deteriorates (SOB)
then a chest tube should be placed.
Occult hemothorax
An occult HTX is defined as a HTX that is only seen on CT scan, but not on CXR. As with
occult PTX, many occult HTX can be managed without a chest tube. Bilello et al. showed
in his series that only 15% of patients with occult HTX <1.5 cm thick (measured on CT)
underwent a chest tube compared to 66% of patients with an occult HTX >1.5 cm. Patients
with an occult HTX <1.5 cm will be observed with a follow-up CXR and patients with a
HTX >1.5 cm should have a chest tube placed. In general, patients with an occult HTX on
anticoagulant/antiplatelet therapy are best managed with chest tube placement.

Retained hemothorax
A retained HTX is defined as evidence of continued HTX on CXR despite placement of
a chest tube. The presence of a retained HTX has been shown to increase the risk of
empyema by 33% (Karmy-Jones et al.). If drainage of the HTX is incomplete, considera-
tion should be made for early VATS. Meyer et al. have shown a decrease in hospital stay
and costs for VATS within 3 days as compared to a second chest tube placement. The
AAST multicenter study of retained HTX shows that VATS has high success rates, but as
many as 25% of patients require at least 2 procedures to effectively clear the retained HTX.
The strongest predictors of successful VATS were absence of an associated diaphragm
injury, use of periprocedural antibiotics prior to tube thoracostomy, and volume of retained
hemothorax <900 cc. The overall empyema rate for retained hemothorax was 27%.
Fibrinolytic Therapy for Retained Hemothorax

The preferred management of retained HTX should be VATS, however, some patients do
not possess the pulmonary or physiologic reserve to tolerate an operation or cannot undergo
single lung ventilation. In this select patient population, fibrinolytic therapy through the
chest tube may be considered. Since the 1940’s, small case-series have demonstrated the
efficacy of intra-pleural fibrinolysis in resolving complicated pleural effusions (Hunt et al).
There have been numerous dosing regimens reported, but the most robust data comes from
a randomized controlled trial in infectious empyema (MIST-2). In this trial, both
recombinant tissue plasminogen therapy (TPA) and DNAse were infused into the pleural
space via the chest tube with improvement of pleural opacity and decreased surgical referral
compared to placebo.
Alteplase/DNAse Protocol
One 10mg/10mL syringe (10mgs.) of alteplase (tPA) from the pharmacy may be diluted to
a desired volume (usually 30 ccs). This mixture should be injected with a small gauge (22
ga. or less) needle through a chlorhexidine-prepped area of the rubber tubing connecting the
chest tube to the collection system. The needle should be inserted obliquely so that the hole
will seal post-injection. The tube may be clamped for up to 1 hour, and the patient’s
position should be rotated every few minutes as tolerated during the dwell. The DNAse
solution, a syringe of 5 mg/30 ml H2O, should be administered in the same fashion 2 hours
after tPA. This process will be done twice daily for 3 days. Daily CXRs should be obtained
to assess for complete evacuation.
1. Bilello JF, Davis JW, Lemaster DM. Occult traumatic hemothorax: when can sleeping dogs lie? Am J
Surg2005;190:841– 4.
2. Karmy-Jones R, Holevar M, Sullivan RJ, Fleisig A, Jurkovich GJ. Residual hemothorax after chest tube placement
correlates with increased risk of empyema following traumatic injury. Can Respir J.2008;15:255–258.
3. Meyer DM, Jessen ME, Wait MA, Estrera AS. Early evacuation of traumatic retained hemothoraces using
thoracoscopy: a prospective, randomized trial. Ann Thorac Surg. 1997;64:1396 –1400.
4. Dubose et al. Management of post-traumatic retained hemothorax: A prospective, observational, multicenter
AAST study. J Trauma Acute Care Surg 2012 Jan;72(1):11-22
5. Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural
infection. N Engl J Med 2011; 365:518-526.

Blunt Abdominal Trauma

Blunt abdominal trauma is the most frequent cause of hemorrhagic shock in the injured
patient but also one of the most difficult injuries to assess and manage. Evaluating the
hemodynamically stable patient with suspected intestinal injury can be even more
challenging. Early involvement of the trauma attending in uncertain cases is important
since delays in diagnosis and treatment can significantly increase morbidity and mortality.
About half of abdominal injuries, most notably solid organ injuries, can be managed non-
operatively.
Initial approach to patient with suspected abdominal trauma:
• Resuscitation (ATLS 10th edition) 1L NS, then PRBCs if SBP remains <90mmHg
• FAST for SBP <90, if (+) to OR for exploratory laparotomy
• OR if + FAST, signs of peritonitis (rebound tenderness, significant guarding), hard
signs (free air, evisceration)
Role of FAST:
• Non-invasive, quick, but operator dependent, repeatable, portable
• Wide range of reported sensitivity for abdominal bleeding in hypotensive patients
(47-85%)
• Requires 100-620mL of fluid to yield a positive test
• Not as useful in hemodynamically (HD) stable patients
• NO ROLE in penetrating abdominal trauma (except pericardial view)
Diagnostic Peritoneal Lavage (DPL):

• HD unstable patients with equivocal FAST or after 2 negative FASTs
• Patients with suspected bowel injury that are not evaluable (severe TBI, intoxication,
chemical paralysis, high cord injury)
• Rule out possible left sided diaphragmatic injury
Indications for use of CT in Abdominal Trauma:

• Exam Findings
Spinal cord injury, GCS ≤9, significant chest trauma, significant abdominal pain or
tenderness, gross hematuria, unexplained tachycardia and/or transient hypotension
(with normal ultrasound exams / DPL)
• Other Injuries
Myocardial or pulmonary contusion, mediastinal hematoma, scapular fracture, first or
second rib fracture, multiple (which is > than 2 unilateral) rib fractures, lower (8-12)
rib fractures, pelvic fracture
• High energy mechanism
Pearls:
• Type and screen, activate DCR if hemorrhagic shock and suspected major vascular
injury
• Admit for serial exams if concern for hollow viscus injury (e.g., free fluid without solid
organ injury)
• Repeat CTA/P with oral contrast +/- rectal may be helpful in certain circumstances
• DO NOT withhold IV contrast due to renal failure. Obtain the best imaging possible if
the patient has an indication to be imaged.

1. Carter JW, Falco MH, Chopko MS, Flynn WJ Jr, et al. Do we really rely on fast for decision-making in the
management of blunt abdominal trauma? Injury. 2015 May;46(5):817-21.
2. Natarajan B, Gupta PK, Cemaj S, Sorensen M, et al. FAST scan: is it worth doing in hemodynamically stable blunt
trauma patients? Surgery. 2010 Oct;148(4):695-700; discussion 700-1.
3. Talari H, Moussavi N, Abedzadeh-Kalahroudi M, et al. Correlation Between Intra-Abdominal Free Fluid and Solid
Organ Injury in Blunt Abdominal Trauma A. Arch Trauma Res. 2015 Aug 29;4(3):e29184.
4. Patel NY, Riherd JM. Focused assessment with sonography for trauma: methods, accuracy, and indications. Surg
Clin North Am. 2011; 91:195-207.

Blunt Splenic Trauma: Adult

Background
• ANY hypotension (SBP<90) in the ED is strongly predictive of failure of non-operative
management (NOM). Other predictors of failure of NOM include injury grade, contrast
extravasation, and pseudo-aneurysm.
• Patients with isolated grade I and II injuries do not warrant bed rest or ICU admission.
DVT prophylaxis and a diet may be started early at the discretion of the trauma
attending.
Management
• Hemodynamically unstable patients with a (+) FAST OR known splenic injury
should proceed to OR for exploratory laparotomy
• NOM of stable patients:
• Bed rest, telemetry monitoring, hemoglobin checks every 12 hours. If higher grade of
injury or associated injuries, consider more frequent checks.
• Frequent abdominal examinations first 24 hours
• Patient becomes hypotensive or hemodynamically unstable → splenectomy.
Embolization and splenic salvage

• Increased salvage in patients with arterial blush, pseudo-aneurysm, or A-V fistula who
undergo angio-embolization (EMBO)
• Caveats: A-V fistula or pseudo-aneurysms on CT scan highly predictive of failure of
NOM in EMBO patients
• Patients with any evidence of post-EMBO bleeding or hemodynamic instability should
have an immediate splenectomy
• There is still a significant NOM failure rate of patients with AAST grades III-V injuries
who undergo EMBO.
• A second try at EMBO is never indicated—patients who fail NOM need an operation
Vaccines
Patients with functional asplenia (patients who have undergone a splenectomy or main
splenic artery EMBO) should have the following vaccines 14 days post-splenectomy or
prior to discharge, whichever is sooner:
• Hemophilus B
• Pneumococcal 13-V (Prevnar®)
• Meningococcal Serogroups A, C, W, Y (Menactra®)
• Meningococcal Serogroup B (Bexsero®)
**If a patient has a Latex allergy, they may receive Trumenba® in place of Bexsero®**
Patients should also receive a second round of vaccination ~8 weeks after initial vaccination
with the following vaccines:
• Pneumococcal 23-V (Pneumovax®)
• Meningococcal Serogroups A, C, W, Y (Menactra®)
• Meningococcal Serogroup B (Bexsero®)
**If a patient has a Latex allergy, they may receive Trumenba® in place of Bexsero® and
will require one additional dose at 6 months to complete the series**

Return to activity
• Little objective data about when it is safe for patients with NOM splenic injuries to
return to full activity
• Some data says that 84% of grade III-V injuries are healed by 37 days.
• If the patient wants to return to vigorous activities or contact sports, then a CT scan
at 2 months post injury is required to document healing. (For all others, no repeat CTs
are indicated)
1. Velmahos GC, Toutouzas KG, Radin R, et al. Non-operative treatment of blunt injury to solid abdominal organs:
a prospective study. Arch Surg. 2003 Aug;138(8):844-51.
2. Claridge JA, Carter JW, McCoy AM, et al. In-house direct supervision by an attending is associated with
differences in the care of patients with a blunt splenic injury. Surgery. 2011 Oct;150(4):718-26.
3. Haan J, Marmery H, Shanmuganathan K, et al. Experience with splenic main coil embolization and significance
of new or persistent pseudoaneurysm: re-embolize, operate, or observe. J Trauma. 2007; 4. 63:615-619.
4. Savage SA, Zarzaur BL, Magnotti LJ, et al. The evolution of blunt splenic injury: resolution and progression. J
Trauma. 2008;64: 1085-92.
5. Smith J, Armen S, Cook C, Martin L. Blunt splenic injuries: have we watched long enough? J Trauma.
2008;64:656-665.
6. Bhangu A, Nepogodiev D, Lal N, et. al. Meta-analysis of predictive factors and outcomes for failure of non-
operative management of blunt splenic trauma. Injury. 2012 Sep; 43:1337-46

Renal and Other Genitourinary Trauma

Genitourinary trauma is rare, but the rate of these injuries increases to 10% when there is
abdominal trauma. Practice patterns among trauma surgeons and urologists are often
disparate and inconsistent due to the paucity of class I evidence to guide management.
Survey data has shown dramatic differences in utilization of embolization for renal contrast
extravasation and ureteral stents for isolated collecting system injuries among trauma and
urologic surgeons. There are also differences in opinion between the services on duration of
bed rest for renal injuries and duration of Foley catheters. To provide good patient care,
thorough communication between the trauma and urology services must occur. Clearly,
multi-institutional trials are needed to advance the evidence and care of patients with renal
injuries.
Renal Trauma Overview:

• Highest success rate of non-operative management of all solid organ injuries
• 82-97% blunt, 1-19% penetrating
• 75-90% are grade I and require no intervention
• Higher rates of renal preservation, less transfusion, shorter ICU duration with
NOM
• CT scan with IV contrast initial study of choice
• Delayed images needed to evaluate collecting system
Who should receive CT imaging?

− HD stable patients with gross or microscopic hematuria
− Deceleration mechanisms
− Physician discretion
"Delayed Images" - Used when there is suspicion for pelvic-calyceal collecting system or
ureteral injury. Low dose contrast is given, and images taken 5-10 minutes later to allow
for renal contrast excretion to occur.
Evaluation: All trauma patients with abdominal trauma should have a urinalysis. Most
patients with major renal trauma present with gross hematuria or hypotension and only
about 1% of patients with major renal injuries have neither of these two findings.
Microscopic hematuria: (˃5 RBC/HPF): Rarely associated with significant renal system
injury. Patients require observation, repeat UA later in the ER or hospital to demonstrate
resolution or to rule out other sources of hematuria such as malignancy.
Gross hematuria: Patients require abdominal/pelvic CT with cystogram if hemo-

dynamically stable. A retrograde urethrogram (RUG) should be performed if there is frank
blood at the meatus prior to attempting Foley catheter insertion. RUG should also be done
for open book pelvic fractures, symphyseal disruption >4cms, or if worrisome physical
exam findings (perineal or scrotal ecchymosis, high-riding prostate, inability to void) in
the setting of a suspicious mechanism. RUG must be done prior to Foley insertion in these
patients.

Blunt vs. penetrating: Blunt injury and stab wounds may be worked up in a similar
fashion. Gunshot wounds to the back/abdomen require urgent abdominal exploration.
Do NOT explore a Zone II hematoma UNLESS it is expanding. Previously all penetrating

renal trauma was explored, but this leads to an increased rate of nephrectomy. Currently,
exploration is more selective and is reserved for those patients with signs of active
hemorrhage. BE SURE to evaluate the ureter for injury.
Management:
• Notify Urology Service.
• Patients with a major renal injury (Grade IV-V injuries) are still candidates for
NOM IF:
o Hemodynamically stable AND contained urine leak
• Patients should be monitored in the TICU for the first 24-48 hours.
• Recommendations for bed rest until the resolution of hematuria are anecdotal and
early mobilization has been shown to be safe in retrospective reviews.
Who needs an operation for renal trauma?
• Hemodynamic instability
• Ongoing transfusion requirement, failed angio-embolization
• Pulsatile or expanding hematoma while exploring the abdomen for other injuries
• Renal pedicle avulsion without thrombosis
Angio-embolization: Patients with renal injuries AND contrast extravasation AND

perirenal hematoma diameters (PRD) of >30-35mm should undergo empiric angiography.
Angio-embolization should be done if the diagnostic angio is positive. Patients with
ongoing bleeding attributable to the kidney (2 units PRBCs), or a renal hematoma that
crosses the midline should also undergoing angiography.
Double J Stent: Patients with evidence of urinary extravasation on initial CT scan can be
observed. If a urinoma develops, consider stenting and/or percutaneous drainage.
Ultimately, less than 10% of patients require surgery for failure of stents to control urine
extravasation however the usage of stenting for collecting system injuries is falling out of
favor and data is accruing showing that this is safe.
Percutaneous drainage: Urinoma and abscess are complications of NOM. Both are
amenable to percutaneous drainage. Open surgery should be reserved as a last option and
is likely associated with higher rates of nephrectomy.
Intra-op considerations: Assess urinary extravasation by systemic injection of methylene

blue 50mg IV over 5 minutes or indigo carmine 5 mL IV. The goals of operative renal
trauma management are debridement, homeostasis, watertight closure of the collecting
system, re-approximation of the parenchyma, and drainage of the retroperitoneum.
Omentum or Vicryl® mesh is helpful to wrap the kidney after repair. This will compress
the kidney to aid hemostasis and improve the success rate of nephrorrhaphy. Renal salvage
should NEVER be attempted in hemodynamically unstable patients.
Revascularization: Revascularization has been employed for traumatic renal artery

occlusion. Salvage in this situation is rarely successful and should not be undertaken in
the acutely injured patient.

Revised AAST Renal Injury Grading
1. Yeung LL, Brandes SB. Contemporary management of renal trauma: differences between urologists and trauma
surgeons. J Trauma Acute Care Surg. 2012 Jan;72(1):68-75; discussion 75-7.
2. Santucci RA, Wessells H, Bartsch G,et al. Evaluation and management of renal injuries: consensus statement of
the renal trauma subcommittee. BJU Int. 2004 May;93(7):937-54.
3. Dayal M, Gamanagatti S, Kumar A. Imaging in renal trauma. World J Radiol. 2013 Aug 28;5(8):275-84.
4. Shenfeld OZ, Gnessin E. Management of urogenital trauma: state of the art. Curr Opin Urol. 2011 Nov; 21:449-
54
5. Jawas A, Abu-Zidan FM. Management algorithm for complete blunt renal artery occlusion in multiple trauma
patients: case series. Int J Surg. 2008 Aug; 6:317-22.
6. Smith TG 3rd, Coburn M. Damage control maneuvers for urologic trauma. Urol Clin North Am. 2013 Aug;
40:343-50

Diagnosis of Blunt Bowel and Mesenteric Injury

The small intestine is particularly vulnerable to injury covered only by the anterior
abdominal wall and can be injured by shearing, bursting, or crushing mechanism. The
evaluation and decision to operate is far more complicated than the operative therapy. The
decision to operate or admit for serial examinations is most often based on careful physical
examination and a thorough review of a CT scan. Early recognition of injuries is important
since abscesses; wound infection, anastomotic failure, and mortality have been shown to
increase when operations are delayed by even 8 hours.
Physical exam findings:
• Abdominal tenderness (approx. 72.5%)
• Peritoneal irritation (approx. 33.5%)
• Increasing distention
• Abdominal bruising
• Seatbelt sign (seatbelt sign + tenderness) is much more likely to have intestinal
injury
“Hard signs” on PE mandating exploratory laparotomy are frank peritonitis, evisceration.
CT scan is the best imaging test for blunt intestinal and mesenteric injuries. Three CT signs
that create concern:
• Free fluid without solid organ injury
• Mesenteric stranding or haziness
• Bowel wall thickening
If 1 sign → observe, serial exams & CBCs
If 2 signs → consider OR
If 3 signs → exploratory laparotomy
“Hard signs” on CT mandating exploratory laparotomy are pneumoperitoneum and/or oral
contrast extravasation (though rarely given on initial trauma CT).
Free fluid without solid organ injury, mesenteric stranding, and bowel thickening are
suggestive but not specific for blunt bowel or mesenteric injury (BBMI). Malhotra found
that in a patient with a single CT finding 35% had BBMI, 80% if two of these findings
and 100% if all three signs are present. Other suspicious CT findings include bowel wall
or mesenteric hematomas or beading/ termination of mesenteric vessels
In patients with TBI, intoxication, chemical paralysis limiting abdominal examination or
critical illness precluding transport to CT, consider DPL at the bedside. DPL fluid analysis
with >500 WBC/mm3, bacteria on gram stain, root hairs or vegetable matter on micro, and
elevated alkaline phosphatase are indicators of intestinal injury. Alkaline phosphatase>10
IU/L has been shown to have a much higher sensitivity than WBC >500. Clinical judgment
is required when interpreting DPL fluid but in general it is safer to explore equivocal
findings.
Additional points:
• If uncertainty remains about a bowel injury, admit patient for serial examinations
and CBCs
• Consider repeat CT scan with oral contrast
(See APPENDIX – AAST Small Bowel Injury Scale – Page 105)

1. Fakhry SM, et al. Relatively Short Diagnostic Delays (<8 Hours) Produce Morbidity and Mortality in Blunt Small
Bowel Injury: An Analysis of Time to Operative Intervention in 198 Patients from a Multicenter Experience. J
Trauma 2000; 48:408-415.
2. Fakhry SM, Watts DD, Luchette FA. Current diagnostic approaches lack sensitivity in the diagnosis of perforated
blunt small bowel injury: analysis from 275,557 trauma admissions from the EAST multi-institutional HVI trial. J
Trauma. 2003 Feb; 54(2):295-306.
3. Malhotra AK, et al. Blunt Bowel and Mesenteric Injuries: The Role of Screening Computed Tomography. J
Trauma 2000; 48:991-1000.
4. Yu J, Fulcher AS, Turner MA, et al. Blunt bowel and mesenteric injury: MDCT diagnosis. Abdom Imaging. 2011
Feb;36(1):50-61.
5. Jaffin JH, Ochsner MG, Cole FJ, et al. Alkaline phosphatase levels in diagnostic peritoneal lavage fluid as a
predictor of hollow visceral injury. J Trauma. 1993 Jun;34(6):829-33.

Management of Colon Injury

Nearly 30% of abdominal penetrating trauma due to gunshot wounds result in colon injury
vs 5% in stab wounds. These numbers can double in centers with high volume penetrating
trauma.
Flint and AAST Colon Injury Scale (CIS) help classify destructive (severe tissue loss
[>25%], devascularization, and gross contamination) vs non-destructive colon injury and
guide primary repair vs resection/ diversion. The degree of physiologic derangement
(acidosis, hypothermia, coagulopathy, etc.) must factor into decision making regarding
repair vs. resection/ diversion as well. The benefits of proximal diversion are not strongly
supported by data, however patients at higher risk of anastomotic leak may benefit.
Stapled versus hand-sewn anastomosis is controversial in trauma patients. Reviews and

meta-analysis in the emergency general and trauma surgery populations did not elucidate
a preferred method, but hand-sewn anastomoses are preferred in cases of thickened or
edematous bowel. Thus, acute management (prior to edema formation) of colon injury
with stapled anastomosis should suffice. Remember, a true hand-sewn anastomosis resects
all staple lines. The decision to perform an anastomosis versus an ostomy is nuanced and
depends on multiple patient factors such as presence of shock state, vasopressor therapy,
coagulopathy, hypothermia, associated injuries, etc.
Patients with a concern for colonic injury should be given metronidazole (Flagyl®) in
addition to cefazolin (Ancel®) pre-incision; otherwise, metronidazole should be admini-
stered as soon as colonic injury is detected. Midline incision planning should allow for
ileostomy/colostomy creation. Colonic assessment should involve all sides of the colon
and mesentery at the site of injury. All colonic hematomas must be fully explored. Blunt
trauma often leads to devascularization due to mesenteric injury along with colonic injury.
Injuries identified on presentation may be treated similarly to penetrating trauma, but
delayed findings of colonic injury are best treated with resection and diversion.
1. Maxwell RA, Fabian TC. Current management of colon trauma. World J Surg. 2003;27:632–639.
2. Demetriades D, Murray JA, Chan L, Ordonez C, Bowley D, Nagy KK, et al. Penetrating colon injuries requiring
resection: diversion or primary anastomosis? An AAST prospective multicenter study. J Trauma. 2001:50:765–
775.
3. Naumann DN, Bhangu A, Kelly M, Bowley DM. Stapled versus hand sewn intestinal anastomosis in emergency
laparotomy: a systematic review and meta-analysis. Surgery. 2015; Apr: 157 (4): 609-18
4. Gonzalez RP, Falimirski ME, Holevar MR. The Role of Presacral Drainage in the Management of Penetrating
Rectal Injuries. J Trauma. 1998; 45 (4). Pp 656-661

Rectal Injury
The mortality and morbidity from penetrating rectal injury has declined dramatically over
the last few decades due to earlier recognition of injuries and prompt surgical diversion.
Most injuries occur from handguns, impalements, and rarely pelvic fractures. Handguns are
considered low velocity while military weapons or hunting rifles are high velocity and
cause much more tissue destruction. This distinction has allowed management of rectal
injuries from handguns to evolve to now include almost exclusively proximal diversion and
only rarely is distal rectal washout and presacral drainage needed.
Injury anatomy: Rectum ~ 15cm
• Intraperitoneal: anterior and lateral upper 2/3 of rectum, has serosa, managed
similar to a left colon injury
• Extraperitoneal: posterior and entire distal 1/3 of rectum, no serosa
Intraperitoneal rectal injuries should be primarily repaired with or without fecal diversion.
Recent studies have suggested extraperitoneal rectal injuries should be left untouched and
only a diverting colostomy should be performed. This is because primary repair of
extraperitoneal rectal injuries is difficult due to the confined pelvic space, the adjacent
sacral venous plexus and urogenital structures, and the hypogastric nerve plexus. Easily
visualized injuries with minimal dissection should be primarily repaired but DO NOT
mobilize the distal rectum to repair the injury. If mobilization is required to repair an
associated injury (bladder, vagina, etc.) and the rectal injury is exposed then proceed with
rectal repair.
Workup plan:
• All patients in ER should receive a digital rectal exam (DRE) for gross blood using
a clean glove (double glove, take off bloody top glove PRIOR to DRE). Try to
avoid spill over from other wounds.
• If the patient is going to the OR for suspected rectal injury, be sure to communicate
the need for dorsal lithotomy, stirrups, and a rigid sigmoidoscope.
o Rigid sigmoidoscopy is MANDATORY for those with gross blood on DRE
or bullet trajectory near the rectum
• Diversion with a loop colostomy preferred over end colostomy.
• Hematuria should raise level of suspicion of concomitant GU injury and prompt
further workup
Patients can often be reversed in 1-2 weeks after injury as long as a contrast enema does not
show fistula or stricture. It can often be done the same admission with similar rates of
success to reversal done much later.
1. Khalid MS, Moeen S, Khan AW, et al. Same admission colostomy closure: a prospective, randomized study in
selected patient groups. Surgeon. 2005 Feb;3(1):11-4.
2. Navsaria PH, Edu S, Nicol AJ. Civilian extraperitoneal rectal gunshot wounds: Surgical management made
simpler. World J Surg. 2007 Jun; 31(6):1345-51.
3. McGrath V, Fabian TC, Croce MA, et al. Rectal trauma: management based on anatomic distinctions. Am Surg.
1998 Dec; 64(12):1136-41.

Unstable Pelvic Fractures

Pelvic ring fractures are among the most challenging injuries to manage. They often occur
in conjunction with other life- threatening injuries such as intracranial hemorrhage, blunt
chest trauma, and major abdominal injuries. Fractured pelvic bones can lacerate soft tissues
and vessels resulting in exsanguinating hemorrhage and the deadly triad. Patients with
unstable pelvic fractures and hypotension have mortality rates of 33-45%1. With the
institution of multidisciplinary protocols including DCR, pelvic binders and pre-peritoneal
packing, mortality rates appear to be decreasing, especially in younger, healthier patients.
Key initial principles of management
• Obtain pelvic X-ray if hemodynamical OR mechanical instability. If a patient is
hemodynamically unstable and has an unstable pelvis on physical exam place
the T-Pod immediately. Do not wait for X-ray to identify the fracture pattern.
• Control of hemorrhage in ER by pelvic compression (T-Pod centered on greater
trochanters)
• Transfuse whole blood and activate DCR. Administer TXA.
• Diagnosis and treatment of associated injuries
• Early use of IR if there is arterial extravasation on CT-only ~ 20% of bleeding
that causes HD instability is arterial
• Pre-peritoneal packing. Consider the need for this when planning laparotomy
incision!
• Consult orthopedics early. Some lateral compression fractures may be worsened
by binders. Vertical shear mechanisms typically require traction.
• Hemodynamically stable patients should undergo CT scanning of the abdomen and
pelvis to detect occult injuries or contrast extravasation. The finding of the contrast
extravasation in the pelvis is highly suggestive of significant arterial bleeding that
may require angio-embolization. Ongoing transfusion requirements or transient
response to transfusion also constitute an indication for arteriography.
Identification of alternative sites of bleeding is central to the care of these patients.
Physical examination, chest x-ray, and FAST will identify significant extra-pelvic
hemorrhage, allowing timely intervention. If ultra-sonography is equivocal,
supraumbilical DPL should be performed, and the patient explored if DPL is
grossly positive. (>10 ccs blood on aspiration).
Who should go to IR?

• Hemodynamically stable patients who have arterial extravasation on CT
• Ongoing bleeding despite going to OR, packing and T-POD.
• Discussion should occur between trauma and IR attending
Preperitoneal packing
• Low vertical incision (leave skin bridge from midline laparotomy) or Pfannestiel
• 3 Packs on either side of the bladder (narrow ribbon helps)
• Some improvements in mortality of hemodynamically unstable pelvic fractures
Other operative points
• Bi-manual AND rectal exams to rule out open fractures in women, rectal exam
in all males

• In the OR, exsanguinating pelvic arterial hemorrhage may require Hypogastric

ligation (unilateral +/- bilateral)
(See APPENDIX – Burgess & Young Pelvic Fracture Grading – Page 107)
1. Black SR, Sathy AK, Jo C, et al. Improved Survival After Pelvic Fracture: 13 Year Experience at a Single Trauma
Center Using a Multi-disciplinary Institutional Protocol. J Orthop Trauma. 2015 Sep 3.
2. Lustenberger T, Wutzler S, Störmann P, et al. The role of angio-embolization in the acute treatment concept of
severe pelvic ring injuries. Injury. 2015 Oct;46 Suppl 4:S33-8.
3. Tai DK, Li WH, Lee KY. Retroperitoneal pelvic packing in the management of hemodynamically unstable pelvic
fractures: a level I trauma center experience. J Trauma. 2011 Oct;71(4):E79-86
4. Cothren CC, Osborn PM, Moore EE, et al. Preperitoneal pelvic packing for hemodynamically unstable pelvic
fractures: a paradigm shift. J Trauma. 2007 Apr;62(4):834-9; discussion 839-42.

The Open Abdomen

Few operative strategies have positively affected survival of severely injured patients more
than damage control laparotomy (DCL). The principles of DCL are to avoid onset of the
lethal triad by minimizing operative time by controlling major intra-abdominal bleeding
with packs, clips, shunts, and to minimize contamination from bowel sources but not
necessarily restore bowel continuity.
The abdomen is covered by a temporary negative pressure abdominal dressing and the
fascia is left open. In the controlled environment of the ICU further resuscitation occurs.
Acidosis, coagulopathy, and hypothermia are reversed, and other injuries are treated.
A number of trauma centers have taken on quality improvement initiatives in the last 3
years to reduce use of the DCL approach. These initiatives have been ineffective.
Two temporary closure setups are typically used
• Abthera® VAC system by KCI. This is the PREFERRED temporary abdominal
dressing. It’s faster to apply, has its own suction system but is slightly more
expensive. This is best used when abdominal closure is uncertain since there is
some data showing improved, long-term fascial closure with Abthera®.
• Homemade Barker style dressing with 2 towels sandwiched around 2 JP drains
over a fenestrated gut bag all covered with Ioban. This dressing is best used when
abdominal closure is assumed to happen on the next take-back and a long-term
open abdomen is unlikely.
Return to OR
• DCL patients should return to OR when acidosis, hypothermia, coagulopathy, and
hemodynamics have been stabilized.
Feeding the open abdomen
• Patients can be fed enterally
• May promote venous return and reduce bowel edema
• Can reduce risk of ileus
• May reduce fistula rate and improve closure rate
Patients can be extubated with an open abdomen in isolated cases.
Diuresis can aid abdominal closure – MUST be discussed with TICU attending
• Patient must be hemodynamically normal, euvolemic
• Stable renal function and urine output (UOP)
• Initiate furosemide drip 1-5mg/hr. often effective, 25% albumin if hypovolemia
develops
• Escalating doses of furosemide, poor UOP or hypotension indicates inadequate
intravascular volume or capillary leak from infection or ongoing inflammation –
STOP diuresis and investigate
• STOP diuresis if worsening azotemia or hypernatremia
• Correct hypokalemia with potassium supplementation, metabolic alkalosis with
acetazolamide

Ultimately the goal is to minimize risk of fistula by achieving fascial closure as early as
possible if this is not likely move to vicryl mesh and skin graft.
1. Rotondo MF, Schwab CW, McGonigal MD,et al. 'Damage control': an approach for improved survival in
exsanguinating penetrating abdominal injury. J Trauma. 1993 Sep;35(3):375-82; discussion 382-3.
2. Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann
Surg. 1983;197:532-5.
3. Roberts DJ, Zygun DA, Grendar J, et al. Negative-pressure wound therapy for critically ill adults with open
abdominal wounds: a systematic review. J Trauma Acute Care Surg. 2012 Sep;73(3):629-39.
4. Harvin JA, Sharpe JP, Croce MA et al. Better understanding the utilization of damage control laparotomy: A
multi-institutional quality improvement project. J Trauma Acute Care Surg. 2019 Jul;87(1):27-34.

Threatened Limb
Extremity injuries with significant damage to multiple tissue components (skin,
subcutaneous tissue, muscles, bone, nerve, and vasculature) are often called mangled
extremities. A threatened limb may appear normal but has an arterial injury (e.g., popliteal
artery injury). Both typically require arterial repair to restore limb viability, but unlike an
isolated vascular injury the prognosis for a true mangled extremity is often dismal.
Morbidly obese individuals are at risk for threatened limbs due to low velocity, high energy
knee dislocations or fractures that cause arterial and/or nerve injury without skin wounds.
For mangled lower extremities, amputation MUST be considered since it may be a better
alternative to attempted limb salvage, especially when risk of systemic complications is
high, the patient’s reserve is poor, or the salvaged limb will be far less functional than
prosthesis.
Patients often arrive hours after injury and have had significant warm ischemia time thus
communication is crucial to get the limb revascularized as soon as possible. The trauma
attending will coordinate care by communicating with the vascular and orthopedic surgery
attendings directly. The goal is completed communication with all elements of the team
within 15 minutes of the patient’s arrival. The trauma attending can take the patient to the
OR and get the operation under the way until the vascular and/or orthopedic faculty arrives.
The goal is to get the patient into the OR within 60 minutes of arrival. For patients with a
threatened limb AND hypotension, please document the time that the orthopedic
consultation is called, as well as the arrival of the first orthopedic team member; this
is an important trauma quality metric.
Scoring systems to predict limb salvage are based on data from lower extremity injuries
and none has been shown to be superior to others. The NISSSA scoring system emphasizes
factors which impact limb salvage for mangled extremities: nerve injury, ischemia, soft
tissue/contamination, skeletal trauma, presence of shock, and patient age. Limb salvage
with acceptable functional results is usually possible when NISSSA is <7 and few limbs
can or should be salvaged when the NISSSA >10. The NISSSA score must be documented
in the patient’s medical record.
Diagnosis of a threatened limb is made by physical exam alone and this should be augmen-
ted by performing ankle-brachial indices (ABIs) on all patients. An unequal ABI suggests a
vascular injury. Imaging studies such as CTA or formal angiographies are typically not
required and add time to a limb already suffering warm ischemia. On table angiography is
an excellent tool to identify and delineate injuries, particularly in cases where multiple
sites of vascular injury are possible. Temporary arterial shunts, external fixators and
fasciotomies are options in these types of injuries.
Time is of the essence! Unless adequately perfused, nerve and muscle become
progressively unsalvageable after 4 to 6 hours.
The trauma attending should be called for patients in the TICU with the following
derangements who have had re-implantation or salvage attempts:
• Increasing vasopressor needs
• Ongoing bleeding or transfusion requirements
• Signs of end organ ischemia

NISSSA Rating Criteria
Type of injury Degree of Points Description

Injury
N – Nerve Injury Sensate 0
No major nerve injury
Dorsal 1
Peroneal (deep or superficial), femoral
nerve injury a
Plantar partial 2 Tibial nerve injury a
Plantar complete 3 Sciatic nerve injury a
I – Ischemia None 0 Good to fair pulses, no ischemia
Mild 1b Reduced pulses, perfusion normal
Moderate 2b No pulse(s),  cap refill, Doppler
signals present
Severe 3b Pulseless, cool, ischemic, no Doppler
pulses
S – Soft Tissue (ST) / Low 0 Minimal to no ST contusion, no CON
Contamination (CON) Medium 1 Moderate ST injury, low-velocity
GSW, moderate CON, minimal crush
High 2 Moderate crush, deglove, high velocity
GSW, moderate ST injury,
considerable CON
Severe 3 Massive crush, farm injury, severe
deglove, severe CON, requires soft-
tissue flap
S – Skeletal Low energy 0 Spiral, oblique fracture, no/minimal
displacement
Medium energy 1 Transverse fracture, minimal
comminution, small caliber GSW
High energy 2 Moderate displacement, moderate
comminution, high velocity GSW,
butterfly fragment(s)
Severe energy 3 Segmental, severe comminution, bony
loss
S – Shock Normotensive 0 BP normal, SBP always >90 mm Hg
Transient BP 1 Transient SBP <90 in field or ED
Persistent BP 2 Persistent SBP <90 despite fluids
A – Age Young 0 <30 years
Middle 1 30-50 years
Old 2 >50 years
TOTAL SCORE (N + I + S + S + S + A) ___________
a
Nerve injury as assessed primarily in emergency room.
b
Score doubles with ischemia >6 h.
(See APPENDIX – Gustilo Open Fracture Classification – Page 106)
1. Georgiadis AG, Mohammad FH, Mizerik KT, et al. Changing presentation of knee dislocation & vascular injury
from high-energy trauma to low-energy falls in the morbidly obese. J Vasc Surg. 2013 May;57(5):1196-203.
2. Dua A, Patel B, Kragh JF Jr, et al. Long-term follow-up & amputation-free survival in 497 casualties with combat-
related vascular injuries & damage-control resuscitation. J Trauma Acute Care Surg. 2012 Dec; 73:1517-24
3. McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: A retrospective evaluation
of the Mangled Extremity Severity Score. J Orthop Trauma 1994; 8:81-87.
4. American College of Surgeons Committee on Trauma, ACS TQIP Best Practices in the Management of
Orthopaedic Trauma 2015 https://www.facs.org/-/media/files/quality-programs/trauma/tqip/ortho_guidelines.ashx

5.
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
Portal vein Repair
fluid sequestration in splanchnic vascular
bed and bowel infarction
Cannot ligate - fewer collateral than left
Right renal vein Repair
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 Especially if proximal to gastroduodenal
Ligate
arteries branch
Right/left hepatic arteries Ligate Especially if portal vein is intact
Splenic artery Ligate Short gastric a. from left gastroepiploic
Iliac vein - comm/ext Ligate
Iliac artery - comm/ext Repair
Femoral/popliteal arteries Repair
Can ligate but need to ensure patency of
Tibial arteries Repair
other leg arteries. Single runoff is OK
Can ligate if distal to profunda brachia
Brachial artery Repair branch since the elbow has a rich
collateral of blood flow
Can ligate but need to ensure patency of
Radial/ulnar arteries Repair
another artery

Analgesia, Sedation and Delirium Protocols
ANALGESIA GOALS OF TREATMENT FOR ALL

PATIENTS ON PROTOCOL
FENTANYL (bolus dosing)
50 mcg IV every 5 minutes x3 PRN to achieve ▪ Always assess for and treat pain FIRST
RASS of 0 to –2 & CPOT <3 ▪ If escalating doses of sedation for 24
▪ In patients >65 or opiate naïve, use 25 mcg IVP hours, PMH of psychiatric disorder,
▪ In opiate tolerant patients, use 200 mcg IVP long length of stay in unit, assess for
delirium using Confusion Assessment
If at any point during every 5 minutes bolus dosing Method ICU (CAM-ICU)
RASS is 0 to –2 and CPOT < 3, then stop and move ▪ Maintain RASS score 0 to –2 PRN
to bolus dosing as follows: bolus dosing is the preferred method
▪ Bolus with same dose utilized in every 5 minute for managing pain and agitation
bolusing period every fifteen minutes x2 ▪ This protocol is to serve as a guide for
▪ Then bolus with same dose every hour to maintain patient care and should not replace the
RASS at 0 to –2 and CPOT <3 clinical judgment of the licensed
independent practitioner
If after 3 consecutive 5-minute PRN bolus doses
All sedation will be stopped each
RASS is ≥1 and/or CPOT >3, then move to
morning at a time determined by nursing
FENTANYL drip per guidelines below:
and physician staff to allow for a neuro-
FENTANYL (infusion)* start infusion at bolus
logical examination and spontaneous
dose (e.g., if bolus dose was 50 mcg, then start
breathing trial (SBT). Please see
infusion at 50 mcg/hr.), titrate to goal RASS 0 to –2
procedure below.
▪ Patient comfortable and at goal: Re-assess
CPOT every two hours SPONTANEOUS AWAKENING
▪ If patient is NOT at goal TRIAL (SAT)
▪ If RASS <-2, decrease infusion rate by 25 mcg**
Every patient will have a SAT trial each
every hour until RASS is 0 to –2
morning unless they meet set exclusion
▪ If RASS is >0, re-bolus 50 mcg and increase
criteria. The procedure is as follows:
infusion by 25 mcg every hour until RASS is 0
▪ Continuous infusion of opiates will be
to –2
reduced by 50%
▪ Once target RASS (0 to –2) has been met for 2
▪ Continuous infusions of sedatives will
hours, begin decreasing dose by 25 mcg every 4
be stopped
hours
▪ PRN doses will be held for a time
*Please contact physician if dose exceeds 300 determined by the critical care team
mcg/hr. onward in anticipation of a SAT
** If at 25 mcg, decrease dose by half or hold, and UNLESS the patient meets any of the
utilize PRN dosing following EXCLUSION CRITERIA:
o Intracranial hypertension/coma,
SEDATION hemodynamic instability, on
Anticipated extubation <72 hours MAP >60 or neuromuscular blockade, propofol
SBP >90 >50 mcg/kg/min, open abdomen,
PROPOFOL (infusion) scheduled for OR same day, or a
Initiate infusion at 5 mcg/kg/min, titrate to goal physician documented
RASS 0 to -2 contraindication.
▪ Titrate in increments of 5 mcg/kg/min every 5 o Patients on dexmedetomidine
minutes to RASS of 0 to –2 (Precedex) will remain on their
▪ Increase or decrease dose by 5 mcg/kg/min every infusion.
5 minutes if under or over-sedation (i.e., RASS All patients who successfully awaken
not within goal of 0 to –2) after one hour of a SAT will then be
▪ Max dose is 50 mcg/kg/hr. Notify physician if started on a spontaneous breathing trial
target RASS goal not achieved at max dose. (SBT) as outlined below

Sedation de-escalation or anticipated extubation SPONTANEOUS BREATHING

<72 hours TRIAL (SBT)
DEXMEDETOMIDINE (infusion)
Initiate infusion at 0.4 mcg/kg/hr. titrate infusion to The Respiratory Therapist (RT) will then
RASS of 0 to -2. start all patients who successfully awaken
• Increase or decrease dose by 0.1 mcg/kg/hr. every after one hour of a SAT on an SBT unless
20 minutes until RASS goal of 0 to -2 is achieved. the patient has any of the following
• Max dose 1.5 mcg/kg/hr. Notify physician if target exclusion criteria:
RASS goal not achieved at max dose. ▪ Acute Respiratory Distress Syndrome
(ARDS), known threatened airway,
Anticipated extubation >72 hours and / or complete lack of cough with
Hypotensive (MAP <60 or SBP <90) endotracheal suctioning, or another
LORAZEPAM physician documented contraindication.
1 mg IVP every 10 minutes, up to 3 doses per hour
to achieve RASS of 0 to –2 The SBT will consist of pressure support
▪ In patients with hepatic dysfunction or age >65, with PEEP of 5 mmHg and CPAP of 5cm
use 0.5 mg IVP with flow by for 1 hour.
▪ In patients with a history of drug abuse, use 2 mg
IVP The RT will document the results of the
▪ Assess RASS between each dose SBT (either positive or negative) and then
place the patient back on the same
Patient comfortable and at goal: Reassess sedation ventilator settings preceding the test.
RASS every two hours
If patient is NOT at goal: Use initial bolus dose
IVP every 30 minutes x2 PRN, then initial dose IVP
every hour PRN, reassess RASS between each dose,
if RASS goal not achieved within 2 hours, proceed
to midazolam infusion.
MIDAZOLAM (infusion)
Initiate infusion at 2 mg/hr., titrate infusion to RASS
of 0 to –2
▪ Increase or decrease dose by 1 mg/hr. every 20
minutes until RASS goal of 0 to -2 is achieved.
▪ Once target RASS (0 to –2) has been met for 2
hours, begin decreasing dose by 1 mg every four
hours.
▪ Max dose is 10 mg/hr. Notify physician if RASS
goal not achieved at max dose.
Minimizing benzodiazepine use has shown to reduce
ICU length of stay, duration of mechanical ventila-
tion, and rates of delirium.
▪ Use minimum amount of benzodiazepine dosage
necessary
▪ Use with caution in elderly patients and those with
hepatic and/or renal insufficiency
DELIRIUM
Quetiapine 25 mg PO ▪ Use lower doses in elderly patients or hepatic dysfunction
every 8 hrs ▪ Increase dose by 25 mg PO every 8 hours. Can cause QTc
prolongation
▪ Max dose studied for delirium is 400 mg/day; doses up to 800
mg/day are used for other indications. Higher doses are more
antihistaminergic.
▪ Obtain baseline ECG and recheck with increasing doses or
concomitant medications that have the potential to prolong the
QTc. Discontinue if significant QTc prolongation >500 ms
▪ Wean dose in 25 mg increments if delirium absent for 24 hours

Olanzapine 5 mg PO every ▪ Available as an orally disintegrating tablet for patients who are
24 hrs NPO
▪ Increase dose by 5 mg PO every 24 hours. Up to 10 mg per day has
been studied for delirium
▪ Obtain baseline ECG and recheck with increasing doses or
concomitant medications that have the potential to prolong the
QTc. Discontinue if significant QTc prolongation >500ms
▪ Wean dose in 5 mg increments if delirium absent for 24 hours
Haloperidol 2.5 mg IV ▪ Use in elderly patients or hepatic dysfunction
every 6 hrs ▪ Reassess in 24 hours, if delirium absent, continue for 24 hours then
discontinue.
▪ IF delirium present, increase dose to 5 mg every 6 hours.
Haloperidol 2.5 mg IV Use in elderly patients or hepatic dysfunction up to 40 mg in 24 hours
every 1-hr PRN delirium
Haloperidol 5 mg IV ▪ Reassess in 24 hours, if delirium absent, continue for 24 hours then
every 6 hrs discontinue.
▪ If delirium present, increase dose to 10mg every 6 hours.
Haloperidol 5 mg every Up to 40 mg in 24 hours
1-hr PRN delirium
Notify House Officer Once delirium is absent for 48 hours, discontinue haloperidol

Infections and Antibiotics in the ICU

Fever Work-Up
• Fevers over 101.5 warrants investigation with urine analysis/culture, blood
cultures, chest x-ray, assessment of CPIS (see below) and discussion for potential
removal of foreign catheters
• Fevers occurring within 24 hours of operative intervention are expected
• TBI poses a unique problem as the injury may alter the hypothalamic set point
Management of Fevers
Fevers are a natural response to infection and part of the immune system’s defenses.
Recent data suggests that aggressive control of fevers (>101.3F) had increased mortality
compared to a more permissive group. With this in mind, we will treat fevers with
acetaminophen and other adjuncts when above 104F. The exception to this is intracranial
hypertension or when there is a reduced SVO2. Cooling blankets should NOT be used.
Foley Catheters, Arterial Lines, and Central Lines
Infections associated with indwelling foreign catheters remain a problem. Each day assess
the need for any indwelling catheters. The best way to prevent an infection due to one of
these catheters is to not have one in place.
Ventilator-Associated Pneumonia
Ventilator-associated pneumonia (VAP) occurs in up to half of mechanically ventilated
patients, with a mortality rate approaching 20%. The incidence of VAP increases by
approximately 1% per day cumulatively in the intubated patient. VAP “bundles” have
been shown to reduce the incidence of VAP, thus head-of-bed elevation greater than 30
degrees, minimization of sedation with daily interruptions, and extubation as soon as
possible are strategies demonstrated to reduce the rate of VAP.
The diagnosis of VAP is controversial; bronchoalveolar lavage (BAL) with quantitative
culture is our strategy. Recent evidence has demonstrated decreased mortality and anti-
biotic usage when BAL was used to diagnose VAP. Since BAL is an invasive procedure,
the suspicion of VAP must warrant the risk of the procedure. Patients with CPIS ≥ 5 and/
or clinical suspicion should undergo BAL. The PaO2 to FiO2 ratio (P/F) appears to be
the component of the CPIS with the best predictive value for VAP especially when <240.
Modified Clinical Pulmonary Infection Score (CPIS)
Temperature (o F) WBC Count
> 96.8 & < 101.2 0 points > 4,000 & < 11,000 0 points
> 101.2 & < 102 1 point < 4,000 & > 11,000 1 point
> 102.1 or < 96.8 2 points (>50% band forms) 1 point
Tracheal Secretions Culture
Absent 0 points < 105 cfu/ml 0 points
Non-purulent 1 point > 105 cfu/ml 1 point
Purulent 2 points Gram stain & Cx same 1 point
PaO2/FIO2 Progression of infiltrate
> 240 or ARDS 0 points None 0 points
< 240 & no ARDS 2 points Progression 2 points
X-ray Infiltrate
None 0 points
Diffuse / patchy 1 point
Localized 2 points

BAL is performed by wedging the bronchoscope into the affected segment, keeping the
scope wedged, instilling, and aspirating five 20 ml aliquots of non-bacteriostatic sterile
saline, discarding the initial aliquot, and pooling the remaining effluent for BAL culture.
To decrease false positives do NOT use preserved multi-dose lidocaine. Broad spectrum
antibiotic coverage should be initiated at the time of BAL. Patients who have been in the
hospital for 3 days or more should be started on empiric coverage for MRSA and gram
negative rods, while those with suspected VAP <3 days require MSSA and community
flora coverage.
Studies have demonstrated that appropriate empiric antibiotic coverage in patients with
VAP reduces mortality and ICU length of stay. It is imperative that antibiotics be narrowed
or discontinued as soon as final culture results are known. VAP defined as a count of
>104organisms/ml. Recent evidence has identified no differences between short-course
(7-8 days) and long-course (10-15 days) regimens in terms of mortality, clinical cure,
and recurrent pneumonia. This includes those patients with non-fermenting gran
negative bacilli and MRSA. Short-course regimens are associated with reduced
recurrent VAP due to multi-drug resistant pathogens when compared to long-course
regimens.
Prophylactic Use of Antibiotics in Trauma Patients
The inappropriate use of prophylactic antibiotics is associated with devastating
consequences including increased antibiotic resistance and secondary infections as well as
the emergence of drug-resistant pathogens such as fulminant Clostridium difficile. It is
imperative that indications for antibiotics be continually reviewed, and prescriber discipline
maintained. The most effective therapy is timely operative debridement, NOT antibiotics.
Chest Tubes
There are few randomized controlled trials regarding the prophylactic antibiotics and chest
tube insertion. The preponderance of the literature suggests a single dose of a 1st generation
cephalosporin, given 30 minutes prior to tube insertion may reduce empyema rates and
should be given to all patients undergoing tube thoracostomy AS LONG AS THERE IS
ADEQUATE TIME. Truly emergent chest tubes should not be delayed waiting for
antibiotics to be administered and should be done promptly.
Intracranial Pressure Monitors and Drains
Neither peri-procedural nor prophylactic antibiotics are indicated for External Ventricular
Drain (EVD) placement since both regimens have been associated with higher rates of non-
CSF infection rates. Antibiotic impregnated External Ventricular Drain catheters are as
effective at reducing intra-cranial infection as systemic antibiotics without the concomitant
increase of extra-cranial infections. Studies have shown that antibiotic prophylaxis of EVDs
engenders antibiotic resistance and promotes distant infections thus there is no role for
routine use of antibiotics before, during or after EVD placement.
Open Fractures
Treatment with antibiotics should be based upon the Gustilo-Anderson Classifica-
tion. Patients should receive antibiotics immediately upon identification of an open
fracture in ED and continued up to 24-48 hours following surgical debridement.
• Type I (<1 cm wound and clean) should receive Cefazolin for 24-48
hours after the operation.
• Type II (>1 cm without extensive soft tissue damage) should receive
Cefazolin for 24-48 hours after the operation.

• Type III (open, segmental, extensive soft tissue damage, heavily

contaminated) should receive Cefazolin and Gentamicin for 24-48
hours after the operation
• For saltwater, freshwater, organic/fecal contamination and/or
anaphylaxis allergies to penicillin consult a pharmacist.
Skull Fractures and CSF Leaks
Although there is a theoretical concern for meningitis with a basal skull fracture (BSF) and
some have advocated for prophylactic antibiotics, a 2006 review of 5 RCTs and 17 non-
RCTs revealed that the currently available evidence does NOT support prophylactic
antibiotic use in patients with BSF, even in the presence of CSF leakage. Although some
series have demonstrated complication rates as high as 16% in patients with frontal sinus
fractures with disruption of the frontonasal duct, the largest series in the literature does not
report increased infection rates. Rodriguez et al stated that the best approach to minimize
complications is early appropriate operative intervention. Other studies are small, lack
appropriate controls, and fail to demonstrate any benefit from prophylactic antibiotics.
Additionally, there is no role for antibiotics to treat pneumocephalus.
Facial Fractures
The data on antibiotics in facial fractures is limited, but there is no compelling data to
support treating closed facial fractures with antibiotics. A meta-analysis of randomized
controlled trials demonstrated that prophylactic antibiotics provided no benefit in maxillary,
zygoma or mandibular condyle fractures. Chloe et al demonstrated that operatively
managed closed facial fractures should also follow the federal mandates of a single pre-
operative dose of antibiotics just prior to time of incision, and do not require further anti-
biotic exposure. Subsequent studies have confirmed that there is no benefit to prolonged
(5-day vs 1-day) course of post-operative antibiotics for both mandible and facial fractures.
Ballistic injuries and contaminated open facial fractures must be treated with the same
expeditious operative debridement and wound care as open fractures elsewhere in the
body. Antibiotics have never been shown to be equal to let alone superior to, early operative
debridement. The highest rates of infection occur with fractures at the angle of the mandible
involving the third molar, thus open mandibular fractures involving the angle should
receive preoperative antibiotics and 1-2 doses postoperatively, even in the case of infected
wounds.
1. Schulman, CI, et al. The effect of antipyretic therapy upon outcomes in critically ill patients: a randomized
prospective study. Surgical Infections. 2005, 6(4) 369-75
2. Heyland DK, et al. The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated
pneumonia. Chest. 19999; 115:1076-1084
3. Fagon JY, et al. Invasive and non-invasive strategies for management of suspected ventilator-associated
4. pneumonia, Ann Int Med 2000; 132:621-630.
5. Croce M, et al, The futility of the clinical pulmonary infection score in trauma patients. J Trauma 2006; 60:523-7.
6. Dupont H, et al, Impact of appropriateness of initial antibiotic therapy on the outcome of ventilator associated
pneumonia. Intensive Care Med. 2001; 27:355-362.
7. Kollef MH. Antimicrobial therapy of ventilator-associated pneumonia: how to select an appropriate drug
regimen. Chest. 1999; 115:8-11.
8. Singh N, et al. Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive
care unit. Am J Respir Crit Care Med. 2000; 12:505-5111.
9. Bosman A, de Jong MB, Debeij J, et al. Systematic review and meta-analysis of antibiotic prophylaxis to prevent
infections from chest drains in blunt and penetrating thoracic injuries. Br J Surg. 2012 Apr; 99:506-13
10. Alleyne CH, Hassan M, Zabramski JM. “The efficacy and cost of prophylactic and periprocedural antibiotics in
patients with external ventricular drains” Neurosurgery 2000; 47(5): 1124-1127.
11. Ratilal BO, Costa J, Sampaio C, et al. Antibiotic prophylaxis for preventing meningitis in patients with basilar
skull fractures. Cochrane Database Sys Rev. 2011 Aug 10; (8):CD004884.

12. Hauser CJ, Adams CA Jr, Eachempati SR; Council of the Surgical Infection Society, Surgical Infection Society
guideline: prophylactic antibiotic use in open fractures: an evidence-based guideline. Surg Infect (Larchmt). 2006
Aug; 7(4):379-405.
13. The FLOW Investigators, A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds.
NEJM, 2015,
14. Andreasen JO, Jensen SS, Schwartz O, et al. A systematic review of prophylactic antibiotics in the surgical
treatment of maxillofacial fractures, J Oral Maxillofac Surg. 2006 Nov; 64:1664-8.
15. Schaller B, Soong PL, Zix J, et al. The role of postoperative prophylactic antibiotics in the treatment of facial
fractures: a randomized, double-blind, placebo-controlled pilot clinical study. Part 2: mandibular fractures in 59
patients. Br J Oral Maxillofac Surg. 2013 Dec; 51:803-7.
16. Zosa BM, Elliott CW, Kurlander DE, et al. Facing the facts on prophylactic antibiotics for facial fractures: 1 day
or less. J Trauma Acute Care Surg 2018;85:444-50.
17. Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-
associated pneumonia. 2016 clinical practice guidelines by the Infectious Disease Society of America and the
American Thoracic Society. Clin Infect Dis 2016 Sep 1;63(5):e61-111.
18. i Zalavras CG. Prevention of Infection in Open Fractures. Infect Dis Clin N Am 2017; 31: 339-352
19. ii Brophy RH, Bernholt DL. Aquatic Orthopaedic Injuries. JAAOS 2019; 27(6): 191-199.

DVT/PE Prophylaxis in Adults Following Multiple

Trauma
The National Institute of Health estimates that approximately 20% of multi-injured young
people develop DVT.1 All non-ambulatory trauma patients require prophylactic DVT
chemoprophylaxis. Low molecular weight heparin (LMWH) appears to offer a safer, more
effective means of protecting against DVT than unfractionated heparin2 LMWH is the
choice on the trauma service EXCEPT in renal failure (calculate creatinine clearance and
avoid in CrCl < 30mL/min. in elderly and patients with epidurals. Prior to anticoagulation,
the relative risk of DVT must be identified as greater than that of potential bleeding
complications. Absolute contraindications to anticoagulation include acute neurotrauma
(intracranial or intraspinal bleeding) as well as ongoing coagulopathy or bleeding with the
following recommendations:
• Stable intracranial bleed on head CT, start prophylaxis at 24 hours
• Definitive spine operation/ spine fracture, start prophylaxis in 24 hours
• Ongoing coagulopathy/bleeding at the discretion of the trauma attending
Prophylaxis Treatment
Preferred Enoxaparin 30 mg subQ Q12H Enoxaparin 1 mg/kg subQ Q12H
Alternate Heparin 5000 units subQ Q8H Heparin high dose drip
• Morbidly obese patients represent a challenge and are at even greater risk for
DVT. For those patients > 120kg, initiate Enoxaparin 40mg subQ Q12h. Consider
continuing DVT prophylaxis after discharge for 28-days in HIGH-RISK patients.
Obesity >120kg >150 kg

Prophylactic
Dosing
Heparin 7500 units SubQ Q8h 10000 units subQ Q8h
Enoxaparin 40mg SubQ Q12h 60mg SubQ Q12h and check antiXa level
4 hours post dose (goal 0.2-.4 units/mL)
Use of prophylactic IVC filters should be reserved for patients with multiple risk factors
(i.e., high risk patients) for whom an extended period of immobilization is anticipated, in
the event of failure of or contraindication to anti-coagulant therapy or in those subject to
repeated dose holds due to procedures.4 If not contraindicated, concomitant use of
anticoagulants following IVC filter insertion should be considered.5
1. Consensus Conference, National Institutes of Health: Prevention of venous thrombosis and pulmonary embolism.
JAMA 1986; 256:744.
2. Geerts WH, Jay RM, Code KI et al. A comparison of low-dose heparin with low molecular weight heparin as
prophylaxis against venous thromboembolism after major trauma. N England J Med 1996; 335:701-707.
3. Knudson MM, Lewis FR, Clinton A, et al. Prevention of venous thromboembolism in trauma patients. J Trauma
1994; 37: 480-487.
4. Greenfield LJ, Proctor MC, Rodriguez JL, et al. Post-trauma thromboembolism prophylaxis. J Trauma 1997; 42:
100-103.
5. Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena cava filters in the prevention of pulmonary
embolism in patients with proximal deep vein thrombosis. N England J Med 1998; 338:409-415

Enteral Access and Nutrition Policy in the ICU

Trauma patients are at risk of developing malnutrition. Delivery of adequate protein and
calories can be impeded by gastric ileus, resuscitation problems, need for vasopressor
support, altered mental status, anorexia, frequent procedures, or surgery. Early initiation of
nutrition may help blunt hyper-metabolism, preserve lean body mass, and reduce infections.
The plan for nutrition should be formulated on hospital day 2 and must be frequently
reassessed. Nutritional support should begin once resuscitation is complete. Most patients
can successfully be fed into the stomach. Initially, a concentrated tube feeding formula
should be used (adults). For patients with severe head injuries and facial fractures, or large
burns early PEG should be considered. If there is sub-optimal delivery or intolerance to
enteral nutrition, parenteral nutrition should be initiated. In all ICU patients, tube feeds
should be started by day 2 (unless clinically unstable) and if not adequate by day 5, TPN
should be initiated. Most trauma patients who can consume an oral diet should have
additional enteral supplements added to their diet. Geriatric patients nearly always benefit
from enteral supplements and often this can be a major source of their caloric intake during
their hospitalization. The Registered Clinical Dietitian helps formulate the nutritional care
plan for the patient and routinely monitors the tolerance and adequacy of the plan.
The following are strategies to help facilitate enteral access and continue feeding:
• Nutrition will be maintained in patients with protected airways (cuffed
endotracheal or tracheostomy) with the following guidelines
o Bedside interventions: CONTINUE feeds until the procedure
o Feedings will stop when patient is called to OR.
o When the feeds are stopped the following process will be completed
• The feeding tube will be flushed with water to prevent clogging.
• Placing an NGT/OGT to continuous low-wall suction will empty
the stomach.
• G-tubes and PEGs should be put to gravity drainage.
• Gastric decompression will continue throughout the procedure.
• Patients on continuous insulin infusions should have their insulin
infusion rates reduced or held and should be monitored closely for
hypoglycemia during the period when feedings are held.
• Feedings will resume post-procedure once the patient is hemo-
dynamically stable and/or the ICU team deems the patient ready.
• Enteral feeding is NOT contra-indicated in patients with open abdomen
• Enteral feeding is safe in patients weaning OFF pressors or when the initial
resuscitation is complete. Enteral feeding should NOT be done while on
Vasopressin or escalating pressors. If feedings are done on pressors, serial exams
are mandatory.
• Checking residuals reduces caloric intake and does not influence complication
rates.
• In the OR, placement of nasal jejunal tube is recommended if patient cannot
tolerate gastric feeds. Otherwise, a nasogastric tube is adequate to deliver enteral
nutrition.
• In order to limit use of central and peripheral IV access, conversion of all
medications from IV to enteral should be accomplished as soon as possible

1. Bosman A, de Jong MB, Debeij J, et al. Systematic review and meta-analysis of antibiotic prophylaxis to prevent
infections from chest drains in blunt and penetrating thoracic injuries. Br J Surg. 2012 Apr; 99:506-13
2. Alleyne CH, Hassan M, Zabramski JM. “The efficacy and cost of prophylactic and periprocedural antibiotics in
patients with external ventricular drains” Neurosurgery 2000; 47(5): 1124-1127.
3. Ratilal BO, Costa J, Sampaio C, et al. Antibiotic prophylaxis for preventing meningitis in patients with basilar
skull fractures. Cochrane Database Sys Rev. 2011 Aug 10; (8):CD004884.
4. Hauser CJ, Adams CA Jr, Eachempati SR; Council of the Surgical Infection Society, Surgical Infection Society
guideline: prophylactic antibiotic use in open fractures: an evidence-based guideline. Surg Infect (Larchmt). 2006
Aug; 7(4):379-405.
5. Andreasen JO, Jensen SS, Schwartz O, et al. A systematic review of prophylactic antibiotics in the surgical
treatment of maxillofacial fractures, J Oral Maxillofac Surg. 2006 Nov; 64:1664-8.
6. Schaller B, Soong PL, Zix J, et al. The role of postoperative prophylactic antibiotics in the treatment of facial
fractures: a randomized, double-blind, placebo-controlled pilot clinical study. Part 2: mandibular fractures in 59
patients. Br J Oral Maxillofac Surg. 2013 Dec; 51:803-7.

ICU Electrolyte Protocol

Electrolyte abnormalities are commonplace in ICU patients. Shifting electrolyte values are
due to changes in volume, drains, tubes, wounds, etc. but clinicians should always consider
that changes in electrolytes may represent a more serious medical condition and investigate
accordingly. The TICU will employ an electrolyte replacement protocol to achieve timely
repletion and reduction in nursing work. It is imperative that physicians are aware of
laboratory results and communicate frequently with the nursing staff to ensure safe manage-
ment of electrolytes. The protocol can be found on the intranet under Electrolyte Repletion
Protocol & ordered through LifeChart.
Intensive Care Unit Electrolyte Repletion Protocol

Intended for adult ICU patient with the following exclusion criteria
• Renal insufficiency (SCr >1.5 mg/dl, CKD ≥ III)
• Renal replacement therapy (any form of dialysis)
• Average urine output < 10 ml/hr. over the previous 4 hours (Oligo-anuria)
MAGNESIUM
Oral magnesium causes abdominal pain, cramps and diarrhea and oral repletion should be
AVOIDED.
RIH/TMH normal range: 1.3-1.9 mEq/L (Goal magnesium > 1.5 mEq/L)
Intravenous
Magnesium Dose Lab Monitoring
Access
Central or 2g magnesium sulfate IV
1.2-1.5 mEq/L
peripheral IV Recheck with routine
Central or 4g magnesium sulfate IV morning labs
< 1.1 mEq/L
peripheral IV 2g over 1 hour x 2 doses
PHOSPHATE
If patient requires phosphorus repletion (phosphorus <2.5 mg/dL) AND potassium repletion
(potassium <3.5 mEq/L), the following algorithm should be used to adjust potassium
repletion recommendations. While oral phosphate may be used to replete phosphorus in
patients on a diet or enteral nutrition, it is exceedingly slow to correct hypophosphatemia
and is best relegated to repleting minor deficiencies. Phosphate levels should be rechecked
with routine morning labs but consider obtaining a post-repletion level if phosphorus <1.5
mg/dL. Refer to the Electrolyte Repletion Protocol on the intranet for a phosphate repletion
algorithm; this can be located by searching “electrolyte repletion” on the upper right corner
Search tab on the Lifespan Intranet homepage.
POTASSIUM*
Select the concentration of potassium chloride that is appropriate for the patient’s venous
access. Central line preferred if available. Oral potassium should be selected if patient is
ordered for oral diet or enteral nutrition via gastric tube.
RIH/TMH normal range: 3.6-5.1 mEq/L (Goal potassium >3.5 mEq/L)

Intravenous Lab
Potassium Total Dose
access Monitoring
40 mEq potassium chloride IV
Choose one of the Central line 20mEq/50mL over 1 hour x 2
following: doses Recheck
3.1 to 3.5 40 mEq potassium chloride IV potassium
mEq/L Peripheral IV 10mEq/100mL over 1 hour x 4 with routine
doses morning labs.
60 mEq potassium chloride PO
Oral
20mEq every 2 hours x 3 doses
60 mEq potassium chloride IV
Choose one of the
Central line 20mEq/50mL over 1 hour x 3

Recheck
following:
doses
potassium
< 3.0 60 mEq potassium chloride IV
one hour after
mEq/L Peripheral IV 10mEq/100mL over 1 hour x 6
last dose is
doses
infused.
Not recommended as
Oral
monotherapy
*OnlyforpatientswhoareNOTreceivingpotassiumphosphate(seephosphatealgorithmforrecommendations)

Alcohol Withdrawal
While many believe that the incidence of alcohol abuse in trauma patients is near universal,
a large survey of trauma patients found only 0.8% developed Alcohol Withdrawal
Syndromes (AWS) during their hospital stay. Nonetheless trauma patients are at increased
risk of alcohol abuse compared to the general population and can present with many
conditions that mimic alcohol during their hospital stay. It is of the utmost importance to
keep the differential broad and to remember that the diagnosis of AWS is a diagnosis of
exclusion and all other causes of agitation, altered mental status, etc. must be ruled out.
Typical times for AWS findings to be observed following the last drink are as follows:
minor symptoms 6-36 hours, seizure 6-48 hours, hallucinations 12-48 hours, Delirium
Tremens (DT) 48-96 hours.
Supportive Care
The best predictor that a patient might develop AWS is a previous episode of alcohol
withdrawal. All patients in whom alcohol abuse is suspected should have their nutritional
(thiamine, folic acid) and electrolyte abnormalities corrected and should have an order for
CIWA-Ar protocol. Multivitamin, thiamine, and folate supplementation do not prevent
AWS but correct underlying nutritional deficiencies and should be discontinued after the
third day of supplementation (see Table 1 for dosing). Fluid resuscitation is important due
to the high prevalence of intravascular depletion among alcoholics. Electrolyte deficiencies
are common and require vigilant monitoring and replacement.
Table 1. Standard Dosing for Micronutrient Supplementation in Alcohol Withdrawal

Medication Indication Dose/Route
Acute Intoxication 200 mg IM or IV x 1 dose
Acute Repletion 100 mg PO or IV x 3 doses
Thiamine Suspected Wernicke’s 500 mg IV q8h x 6 doses,
Encephalopathy followed by 200 mg IV daily x
(i.e., ataxia, nystagmus, confusion) 5 doses
Folic Acid 1 mg PO or IV once daily x 3
doses
Acute Repletion
Multivitamin 1 tablet PO or 10 mL in 500
with minerals mL IVPB once daily x 3 doses
Screening
Prior to initiation of treatment of AWS, the AUDIT-C score should be reviewed and
patient should be discussed with the social worker/substance abuse practitioner. If they
are not following the patient, then consultation should be promptly obtained. Once AWS
occurs, early and frequent assessment of symptoms is necessary to avoid potential
complications such as seizures. The CIWA-Ar has not been validated in the critically ill
population but is commonly utilized for patients who are able to communicate. In patients
who are mechanically ventilated or unable to communicate, the use of a sedation scoring
tool such as the Richmond Agitation Sedation Scale (RASS) should be utilized to target
a RASS 0 to -2.

Treatment
Benzodiazepines
Treatment of AWS is best done in the ICU thus patients who are “scoring” on CIWA-Ar
(score > 8) and require benzodiazepines (BZD) should be transferred to the TICU. While
BZDs are the main treatment of AWS, it has been shown that protocolized dosing of these
leads to better outcomes. Symptom-triggered regimens are generally preferred over fixed
dose regimens as literature has consistently shown a lower total BZD requirement and
shorter duration of AWS with this strategy, including in critically ill patients. Older adults
are more sensitive to BZD, especially in combination with opioids, so lower BZD doses
may be needed for this patient population. Diazepam and lorazepam are preferred over
other BZDs such as midazolam due to their longer duration of action. Lorazepam may be
preferred in elderly patients or those patients with underlying hepatic insufficiency due to
its inactive metabolite vs. diazepam which has active metabolites with long half-lives.
Patients must be closely monitored for withdrawal symptoms as well as adverse effects
such as over-sedation and respiratory depression while receiving BZD therapy. After the
withdrawal period has concluded (approximately 96 hours), BZD therapy should be weaned
and ultimately discontinued to minimize the risk for delirium.
Table 2. Suggested Symptom-Triggered Benzodiazepine Dosing for Alcohol
Withdrawal
Diazepam Lorazepam
Loading Dose
Consider for patients with
10 mg PO or IV x 1 2 mg PO or IV x 1
history of withdrawal
seizures or DT
CIWA-Ar Score
5 mg PO or IV 1 mg PO or IV
9-14 (mild to moderate)
Reassess CIWA-Ar every 2 hours
15-19 (moderate)
20 or greater (severe)
If patient is mechanically ventilated, consider propofol or midazolam as first choice of
sedative agent and titrate to RASS 0 to -2.
Standing benzodiazepine orders for AWS should not be ordered for patients outside
the ICU. Prior to transfer out of ICU, remove all standing benzodiazepine orders, and
review treatment plan for AWS with the floor team.
Dexmedetomidine
In the ICU, dexmedetomidine may be beneficial in the treatment of AWS by reducing the
autonomic hyperactivity and controlling the sympathetic symptoms such as tremor,
hypertension, and tachycardia without causing respiratory depression. However, it has no
GABA activity and therefore does not directly treat an underlying mechanism of AWS.
Therefore, it should be used as an adjunct with BZD and not in place of BZD treatment.
Dexmedetomidine has the added benefit of reducing the total amount of BZDs required and
may help prevent the need for intubation. Limiting the amount of BZD administered is
desirable since this can improve pulmonary toilet, lessen the risk of delirium, respiratory
depression, etc.

Clonidine
Clonidine works through a similar mechanism to dexmedetomidine and may be used as an
oral option when weaning off a dexmedetomidine infusion. Like dexmedetomidine, it has
no GABA activity and therefore does not directly treat an underlying mechanism of AWS.
Therefore, it should be used as an adjunct with BZDs and not in place of BZD treatment.
Clonidine may also be useful if concomitant opioid withdrawal is also a concern. Consider
clonidine 0.1 mg po/enterally q8h in patients receiving < 0.7 mcg/kg/hr. of dexmedetomi-
dine and clonidine 0.2 mg po/enterally q8h in patients receiving > 0.7 mcg/kg/hr. of
dexmedetomidine to facilitate weaning. Patients receiving either clonidine or dexmedetomi-
dine for > 7 days should be weaned off over a course of 5-7 days to prevent reflex
tachycardia and hypertension. Caution use in patients who are bradycardic, hypotensive, or
who have significant cardiovascular disease.
Propranolol
Beta-blockers, such as propranolol, can be used to treat the hyperadrenergic state of alcohol
withdrawal. Although these medications may correct some of the autonomic manifestations
of withdrawal, they have not been demonstrated to have any effect on seizures or DT and
they should be used only in conjunction with benzodiazepines in the treatment of alcohol
withdrawal. In patients who are beta-blocker naïve, consider starting with a lower dose such
as propranolol 10 mg PO/enterally q6h and titrating up as necessary. The IV dosage form
is extremely short acting and should not be routinely used. Caution use in patients who are
bradycardic, hypotensive or have underlying conditions such as asthma or hyperthyroidism.
Barbiturates
Due to its long duration of action, phenobarbital has a low addiction potential compared to
other barbiturates and therefore has been the most commonly utilized barbiturate for the
treatment of AWS. In the ICU setting, for patients requiring escalating doses of BZDs to
alleviate severe withdrawal and DT, barbiturates have proven to be beneficial. Based on
current literature, phenobarbital’s role in therapy appears to be as a second-line option for
patients who are unresponsive to large doses of BZDs. It does not appear to offer any
advantage over BZDs as an alternative. Over-sedation and respiratory depression are
concerns with phenobarbital, similar to BZDs. Patients admitted to the TICU are generally
responsive to BZD therapy and phenobarbital is therefore not needed in this patient
population.
1. Jawa, et al. Alcohol Withdrawal Syndrome in the Admitted Trauma Patients. Am J Surg, 2008 (5), 781-7.
2. Bielka, K, et al. Addition of dexmedetomidine to benzodiazepines for patients with alcohol withdrawal syndrome
in the intensive care unit: a randomized controlled study. Ann Intensive Care 5(1):33.
3. Duby, et al. Alcohol withdrawal syndrome in critically ill patients: protocolized versus nonprotocoloized
management. JOT 77(6) 938-43.
4. Management of acute alcohol withdrawal syndrome in critically ill patients. Pharmacotherapy 2016;36(7):797-
822.

Rhabdomyolysis, Crush Injury and Compartment

Syndrome
Rhabdomyolysis is the breakdown of damaged muscle fibers. Etiologies include:
• Direct trauma & Crush injury (including “found down,” intoxication, narcotic
overdose)
• Ischemia-reperfusion injury (including exertion, exercise & seizure)
• Compartment syndrome
• Electrical injury
Muscle injury is initially local but may progress to systemic effects. The magnitude of
systemic response is related to the mass of muscle affected. Crush injury, compartment
syndrome and ischemia-reperfusion injury are distinct but synergistic pathologies.
Ischemia-reperfusion injury
Ischemia reperfusion injury is the inflammatory response following restoration of blood
flow to acutely ischemic tissue. Neutrophil activation and reactive oxygen species (ROS)
lead to cell death, capillary leak, and systemic inflammation. Profound edema following
reperfusion can lead to compartment syndrome after revascularization of acutely ischemic
limbs.
Crush injury (“Found down”)

Crush injury is muscle damage caused by external compression. Direct trauma destroys
muscle by stretching or tearing the myofibrils while compression of blood flow causes
ischemia and myonecrosis. After release of compression and restoration of circulation,
reperfusion injury results in further cell lysis and muscle death and causes synergistic
damage. Metabolic changes include hyperkalemia, hypocalcemia, hyponatremia, and
hypovolemia. Crush injury may present with “soft” compartments. Limbs crushed
for >12 hours are usually beyond salvage.
Compartment syndrome
Increased pressure within a closed fascial space causes compartment syndrome. Etiologies
include hemorrhage, edema, or ischemia-reperfusion injury. Internal compression results in
microvascular compromise, tissue ischemia and nerve damage. Compartment syndrome is
associated with the 5 P’s (pain out of proportion to exam or pain on passive stretch, pallor,
paralysis, paresthesias, and pulselessness) however irreversible nerve damage occurs long
before loss of pulse. Compartment pressures  30 mmHg cause critical ischemia and
demand urgent decompression to preserve function, however clinical suspicion drives
intervention. When in doubt Stryker the compartment and err on the side of
aggressive intervention in the setting of equivocal pressures.
Systemic manifestations of rhabdomyolysis

• Shock: Sequestration of fluid in muscle & 3rd spacing causes hypovolemic shock.
Release of inflammatory mediators causes distributive shock. May need both volume
& pressors.
• Cardiac: Hyperkalemia and hypocalcemia provoke arrhythmias. Decreased inotropy
and vascular tone are due to hypocalcemia. Sudden cardiovascular collapse may
occur when cold, acidotic & hyperkalemic blood washes back into circulation.

• Pulmonary: Systemic inflammation causes capillary leak, pulmonary edema &

ARDS
• Renal: Up to one half of patients with rhabdomyolysis develop acute kidney injury.1
Rhabdomyolysis is a pre-renal state and the initial insult is caused by decreased
circulating volume. Myoglobin from lysed muscle cells is nephrotoxic causing both
renal vasoconstriction and precipitates in the acidic environment of the tubules.
Occult rhabdomyolysis
Muscle damage is not always clinically obvious and delay in diagnosis can lead to
significant myonecrosis, renal failure, superinfection, and death. Several scenarios warrant a
high index of suspicion, especially in patients whose clinical deterioration is unexplained:
• Secondary extremity compartment syndrome: Like abdominal compartment
syndrome, this complication is associated with massive resuscitation. Incidence is
rare (<0.2% of trauma admissions), but the mortality rate is 35-70%.2 Patients who
receive massive resuscitation (> 10L or >6 units of blood products in 12 hours)
AND who are intubated, chemically paralyzed or have a GCS that precludes
reliable exam should be screened with serial Creatinine Kinase (CKs) levels
every 6 hours. Elevated values mandate Stryker measurement of uninjured
extremities in order to detect occult compartment syndromes.
• Gluteal compartment syndrome: Uncommon except after prolonged immobility such
as intoxication. The large mass of muscle increases risk of systemic effects.
• Obesity: Increased body mass requires shorter compression time to cause ischemia.
• Postoperative rhabdomyolysis: Operative immobilization, particularly with spine
surgery, as well as prolonged operative time and obesity are risk factors.
Diagnosis
• Requires a high index of suspicion based on clinical context.
• Physical exam: Unreliable, with a sensitivity as low as 13-19%3 and worse in
sedated or altered patients. Myonecrosis or compartment syndrome can exist in the
presence of intact pulses and/or soft compartments.
• Compartment pressures: Absolute pressures ≥30 mmHg measured by Stryker
require emergent fasciotomy. Crush injury can cause muscle damage with
normal pressures.
• Creatinine kinase: Rises 12 hours after injury and peaks at 1-3 days. CK >5,000 U/L
increases risk of AKI.
• Myoglobinuria: Grossly tea-colored urine. Urinalysis shows heme pigment with no
RBCs. “Large blood, no cells”
Management
• Fluid resuscitation: Crystalloid. Goal urine output 200 cc/hr. until CK drops below
5,000. Alkalinization of the urine & mannitol do not improve mortality or need for
dialysis.4
• Foley catheter: Monitor urine output and pigmenturia
• EKG & telemetry: Assess peaked T waves and arrhythmias.
• Labs: Chem-7, creatinine kinase (CK)
• Electrolyte management: Correct hyperkalemia and hypocalcemia
• Dialysis: May be indicated in setting of acute renal failure
• Antibiotics: Tetanus prophylaxis. Clean wounds do not require prophylactic
antibiotics.

• Surgery: Compartment syndrome requires emergent fasciotomy. Crush injury

requires serial debridement of dead muscle. The decision to operate is a clinical
one, and the bias should be towards early operation.
Anterior
Posterior tibial
1. Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med. 2009;361(1):62-72.
2. Goaley TJ, Jr., Wyrzykowski AD, MacLeod JB, et al. Can secondary extremity compartment syndrome be
diagnosed earlier? American journal of surgery. 2007;194(6):724-726; discussion 726-727.
3. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the
disorder? J Orthop Trauma. 2002;16(8):572-577.
4. Scharman EJ, Troutman WG. Prevention of kidney injury following rhabdomyolysis: a systematic review. Ann
Pharmacother. 2013;47(1):90-105.

TICU Bedside Surgery Protocol

Occasionally it is necessary to perform bedside surgery in the ICU. Generally, patients who
require operative intervention should be transported to the operating room; however, in
extreme circumstances this may be impossible. Ultimately the decision to perform bedside
surgery should be made by the Trauma Attending. This protocol is designed to cover true
operative interventions in the ICU, and it is not the intention of this policy to supersede
clinical practice that is well established governing the performance of bedside procedures.
In this regard, open abdomens with a temporary abdominal closure consisting of a wound
vac may be changed in the ICU. The indications for bedside surgery in the ICU include:
• Decompressive laparotomy or exploratory laparotomy in patients having significant
ventilatory requirements or hemodynamic instability that prohibits safe travel to the
operating room.
• Any necessary operative intervention in a patient having a condition or equipment
that precludes safe transport, (e.g., Gardner-Wells tongs).
• Burn escharotomies, fasciotomies, open fracture washouts, etc. (in patients whose
clinical status makes transport to the OR unsafe or unwise.)
Once the decision has been made to perform bedside surgery several steps need to happen
in a rapid fashion.
1. The clinical manager (or designee) of the ICU should be notified as should the ICU
charge nurse. Some reassignments of patient care duties may be necessary because
the bedside nurse will be now on a one-to-one basis with the patient undergoing the
operative procedure. After hours the nursing supervisor MUST be notified.
2. If the Trauma Attending determines that the operative intervention requires additional
equipment, supplies, etc. then the OR control desk (4-5657) should be contacted, and
the case booked with the control desk. If the OR has available staff, they may be able
to come to the bedside and assist, but this will not always be possible.
3. The ICU should be cleared of visitors and locked. The room where the procedure is to
take place should be emptied of all extraneous supplies to create as much space as
possible as well as limit the amount of equipment exposed to body fluids.
4. Respiratory therapy should be notified that the patient will be undergoing a bedside
procedure and that they may need to be present for the entire performance of the bed-
side surgical procedure.
5. Informed consent should be obtained from the family otherwise the Trauma Attending
must write a note, documenting the need for urgent intervention.
6. From this point on a sterile parameter should be observed around the patient’s room.
All individuals entering the room should have full surgical attire. Strict hand hygiene
should be observed as well.
7. The personnel in the room must be limited to those directly involved in the care of the
patient and the number of non-essential personnel should be minimized.
For true bedside surgical procedures and not for routine ICU procedures, such as
tracheostomy, central line, tube thoracostomy, etc. a second ICU Critical Care attending
should be requested to assist managing the patient (oversee the analgesic, sedative, muscle
relaxants, resuscitation, hemodynamic monitoring, etc.), however the absence of the 2 nd
provider should not hold up the emergent procedure.

For documentation purposes a conscious sedation sheet should be utilized in addition to

routine patient monitoring and charting. If a new surgical wound is to be created, the
patient should receive appropriate antibiotic skin prophylaxis.
In cases where a second surgical attending is not available, the OR control desk should be
contacted, and a request made for an Anesthesia provider to be present. In those situations
when a second provider (Surgeon or anesthesia) cannot be present, the bedside nurse will
continue functioning in the role of monitoring the patient’s vital signs and hemodynamics,
and will also be the one who administers narcotics, anxiolytics, and paralytics on an as
needed basis at the direction of a physician or LIP, typically the senior most member of
the surgical house staff available (i.e., Chief resident).
FOR LAPAROTOMIES/ OTHER MAJOR PROCEDURES (WITHOUT OR STAFF

ASSISTANCE):
1. As stated previously a sterile parameter should be observed around the patient’s room,
all individual entering the room should have a head covering, surgical mask, and eye
protection.
2. Preoperative sterile hand wash should be performed either using a chlorhexidine wash,
generous amounts of Avagard® or Purell®.
3. Members of the surgical team should be cognizant of the tight quarters, unfamiliar
setting, etc. and should be extra cautious to maintain sterility and avoid contamination
at all times.
4. Patients should be prepared with ChloraPrep® if a fresh surgical wound is to be made,
Hibiclens® for open abdomens and as a last choice, Betadine®.
5. The patient’s room should have a fresh, empty suction canister and additional suction
canisters and tubing should be readily available should this become full.
6. Warm sterile saline can be obtained from the OR. In general, limit irrigation during
bedside surgery in the ICU to minimize the creation of potential biohazardous waste.
7. The Universal Protocol should all occur in accordance with existing RIH policy.
8. Only gauze and sponges with a radio-opaque marker should be used in a patient with an
open abdomen. RIH policy on Surgical Counts should be observed. Dressing material
without a radio-opaque marker should never be packed into an abdomen or body cavity.
9. If an abdomen is to be closed (primarily or with mesh) at the bedside, then x-rays of
the ENTIRE abdomen must be obtained to exclude retained foreign bodies. X-rays are
needed irrespective of surgical counts, etc. These films will need to be discussed with
the Attending radiologist and documented in the medical record in accordance with
RIH policy.

Geriatric Trauma
Geriatric patients are defined as individuals aged 65 years and older. Super-elderly patients
are those aged 80 years and older. Although increasing age correlates with increased risk of
mortality, physiological reserve is more predictive of geriatric trauma outcomes. Elderly
individuals are at increased risk for trauma from an increasingly active lifestyle in the
setting of declining motor and cognitive functions. Minor mechanisms, such as fall from
standing, can lead to major injury patterns (pelvic fracture or TBI) equivalent to high energy
mechanism in young patients. 30% of geriatric individuals fall annually with an estimated
risk of death of 5-10% among those that require hospital admission.
Initial presentation and diagnostic challenges – Mechanisms and vital signs may be
unreliable in Geriatric patients
• Geriatric patients often fail to develop a tachycardic response, masking shock Class II
shock.
• The effects of hypotension upon mortality are seen at systolic BP of 110mmHg in
elderly patients.
• Intubations are more difficult due to kyphosis, spondylolysis or arthritic spine changes
and dentures may obstruct the airway.
• Geriatric patients are more susceptible to the effects of etomidate, have limited
pulmonary reserve, diminished inspiratory and expiratory force and are more likely to
decompensate during an intubation compared to younger patients.
• Fluid resuscitation should not be withheld based on age alone. Under-resuscitation is
often more lethal than over resuscitation and is considerably more difficult to reverse.
• Even mild under-resuscitation in geriatric patients can rapidly progress to irreversible
shock and end organ failure. Renal failure, often due to inadequate resuscitation, is a
leading cause of ICU related mortality in geriatric trauma patients.
• CT scanning follows the same guidelines of younger patients. Use IV contrast, even if
chronic renal failure. Non-contrast CTs miss blushes, signs of bowel injury, some organ
injuries.
The BEERS Criteria (https://www.ncbi.nlm.nih.gov/pubmed/26446832) comprise medications
or classes of medications which are potentially inappropriate in the older patient.
• One in 6 geriatric patients, across all medical disciplines, experience serious side effects
directly related to medications.
• The 2019 Beers Criteria include medications to be avoided or dosed differently in patients
with altered renal function.
• Creatinine is often an unreliable indicator of true renal function in elderly patients. When in
doubt about true renal function, calculate creatinine clearance via the Cockcroft Gault
equation.
• The 2019 Beers criteria also included combinations of medications that are noted to be major
risk factors for falls, fractures and/or urinary incontinence.
Disposition
Following admission, elderly patients suffer accelerated deterioration in mental and
physical reserve unmasking baseline malnutrition, loss of muscle mass, dysphagia, or
depression. PT, OT, case management, Geriatrics, and the patient’s family are all essential
for optimizing disposition. Geriatric patients are forced to face the reality that trauma
admission is a sentinel event signifying the end of their ability to live independently; the
need for assisted living or a nursing home; or the ability to drive.

End of life
It is important to keep the focus on what the patient would want, not what the family would
want, especially if custodial care, tracheostomy and feeding tubes are required. Multi-
disciplinary discussions should be held early and often with the patient and their relatives to
establish realistic expectations. The concept of “futility” must be viewed through the prism
of the patient’s wishes so that while medically acceptable outcomes may be achievable, the
patient’s expectations may not be obtainable and these incongruencies must be addressed
and respected.
Within 24 hours:
- A health care proxy should be located
- Obtain advance directive documents
- Perform a prognostication assessment
- Provide emotional and informational support to the family and patient
- Address urgent and focused advanced care planning
- Screen for further palliative care needs
1. Heffernan DS, Thakkar RK, Monaghan SF, et al. Normal presenting vital signs are unreliable in geriatric blunt trauma
victims. J Trauma. 2010 Oct; 69:813-20.
2. Inouye SK, Studenski, S, Tinetti ME et al. Geriatric syndromes: clinical, research and policy implications of a core geriatric
concept. J Am Geriatr Soc 2007; 55(5): 780-791
3. Hranjec T, Sawyer RG, Young JS, et al. Mortality factors in geriatric blunt trauma patients: creation of a highly predictive
statistical model for mortality using 50,765 consecutive elderly trauma admissions from the National Sample Project. Am
Surg. 2012 Dec; 78:1369-75
4. Joseph B, Pandit V, Rhee P, et al. Predicting hospital discharge disposition in geriatric trauma patients: Is frailty the answer? J
Trauma Acute Care Surg. 2014 Jan; 76:196-200.
5. Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol 2009;
5(4):210-220
6. Steinman MA, Beizer JL, DuBeau CE et al. How to use the American Geriatrics Society 2015 Beers criteria – a guide for
patients, clinicians, health systems and payors.” J Am Geriatrics Soc 2015; 63(12); e1-e7

Trauma in Pregnancy
Roughly 1 in 12 pregnant women will experience a traumatic injury; two-thirds are injured
in MVCs, falls and assaults. Up to 20% of pregnant women are victims of domestic
violence and 50%-80% of domestic abuse occurs for the first time during pregnancy.
Trauma is the leading cause of non-obstetrical maternal death. Life threatening maternal
trauma is associated with 50% fetal loss rate; less severe injuries still have fetal loss rates
of up to 5%. Since minor injuries are much more common, most fetal losses result from
relatively minor maternal injuries. Thus, special attention must be paid to the pregnant
trauma patient, with a coordinated effort among emergency physicians, trauma surgeons,
obstetricians, and sometimes neonatologists. The highest priority in caring for a
pregnant trauma patient is to evaluate and stabilize the mother. Losing sight of this
jeopardizes both mother and fetus.
Initial Management
AIRWAY - Special concerns for a pregnant patient’s airway include the increased risk for
aspiration due to decreased GI motility and upward displacement of the stomach coupled
with a higher rate of failed intubation. All airways in pregnant patients should be considered
potentially difficult and appropriate help should be called for from the outset.
BREATHING - The fetal 02-hemoglobin dissociation curve is shifted to the left, so
minimal decreases in maternal Sa02 can significantly compromise fetal oxygenation. Avoid
hypoxemia!
CIRCULATION - Physiologic changes in pregnancy (30-50% increase in blood volume,
peripheral vasodilation) may result in delayed manifestation of shock. Supine positioning
may lead to hypotension as the gravid uterus compresses the IVC. This can be avoided by
positioning the mother’s right hip on a bump to displace the uterus.
Determination of Fetal Viability

Gestational age may be estimated by assessing uterine fundal height; if it is below the
umbilicus, the fetus is probably 20 weeks or less and is not viable. The survival of a
neonate delivered at 21 weeks is 0%; at 25 weeks it is 75%. Difficult decisions must be
made between 22 and 25 weeks and even if the fetus survives, long term morbidity is
common. 50% of surviving newborns delivered at 25 weeks or less have disabilities in
psychomotor development, neuromotor and/or sensory/communication function, with
one-quarter having severe deficits if delivered at 30 weeks of life. Pre-delivery decisions
about neonatal management may be altered depending on post-natal age assessment,
condition of the neonate at birth, and the newborn’s response to resuscitation. Counseling
of parents and documentation of decision-making is CRITICAL!
Obtaining an Obstetrical Consult

All pregnant patients with >20-week gestation who suffer trauma should have a physician-
to-physician discussion with Maternal Fetal Medicine (MFM). A quick physician-to-
physician discussion can determine patient acuity and the need for further obstetrical care.
Patients will most likely need cardiotocographic monitoring for a minimum of 6 hours.
Monitoring should be continued for a longer period if there are any concerning findings.
Ideally, a Kleihauer-Betke analysis should be performed in all pregnant patients >12-week
gestation to assess for fetal erythrocytes in the mother’s circulation. The first priority is to
stabilize the mother, but a timely OB consult should be a high priority. If an obstetric/
gynecological intervention is required, the trauma attending must be notified.

MFM Direct number: 401-430-4780, Indirect number: 401-274-1122 ext. 44780

Alternatively, call W&I main number: 401-274-1100 and ask for ext. 44780
Patients with <20-week gestation who are admitted to RIH following trauma, should have
a daily Doppler fetal heart documented by the trauma team.
Diagnostic Testing
Ultimately, the fetus is at highest risk of mortality if there is unnecessary delay in diagnosis
of the maternal injuries, sometimes even after relatively “minor” trauma. Thus, failure to
undertake the appropriate imaging of the mother places the fetus at an unacceptably high
risk. The critical concept that needs to be applied regarding the pregnant woman is to treat
and work up the patient as though she was not pregnant. Ultrasound cannot supplant the
appropriate use of CT scans. There are no documented adverse fetal effects of MRI, but it is
arbitrarily recommended to avoid MRI in the first trimester. MRI carries a significant time
burden and is CONTRAINIDICATED in working up a severely injured pregnant patient.
If CTs are going to be obtained, plain films of the chest and pelvis may be omitted at the
discretion of the trauma attending in order to minimize fetal radiation however maternal
health should never be jeopardized in order to achieve this goal. The rate of childhood
leukemia increases from 1/3000 (background) to 1/2000 among children exposed in utero
to ionizing radiation, with the greatest risk of anomalies during organogenesis in the first
trimester. However, total exposure of less than 5 rads has never been associated with
anomalies, growth restriction, or spontaneous abortions. A pan-CT scan does not
exceed 5 rads and provides a substantially larger amount of information compared to plain
films. Frequently, the most practical way to avoid unnecessary radiation is to obtain a pan-
CT at the initial testing to avoid the possibility of having to repeat plain imaging later.
The American College of Obstetricians and Gynecologists’ committee opinion, which

has been endorsed by the American College of Radiology, states that concern about
possible effects of radiation exposure should not prevent medically indicated
diagnostic x-rays or CT scans from being performed on the mother.
Should a pregnant patient require diagnostic imaging, the radiology department routinely
calculates the exact radiation dose for that patient and fetus and places this in the medical
record.
Blunt trauma may cause fetal death by maternal loss of life or direct fetal injury. Over
50% of fetal losses are due to placental abruption, typically occurring within 6 hours of
the event. The classic triad of frequent contractions, vaginal bleeding and abdominal pain
occurs in fewer than half of cases, and ultrasound will identify placental clot only 50% of
the time. Thus, the only clues to abruption may be contractions and abnormal fetal heart
tracings. Up to 2 L of blood can be sequestered retro-placentally, so if the mother is
hypotensive without an obvious source of hemorrhage, abruption MUST be considered.
Uterine rupture is not common and can be difficult to diagnose. The classic presentation is
searing pain, abnormal fetal heart rate and trans-abdominal palpation of fetal parts. The
mother may rapidly deteriorate due to hemorrhage, and there is a very high fetal loss rate.
Fetal-maternal hemorrhage, defined by the presence of fetal blood cells in the maternal
circulation, can lead to fetal anemia and fetal compromise. Exposure of a Rh(-) mother to
fetal Rh(+) erythrocytes can stimulate the mother’s immune system to make immune
globulins against Rh(+) blood cells. In subsequent pregnancies, an Rh(+) fetus can suffer
hemolysis and possible fetal death.

To avoid this potential complication, all pregnant trauma patients with Rh(-) blood type
should receive a vial of Rh immune globulin (RhoGAM) within 72 hours of the incident.
The amount of blood exchanged can be estimated by the Kleihauer-Betke (KB) test, which
is performed on maternal blood. Although the amount of blood exchange does not
accurately predict fetal prognosis, additional vials of RhoGAM must be administered when
there has been >30 ml hemorrhage.
Penetrating trauma is associated with relatively high fetal loss rates due to umbilical cord,
placental, or fetal trauma. Cesarean section is frequently necessary. The distended uterus
may shield the maternal viscera and it displaces the bowels superiorly.
Burns over 40 -50% BSA correlates with very poor fetal survival, prompting some to
recommend Cesarean Section.
Electrical injuries have not been well studied. The link between minor household electrical
shocks and stillbirths is unclear, but fetal mortality is as high as 50-75% following
significant electrical injury such as a lightning strike. Early fetal heart monitoring should be
considered.
Surgery on the Pregnant Patient

General anesthesia has not been linked with any specific problems. It is important to
maintain uterine perfusion by maintaining high maternal Sa02, adequate fluid resuscitation,
operating in the left uterine displacement position, and avoiding vasopressors whenever
possible. Fetal heart monitoring can be performed during surgery by placing the monitor in
a sterile sleeve.
Peri-mortem Cesarean Section

Once there is maternal loss of vital signs there should be an immediate consideration for the
performance of an ED Thoracotomy, Cesarean section if the fetus is viable, or both. C-
section is necessary for both maternal resuscitation and fetal survival. This data is based on
THREE patients in the largest series. Survival is optimized if performed within 4 minutes.
If the fetus is delivered >15 min after maternal death, fetal survival is only 5% and most of
those survivors have severe neurological sequelae.
Disposition
If a pregnant patient <22 weeks gestation has been evaluated, treated and is ready for
discharge, she should be instructed to contact her obstetrician within 24 hours for a follow-
up appointment. She should also be instructed to call if she develops any lower abdominal
pain, bleeding, fluid loss, or a decrease in fetal movement. If a pregnant patient with a
viable fetus has been stabilized, she should undergo fetal monitoring for 4-6 hours for
minor trauma, and at least 24 hours for major trauma. If the mother is stable for discharge
from RIH, the fetal monitoring can be done at W&I. In general, local anesthetics,
acetaminophen, and narcotics can be used when indicated but NSAIDS, tetracyclines and
quinolones should be avoided.
1. Practice Management Guidelines for the Diagnosis and Management of Injury in the Pregnant Patient: The
EAST Practice Management Guidelines Work Group. J Trauma. 2010;69;211-14.
2. ACOG Committee Opinion. Guidelines for Diagnostic Imaging During Pregnancy and Lactation. Number 656.
February 2016.
3. Mendez-Figueroa et al. Trauma in pregnancy: an updated systematic review. Am J Obstet Gynecol. 2013; 209:
1-10.

Diagnosis of Brain Death: Adult & Pediatric

Adult Patients:
REFER TO THE RIH POLICY (ADMIN-66) on the Lifespan Intranet, “Brain Death
Diagnosis in Adults”).
Pediatric Patients:
REFER TO THE RIH/HASBRO POLICY (ADMIN-116) on the Lifespan Intranet,
“Death in Children Based on Neurological Criteria (Determination of)”.

Speech Language Pathology Services

Traumatic injuries may lead to short or long-term loss of ability to speak/communicate,
therefore referral to a speech-language pathologist (SLP) is indicated to evaluate for the
need and type of augmentative communication (communication board or electronic device),
Passy-Muir speaking valve, or speech therapy. Head trauma can also lead to cognitive
impairments (attention, memory) and/or aphasia in which case a speech pathologist may
perform a cognitive/linguistic evaluation. Long term intubation, tracheostomy, and long
term use of nasal tubes can all have a negative effect on swallowing function and may
warrant SLP evaluation.
Geriatric patients, especially those in cervical collars/Halo vests, are at exceedingly high
risk for aspiration and should always be evaluated for swallowing dysfunction. It is not
uncommon that geriatric patients have been aspirating before their trauma admission,
but that it is not recognized until they encounter the health-care team. In these cases,
communication regarding the patients and family’s wishes should occur BEFORE SLP
consultation and be documented in the medical record. It is not uncommon that these
patients (families) will accept the risk of aspiration rather than undergo enteral access
procedures. The concept of “eat for comfort” should be introduced and is often linked to
a discussion of code status and role of intubation.
ASSESSMENTS:
Speech-Language Pathology/ Feeding/Swallow Evaluation
Clinical Swallow Evaluation
Patient is seen at bedside. A comprehensive swallowing evaluation is completed which
includes an oromotor examination and administration of food and liquid consistencies.
Based upon this assessment recommendations may be made for treatment and additional
testing.
Communication Evaluation
Voice, speech and language, and cognition are assessed. Recommendation regarding type
of treatment or any additional assessment, which may include Passy-Muir valve evaluation,
augmentative communication evaluation/treatment, videostroboscopy or clinical voice
evaluation/treatment, will be made.
Modified Barium Swallow (MBS)

Examination is completed in the radiology department(s) along with a radiologist. Patient
is seated upright and administered trials of various consistencies and is viewed under
fluoroscopy. Evaluation is made of the oral phase and pharyngeal phases of the swallow.
The pharyngeal phase of the swallow is assessed with regard to timeliness of the swallow,
residue in the pharynx, symmetry of pooling/residue, premature spillage of bolus, number
of swallows per bolus, presence or absence of laryngeal penetration, presence or absence
of aspiration, patient response to laryngeal penetration or aspiration. Based on the exami-
nation, recommendations are made by the SLP regarding dietary textures, swallowing
strategies, treatment, and further testing. MBS is indicated to objectively assess the
oropharyngeal swallowing mechanism and to assess for aspiration/risk of aspiration.

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

A speech language pathologist completes examination at bedside. A flexible fiberoptic
scope is placed into the patient’s nose and advanced to the level of the pharynx in order to
assess structure and function. The patient is presented with trial of food and liquid of
various consistencies. The pharyngeal phase of the swallow is assessed with regard to
timeliness of the swallow, residue in the pharynx, symmetry of pooling/residue, premature
spillage of bolus, number of swallows per bolus, presence or absence of laryngeal
penetration, presence or absence of aspiration, patient response to laryngeal penetration or
aspiration. Based on the examination, recommendations are made by the SLP regarding
dietary textures, swallowing strategies, treatment, and further testing. FEES is indicated
to assess the pharyngeal swallow phase and to assess for aspiration/risk of aspiration and
may also be recommended when positioning in or transport to radiology may be
problematic, for assessment laryngeal competence (post-intubation, tracheostomy), or
assessment of secretion management.
Videostroboscopy/Comprehensive Voice Assessment

A speech language pathologist completes examination in the videostroboscopy room on
COOP-1. The examination is reviewed with an Otolaryngologist. A rigid scope is placed
into the oral cavity to the level of the pharynx. If the patient is unable to tolerate the rigid
scope orally, a flexible scope may be used nasally. The larynx is viewed under a constant
and a stroboscopic light source. A comprehensive assessment of the laryngeal structures
and function is completed. Based on the examination, recommendations are made by the
speech language pathologist and Otolaryngologist regarding further testing and treatment.
The Otolaryngologist may also suggest other medical or surgical intervention as indicated.
Videostroboscopy is indicated when there is concern for laryngeal pathology. Video-
stroboscopy allows for more detailed evaluation of the larynx/vocal folds but not
swallowing.
Treatment/Therapy
Based upon the results of the evaluations that have been completed, treatment goals will be
established by the SLP to address voice, swallowing, communication, and cognition/
language as indicated.

Reporting Abuse and Neglect

All care providers share the responsibility to report known or suspected abuse in cases
involving special populations. This function is just as critical and potentially life-saving as
any traumatic injury and must be approached with the same care and dedication. All care
providers are considered Mandatory Reporters in cases of abuse or neglect involving
children, the elderly and in adults with impairments. Unfortunately reporting of domestic
violence is NOT considered mandatorily reportable, and reporting is a HIPAA violation.
Be sure to consult social work for assistance.
Elderly
All patient care providers are considered mandated reporters of elder abuse, adults Age 60
and over.
When to suspect elder abuse:
1. Multiple or repeat injuries, injuries in various stages of healing
2. Non-consensual sexual contact, threat of sexual violence
3. Contracture, decubitus ulcers, dehydration, malnutrition, poor hygiene, urine burns.
Inappropriate or haphazard administration of medications or medical treatment
4. Elder left in unsafe environment, caretaker willingly fails to provide appropriate
care
5. Improper or unauthorized use of elder’s assets or belongings, undue influence over
elder’s finances
6. Emotional threats, intimidation, isolation, or other abusive conduct towards the elder
7. Self-neglect
Procedure for patients living in the community:

1. Consult social work for assistance.
2. Initiate mandated report to the Office of Healthy Aging at
https://fw1.harmonyis.net/RILiveIntake/ or the Office of Healthy Aging Hotline
(462-0555) or fax DEA Referral Form to 462-0545. This form can be obtained from
Social Work. The DEA Referral Form should also be returned or faxed (444-5715)
to Social Work to be maintained in a confidential file.
3. Contact Police Department of the town where the alleged incident occurred.
Procedure for patient living in a facility (includes hospitals, nursing home, assisted
living facility, home care or home nursing care provider, or a group home):
2. Initiate mandated report to the Rhode Island Department of Health, Facilities
Regulation Division at 222-5200 within 24 hours.
3. A written report should be faxed to 222-3900 or 222-5901. The same report should
be faxed to social work (444-5715) to be maintained in a confidential file.
4. If the abuse/neglect occurred at RIH/HCH, contact Risk Management at 444-8265
or by paging the Risk Manager on call. A Safety Net should be filed as well if
incident occurred at RIH/HCH.
5. If the patient resides in a community residency such as a group home, then a report
must also be made to the Department of Behavioral Health Care, Developmental
Disabilities, and Hospitals at 462-2629.

6. If the patient resides at a nursing facility, then the Alliance or Better Long-Term
Nursing Care should be contacted at 785-3340.
7. Notify the administrator of the health care facility of the suspicion and report.
Adults with severe impairment:

All patient care providers are considered mandated reporters for suspicion of abuse/neglect
in adults with severe impairment, mental or physical that result in functional limitations in
the following areas: mobility, self-care, communication, receptive/expressive language,
learning, self-direction, capacity for independent living, economic self-sufficiency.
Procedure for patients living in the community:

2. File mandated report to Department of Behavioral Healthcare and Developmental
Disabilities Hotline at 462-2629.
3. File report with police department of town in while alleged incident occurred.
4. Collaborate with Social Work and Case Management to develop safe discharge
plan.
Domestic Violence:
Patient care providers are NOT mandatory reporters for domestic violence. Staff can place
patients at increased risk by reporting without the patient’s knowledge and consent. If the
patient does wish to contact police, consult Social Work to assist with the process.
When to suspect domestic violence:
1. Injuries during pregnancy
2. Multiple or repeated injuries
3. Chronic pain, apparently psychogenic or pain due to diffuse trauma without visible
evidence
4. Anxiety, somatic complaints
Procedure:
1. Consult social work for all cases of suspect domestic violence.
2. Offer the Domestic Violence Advocate (1-800-494-8100).
3. Social Work will offer resources for psychosocial support and community
resources.
4. Again, DO NOT contact police without the patient’s permission.

Law Enforcement and the Trauma Patient

Permissible Disclosure (Release of Information) to Law Enforcement.
A patient’s confidential health care information shall NOT be released or transferred with-
out the written consent of the patient or authorized representative. If a situation should arise
where there is disagreement or uncertainty regarding the appropriateness of a disclosure,
Risk Management should be consulted via the page operator for clarification and support.
Remember, when in DOUBT, ask BEFORE you speak.
Risk Management: 444-8625 or the 24 hour on-call pager: 350-5274.
General Principles:
• A Law Enforcement Official (LEO) may obtain PHI in the following
circumstances:
1. The LEO presents a court order, search warrant, or valid subpoena, or
2. The patient or the patient’s representative signs an Authorization to Use or
Disclose Protected Health Information form, or
3. The LEO completes the Law Enforcement Official Initiated Request for
Permitted Disclosure and Use of PHI form declaring the request is for the
purpose of carrying out the responsibilities of the office of law enforcement.
• Sensitive protected health information (PHI) pertaining to mental health, alcohol or
drug abuse, HIV or sexually transmitted diseases have a higher level of protection and
should only be released with a HIPAA-compliant patient signed consent or a court
order.
• In cases of known domestic violence, information should only be released and
disclosed with a HIPAA-compliant patient signed consent[1] or a court order.
• If a patient has opted out of the patient directory, FEDERAL LAW does not permit
confirmation or verification of the patient’s presence, location or condition without a
court order or a HIPAA compliant signed consent.
• Disclosures should be limited to minimum information necessary to accomplish the
intended purpose of the release of information as defined on the LEO form.
All disclosures to LEOs require documentation in the medical record and entry in Quick
Disclosure.
(1)
Exigent Circumstances: There may be special circumstances when an adult patient
who is a victim of domestic assault does not agree to provide written consent, but the
health care provider strongly believes a report is necessary to prevent serious harm to
the patient or others. In those cases, the provider should first consult with Risk and/or
Office of General Counsel.

Mandatory Disclosure to Law Enforcement

• Gunshot injuries, reportable to the city’s police department where the hospital is
located (i.e., Providence PD). Cities that are the scene of the incident can request
information from PPD.
• Suspected child abuse or neglect including sexual assault.
• Deaths in the ED, reported to the Medical Examiner’s Office
• Elder Abuse/Neglect, reported to the Office of Healthy Aging
• Animal bites, report to RI Dept. of Health and Police Dept. where bite occurred.
• Burns >5% TBSA (2nd / 3rd only) or explosive injuries, report to RI State Fire
Marshal
• Adult sexual abuse can ONLY be reported if the patient requests it
Request for and disclosure of protected health information to a law enforcement official
(Lifespan system-wide policy CCPM-65):
https://intranet.lifespan.org/sites/default/files/CCPM%20%2365%20Requests%20for%20an
d%20Disclosure%20of%20Protected%20Health%20Information%20to%20a%20Law%20E
nforcement%20Official_1.pdf

Maintaining the Chain of Evidence in Trauma/Criminal

Cases
The proper handling and documentation of evidence must be maintained. This applies to
forensic specimens and patient property. Please refer to the policy Admin-234: Chain of
Custody for Evidence Handling and Documentation on the intranet.
If there are any questions, contact Risk Management for guidance, phone 444-8625 or
the 24 hour on-call pager 350-5274.
If a Trauma Patient is Pronounced Dead:

1. NO PROCEDURES CAN BE DONE ON THE PATIENT. This is RI State Law.
2. One to two large sutures may be placed to close large incisions (e.g., open
thoracotomy).
3. Do not remove or re-position any tubes or catheters.
4. Do not wash/clean the patient.
5. Family members may see the patient but may not touch as they may transfer/ effect
evidence. They may not be left alone with the body.
6. Clothing and valuables (including money) become the property of the ME’s office and
must be turned over to them. Belongings must be labelled and in a paper bag to
accompany the body. Weapons should be given to the police with documentation in the
medical record as noted in the policy: Chain of Custody for Evidence Handling and
Documentation.
7. Call the ME’s office (222-2948) and report the death.

APPENDIX
AAST Liver Injury Scale
AIS-
Grade Injury Description 90
Hematoma Subcapsular, nonexpanding, <10cm surface area 2
I Capsular tear, non-bleeding, <1cm parenchymal
Laceration 2
bleeding
Subcapsular, nonexpanding, 10 to 50% surface area
Hematoma 2
intraparenchymal nonexpanding <10cm in diameter
II
Capsular tear, active bleeding; 1-3cm parenchymal
Laceration 2
depth <10cm in length
Subcapsular, >50% surface area or expanding;
Hematoma ruptured subcapsular hematoma with active bleeding; 3
III intraparenchymal hematoma >10cm or expanding
Laceration >3 cm parenchymal depth 3
Ruptured intraparenchymal hematoma with active
Hematoma 4
bleeding
IV
Parenchymal disruption involving 25% to 75% of
Laceration 4
hepatic lobe
Laceration Parenchymal disruption involving >75% of hepatic lobe 5
V Juxtahepatic venous injury (i.e., retrohepatic vena
Vascular 5
cava)
VI Vascular Vascular avulsion 6
*Advance one grade for multiple injuries up to grade III.
AIS = Abbreviated Injury Score
AAST Small Bowel Injury Scale

Type of AIS-
Grade* Injury Description of Injury 90
Hematoma Contusion or hematoma without devascularization 2
I
Laceration Partial thickness, no perforation 2
II Laceration Laceration < 50% of circumference 2
Laceration > 50% of circumference without
III Laceration 3
transection
IV Laceration Transection of the small bowel 4
Transection of the small bowel with segmental
Laceration 5
V tissue loss
Vascular Devascularized segment 5

APPENDIX
AAST Spleen Injury Scale

AIS-
Grade* Injury Description 90
Hematoma Subcapsular <10% surface area 2
I
Laceration Capsular tear <1 cm parenchymal depth 2
Subcapsular 10-50% surface area; intraparenchymal
Hematoma 2
<5 cm
II
Capsular tear 1-3 cm parenchymal depth not
Laceration 2
involving trabecular vessel
Subcapsular >50% surface area or expanding;
Hematoma ruptured subcapsular or parenchymal hematoma; 3
III intraparenchymal hematoma >5 cm or expanding
>3 cm parenchymal depth or involving trabecular
Laceration 3
vessels
Laceration involving segmental or hilar vessels
IV Laceration 4
producing major devascularization (>25% of spleen)
Laceration Completely shattered spleen 5
V
Vascular Hilar vascular injury with devascularized spleen 5
Open Fractures - Gustilo Classification
Type Gustilo Classification

I Open fracture with a skin wound <1 cm in length and clean.
Open fracture with a laceration >1 cm in length without extensive soft-tissue
II
damage, flaps, or avulsions.
Open segmental fracture with >10cm wound with extensive soft-tissue injury
III or a traumatic amputation (special categories in Type III include gunshot
fractures and open fractures caused by farm injuries).
IIIA Adequate soft tissue coverage.
Significant soft tissue loss with exposed bone that requires soft tissue transfer
IIIB
to achieve coverage.
IIIC Associated vascular injury that requires repair for limb preservation.

APPENDIX
Burgess & Young Pelvic Fracture Grading
Lateral Compression
Anterior-posterior Compression
Vertical Shear

Pediatric Contents
If no pediatric specific complement
is provided, please refer to the
adult trauma guideline.

Pediatric Service Assignments
To facilitate patient care and to eliminate potential misunderstandings between various

services caring for trauma patients, the Pediatric Trauma Committee (PTC) has established
the following guidelines regarding admission to, and transfers of pediatric trauma patients
between services.
• Patients with multiple injuries are admitted to the Pediatric Surgery Service.
• Pediatric patients are defined as <18 years of age.
• Once associated/occult injuries have been ruled out, these patients can be transferred
to another appropriate service, but only with direct communication between attendings
or chief residents of the involved services. After transfer, documented follow-up by
the Pediatric Surgery Service will continue at least until after completion of the tertiary
survey.
• Patients with isolated trauma (by mechanism and finding) are admitted to the
appropriate service.
• Neurosurgical trauma patients admitted to the PICU will be concomitantly managed
by the Pediatric Critical Care Service.
• The Pediatric Critical Care Service will be actively involved in the care of the multi-
injured patient whenever the active and sustained involvement of the Neurosurgical
Service is required (e.g., more than a one-time C-spine clearance).
As communication is of the utmost importance:
• All involved Services and their representatives (attendings, fellows, residents) will be
clearly identified in the chart and at the bedside, to allow seamless continuity of care.
• All multidisciplinary issues will be discussed through direct physician-to-physician
communication
• Admission orders will be written before a patient is admitted to the PICU or other
in-patient unit
Clinic numbers:
Clinic Phone # Fax #

Burn 444-5471 444-4557
Dermatology - Surgery 444-5507 444-8602
ENT 444-5507 444-8602
Gastroenterology 444-5471 444-4557
Hepatology 444-5280 444-4480
Medical Primary Care Unit 444-5280 444-4480
Neurology 444-4741 444-4445
Neurosurgery 444-5507 444-8602
Ophthalmology 444-5507
Orthopedics 444-5509 444-6763

Pulmonary 444-5662 444-4557

Rheumatology 444-5280 444-4480
Sleep 444-5280 444-4480
Trauma 444-5280 444-4480
Urology 444-5471 444-4557
Dr.’s line for clinic 444-3010

CT (24/7) 444-6159

Role of Trauma Team Members: Pediatric

Trauma Resuscitations
The following are guidelines for the management of severely or multiply injured pediatric
patients (<18 years of age) for Hasbro Children's Hospital.
Availability of the Pediatric Trauma Team
The Pediatric Trauma Team is always available in the hospital. An Attending Pediatric
Trauma Surgeon is always on-call. The in-house Attending Trauma Surgeon is available as
back-up for all Code Yellow Level A activations and will care for the patient until relieved
by the on-call Pediatric Surgery Attending*
Pediatric Trauma Team Activation

• The Pediatric Trauma Team will be activated as soon as the Hasbro Emergency
Department is made aware of a patient meeting Level A or B Pediatric Trauma
Triage Criteria. GOAL: Notification prior to patient arrival to allow the Pediatric
Trauma Team (Level A and B) and Trauma Attending (Level A) to arrive before
the patient.
• Patients meeting Level C criteria will be evaluated upon arrival and the Pediatric
Trauma Team notified as soon as activation criteria is confirmed.
• The Pediatric Trauma Team may be activated by the Pediatric Emergency
Department Nurse, Attending, or Fellow, based on Pediatric Trauma Triage
Criteria.
Pediatric Trauma Team Members:
Level A Level B
Surgery Attending P A
Surgical Team Leader P P
PEM Attending/Fellow P P
Bedside Resident/LIP P P
Orders Resident/LIP P P
Nurse Scribe P P
Primary Nurse P P
Assisting Nurse P A
Charge Nurse A A
Respiratory Therapist P P
Radiation Technologist P P
Registration P P
Clinical Social Work P P
Security P P
CAN/UA A A
Pastoral Care A A
CT Technician S A
OR / Anesthesia S A
P - present, A - available, S - standby

Team Leader:
• Team Leader is the physician in charge of the resuscitation.
• He / She may delegate “leadership” roles as necessary (e.g., airway, medications,
fluids, etc.); but must make decisions clear to the rest of the team.
• Team Leader may change as various team members arrive, (see below).
1. Surgical Attending Physician
2. Pediatric Surgical Fellow
3. Senior Pediatric Surgical Resident (PGY 4)/Trauma Resident (PGY 4-5)
4. Pediatric Emergency Medicine Attending or Fellow
• Team Leader should be the only physician giving verbal orders to the nursing team
members. Other-wise, orders and suggestions from other physicians should be passed
through the Team Leader.
Ultimate responsibility for the pediatric trauma patient lies with the Pediatric
Surgical Attending. If he/she is not present, ultimate responsibility lies with the
in-house Trauma Attending. If he/she is not present, ultimate responsibility lies
with the Pediatric ED Attending. Any conflicting plans that are not immediately
resolved should be escalated to the attending level without delay.
Roles of the Pediatric Trauma Team:
A. Pediatric Surgical Attending /Trauma Attending
• Supervises the resuscitation.
• Takes ultimate responsibility for the patient when present.
• Notifies OR of disposition of Level A patients.
B. Surgery Team Leader
• Assigns roles in the Trauma Room.
• Directs major surgical intervention (DPL, chest tube insertion, venous cut-down,
and thoracotomy).
• Contacts surgical attending, (Level B – within 30 minutes, Level C – time of ED
disposition), or as soon as surgical intervention is considered necessary.
• Responsible for management of patient upon definitive transfer from the ED.
• In the event of greater than two simultaneous trauma cases in the trauma rooms,
may summon additional general surgery house staff from other services, (see
Hasbro Disaster Policy).
• Works in conjunction with the Pediatric ED Attending on patient management.
C. Pediatric ED Attending/Fellow
• May serve as Team Leader until the surgical Team Leader or attending arrives.
• Oversees airway management, as needed.
• Provides medical direction during full cardiac arrest, as needed.
• Completes ED record.
• Assures that Pediatric Intensive Care Unit is informed of possible admission(s).
D. Bedside Resident/LIP
• ATLS Certified Trauma Resident/ Pediatric Surgical Resident/ ER
Resident/Pediatric Resident/NP/PA
• Completes physical exam
• Assists senior surgical resident in performing bedside procedures (e.g., chest tube
insertion, pericardiocentesis, etc.)

• Oversees or completes placement of NGT/OGT, Foley catheter (assures rectal

exam is done prior to Foley insertion)
• Oversees or completes LifeChart Trauma H&P. If unable to complete, “shares”
the Trauma H&P so it can be completed by another team member
• Accompanies patient to CT, VIR, OR, or ICU
• These duties may be delegated to multiple residents be the Team Leader as the
situation dictates
E. Orders Resident/LIP
• Trauma Resident/ Pediatric Surgical Resident/ ER Resident/Pediatric
Resident/NP/PA
• Places orders for laboratory testing or images
• Assists bedside resident/LIP with preparation of equipment and procedures
F. Trauma Nursing Team
• There are daily assignments for Charge Nurse, Trauma Nurse, Nurse Recorder and
Secondary Nurse Recorder (for a potential second trauma). Additional assignments
are made as needed by the Charge Nurse.
• Assess trauma staffing needs - Assures adequate staffing, resources, ancillary staff
are available and other ED nursing needs are met.
• Assigns runners for equipment, blood products, additional staff
Nurse Recorder:
• Documents critical elements of resuscitation in the LifeChart Trauma Navigator
• Attending Surgeon name and time of arrival
• Time, Activation Level, Trauma Activation Criteria
• Full GCS & full vital signs within 30 minutes
• Medications
• Interventions
• Exam Findings
• Calls out any missing documentation elements to the Team Leader
• Ensures lab and patient labels are correct for the patient
Primary Nurse/Trauma Nurse:
• Prepares/labels medications, IV’s, equipment (e.g., Foley catheter) prior to patient
arrival
• Reviews Intubation Checklist with team, as needed
• Establishes IV
• Ensures labs are drawn, labeled, sent
• Accompanies patient throughout ED stay until final disposition (CT, VIR, OR,
PICU)
• Gives verbal handoff report to receiving nurse
Assistant Nurse:
• Establishes second IV
• Assists primary nurse with medications, blood products, ancillary equipment
(Level 1 infuser, etc.)
• Assists is obtaining needed equipment in the Trauma Room for procedures

CNA/UA:
• Run blood products, equipment, etc.
• Assist with CPR
G. Radiology Technician
• Responds with sufficient number of cassettes to perform x-ray series as directed
by the Team Leader.
• Waits in trauma room for urgent procedures to be completed.
• Obtains and processes the x-rays in the order directed by the Team Leader. If no
specific order given, the CXR should be obtained and processed first.
• Calls for additional help if required.
H. Respiratory Care Practitioner
• Responds immediately to trauma room when paged.
• Assists with bag-valve mask ventilation.
• Suctions patient PRN.
• Provides mechanical ventilation.
• Accompanies the patient to CT, VIR, OR, or ICU.
I. Clinical Social Work and Pastoral Services
• Performs crisis intervention with patient and family members.
• Acts as liaison between trauma team and family.
• Updates family periodically.
• Responds to patient’s religious needs.
J. Security
• Available in ED waiting room for assessment of need for further security
assistance.
• On stand-by outside of trauma room for crowd control or assistance with patient
restraint as deemed necessary.
Orderly Resuscitation Workflow
ATLS protocol will be followed, as noted below:
• Primary Survey: Team Leader will oversee a rapid assessment of Airway,
Breathing, and Circulation, prior to moving the patient from the EMS stretcher.
Findings will be called out in a clear voice. The Team Leader will direct any
immediate life-saving treatments and movement of the patient form the EMS
Stretcher.
• AMPLE History (Allergies, Medications currently taking, Past illness/Pregnancy,
Last meal, Events): QUIET should be maintained while EMS staff gives report.
• Secondary Survey: Team Leader will direct a detailed head-to-toe exam of
Airway, Breathing, Circulation, Deformity, and Exposure, while maintaining a
proper Environment. All pertinent positive and negative findings will be called out
in a clear voice by the individual performing the exam. The Scribe Nurse is
responsible to ask in a clear voice for any missing information from the LifeChart
Trauma Narrator.
• Adjunctive Studies and Initial Treatments: Team Leader will direct the
ordering of indicated adjunctive imaging, laboratory tests, and consultations as
well as any initial treatments. The Scribe Nurse will keep a record of times of
procedures, medications, and other relevant events.

• Disposition: The Pediatric Surgery Attending/Trauma Attending in conjunction

with the PEM attending or fellow, will decide on the proper disposition of the
patient after leaving the Trauma Room. The Trauma Attending or their designee
will contact the Main Operating Room Desk (444-5657) for all Level A
Activations to inform the clerk whether the patient will need the Operating
Room or not.
Trauma Room Conduct
Communication and teamwork are essential.
• Communication: QUIET should be maintained so that everyone can hear the
Team Leader and EMS.
• Teamwork: Each person in the Trauma Room must have a specific role. Roles
will be assigned by the Team Leader. Excess personnel without a defined role
should remain outside the room unless specifically given a task in the resuscitation.
The trauma resident and pediatric surgical resident must remain in attendance until
the patient assessment is completed.
*The attending on-call list is located on the Lifespan Intranet/Administrative Tab/On-Call

Schedules (Smart Web).

Trauma Team Activation and Criteria: Pediatric

Trauma Team activations are known as “Code Yellow”. It is a 3-tiered system with levels
entitled A, B, or C. The Emergency Medicine Physician, advanced practitioner, or public
triage nurse will receive information that a trauma patient will be arriving and will activate
the appropriate trauma team through the web-based program EZ-Notify.
It is the expectation that a pre-notification page will be sent for all Level A patients
immediately upon notification by EMS. In addition, a page will be sent once the Level A
patient arrives in the ED. On occasion, a Level A will arrive to the ED without pre-
notification, which will result in an arrival page only.
Level A page information should include age, mechanism, vital signs, GCS, estimated time
of arrival, and critical care room location. Level B and C trauma pages may or may not have
a pre-notification page but will have an arrival page.
Pagers for all members of the Group Page will display “Code Yellow AAA-4900” for a
Code Yellow Level A, “Code Yellow BBB-4900” for a Code Yellow Level B, and “Code
Yellow CCC-4900” for a Code Yellow Level C, indicating the arrival of a surgical trauma
patient.
When you are paged, do NOT call the ED or the trauma room; just report to the
Hasbro trauma room. For Level A activations, the Pediatric Surgery or Trauma
Attending MUST report to the Trauma Room within 15 minutes of patient arrival,
even if the patient is pronounced or “down-graded”, in order to comply with ACS
requirements.
HASBRO CHILDREN’S HOSPITAL TRAUMA TRIAGE CRITERIA

Activations are for acute trauma (<24 hours); if over 24 hours since event and hemodynamically stable,
please call a trauma consult; if hemodynamically unstable, please call trauma activation


Routine Trauma Labs
The following laboratory tests should be ordered for all Level A and Level B pediatric
trauma patients evaluated in the trauma rooms:
• CBC with differential
• Urinalysis
• UCG for females >age 12
• Type and screen. Type and cross for patient with SBP <90 (age >5), SBP <80
(age 3-5), SBP <70 (age <0-2); Penetrating truncal injury; going directly to the OR
• Urine “Drugs of Abuse” toxicology screen (age >12)
• Blood alcohol level (age >12)
The following labs may also be indicated:

• PT/PTT for any patient with a GCS <10

Substance Use Screening Tool (CRAFFT)

Please complete the CRAFFT screening tool for admits 12-17 years of age on
either the Trauma H&P or Tertiary Survey form. If the CRAFFT cannot be
completed due to patient condition, kindly mark UTO. The CRAFFT must be
completed even in the setting of a positive urine tox screen. Further information
about the substance use screening can be found on the following slides.
• It is a requirement to screen patients for substance use in verified

pediatric trauma centers
• Our program utilizes the CRAFFT screen for patients 12-17 years of age
• Please screen with the CRAFFT on either the Trauma H&P or the
Tertiary Survey. If the screen is unable to done due to patient condition,
consider marking CRAFFT “UTO”
• If the CRAFFT is positive, please order a CSW consult for + CRAFFT
score; this response to a positive CRAFFT is required by ACS guideline

Rapid Sequence Induction for Pediatric

Patients
1. Assemble staff, (e.g., physicians, nurses, and respiratory therapist).
2. Continuous monitoring of BP (rapid cycling), EKG, pulse oximetry.
3. Evaluate and establish intravenous access. (Ideally this should not delay intubation.)
4. LEMON: Evaluate airway: facial, cervical, laryngeal trauma/congenital anomalies.
Consult anesthesiologist and/or surgeon (cricothyroidotomy).
5. Consult Anesthesiology if airway problems anticipated (e.g., short neck, facial trauma,
obvious C-spine fracture).
6. Prepare equipment (suction, ETT with syringe, end-tidal CO2 device, stylet, laryngeo-
scope, ambu bag, mask, oral/nasal airways, scalpel).
• Range of ETT sizes and stylet
• ETT size = (age in years/4) + 4, obtain 1 larger and smaller ETT than calculated,
Consider cuffed ETT even in infants
7. Pre-oxygenate patient with 100% O2. Assess chest rise. If patient is not breathing
spontaneously: cricoid pressure and bag mask ventilation.
8. Have Atropine available (to reverse bradycardia).
9. Maintain in-line C-spine immobilization.
10. Sedation and muscle relaxation. See intubation medications.
11. Maintain cricoid pressure. Await full paralysis (check eyelid reflex, jaw).
12. Intubate orally. Depth of intubation: Age (years) / 2 + 12 or 3 x ETT size.
13. Confirm ETT placement with end-tidal CO2 device (capnography or easy cap),
auscultation, and ultimately a CXR or bronchoscope.
14. If unsuccessful and O2 saturation <90%, remove ETT and mask ventilate. Return to #7.

Damage Control Resuscitation Protocol for

Pediatric Patients
The Damage Control Resuscitation Protocol (DCR) is a type of massive transfusion which
is used when it is anticipated that a large volume resuscitation of red blood cells will be
needed to stabilize an injured trauma patient. The DCR is a prospective and anticipatory
tool which causes the earlier use of plasma and platelets in approximately a 1:1:1 ratio in
the resuscitation.
Activation criteria:
To be activated when the patient is anticipated to need a very large volume (>40 ml/kg or
50% estimated blood volume) of red blood cells relative to his or her blood volume over a
6-8 hour period as judged by the attending trauma physician or emergency room attending.
Activation procedure:
- Attending determines the need for activation of the DCR
- An order is placed in the computer under “Pediatric Damage Control Protocol”
[see screen shot]
- A call is placed to the blood bank (Ext 4-5294 or 4-5295) by either the attending
or his/her representative in order to activate the protocol
Logistics:
- A transporter (“runner”) is sent from the ED (or wherever the patient is located
at the time of activation) to pick up products from the blood bank
- The blood bank is notified by the team when the patient changes location
Products received:
Patient RBCs Plasma Platelets Cryo
Weight (units) (units) (doses) (doses)
Cooler 1 <40 Kg 3 2 1 0
>40 Kg 4 4 1 0
Cooler 2 <40 Kg 3 2 0 1
>40 Kg 4 4 0 2
All volumes of products are ADULT volumes.

Cooler 2 and subsequent coolers are available a minimum of 15 minutes after the
previous is delivered.

A. In LifeChart, the patient has to be in ED or PICU census to order DCR

• Search Transfusion or Blood in Orders
• Select Pediatric Blood Administration
B. In the LifeChart Order section, go to: Uncrossed Emergent Transfusion

Orders
• Look for: ED/Surgery DCR Blood Administration
• Select: “Initiate DCR Protocol”
• Enter appropriate order time on pop-up window

Thromboelastography (TEG) and Pediatric

Trauma
Traditional Thromboelastography (TEG) is a visco-elastic in vitro method which evaluates

the different phases of blood changing from a fluid to a gel (clotting). The device generates
a two-dimensional tracing over time as citrated whole blood forms a clot after activation
with an activator (kaolin) and the addition of calcium. The recalcified and activated whole
blood is placed in a cup and changes to the resistance between a central pin and the walls of
the cup are assessed over time.
As thrombin is generated and fibrin strands form, resistance is increased and displayed on a
tracing as voltage changes:
TEGs at this institution are run in the blood bank. Due to the number of staff currently
trained to run and interpret the assay, they are available seven days a week but not 24 hours
a day, although there are often evening volunteers on call to help.
Indications for obtaining TEGs for pediatric trauma patients:

- Level A activation
- Anticoagulated patient on presentation with trauma
- After completion of a damage control resuscitation (DCR)
or massive transfusion protocol
- At the discretion of the attending trauma physician

Interpretation of Thromboelastography (TEG)
R (Reaction) time: time from calcium addition to the “split,’ when thrombin is formed.
Analogous to PTT and measured in units of time (minutes). Increase in R time indicates
either an anticoagulant or clotting factor deficiency; anticoagulation antidote or clotting
factor replacement with plasma may be appropriate.
Angle: relates to the rate of fibrin formation and is affected by fibrinogen concentration
and the rate of thrombin generation. Decrease in angle with a lower MA suggest fibrinogen
depletion; repletion with cryoprecipitate may be appropriate.
Maximum amplitude (MA): assesses both fibrinogen concentration and platelet
concentration (count). Measured in millimeters. Lower MA and normal angle indicate
decreased platelets and platelet transfusion may be appropriate.
Pattern of hyperfibrinogenolysis (graph above): Manage with antifibrinolytic therapy

such as IV Tranexamic acid
The TEG interpretation should be used in conjunction with clinical assessment. A normal
TEG in the presence of clinically relevant bleeding suggests an anatomic site rather than a
disorder of hemostasis as the cause of the bleeding. A careful assessment of the TEG
parameters can assist in the prioritization of the use of plasma, platelet, or cryoprecipitate
and avoid pan-therapy with non-red cell components (“kitchen sink approach to bleeding
patient”)

Interpretation of TEG - Advanced

The TEG6s is a more advanced device and provides3- 4 simultaneous channels. There are
two cartridges, one for heparin and used in cardiac surgery or for ECMO and another
cartridge for Trauma.
Heparin TEG 6s Cartridge: Channel 1 (CK) is the traditional TEG. Channel 2 (CRT) is a
rapid TEG in which the R time is greatly reduced by adding tissue factor rather than kaolin.
It is similar to a prothrombin time. It is used to get a quicker assessment of the MA.
Channel 3 (CKH) is the traditional TEG in which exogenous heparinase is used to
neutralize heparin. Channel 1 and Channel 3 are useful when used together to assess the
presence of and degree of heparinization. This is used in cardiac and vascular surgery and
ECMO. Channel 4 (CFF) is a functional fibrinogen in which antiplatelet antibodies to
glycoprotein IIb/IIIA are added. This blocks the platelet contribution to the MA and
therefore is a semi-quantitative method to measure fibrinogen. The usefulness of the TEG6s
is as follows:
Channel 1 (CK) R increased with Channel 3 (CKH) R normal = Heparin effect
Channel 1 R (CK) increased with Channel 3 (CKH) R increased= clotting factor deficiency,
consider plasma administration at 15mls/Kg
Channel 1 (CK) angle decreased, Channel 4 (CFF) MA decreased = fibrinogen depletion,
consider cryoprecipitate administration, 2 pools (10 units)
Channel 2 (CRT)MA decreased and Channel 4 (CFF) MA normal = low platelet count,
consider platelet administration
Trauma TEG6s:
Channel 1 (CK) is the traditional TEG. Channel 2 (CRT) is a rapid TEG in which the R
time is greatly reduced by adding tissue factor rather than kaolin. It is similar to a
prothrombin time. Channel 3 is a functional fibrinogen in which antiplatelet antibodies
to glycoprotein IIb/IIIA are added. This blocks the platelet contribution to the MA and
therefore is a semi-quantitative method to measure fibrinogen. The usefulness of the
Trauma TEG6s is as follows:
Channel 1 provide traditional TEG values. Prolonged R suggest clotting factor deficiency.
However, this channel has a lysis measure which can assist in assessing hyperfibrin(ogen)-
olysis and the usefulness of tranexamic acid.
Channel 2 provides a quicker assessment of the MA which assesses fibrinogen and
platelets.
Channel 3 provides a measure of fibrinogen. A low MA in channel 2 and a low fibrinogen
in channel 3 suggest cryoprecipitate replacement. A low MA in channel 2 and a normal
fibrinogen in channel 3 suggest platelet transfusion.
Anticoagulation Reversal Protocol

The most common anticoagulants used in pediatric patients are aspirin and Lovenox. If
concerned about bleeding in a trauma patient on aspirin on presentation, please consult the
blood bank. For any patient on Lovenox presenting with trauma and with an injury prone
to ongoing bleeding, administer protamine 25 mg.

Pediatric Traumatic Brain Injury Clinical

Pathway
Patient definition
• Age birth to 18 years
• With severe accidental or abusive traumatic brain injury with Glasgow Coma Scale
≤8
Objectives
Minimize secondary brain injury by targeting an intracranial environment conducive to
prevention of further neurocyte injury as well as promotion of healing.
Clinical Goals
• Promote oxygen delivery and nutrients necessary to support cellular respiration.
• Reduce exposure to neurotoxic agents.
• Support neuro-vasculature during disruption of autoregulation
• Decrease:
o Duration and number of occurrences of elevated ICP
o Length of time to initial CT scan/OR/PICU admission
o Length of time to placement of invasive ICP monitor
o Length of time from recognition to medical treatment of increased ICP
o Length of time from medically refractory treatment of increased ICP to
decompressive craniotomy
o Number of ventilator days
o Number of central venous line days
o PICU length of stay
o Mortality
Quality Metrics
• Time from initial ED evaluation to initial disposition (CT, PICU, or OR) 30 minutes
or less
• Time to placement of ICP monitor
• Mortality
• Time with ICP >20 mmHg
“Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain
Trauma Foundation Guidelines.” Pediatric Critical Care Medicine, May 2019.
https://journals.lww.com/pccmjournal/Fulltext/2019/03000/Management_of_Pediatric_Severe_Traumatic_Brain.8.asp
x; https://www.braintrauma.org/guidelines/pediatric#/
“Guidelines for the Management of Severe Traumatic Brain Injury 4th Edition,” Brain Trauma Foundation.
https://braintrauma.org/uploads/03/12/Guidelines_for_Management_of_Severe_TBI_4th_Edition.pdf
“Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and
Adolescents, Second Edition,” Brain Trauma Foundation.
https://braintrauma.org/uploads/03/15/guidelines_pediatric2_2.pdf

Head Injury
Arrival in ED
GCS≤8
GCS > 8
See ED MANAGEMENT
Guidelines not ABC’s
applicable C collar
Check pupils
Maintain BP (see “ED BP
Goals”)
Herniation suspected Herniation not suspected
Transiently hyperventilate
Place on 100% FiO2
Hyperosmolar therapy
Additional sedation
CT/OR ≤ 30
min
OR case
PICU
See PICU Management
See ACUTE OR
MANAGEMENT
See OTHER
Elevated ICP CARE
Stabilize
See ICP ESCALATION
GUIDELINES
See
Meets criteria for decompressive
DE-ESCALATION
craniotomy
GUIDELINE
Possible OR
Please note: this diagram is to be used as a guide to direct the clinician to the
appropriate area in the protocol which will contain detail regarding patient care

TRAUMATIC BRAIN INJURY ED MANAGEMENT: PEDIATRIC

Acute ED Management (30 minutes or less)
• Pediatric Trauma Surgery presence at bedside as outlined in trauma guidelines.
• Immediate Neurosurgery consult
o Neurosurgery resident at bedside to obtain exam.
• Alert PICU to pending admission.
• Airway management
o Obtain definitive airway if not achieved in the field.
▪ RSI recommendations: (ketamine 1-2 mg/kg IV and rocuronium 1 mg/kg
IV) OR (etomidate 0.3 mg/kg IV and rocuronium 1 mg/kg IV)
o Goal SpO2: 94-98%
▪ avoid hypoxemia, avoid over-oxygenating.
o Goal EtCO2: 30-34 mmHg
• IV access established and Trauma labs sent. ED BP Goals (assuming no
ICU monitor) MINIMUM
• Place C-Collar if indicated and not already
MEAN ARTERIAL
completed in the field; Miami-J preferred
PRESSURE (MAP) GOALS:
• Pupillary exams per protocol and document • 0-30 days: >40 mmHg
exam • 31 days – 1 year: >45
• Manage clinical signs of elevated ICP. mmHg
o Avoid hypotension (See ED BP Goals) • 1 year – 6 years: >50
o Ensure C-collar has adequate space mmHg
to allow venous drainage. • 6 years – 13 years: >60
mmHg
o Reverse Trendelenburg positioning
• >13 years: >65 mmHg
if feasible; if no thoracic/lumbar/sacral
spinal injury suspected, elevate HOB
to 30 degrees
o If signs of herniation*, treat immediately:
▪ 1) Hyperventilate to transiently lower EtCO2 to reversal of unilateral
pupillary dilation,
• re-evaluate frequently (every 2-4 minutes)
• attempt additional medical treatments to limit periods of
hyperventilation.
▪ 2) Increase FiO2 to 100%
▪ 3) Provide hyperosmolar therapy
• hypertonic 3% saline bolus push (5 ml/kg IV up to 250 mL,
may repeat PRN) first line, mannitol second line (0.5 g/kg IV
push via 0.22 µ filter)
▪ 4) Sedation post-RSI: consider additional ketamine or fentanyl,
administer minimal amount needed and avoid hypotension
• Maintain euvolemia and avoid hypotension.
• STAT non contrast head CT
• Expedite time to definitive care (30 minutes or less to CT scanner, PICU, or OR)
o Patient transport led by Trauma Surgery
• STAT non-contrast head CT

Traumatic Brain Injury Clinical Pathway –

ED Management

Head Trauma Pediatric Patient Admission

Guidelines
Purpose: To guarantee optimal care of children with head trauma once the decision to
admit has been made.
1. The admission of severe pediatric head trauma patients is restricted to either the
Pediatric Surgery or Pediatric Neurosurgery service. Related specialties will be
CONSULTED. 2) It is understood that multisystem trauma patients will be
admitted to Pediatric Surgery, and other services will be consulted. It is
furthermore understood that patients with severe head injury that warrants
admission to the PICU will have a pediatric intensivist (PICU attending) as co-
managing attending. 3) For admissions to the general pediatric service, consider
obtaining a pediatric neurosurgery consult.
A. Criteria for admission to the neurosurgical service – isolated head injury by
mechanism:
1. Radiological finding of intracranial (parenchymal, subdural, subarachnoid)
bleeding/hematoma
2. Radiological findings of depressed skull fracture, with or without symptoms
3. Clinical finding of persistent N/V, alteration of consciousness and mental status in
association with radiological finding of any skull fracture
4. Loss of consciousness with ongoing significant symptoms, regardless of cranial or
intracranial abnormalities.
B. Criteria for pediatric surgery admission:
1. Any of the above criteria and multisystem trauma mechanism or multiple injuries.
C. Patient may be admitted to the general pediatric service in case of:
1. Non–displaced skull fracture without intracranial abnormalities in an asymptomatic
patient. A routine consult to neurosurgery should be made to arrange follow-up.
2. Persistent nausea/vomiting without radiological evidence of skull fracture or
intracranial injuries and without lateralizing neurological findings.
3. Resolution of acute head trauma pathology – patient may be transferred to the
general pediatric service if prolonged, subacute hospital care is anticipated.
4. Minor injuries in an asymptomatic patient requiring admission for suspicion of
neglect or abuse.
D. Criteria for patients admitted with a Traumatic Intracranial Hemorrhage
1. All trauma intracranial hemorrhage injuries should go to PICU.
2. If the head bleed is questionable or extremely small and there are no available
beds, there can be Attending to Attending conversation to de-escalate care, when
limited PICU bed availability occurs. The patient should be admitted to floor with
q4 hour neuro checks especially if the injury is >24 hours old and the patient is
doing well.
Other remark:
If the above criteria (A-D) are not met, the head injury is not acute and/or hospital
admission is not deemed clinically necessary, the patient may be discharged home at the
discretion of the Pediatric Emergency Medicine attending.

C-Spine Evaluations in Pediatric Trauma

Patients
Cervical spine injury should be assumed and systematically ruled out in all pediatric trauma
patients. C-spine stabilization should be maintained until appropriate clinical and imaging
evaluation has been completed [see Diagram A]. It must be recognized that the pediatric
cervical spine differs from that of an adult and there may be spinal cord injury without
radiographic abnormality (SCIWORA).
NOTE: Arrival in the emergency department without cervical immobilization does not
indicate that the c-spine has been cleared.
Practitioners qualified to clear pediatric c-spine: limited to PEM Attending, Fellow, EM

PGY 3 or higher resident; Pediatric Surgery/Trauma Attending, Fellow, Surgery PGY 4 or
higher resident, NP or PA; Neurosurgery Attending, Fellow, NSG PGY 3 or higher resi-
dent, NP or PA; Orthopedic Attending, Fellow, ortho PGY 4 or higher Resident, NP or PA.
Documentation: Removal of the c-spine precautions and associated orders should be made
immediately by the responsible practitioner in the medical record. Documentation of spine
clearance should be in the form of a significant event note or in a practitioner’s H&P or
consult and should be done at the earliest possible timepoint.
Use of NEXUS criteria to minimize unnecessary radiation:

Cervical spine radiography is indicated for patients with neck trauma unless they meet ALL
of the following criteria:
• A normal level of alertness (GCS 15)
• No evidence of intoxication
• No focal neurologic deficit
• No painful distracting injuries
• No posterior midline cervical spine tenderness
• No torticollis
• Age >3 years
• Cooperative
Note: Children 3 years or under or those with neurodevelopmental delay MAY NOT be
able to provide a reliable exam. A lower threshold for imaging must be maintained in this
group, HOWEVER, clinical clearance is possible if an adequate exam IN A CALM
CHILD can be performed.
Regarding distracting injury: In the absence of an observable injury which is life

threatening or requires immediate operative intervention; if, after the primary and secondary
assessment, the patient is able to answer questions clearly, exhibits a decrease in anxiety,
and is able to cooperate with an exam, then the patient does not have a distracting injury
that would prevent c-spine clearance.
Determination that a child may forgo imaging is at the discretion of the Team Leader. If in
doubt, consider imaging. This guideline does not replace sound clinical judgement taking
into consideration all aspects of the patient’s condition.

Exam: Clearance of a c-spine in a pediatric patient, with or without imaging, requires

palpation for midline tenderness as well as extension, flexion, and bilateral lateral rotation
without complaint of pain by the patient
Guidelines for C-Spine Imaging in the Pediatric Trauma Patient:

Age < 5 Years 5-13 Years 15 Years and older
Initial Imaging Lateral and AP Lateral, frontal, and 3 Views
views (no odontoid open mouth (+/- Radiograph or CT*
views) swimmer’s view)
If cannot be cleared Tailored CT of the Tailored CT of the Tailored CT of the
radiographically or level in question + level in question + level in question +
concern persists one level above and one level above and one level above and
below below below
If concern for MRI of entire MRI of entire MRI of entire
SCIWORA or cervical spine cervical spine cervical spine
ligamentous injury
*For patients 15 years or over who are unable to be cleared clinically and have been
involved in a high speed MVC or have head or face trauma, c-spine CT should be used
rather than radiographs.
Other situations where c-spine CT without preceding c-spine radiographs may be

appropriate include:
1. Unresponsive patients
2. Patients with polytrauma including the head and face, of any age, depending on
severity.
3. Patients over 15 years of age who fail clinical clearance and are undergoing CT for
other indication, allowing for clinical judgement.
Tailored CT c-spine is also an appropriate follow up to c-spine radiographs.

1. When x-rays are abnormal or equivocal.
2. When the lower c-spine is not imaged on radiographs and on repeat exam clearance
is still not possible, CT may be needed to image the full c-spine for collar removal.
C-spine evaluation in presence of neurological changes:

Patients with persistent neuropraxia or a mechanism of axial loading (such as spear tackle
or dive injury) should undergo MRI after c-spine imaging. They should also have an urgent
spine consult in the setting of persistent deficit and persistent suspicion for clinical spine
injury, especially severe pain.
Those with an initial presentation with neuropraxia (bilateral upper extremity or multi-
extremity paresthesia or weakness) which has now resolved can be placed in a Miami J or
equivalent collar and discharged home with spine follow up as an outpatient.
Those with a unilateral upper extremity deficit, or “stinger,” which has resolved do not need
a spine consult. They can be placed in a Miami J collar and follow up with spine as an out-
patient.

Persistent c-spine pain without deficit despite negative imaging:

Patients in the ED who can otherwise be discharged home but have persistent c-spine pain
on exam can be discharged in a Miami J collar and follow up with spine as outpatient.
Patients being admitted can be observed. If pain persists, MRI can be obtained to help with
clearance. Spine should only be consulted if there is a high level of concern for c-spine
injury.
C-spine Clearance after Admission:

Cervical spine evaluation and collar removal must be done by, or under the in-person
supervision of, a qualified practitioner. Telephone and remotely entered computer orders
for collar removal are not permitted. For those patients who have been referred to the
Spine Service, c-spine clearance is at the discretion of the Spine attending or the attending’s
qualified designee. Once the spine is “cleared,” either the trauma service or spine service
can remove the cervical collar after communicating with the other service (i.e., trauma can
remove the collar after discussion with spine, and spine can remove the collar after advising
trauma of their intent.)
C-spine Precautions in the Operating Room:

For those patients going to the operating room with c-collar in place, cervical spine
immobilization must be maintained by the surgical team and anesthesiology staff according
to operating room best practices. At the conclusion of the procedure(s), the c-collar must
be replaced unless specifically directed otherwise by a Spine or Trauma attending.
Consultation guidelines for inpatient pediatric spine trauma patients:

It is understood that patients who sustain traumatic injury to their spine will require
consultation by the Orthopedic Surgical service or the Neurosurgical service or both.
1. The first consultation call should be made to the service which is “covering spine”.
Neurosurgery and Orthopedic Surgery services will cover alternating weeks and the
schedule of which service is on call is readily available on the intranet under the
Administration tab.
2. At the discretion of the consulting spine attending, it may be appropriate to involve
both Neurosurgery and Orthopedic services. Physical examination or mechanism
alone may be enough to necessitate consultation of both services given the increased
incidence of SCIWORA in the pediatric population.
3. It is understood that communication between attendings of both services is the
preferred mode of communication.

C-Spine Evaluation Flow Chart for Pediatric

Patients

C-Spine Clearance: ED Dot Phrase

Please use the following dot phrase when the C-collar is removed in the ED during initial
assessment:
.cspine
This will generate the following note:
@name@ was brought to the HCH ED collared. Pt. {WAS/WAS NOT:2100118327}

complaining of neck pain.
Focal Neurologic Deficit? No
Midline Cervical Tenderness? No
Altered LOC? No
Distracting Injury? No
Intoxication? No
Pt was examined and {WAS/WAS NOT:2100118327} alert and orient. GCS of ***.
Motor and Sensation {WERE / WERE NOT:19253} intact. There {WERE / WERE
NOT:19253} significant distracting injuries.
The patient was evaluated and {did/did not:22772} have midline C-spine tenderness or step
offs.
X-rays {WERE / WERE NOT:19253} ordered due to clinical findings.
The c-collar {WAS/WAS NOT:2100118327} removed and patient was able to perform full
range of motion without significant pain.
The NEXUS criteria above have been found to be >99.6% sensitive for identification of
patients at risk for clinically important cervical spine injury. Data for children younger than
8 years of age are limited, but children older than 1 year of age were included in the
derivation and validation studies by Hoffman et al. (Annals Emerg. Med 1998 and NEJM
2001).
Given these data, the clinical findings in this patient, and other factor including mechanism
of injury, I have cleared the patient's cervical collar on clinical grounds. Will re-evaluate
prior to disposition.

Pediatric Spinal Cord Injury Mean Arterial

Pressure (SCI-MAP) Guidelines
Rationale:
• Institutional practice guidelines are currently absent regarding optimal blood
pressure parameters in pediatric spinal cord injury (SCI)
• Variability across providers and teams regarding blood pressure management
creates management uncertainty.
• Standardization of care is broadly associated with improved patient outcomes and
care team interactions1 2 3
Evidence:
• The adult SCI literature suggests supraphysiological target for mean arterial
pressure (MAP) to improve cord perfusion in patients and currently is
recommended by various organizations. 4
• Elevated MAPs are associated with improved outcomes5
• Animal models suggest improved spinal cord perfusion and outcomes in
induced mild hypertension6 7
Recommendation:
• Age-appropriate blood pressure augmentation (at 120% of age appropriate normal)
for 5-7 days in patients without contraindications to blood pressure augmentation
o 120% reflects >85 goal for adults with typical MAP of 65-75
o Reference AAP based normal values using patient age/weight/height.
Guidelines:
Indication: Suspected spinal cord injury with abnormal neurological exam
- Consult Spine Service when condition is recognized
- Ensure patient is in hard collar and on log roll precautions
- STAT MRI of C-spine
- Contact Radiology and MRI to ensure scheduling and prioritization
- Discuss need for imaging of additional levels with Spine consult
- MRI to be ordered as soon as abnormal exam is documented to avoid
delays; order should not be held pending examination by spine service
- Possible STAT CT C-spine if not already done – discuss with Spine service
regarding prioritization.
Treatments to begin in Emergency Department upon recognition of abnormal exam:

- Mean Arterial Pressure (MAP) pushes to 120% of age appropriate normal.
- Need for invasive monitoring with A-line should be discussed with Spine
and Trauma/PICU attendings
- Support MAP with fluid boluses and Phenylephrine
- In the presence of other injures with outcomes that may be adversely affect by
hypertension, Spine, and other involved services (e.g., Trauma, Neurosurgery)
will discuss blood pressure goals
- Serial Neurological Assessments q1H

Possible additional treatments which require discussion with Spine Service before
implementation*:
- Steroids: dexamethasone 10mg IV q6h (appropriate dosing for pediatric
patients); discuss with Spine Service before starting
- Minocycline: 800 mg BID Hospital Day 1, 700 mg BID Hospital Day 2
600 mg then 500 mg Hospital Day 3, 400 mg BID Hospital Days 4-8;
discuss with Spine Service before starting
This guideline was developed by the Pediatric Orthopedic Spine Service, Pediatric Neurosurgery Spine
Service, Pediatric Critical Care Medicine Service, and the Pediatric Trauma Committee.
*These treatments are based on weaker evidence or are controversial and require
approval by the attending spine surgeon before implementation.
1. Zaydfudim VM. Enhanced Recovery in Patients Selected for Pancreatoduodenectomy: Standardization of Care
Improves Patient Outcomes. World J Surg. 2020;44(7):2085-2086. doi:10.1007/s00268-020-05558-3
2. Yousef Y, Youssef F, Homsy M, et al. Standardization of care for pediatric perforated appendicitis improves
outcomes. J Pediatr Surg. 2017;52(12):1916-1920. doi:10.1016/j.jpedsurg.2017.08.054
3. Haddock C, Al Maawali AG, Ting J, Bedford J, Afshar K, Skarsgard ED. Impact of Multidisciplinary
Standardization of Care for Gastroschisis: Treatment, Outcomes, and Cost. J Pediatr Surg. 2018;53(5):892-897.
doi:10.1016/j.jpedsurg.2018.02.013
4. Ryken TC, Hurlbert RJ, Hadley MN, et al. The acute cardiopulmonary management of patients with cervical spinal
cord injuries. Neurosurgery. 2013;72 Suppl 2:84-92. doi:10.1227/NEU.0b013e318276ee16
5. Hadley MN, Walters BC, Grabb PA, et al. Guidelines for the management of acute cervical spine and spinal cord
injuries. Clin Neurosurg. 2002;49:407-498.
6. Guha A, Tator CH, Rochon J. Spinal cord blood flow and systemic blood pressure after experimental spinal cord
injury in rats. Stroke. 1989;20(3):372-377. doi:10.1161/01.str.20.3.372
7. Nikolay L. Martirosyan, MD, M. Yashar S. Kalani, MD, PhD, William D. Bichard, Ali A. Baaj, MD, L. Fernando
Gonzalez, MD, Mark C. Preul, MD, Nicholas Theodore, MD, Cerebrospinal Fluid Drainage and Induced
Hypertension Improve Spinal Cord Perfusion After Acute Spinal Cord Injury in Pigs, Neurosurgery, Volume 76, Issue
4, April 2015, Pages 461–469, https://doi.org/10.1227/NEU.0000000000000638

Blunt Abdominal Trauma Evaluation Pediatric

Child Maltreatment Screening and Evaluation

Child maltreatment is an insidious and underrecognized mechanism resulting in pediatric injury.
All children 12 years and under presenting to the emergency room undergo nursing screening in
triage for potential maltreatment. The assessment consists of two questions:
- Does the presenting history or your initial assessment raise concerns for child abuse or
neglect?
- Do you have concerns about the safety of the patient or family based on the presenting
history or reports of others?
Assessments not completed in the ED are completed by the nurse on admission to the floor.
A “yes” answer to either question initiates a consult by the nurse or resident to social work and the
Aubin Child Protection Program. If the patient is in the ED these consults should be discussed
with the PEM attending before they are placed.
A “Child Maltreatment Screening Set” is in the process of being built for Epic. It will contain the
following orders:
- Consult social work: “possible child abuse”
- Consult Aubin Center: “possible child abuse”
Guidelines for additional workup for possible child abuse and maltreatment
In order to tailor tests to the particular situation of each child, the remainder of the studies ordered
for the evaluation of maltreatment will be determined by the Aubin Center Child Protection Team.
There are some tests which commonly are ordered in particular settings; however, the use of these
should be determined in conjunction with input from the Aubin Center Child Protection Team and
Pediatric ED attending physician.
Under 6 months of age with concern for abuse or under 1 year of age with evidence of
trauma to the head concerning for abuse:
- Head CT
- Ophthalmology in the presence of intracranial blood concerning for abuse
- Skeletal survey
- CXR alone is insufficient for the evaluation of non-accidental trauma.
- CBC, LFTs, amylase, lipase, u/a, PTT/INR/PT
Fracture concerning for abuse
- Bone labs: calcium, phosphorus, PTH, Vit D 25-OH
- CBC, LFTs, amylase, lipase, u/a
- Concerning bruising with fracture: PTT/INR/PT
- Under 2 years of age: skeletal survey; 2-5 years of age: possible skeletal survey, check with
Aubin Center

Patients of any age with abdominal trauma concerning for abuse

- CBC, LFTs, amylase, lipase, u/a, PTT/INR
- Under 2 years of age: skeletal survey; 2-5 years of age: possible skeletal survey
- Consult with the ED attending/at tending radiologist/Aubin Center attending to determine
which other imaging may be appropriate (such as CT abdomen/pelvis).
- Abdominal ultrasound is not an appropriate study for the evaluation of abdominal trauma

Reporting Child Abuse/Neglect and Referrals

to the Child Protection Program
All care providers share the responsibility to report known or suspected abuse in cases
involving special populations. This function is just as critical and potentially lifesaving as
any traumatic injury and must be approached with the same care and dedication. All care
providers are considered Mandatory Reporters in cases of abuse or neglect involving
children, the elderly and in adults with impairments. If there is concern for domestic abuse,
please consult social work for input.
Children
All patient care providers are considered mandated reporters of abuse in children (age <18).
The following criteria should be used to guide your assessment in suspected cases of
abuse/neglect.
• All unexplained head injuries, especially in children <2 years
• All unexplained fractures, in children <1 year
• Each child with thermal injury should be screened for abuse/neglect by both the ED
and Pediatric Surgery teams. If both teams agree there is a low suspicion for abuse/
neglect (documented in note), a referral to SW and/or Child Protection is not
required. If patient’s wounds can be cared for at home, the patient may be
discharged from the ED with pediatric burn clinic follow up. If either or both teams
(ED or Pedi Surg) are concerned for possible abuse/neglect, the patient should be
admitted for an Aubin Center evaluation. When screening for possible abuse/
neglect, special consideration should be taken regarding the child’s developmental
level, language skills, and ability to be a reliable historian (particularly children
under the age of 2).
• All cases where injuries have been inflicted on a child (e.g., “pattern” bruising such
as slap marks, strap marks, or ligature marks)
• All unexplained abdominal injuries
• All sexual assaults in children and adolescents
• All drowning or near drowning in children and adolescents
• All cases where the child is suffering from exposure or starvation
• Delay in seeking care or other medical neglect
• Ingestion of drugs or alcohol caused by parental neglect
• All cases of suspected medical child abuse
• Chronic failure to thrive without medical cause
• Repeat episodes of infantile apnea.
• Falls >3 feet in children <1 year
• Repeated admissions for trauma in children <2 years
• Suspected inadequate supervision or lack of provision for child safety
• Evidence of parental domestic violence, in which children were present or
repeatedly exposed to violence. Also, if a child is injured or a parent has sustained
significant injuries with children in the home
• Any bruising in a non-ambulatory patient

Procedure:
1. Consult social work and inform trauma attending if you have questions.
2. Consult Aubin Child Protection Program at Hasbro Children’s Hospital 4-3996 or
thru the page operator after hours. They are also available to answer any questions
and help you through the report.
3. Call 1-800-RI-CHILD to speak with DCYF and report concerns for RI residents.
If Massachusetts resident, call the area office or 1-800-792-5200 after regular working
hours.
4. Fill out Physician’s Report of Exam (PRE) in Rhode Island/51-A in Massachusetts
as directed by DCYF.
5. Contact Police Department of the town where the alleged incident occurred.
RI DCYF versus MA DCF

RI DCYF MA DCF
Are you a mandatory YES YES
reporter?
Reporting includes Call 1-800-RI-CHILD Call Area Office where child
lives
After hours: 1-800-792-5200
Forms PRE-Physician’s Report of 51-A (on-line)
Examination (paper form)
Filled in by SW, Nursing, MD,
Filled in by MD or NP NP-any employee
72-Hour Hold Child can be placed into NO HOLD
DCYF Custody in hospital or MA DCF investigators will
outside hospital by checking obtain emergency custody in
area on PRE form court
Visitation during Decided by Aubin Center and Within MA hospitals parents
investigation RI DCYF. Often parents will routinely remain in the hospital
not be allowed to visit during with the child during the
the 72 hour hold. investigation. Aubin Center will
review this with MA DCF
investigators for each case
HOSPITAL DOES NOT HOSPITAL DOES NOT

PROVIDE SUPERVISION PROVIDE SUPERVISION FOR
FOR ANY VISITS ANY VISITS
Signature Authority Even when a child is in RI MA DCF signs when a child is
DCYF custody biological in their custody
parents sign except when
Parental Rights have been
Terminated (TPR)
1. Escobar, M.A., Duffy, S. et al. The association of nonaccidental trauma with historical factors, examination
findings, and diagnostic testing during the initial trauma evaluation. (2017). Journal of Trauma and Acute Care
Surgery. Volume 82, Number 6, 1147-1157.
2. Eveline, C.F.M, L. et al. (2014). Accuracy of a screening instrument to identify potential child abuse in
emergency departments. Child Abuse & Neglect. 38 (2014) 1278-1281.
3. Gonzalez, D. et al. Hospital Based screening tools in the identification of non-accidental trauma. 2017. Seminars
in Pediatric Surgery. 26 (2017) 43-46.
4. Sittig, J. et al. (2011). Child abuse inventory at emergency rooms: CHAIN-ER rationale and design. BMC
Pediatrics. 2011, 11:91. Retrieved from: http://biomedcentral.com/1471-2431/11/91.
5. Sittig, J. et al. (2016). Value of systemic detection of physical child abuse at emergency rooms: a cross-sectional
diagnostic accuracy study. BMJ Open access. 2016;6: e010788. Doi:10.1136/bmjiopen-2015-010788.

Pediatric Compartment Syndrome Pathway

Pediatric Microsurgery Protocol for PICU

Careful post-operative surgical, medical, and nursing care is essential to provide the best
microvascular environment for flap survival for patients who underwent replantation of tissue
(extremity/ face) or free flap(s). This may be after trauma (e.g., a replantation of finger or ear)
or may come after elective procedure (e.g., scheduled free flap for a tumor). Microsurgery
procedures are long and arduous. There may be significant fluid shifts and anticoagulation may
have been given or may be required ongoing.
1. Care Environment:
a. PICU admission – typically at least 24-72 hours until successful reperfusion is established.
b. Warmed room at all times to prevent vasoconstriction, 37degrees Celsius or 98.6 degrees
Fahrenheit. Forced air warmers (Bair hugger) may be used for extremities depending on
surgeon preference.
2. Admitting Service and Critical Care Consultation:
a. Elective Microsurgery: Patients will be admitted to the Plastic Surgical service in the PICU,
with consultation of the Pediatric Surgery service.
b. Polytrauma Patients: Injured children requiring ICU care will be admitted to Pediatric
Surgery with Plastic Surgery consulting.
3. Communication:
a. PICU Admission Anticipated: The Plastic Surgery service should communicate to the
Pediatric Surgery senior on call and the PICU charge nurse pre-operatively whenever
possible.
b. Pre-arrival PICU Notification: The OR will communicate with the PICU regarding timing
of bringing the patient to the PICU room when finishing the surgery. At this time, the PICU
nursing staff can warm the room and ensure the Microsurgery Nursing Pathway is instituted.
c. Post-op Handoff: Detailed instruction should occur in-person on arrival to the PICU between
the Plastic Surgery fellow or resident, the Pediatric Surgery senior on call, and the patient’s
nurse.
d. Daily Rounds: Direct verbal communication between teams should occur each morning and
evening at the most senior level possible (attending or fellow) during the PICU stay. This is
best accomplished in-person during multidisciplinary rounds whenever possible.
e. ***Concerns related to flaps/replants***:
i. Immediate call to Plastic Surgery on call pager [page the operator and ask for plastic
surgery resident on call].
ii. If this fails, page the Plastic Surgery senior resident on call.
iii. If this fails, contact the Plastic Surgery attending.
4. Management:
a. Planned Intubation and Sedation: Patients may require intubation for their safety for airway
concerns or to protect the replanted part post-surgery (e.g., lip replant in a 1-year-old child
may require sedation to protect the operative site). Vent weaning should only occur once
flap viability confirmed by Plastic Surgery.

b. Preventing Vasoconstriction: The patient should be kept warm, well hydrated, and pain-free
during this time at all times.
i. If room warming does not sufficiently warm the affected body part, (e.g., replantation of a
finger), then warming blankets/Bair hugger can be used until the Plastic Surgery service
deems this unnecessary.
ii. Vasoconstrictive agents such as caffeine, nicotine, chocolate are avoided. Inotropes should
be avoided as much as clinically possible.
iii. IV fluids to achieve normal UOP for age. Foley for strict UOP during acute perioperative
period.
iv. Analgesia should be scheduled, around the clock with breakthrough pain medication
available. Pediatric anesthesia consult and indwelling catheter may be considered for pain
control.
v. Blood-soaked dressings should be changed regularly to prevent constriction of the re-implant
or digit.
vi. Pressure to the surgical site should be prevented by positioning and padding. Assess for
constriction of proximal blood supply by dressings.
vii. Movement should be avoided with splint as indicated (e.g., extremity splints by OT).
c. Anticoagulation:
i. Anticoagulation regimen and goals of therapy are per the attending Pediatric Surgeon in
consultation with the attending Plastic Surgeon. ***Anticoagulation is critical to flap/replant
survival***
ii. Attending to attending discussion is preferred in the setting of polytrauma with bleeding risks
iii. If heparin drip is indicated, refer to the current PICU Heparin Protocol.
d. Diet/Nutrition:
i. NPO overnight POD #0 until Plastic Surgery service clears the patient.
ii. Goal to achieve full nutrition via GI tract or TPN by 72 hours.
iii. Oral free flap: Consider NG or ND feeds as appropriate.
e. Monitoring:
i. Vital Signs: q15 minutes BP, HR, RR for one hour until normal, then decreased frequency
per Pediatric Surgery as clinical situation requires.
ii. Labs: CBC on arrival to PICU.
iii. Operative site perfusion assessment q1 hour: Documentation of color, warmth, and capillary
refill should be done as a nursing note.
iv. Doppler Exam: Location will be taught by the Plastic Surgery service to the PICU nurse and
Pediatric Surgery senior at the initial handoff.
v. Pinprick to assess bleeding should only be carried out by the Plastic Surgery service, using a
fresh sterile 23G needle each time.
vi. ***Critical Changes in Perfusion***: If the flap or finger becomes congested-purple, cool,
loses Doppler signal or ischemic-pale, mottled, requires an immediate page to the Plastic
Surgery resident and expedient assessment. (Plastic Surgery residents are not in house, so the
expectation is that they will assess the patient when necessary and will get to the hospital as
soon as they can, but it can be challenging when they are not here. Questions will be asked by
the paged surgeon to ensure this is a critical change.)
vii. ***Make the patient NPO in any situation where there is a critical change in case the
patient needs to return to the OR.***

f. Leeching: If there is venous insufficiency, leeches may be used until venous drainage is re-
established (usually 7-10 days).
i. Leeches are obtained from Pharmacy and will have to be ordered in.
ii. Leeches are kept in the fridge and a single leech is applied to the distal digit/ flap each
hour. The leech will feed and then drop off, leaving a puncture wound which will continue
to bleed. If the leech is still feeding at 1 hr. it can be kept in place until it falls off. The fed
leech must be discarded. The leech protocol will get spaced out and decreased in terms of
frequency based on clinical assessment by the treating team as the venous drainage
becomes reestablished. Our service will often expose the nailbed in digital re-plantations
and score/scrub with heparin to encourage bleeding for the leech.
iii. Each leech is only used once and should be counted ‘on’ and ‘off’ the patient in hourly
nursing notes.
iv. Transfusion Threshold: The patient may lose significant amounts of blood when being
leeched and requires at least daily hemoglobin check and transfusion if this drops below
7g/dl, but this will be at the surgeon’s discretion.
v. ***Antibiotic Prophylaxis with Leeches: Ciprofloxacin or Bactrim prophylaxis against
Aeromonas hydrophilia found in the leech mouth-parts. This antibacterial regimen will
need to be adjusted for young children.
g. Transfer to the ward must be authorized by the Plastic Surgery attending: Minimal
criteria include well-established perfusion, the replantation/ free flap can tolerate lower
ambient temperature, less frequent monitoring requirement, and less overall nursing care
needs. ***Transfer before the revascularization is established will jeopardize survival of
the replanted part or free flap***

Pediatric Trauma VTE Prophylaxis Guideline

Acknowledgment: While the best treatment for venous thrombosis is prevention, and the best
preventative measure after injury is early mobilization, chemoprophylaxis against venous
thrombosis is needed for some pediatric trauma patients.
Recommendations:
A. For patients aged 13 years and older who both (1) have altered mobility from baseline and (2)
are severely injured as judged by the admitting physician, chemical prophylaxis should be
strongly considered.
B. For patients of any age who have medical conditions placing them at higher risk of venous
thrombosis* and are injured with altered mobility from baseline, chemical prophylaxis should
be strongly considered.
C. For patients under age 13 years who both (1) have altered mobility from baseline and (2) are
severely injured as judged by the admitting physician, chemical prophylaxis should be
considered.
*Medical conditions placing patients at higher risk of venous thrombosis:

• Protein C deficiency
• Protein S deficiency
• ATIII deficiency
• Lupus anticoagulant/Anti-phospholipid antibody
• Factor V Leiden mutation
• Prothrombin Gene mutation (G20210A)
• Dysfibrinogenemia (thrombotic phenotype)
• Elevated Lp(a)
Contraindications to chemoprophylaxis:
• Intracranial hemorrhage prior to demonstration of injury stability on CT or MRI
• Solid organ injury prior to demonstration of clinical stability
• Evidence of ongoing bleeding
• Heparin induced thrombocytopenia or other medication allergy to chemoprophylaxis
• Uncorrected coagulopathy
• Spinal cord injury with hematoma
• Invasive procedure scheduled within 24 hours
• Congenital bleeding disorder such as hemophilia
Suggested Prophylaxis:
• Chemoprophylaxis: Enoxaparin 0.5 mg/kg BID, maximum dose of 30 mg
• Mechanical prophylaxis such as sequential compression devices if there is a
contraindication for a patient who would otherwise receive chemoprophylaxis
1. Leeper, C. et. Al. (2017). Venous thromboembolism in pediatric trauma patients: Ten-year experience and long-term
follow-up in a tertiary care center. Pediatr Blood Cancer. 2017 Aug;64(8). doi: 10.1002/pbc.26415. Epub 2017 Jan 9.
2. Landisch, R. (2017). Efficacy of surveillance ultrasound for venous thromboembolism diagnosis in critically ill children
after trauma. J Pediatr Surg. 2018 Nov;53(11):2195-2201. doi: 10.1016/j.jpedsurg.2018.06.013. Epub 2018 Jun 20.
3. Mahajerin, A. et al. (2017.) Venous Thromboembolism Prophylaxis, Pediatric Trauma Patients-Joint between EAST and
Pediatric Trauma Society. Retrieved from: https://www.east.org/education/practice management-guidelines/venous-
thromboembolism-prophylaxis-pediatric-trauma-patients-joint-between east-and-pts
4. Rhode Island Hospital. (2017). Trauma Handbook.
5. Thompson, A. et. al. (2013). Venous thromboembolism prophylaxis in the pediatric trauma population. J Pediatr Surg. 2013
Jun;48(6):1413-21. doi: 10.1016/j.jpedsurg.2013.02.059.
6. Truitt, AK. Et al. (2005). Pulmonary embolism: which pediatric trauma patients are at risk? J Pediatr Surg. 2005 Jan; 40(1):
124-7.

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T R A U M A H A N D B O O K

This handbook and the management protocols

There will be many times when it is

Although these educational guidelines have

This handbook provides a quick reference for

Version 14.21.1 - Page 1

SECONDARY SURVEY / DEFINITIVE CARE

Version 14.21.1 - Page 2

Blunt Abdominal Trauma ..................................................................... 54

Version 14.21.1 - Page 3

SECONDARY SURVEY / DEFINITIVE CARE

Version 14.21.4 - Page 1

Trauma Conferences and Clinics

SATURDAY / SUNDAY THURSDAY

Version 14.21.4 - Page 1

Trauma Service Policies

Resident/Medical Student Roles:

Version 14.21.4 - Page 2

7. Trauma Conference presentations.

Trauma Resident Operative Procedure Responsibilities

Trauma Attending Coverage

Version 14.21.4 - Page 3

Trauma Attending Notifications

Version 14.21.4 - Page 4

Universal Precautions in the Trauma Rooms

Verification of Person, Procedure, and Site for Surgical Procedures

Version 14.21.4 - Page 5

As communication is of the utmost importance:

Version 14.21.4 - Page 6

Combined Adult and Pediatric Trauma Transports

Version 14.21.4 - Page 7

Trauma Team Activation: Adult

Version 14.21.4 - Page 8

Criteria for Triage to Trauma Rooms: Adult

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Informed Consent and the Care of the Trauma Patient

Informed Consent in the Impaired Patient

Version 14.21.4 - Page 11

Obtaining Consults on the Trauma Service

Here are some consults to consider:

Substance Abuse/Addiction Medicine

Geriatric Trauma Consult

Version 14.21.4 - Page 12

Routine Trauma Labs

Level A and B Order Set Level C Order Set

Version 14.21.4 - Page 13

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Procedural Goals of EDT

Version 14.21.4 - Page 15

Risks to Healthcare Providers

UNIVERSAL PRECAUTIONS ARE MANDATORY FOR EVERYONE IN THE

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

Vital Signs in ED?* Signs of Life in ED?**

Pronounce DEAD ED Pronounce DEAD

* Vital signs: palpable pulse or obtainable BP

Version 14.21.4 - Page 16

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Intravenous Access and the Trauma Patient

Any patient with GCS ≤13 needs a head CT in <30 minutes