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These management protocols are intended to serve as guidelines only. Individual circumstances need to be considered, as there may be times when it is appropriate or desirable to deviate from these guidelines. These educational guidelines will be reviewed and updated periodically.

This handbook provides a quick reference for some problems but should not be considered a substitute for a trauma textbook or current literature.

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Contents
GENERAL POLICIES Trauma Conferences and Clinics .........................................................................1 Trauma Service Policies .......................................................................................2 Service Assignments and Inter-Service Transfer Guidelines................................7 Code Yellow Trauma Team Activation ...............................................................9 Criteria for Triage to Trauma Rooms: Adult ........................................................11 Criteria for Triage to Trauma Rooms: Pediatric ...................................................12 Role of Trauma Team Members: Adult................................................................14 Role of Trauma Team Members: Pediatric ..........................................................16 Routine Trauma Labs ...........................................................................................21 Combined Family Adult and Pediatric Trauma (Mixed Bundles) .......................22 Police Notification of Emergency Department Cases...........................................23 Maintaining the Chain of Evidence in Trauma/Criminal Cases............................24 PRIMARY SURVEY ED Thoracotomy ..................................................................................................25 Prediction and Management of the Difficult Airway............................................27 Rapid Sequence Induction: Adult ........................................................................29 Rapid Sequence Induction: Pediatric ....................................................................30 Intravenous Access and the Trauma Patient .........................................................32 Resuscitation Guidelines ......................................................................................33 Hypothermia: Pediatric and Adult ........................................................................34 SECONDARY SURVEY / DEFINITIVE CARE Severe Head Injury (GCS 3-8)..............................................................................36 Pediatric Severe Head Injury ................................................................................38 Reversal of Anticoagulation in Patients with Intracranial or Spinal Bleeding.....................................................................................................40 C-Spine Evaluations in Adult Trauma Patients.....................................................41 C-Spine Clearance: Pediatric ................................................................................43 Thoracic/Lumbar/Sacral (TLS) Spine Clearance in the Trauma Patient...............45 Standard Neurological Classification of Spinal Cord Injury.................................46 Penetrating Neck Trauma .....................................................................................47 Penetrating Injuries to the Heart ...........................................................................49 Transmediastinal Gunshot Wounds (TMGSW)....................................................51 Vascular Exposures ..............................................................................................52 Truncal Stab Wounds ...........................................................................................54
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Blunt Cerebrovascular Injuries .............................................................................56 Blunt Aortic Injury (BAI) .....................................................................................58 Blunt Cardiac Injury .............................................................................................60 Rib Fracture Protocol: Adult.................................................................................62 Blunt Abdominal Trauma: Adult ..........................................................................65 Blunt Splenic Trauma: Adult................................................................................66 Renal Trauma .......................................................................................................68 Diagnosis of Blunt Bowel and Mesenteric Injury.................................................70 Rectal Injury .........................................................................................................72 Unstable Pelvic Fractures .....................................................................................73 Mangled Extremity ...............................................................................................75 To Ligate or not to Ligate ....................................................................................77 Trauma Scoring Systems ......................................................................................78 ICU CARE TICU Sedation/Analgesia ....................................................................................80 Ventilator-Associated Pneumonia ........................................................................82 Severe Sepsis and Septic Shock............................................................................84 DVT/PE Prophylaxis in Adults Following Multiple Trauma................................86 Heparin-Induced Thrombocytopenia ....................................................................88 Antibiotic Usage on the Trauma Service ..............................................................90 SPECIAL ISSUES Trauma in Pregnancy............................................................................................92 Reporting Child Abuse and Neglect and Referrals to the Child Protection Program ...............................................................................................95 Speech-Language Pathology Services ..................................................................96 Diagnosis of Brain Death: Adult...........................................................................98 Diagnosis of Brain Death: Pediatric......................................................................80 Informed Consent and the Care of the Trauma Patient ........................................104 Obtaining Consults ...............................................................................................105 End of Life Issues .................................................................................................109

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Routine Trauma Labs

ADULT: The following laboratory tests should be ordered for all adult surgical trauma patients evaluated in the trauma rooms: Code Yellow Level I, IA CBC Chem 7 Blood alcohol level Urine Drugs of Abuse toxicology screen Type and screen. Type and cross for any patient with SBP <90, truncal penetrating injury, or going directly to the OR. Medical Examiner blood PT/PTT Code Yellow Level II CBC BUN/creatinine Blood alcohol level Urine Drugs of Abuse toxicology screen Urine dip (if positive for blood or protein, a UA must be sent), also UCG in female patients of childbearing age PT-INR on isolated head injury or spinal injury Chem 7 on isolated head injury

PEDIATRIC: The following laboratory tests should be ordered for all pediatric surgical trauma patients evaluated in the trauma rooms: CBC with differential Urine dip (if positive for blood or protein, a UA must be sent), UCG for females > age 12) Type and screen. Type and cross for patient with SBP <90 (age > 5), SBP <80 (age 3-5), SBP <70 (age < 0-2); Penetrating truncal injury; going directly to the OR Medical Examiner blood (Code Yellow Level I only) Urine Drugs of Abuse toxicology screen (age > 12) Blood alcohol level (age > 12) The following labs may also be indicated: PT/PTT for any patient with a GCS < 10
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ED Thoracotomy
Emergency department thoracotomy (EDT) was introduced in 1966 as a life-saving measure for patients with thoracic injuries. Since then, multiple critical analyses of EDT have prompted a more selective application of the procedure. Survival with intact neurologic status (meaningful survival) should be the goal of EDT. Selective Approach In deciding whether to perform EDT, the following variables should be considered: Mechanism of injury (blunt vs. gunshot vs. stab); vital signs*, and signs of life** at the scene and on presentation to the ED. The same criteria for performing EDT should apply to children, as their survival closely parallels that of adults. The elderly may be a special population group. In several large series of EDT there are no meaningful survivors over the age of 65. EDT should be used in the over 65 population in only the most favorable circumstances. EDT is most productive for life-threatening penetrating cardiac wounds, especially pericardial tamponade. Outcomes for EDT are shown in the following table: ED: No sign of life BLUNT GSW STAB 1% 1% 3-5% 1/3 of survivors severely neurologically impaired ED: Signs of life, No vital signs 1% 3-5% 10-15% ED: Vital signs 3% 10-15% 30-40% < 1/10 of survivors neurologically impaired

The major goals and potential therapeutic maneuvers of EDT are as follows: release pericardial tamponade; control cardiac and/or great vessel bleeding; control bronchovenous air embolism; perform open cardiac massage; redistribute blood to myocardium and brain, and limit sub-diaphragmatic hemorrhage via aortic cross-clamping. Technique EDT is performed through a left anterolateral incision at the level of the fifth intercostal space, or inferior border of the pectoralis major muscle. The skin, subcutaneous tissue, and chest wall musculature should be incised with one knife pass. The intercostal muscles and pleura should then be incised with heavy Mayo scissors along the superior margin of the rib. A rib spreader is inserted with the handle toward the axilla. The pericardium is opened with a longitudinal incision anterior to the phrenic nerve. Any blood or clot should be evacuated, and attempts made to control cardiac bleeding with sutures (pledgets used in the RV). Transsternal extension into the right chest (clamshell incision) may be helpful in exposing the heart for repair. Open cardiac massage can then be performed. Air embolism or massive bleeding from the lung is controlled with a clamp across the pulmonary hilum. The thoracic aorta is visualized by elevating the left lung anteriorly and superiorly. The aorta is differentiated from the esophagus by palpating the nasogastric tube, and a vascular clamp is placed across the aorta.

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Risks to Trauma Team ED thoracotomy involves the use of sharp instruments and contact with the patients blood in an often-chaotic atmosphere. In urban trauma populations, the rate of HIV and hepatitis B and C infection range from ten to twenty times that of the general population. This rate may be even higher in the population most likely to require ED thoracotomy, making universal precautions and selective use of the procedure essential.

1. 2. 3. 4. 5. 6. 7.

Baxter BT, Moore EE, Moore JB, et al. Emergency department thoracotomy following injury: critical determinants of patient salvage. World J. Surg 1988;12:671-675. Beaver BL, Columbani PM, Buck JR, et al. Efficacy of emergency room thoracotomy in pediatric trauma. J. Pediatric Surg 1987;22:19-23. Biffl WL, Moore EE, Johnson JL. Emergency department thoracotomy. In Feliciano, Mattox, Moore (eds), Trauma, 5th ed., 2004. Branney SW, Moore EE, Feldhaus KM, et al. Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center. J Trauma 1998;45:87-94. Kelen GD, DiGiovanna T, Bisson L, et al. Human immunodeficiency virus infection in emergency department patients: epidemiology, clinical presentations, and risk to health care workers: the Johns Hopkins experience. JAMA 1989;262:516-522. Rothenberg SS, Moore EE, Moore FA, et al. Emergency department thoracotomy in children a critical analysis. J Trauma 1989;29:1322-1325. Sloan EP, McGill BA, Zalenski R, et al. Human immunodeficiency virus and hepatitis virus seroprevalence in an urban trauma population. J Trauma 1995;38:736-741.

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Prediction and Management of the Difficult Airway

The incidence of difficult airway has not been clearly delineated in the trauma population; however, up to 1% of trauma patients requiring intubation require a surgical airway and may require more than one attempt before a successful airway is secured. It is imperative that the trauma physician be able to identify patients with potentially difficult airways, and understand how best to manage them. Assessment: Up to 5% of the population may be difficult to oxygenate via bag valve mask (BVM) these patients should undergo rapid sequence induction only when absolutely necessary. Risk factors that predict that a patient will be difficult to bag include: BMI >26 kg/m2 Absent teeth Presence of a beard Age >55 years Prior to attempting endotracheal intubation, one should examine the patients mouth opening, dentition, thyromental distance, and tongue size. Factors associated with difficult intubation include: Massive facial or neck trauma Receding mandible (<3 finger-breadths from mandibular symphysis to hyoid bone) Short, thick neck (<3 finger-breadths from sternal notch to thyroid cartilage) Narrow mouth opening Large or immobile tongue Immobilized cervical spine Inspiratory stridor suggesting upper airway compromise

Management: Failed intubation in a patient that has also failed BVM requires a prompt surgical airway. Laryngeal mask airway (LMA), or transtracheal jet ventilation (TTJV) are temporary measures that may serve as a bridge to creation of a definitive airway. LMASize 4 is used for adults <70kg, and size 5 for >70kg. The LMA rests in the hypopharynx over the laryngeal opening, and does not require visualization of the cords. Supraglottic pathology may preclude placement. The LMA does not separate the respiratory and alimentary tracts, and thus carries a risk of aspiration, particularly in pregnant or obese patients. LMA is unreliable at delivering high pulmonary pressures, and ventilation may be compromised. TTJVrequires placement of a 12-16 gauge catheter through the cricothyroid membrane and attachment to a high pressure (50psi) oxygen source. One-second inspiratory time followed by 4 seconds for exhalation should be given. CricothyroidotomyDefinitive airway (does not mandate conversion to tracheostomy) using a 6-mm cuffed ETT or a 4-6 tracheostomy tube. Pediatric patients (<12 years old), or patients with a laryngeal fracture should undergo tracheostomy.

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1. 2. 3. 4. 5.

Blanda M, Gallo UE. Emergency Airway Management. Emerg Med Clin North Am. 2003 Feb; 21(1): 1-26. Pollack CV. The laryngeal mask airway: a comprehensive review for the emergency physician. J Emerg Med. 2001 Jan; 20(1): 53-66. Butler KH, Clyne B. Management of the difficult airway: alternative airway techniques and adjuncts. Emerg Med Clin North Am. 2003 May; 21(2): 259-89. Wright MJ, Greenberg DE, Hunt JP, et al. Surgical cricothyroidotomy in trauma patients. South Med J. 2003 May; 96(5): 465-7. Jagminas L, Auerbach PS, Cioffi WG. Airway management in the trauma patient. In Cameron, Current Surgical Therapy, ed. 7, St. Louis: Mosby, 2001: 1032-42.

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Rapid Sequence Induction: Adult

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Assemble staff, i.e., ED attending, nurse, and respiratory therapist. Continuous monitoring of BP, ECG, SaO2. Consult Anesthesiology if airway problems anticipated (i.e., short neck, facial trauma, suspicion of c-spine fracture). Prepare equipment (suction, ETT with syringe, end-tidal CO2 device, stylet, laryngoscope, ambu bag, mask, oral/nasal airways). Examine airway, check anatomy (be ready to hand ventilate patient if airway problem). Pre-oxygenate patient with 100% O2. Bag mask ventilation PRN. Consider Lidocaine 1 mg/kg IV push (preferably 1-2 minutes before induction) in the setting of suspected elevated intracranial pressure. Inducing agent: Thiopental 2-3 mg/kg IV or Etomidate 0.3 mg/kg IV. Have 1 mg Atropine at bedside (to reverse bradycardia). Apply cricoid pressure. Paralyzing dose of Succinylcholine 1.5 mg/kg IV or Rocuronium 0.9 mg/kg IV (in patients with suspected head injury). Wait until full paralysis (60 seconds). Check eyelid/jaw. Inline cervical immobilization of potential C-spine injury. Intubate orally. Confirm ETT position with end tidal CO2 monitor. Release cricoid pressure after balloon is inflated. Consult Anesthesiology if airway problems. Consider long-term paralysis with Pavulon 0.1 mg/kg IV along with longer acting sedative such as lorazepam (Ativan) 0.5-2 mg/IV.

*Avoid succinylcholine if > 24 hours post burn, > 7 days post crush, hyperkalemia, penetrating eye injuries, CVA, rhabdomyolysis, neuromuscular disease, or family history of malignant hyperthermia.
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Rapid Sequence Induction: Pediatric

1. 2. 3. 4. Assemble staff, i.e., ED attending, nurse, and respiratory therapist. Continuous monitoring of BP (rapid cycling), EKG, pulse oximetry. Consult Anesthesiology if airway problems anticipated (i.e., short neck, facial trauma, high index of C-spine fracture). Prepare and assemble equipment: Tonsil tip/Yankauer suction ETT-appropriate suction catheter 2 suction systems at head Range of ETT sizes and stylet, ETT size = (age in years/4) + 4, and 1 larger and smaller ETT Consider cuffed ETT even in infants Laryngoscope and light Bag-valve mask and range of mask sizes Oral airway (length = angle of mandible to corner of mouth) Syringe (to inflate ETT cuff) Tape End-tidal CO2 device (capnograph or easy cap) 5. 6. 7. 8. 9. Evaluate airway: Facial, cervical, laryngeal trauma/congenital anomalies. Consult anesthesiologist and/or surgeon (cricothyroidotomy) PRN. Pre-oxygenate patient with 100% O2. Assess chest rise. If patient is not breathing spontaneously: cricoid pressure and bag mask ventilation. Evaluate and establish intravenous access. Have Atropine available (to reverse bradycardia). Maintain in-line C-spine immobilization.

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10. Sedation and muscle relaxation: Administer in rapid succession one drug from each category: Category Vagolytic Drug
Atropine

Dose 0.02 mg/kg IV

Comments
Minimum dose: 0.1 mg Consider in patients <8

years old to block laryngoscopy induced bradycardia Intracranial Antihypertensive Sedative

Lidocaine

1 mg/kg IV push Give when increased ICP is known or suspected 0.1-0.4 mg/kg IV Less CV effects than thiopental, titrate dose effect (doses > 0.3 mg/kg needed for anesthesia) 0.3 mg/kg IV Decreases ICP, essentially no CV effects 1-2 mg/kg IV Bronchodilator but increases ICP, BP and HR 1-2 mg/kg IV Decreases ICP but may decrease BP and HR 1 mg/kg IV
May have slower onset

Midazolam

Etomidate Ketamine

Thiopental

Paralytic

Rocuronium

Succinylcholine 1-2 mg/kg IV

of action (30-90 vs 30-60 seconds) and is longer acting (28-60 vs 3-*12 minutes) than succinylcholine Contraindications: glaucoma, penetrating eye injuries, neuromuscular disease, FHx malignant hyperthermia or pseudocholinesterase deficiency, patients with sever burns, crush injuries, or hyperkalemia

11. Maintain cricoid pressure. Await full paralysis (check eyelid reflex, jaw). 12. Intubate orally. Depth of intubation: age (years) / 2 + 12 or 3 x ETT size. 13. Confirm ETT placement with end-tidal CO2 device (capnograph or easy cap), auscultation, and if time permits, a CXR. 14. If unsuccessful and O2 saturation <90%, remove ETT and mask ventilate. Return to #6.
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Intravenous Access and the Trauma Patient

Attention to detail is the hallmark of excellent surgical care, whether it takes place in the emergency department (ED), operating room (OR), intensive care unit (ICU), or ward. This attention to detail extends to seemingly trivial matters including intravenous (IV) access. 100% of trauma patients undergo placement of an IV catheter, with many receiving central venous lines. Unfortunately, IV access related complications are common and by and large are preventable. The following recommendations should be observed in order to minimize line-related complications and decrease the risk of superficial thrombophlebitis, cellulitis, catheter-related bloodstream infections, sepsis and septic shock, DVT/PE and death. 1. All lines placed in the field, ED or OR are considered suspect and should be replaced as soon as feasible. Exceptions include central lines placed utilizing full barrier precautions (see below). The preferred site of central access in an unstable (hemodynamically abnormal) trauma patient is the femoral vein, while the preferred site in a stable (hemodynamically normal) patient is the subclavian vein.1-2 a. In the acute setting large-bore IV access above AND below the diaphragm is desirable. Large-bore (14 or 16 gauge) peripheral IV cannulas are recommended for upper access. b. Femoral access should be utilized with caution in unstable patients with severe pelvic fractures or likely vena caval injuries. c. Patients with suspected cardiogenic shock or in need of central venous pressure monitoring should have a subclavian or internal jugular venous central line placed. ALL central lines should be placed under full barrier precautions defined as sterile gown and gloves, cap and mask, and FULL draping (3/4 sheet, lap drape, etc). Chlorhexidine is the preferred prep agent and is available as a ChloraPrep stick on most central line kits. Cap and masks are recommended for those nearby (i.e. bedside RN), while full barrier precautions should be observed by those assisting.1-3 All TICU patients who have a central line placed should have ALL peripheral IV cannulas removed in order to decrease the incidence of thrombophlebitis as well as save the veins for IV insertion upon transfer from the TICU so that central venous access can be discontinued in floor-level care patients. Central lines should be dressed with clear adhesive dressings unless the site is bleeding, or the patient is diaphoretic, in which the preferred dressing is sterile gauze. Chlorhexidine-impregnated disks have been shown to reduce line infections threefold in a PRCT.3

2.

3.

4.

5.

1. Mermel LA, et al. Am J Med 1991, 91:197S-205S. 2. Goetz AM, et al. Infect Control Hosp Epidemiol 1998, 16:842-5. 3. www.CDC.gov/mmwr/PDF/rr/rr5110.pdf

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Resuscitation Guidelines
The traditional endpoints of resuscitation include normal blood pressure, heart rate and urine output. However, after normalizing these parameters, up to 85% of severely injured trauma patients still have evidence of inadequate tissue perfusion. This condition is described as compensated shock.1 The initial base deficit (BD) and serum lactate (LA) are reliable indicators of the need for ongoing resuscitation.2,3 Furthermore, the time to normalization of these parameters is predictive of multiple organ failure (MOF) and survival. Consequently, expeditious evaluation of life and limb threatening injuries and early aggressive resuscitation are warranted. In addition to hemodynamic compromise, other factors that have been identified as independent predictors of MOF are age > 55 years, injury severity score (ISS) >25 and transfusion of more than 6U of red blood cells in the first 12 hours.4,5 High-risk patients are defined as follows: ISS>25

High-Risk

Transfusion >6U in 12 hours Age>55 and ISS>15 Age>70 and ISS>9

High-risk patients should have an arterial blood gas and lactate level measured early during their ED course. These high-risk patients should be fast-tracked through the ED and brought up to the TICU as soon as possible. Non-essential imaging should not delay this process.

If patient is not responding to intervention consultation with trauma attending is imperative. Keep in mind that over-aggressive resuscitation may be associated with morbidity.6
1. Scalea TM, Maltzs, Yelon J, et al. Resuscitation of multiple trauma and head injury: role of crystalloid fluids and inotropes. Crit Care Med 1994:20:1610-1614. 2. Rutherford EJ, Morris JA, Reed GW, et al. Base deficit stratifies mortality and determines therapy. J Trauma 1992; 33:417-423. 3. Davis JW, Parks SN, Kaups KL, et al. Admission base deficit predicts transfusion requirements and the risk of complications. J Trauma 1996;41:769-774. 4. Sauaia Am Moore FA, Moore EE, et al. Early predictors of postinjury multiple organ failure. Arch Surg 1994;129:39-45. 5. McKinley BA, Kozar RA, Cocanour CS, et al. Normal versus supranormal oxygen delivery goals in shock resuscitation: the response is the same. J Trauma 2002;53:825-832. 6. Balogh Z, McKinley BA, Cocanour CS, et al. Supranormal trauma resuscitation causes more cases of abdominal compartment syndrome. Arch Surg 2003;138:637-643.

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Hypothermia: Pediatric and Adult

1. Hypothermia Protocol The severity and treatment of hypothermia depends on core body temperature, cardiac rhythm and associated injuries. Moderate, severe or extreme hypothermia ( 32 C, or 90 F) by rectal or vesical thermistor bladder catheter, and confirmed esophageally (core temperature); or any hypothermia with cardiac arrest should prompt activation of hypothermia protocol: Notify Trauma Team/Pediatric Surgery Service (Code Yellow Level I) ED physician notifies O.R. desk to activate bypass protocol: operating room set-up, cardiac anesthesiologist, perfusion team and cardiac/bypass surgeon

2.

Definitions of Hypothermia Mild 32 - 35 C Moderate Severe Extreme 28 - 32 C 25 - 28 C < 25 C

90 - 95 F 82 - 90 F 77 - 82 F < 77 F

3.

Core Rewarming a. Indications Moderate hypothermia (28 - 32 C) with any perfusing cardiac rhythm or Severe hypothermia (25 - 28 C) with stable cardiac rhythm* b. Initial Management CBC, serum glucose + electrolytes + BUN/Crea + Ammonia, PT/PTT, Fibrinogen, ABG, T&C for 2 U of PRBC Temperature monitoring by esophageal and bladder thermometers Ambient temperature at 32 C (90 F) Contact rewarming (Bair Hugger ) Warmed humidified oxygen by mask (40 C) or ET tube (40 - 50 C) Intravenous fluids: 40 C by Level l re-warmer Nasogastric tube; lavage with NS at 40 C Bladder catheter; lavage with NS at 40 C Allow dwell times of 5-10 minutes to maximize heat exchange during lavage If rewarming < 1 C/15 minutes: add (choice and order at discretion of ED/Trauma team) Peritoneal lavage with NS at 40 C Bilateral tube thoracostomy and pleural lavage with NS at 40 C

4.

Cardiopulmonary Bypass Rewarming a. Indications Moderate (28 - 32 C) or severe (25 - 28 C) hypothermia, with cardiac arrest or unstable cardiac rhythm* Extreme hypothermia (< 25 C)

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Moderate or severe hypothermia, managed with core rewarming, who develops cardiac arrest or who remains hypothermic and fails to regain stable cardiac rhythm* and adequate perfusion after 30 minutes of core rewarming.

b.

Exclusion from Cardiopulmonary Bypass Only at the discretion of the Trauma team and Bypass team, such as Severe injury not compatible with life Immobile frozen body Initial Management The treatment of choice in these select patients is cardiac bypass. CPR Do not delay bypass to attempt core rewarming in ED ED rewarming continues until OR is ready for patient Full volume resuscitation CBC, serum glucose + electrolytes + BUN/Crea + Ammonia, PT/PTT, Fibrinogen, ABG, T&C for 2 U of PRBC Nasogastric tube, bladder catheter Arterial line Temperature monitoring by esophageal and bladder thermometers Transfer to OR/bypass ASAP Full systemic anticoagulation to maintain activated clotting time at 450480 sec, unless absolute contraindication (severe associated trauma) - at discretion of the bypass team Intravenous antibiotics: e.g., Cefazolin Patient < 20 kg: consider immediate median sternotomy and central (atrial-aortic) bypass Patient > 20 kg: Cannulation of femoral artery and vein - cannulas appropriate for patient size Median sternotomy and atrial-aortic bypass if inadequate rewarming or flow, cardiac arrest, or at discretion of bypass team Rewarming rate: 0.5-1.0 C/minute

. c.

d.

Core temp > 37 C and spontaneous-stable cardiac rhythm and weanable

to mechanical respirator

Bypass termination when:

Severe injury incompatible with life (pronounce dead) Failure to wean from bypass (pronounce dead)
*Bradycardia alone does not constitute an unstable cardiac rhythm in hypothermic patients. Rev. 7/20/07

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Severe Head Injury (GCS 3-8)

Trauma causes 150,000 deaths in the United States each year, about half due to fatal head injuries. Not all neurologic damage occurs at the moment of injury; further injury can occur over the ensuing hours and days. Early goals of therapy are to evacuate surgically correctable intracranial mass lesions and avoid secondary brain injury by protecting brain perfusion by meticulous critical care. Patients should be evaluated, resuscitated and treated according to ATLS guidelines (1o and 2o survey). A majority of patients with severe closed head injury can be managed with relatively simple, but meticulous care. They will be referred to as 1st Tier Therapies (Table). Patients with more severe injury need more aggressive therapy. This will be called 2nd Tier Therapies. (Figure) In patients who are not responding to therapy, repeat CT scans early can be considered to detect delayed/ undiagnosed or evolving injury. Status epilepticus and need for EEG should also be considered. Table: 1st Tier Therapy for Closed Head Injury Endotracheal Intubation / Mechanical Ventilation. Target SaO2 > 90%, PaCO2 35-40 mmHg* Euvolemic Resuscitation consider CVP / PA Catheter ICP Monitoring EVD for drainage# Seizure Prophylaxis (Phenytoin 1g load, 300 mg/day x 7 days) Normothermia Euglycemia Stress ulcer, DVT prophylaxis Short-acting sedatives / analgesics Head of bed 30o

* There is no role for prophylactic or prolonged hyperventilation to decrease ICP. Temporary hyperventilation may be considered in acute neurologic deterioration.
#

Some patients with a GCS < 8 may not need an EVD. Young (age < 40), hemodynamically stable (SBP > 90) patients with normal CT scans on admission can be observed and followed clinically without an EVD.

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Figure: 2nd Tier Therapy

1. 2. 3. 4. 5. 6. 7. 8.

Brain Trauma Foundation, American Association of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care: Guidelines for the management of severe head injury. J Neurotrauma 1996;13:641-734. Muizelaar JP, Marmaron A, Ward JD, et al. Adverse effects of prolonged hyperventilation in patients with severe head injury; a randomized clinical trial. J Neurosurgery 1991;75:731-739. Temkin NR, Dikmen SS, Wilensky AT, et al. A randomized, double blind study of phenytoin for the prevention of post-traumatic seizures. N Engl J Med 1990;323:497-502. Doyle JA, Davis DP, Hoyt DB. The use of hypertonic saline in the treatment of traumatic brain injury. J Trauma 2001;50:367-383. Clifton GL, Miller ER, Choi SC. Lack of effect of induction of hypothermia after acute brain injury. N Engl J Med. 2001;344:556-63. Rosner MJ, Rosner SD, Johnson AH. Cerebral perfusion pressure: management protocol and clinical results. J Neurosurg. 1995;83:949-62. Robertson CS. Management of cerebral perfusion pressure after traumatic brain injury. Anesthesiology 2001;1995:1513-7. Whitfield PC, Patel H. Bifrontal decompressive craniectomy in the management of posttraumatic intracranial hypertension. Br J Neurosurg 2001;15:500-7.

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Pediatric Severe Head Injury

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References 1. Guidelines for the acute medical management of severe traumatic brain injury in infants, children and adolescents. Chapter 17. Critical pathway for the treatment of established intracranial hypertension in pediatric traumatic brain injury. J Trauma 2003;54:S300-S302. Rev. 8/10/07

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Reversal of Anticoagulation in Patients with Intracranial or Spinal Bleeding

In an effort to streamline emergency care of patients with neuro trauma who are on wafarin (Coumadin) and antiplatelet agents, the following guidelines should be followed in the Emergency Department. 1. 2. 3. Neurosurgery or Spine should be informed of all CT scans demonstrating intracranial or spinal trauma in patients taking warfarin or antiplatelet agents. A STAT CBC, type and screen, and coagulation profile should be obtained. For patients who are taking warfarin (Coumadin): a. The blood bank should be contacted and two units of AB FFP should be requested utilizing the Trauma AB plasma protocol and the Emergency Release Form for Blood and Blood Components should be completed. b. The two units of Trauma FFP should be available for pick up in about 15-minutes. c. Additional type specific FFP should be ordered and transfused at a dose of 15mL/kg (less the volume of the two Trauma AB units). This infusion should take no more than 1 hour. 1. Watch for pulmonary edema with the administration of large volumes of FFP. d. Vitamin K 10mg i.v. should be administered as soon as possible. e. At the completion of the FFP infusion, repeat a STAT coagulation profile and calcium level. For patients who are on antiplatelet agents: a. A 5-pack of platelets should be requested from the blood bank and administered as soon as possible regardless of the measured platelet count. These agents induce thrombasthenia which is a functional platelet defect NOT reflected by the platelet count! b. Due to the long half-life of clopidogrel it may be necessary to give additional platelets in 1-2 hours for those patients undergoing invasive procedures. c. Repeat platelet counts are not helpful but a bleeding time determination may be considered if ongoing platelet dysfunction is suspected.

4.

n.b. Recombinant Activated Human Factor VII (NovoSeven) should be considered for use in the setting of severe coagulopathy and evolving neurological deficits that may require surgical intervention. Consult with Trauma Attending and Neurosurgery/Spine service prior to use. NovoSeven doses of 20-40mcg/kg have been reported in the literature for the reversal of anticoagulation in patients with neurotrauma1-2.
1. 2. Sorensen B, Johansen P, Nielsen GL, et al. Blood Coagut Fibrinolysis 2003, 14:469-477 Lin J, Hanigan WC, Tarantino M, et al. J Neurosurg 2003, 98:737-740

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C-Spine Evaluations in Adult Trauma Patients

The rate of missed cervical spine injuries with plain films alone is unacceptably high1, thus the imaging study of choice in blunt trauma patients should be CT imaging. Initial evaluation of the patient will place the patient in one of three categories: 1) Awake and able to cooperate with physical examination. Assess for one of the following (NEXUS Criteria2) a) Examine for midline neck tenderness. b) Focal neurological deficit. c) Distracting injury. d) Intoxication with drugs or alcohol. e) Central neurological deficit defined as GCS <15. If none of the above is present Clinical examination is acceptable. Examine for midline tenderness If present, obtain CT scan cervical spine. If patient is non-tender then passive flexion-extension, rotation & axial loading should be performed. If the patient remains without pain, and without focal neurological deficit then the cervical spine is deemed cleared and the collar may be removed. Exam findings, date, and time should be documented in the medical record. If any one or more of the above is present Proceed to CT scan imaging of the cervical spine.

2) Non-Obtunded but with obvious distracting injury or alteration in cognition A distracting injury has been defined as any injury to the head, neck, chest or upper extremity, or an injury that is so painful that it requires such doses of analgesics that the patient is unable to co-operate with a clinical examination3. An alteration in cognition is defined at a GCS <15. In either case CT of the cervical spine. 3) Obtunded patient CT scan of complete Spine Cervical, thoracic, lumbar and sacral with reconstruction. If there is absolutely no evidence of bony injury or mal-alignment of the cervical spine on CT scan Remove the collar. If there is any anomaly on the CT scan Consult spine services. o If ligamentous injury is suspected, the spine service may request a cervical MRI or perform passive real-time flexion-extension imaging at their discretion. The collar should remain in place until the spine consultant documents that it may be removed. Note This is a protocol and deviations from the above including obtaining plain films, flexion-extension or MRI, may be undertaken at the discretion of the Trauma attending or spine surgeon. DISCUSSION Role of plain film radiography Plain films are reported to miss 55% of clinically significant cervical spine fractures when compared with multi-slice CT scan imaging1. Up to one third of patients with an
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injury on plain films will have a second cervical spine injury detected by CT scan but missed by plain films. CT Versus MRI The concern for cervical ligamentous injury arose from a finding of cervical spine instability seen on flexion-extension views in 0.1-0.5% of patients who had normal plain films4. This was compounded by studies which relied on older generation CT scans. A multi-slice CT scan with reconstructions that shows no fractures obviates the need for MRI scanning. In general, the most common ligamentous injury discovered by MRI in comatose patients with a normal CT scan is a single column posterior ligamentous complex disruption, which is clinically insignificant and doesnt require operative intervention. Mucha advocated for the use of MRI as the gold standard5, however many problems exist with this study since the meta-analysis included only 5 studies, who were CT scanned before the advent of multi-slice CT scanning or underwent plain films alone. Two of the studies were from the same institution with overlapping patients. Thus it is erroneous to conclude that MRI is the gold standard for trauma patients with a potential cervical spine injury. Tomycz6 reported a 4 year experience of 690 CT and MRIs in blunt trauma patients and found no significant injury by MRI when the CT scan was normal. They concluded that MRI does not add any clinical value in the setting of a normal CT scan. Schuster also found that MRI revealed no occult unstable injuries when the CT scan was normal, including 12 comatose patients who were moving all four extremities on arrival. Hogan found seven acute injuries on MRI that were missed by CT, however none of the injuries were deemed unstable7. Most recently, Como reported that C-spine MRI, did not change management or reveal findings requiring continued collar immobilization in the setting of a normal cervical CT scan8. Stelfox also reported no missed injuries with a helical CT scan when compared to MRI and CT scan, as long as the helical CT scan didnt suggest an abnormality9. Keeping patients in collars awaiting MRI has been associated with increased morbidity, including pressure sore from the collar (6.8%) and higher rate of delirium (49% versus 27% p=0.03). Soft Collars There is little role for the use of a soft collars at any time during the patients work-up or treatment, whether an injury has been identified or not.
1. Mathen R, Inaba K, Munera F, et al. Prospective evaluation of multi-slice computed tomography versus plain radiographic cervical spine clearance in trauma patients. Journal of Trauma 2007;62(6):1427-31. 2. Hoffman J, Mower W, Wolfson A, Todd K, Zucker M, NEXUS. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. New England Journal of Medicine 2000;343:94-9. 3. Heffernan D, Schermer C, Lu S. What defines a distracting injury in cervical spine assessment? Journal of Trauma 2005;59(6):1396-9. 4. David J, Kaups K, Cunningham M, et al. Routine evaluation of the cervical spine in head-injured patients with dynamic fluoroscopy: A reappraisal. Journal of Trauma 2001;50(6):1044-7. 5. Muchow R, Resnick D, Abdel M, Munoz A, Anderson P. Magnetic resonance imaging (MRI) in the clearance of the cervical spine in blunt trauma: A meta-analysis. Journal of Trauma 2008;64(1):179-89. 6. Tomycz N, Chew B, Chang Y-F, et al. MRI is unnecessary to clear the cervical spine in Obtunded/Comatose trauma patients: The four year experience of a level 1 trauma center. Journal of Trauma 2008;64(5):1258-63. 7. Hogan G, Mirvis S, Shanmuganathan K, Scalea T. Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: Is MR imaging needed when multi-detector row CT findings are normal Radiology;237(1):106-13. 8. Como J, Thompson M, Anderson J, et al. Is magnetic resonance imaging essential in clearing the cervical spine in obtunded patients with blunt trauma? Journal of Trauma 2007;63(3):544-9. 9. Stelfox H, Velmahos G, Gettings E, Bigatello L, Schmidt U. Computed tomography for early and safe discontinuation of cervical spine immobilization in obtunded multiply injured patients. Journal of Trauma 2007;63(3):630-6.

Rev. 6/20/08

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C-Spine Clearance: Pediatric

During the initial evaluation of an emergency department patient by the treating physician, he/she will be placed into one of three categories regarding probability of an injury to the cervical spine. Radiographic evaluation alone is not sufficient to determine if a child has a cervical spine injury. This categorization will be determined by a careful history and physical exam rather than whether or not the patient arrives with cervical immobilization. If there is any question, it is best to err toward the more severe category. Cervical spine risk categorization and ordering of spine x-rays may only be done by a physician. PGY 3, more senior Surgery resident, ED resident, Surgery Attending or ED Attending must verify placement in Category III.

Category I A neck injury sufficient to cause a spinal injury may have occurred.
Example: A patient with impaired consciousness or communication, involved in a motor vehicle crash or fall, with evident head trauma, multiple injuries, complaints of severe neck pain, or any neurologic deficit.

Category II There is a history of neck injury, but with a mechanism unlikely to result in an unstable cervical spine injury. Some complaints or physical findings may be present.
Example: An alert, cooperative individual with some pain on motion, spasm, and/or tenderness, but no neurologic findings.

Category III No history, mechanism of injury or physical finding suggests a cervical spine injury.
Example: The patient is alert, has no complaint of neck pain, no tenderness, no head or facial injury or other distracting injuries, and demonstrates a full, pain-free range of neck motion.

Procedure The cervical spine must be evaluated first for all patients.
If the patient falls into Category II or III, the physical exam should be continued to evaluate the thoracic and lumbar spines before x-rays are obtained. Patients placed in Category I will have initial cervical spine x-rays taken and will be evaluated before x-ray examination of the thoracic and lumbar spines. Remember: In children under 2 years of age, physical exam is unreliable. Therefore, a high index of suspicion is necessary (e.g., mechanism of injury). Also, incidence of spinal cord injury without radiographic abnormality (SCIWORA) is more common in children than in adults.

Category-Based Radiographic Evaluation of the Cervical Spine in Emergency Patients Category I

A supine lateral C-spine (with or without swimmer's view, as required to see the cervicothoracic junction), AP, and open mouth view will each be taken while the patient remains immobilized for children over 5 years of age. For children 5 years of age and under, an exaggerated waters view film replaces the open-mouth view film. Trauma oblique views, flexion/extension views, and/or CT scans of areas in question may be obtained at the discretion of the radiologist or treating physician.

Category II
Patients who arrive with a cervical collar in place and who have no other injuries that prevent sitting should have an erect lateral c-spine x-ray taken with the collar on. This film must be evaluated by the PGY 3 or greater emergency or trauma resident, the ED or Surgical attending, or the Radiology resident followed by supine AP and open mouth views out of the collar. If the patient arrives without a collar, place the patient in a collar prior to sending to x-ray. Trauma oblique views, flexion/extension views, and/or CT scans of areas in question may be obtained at the discretion of the radiologist or treating physician.
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Category III
No x-ray of the cervical spine is indicated.

Management Initial Treatment of Spine-Injured Patients.

Patients who are categorized as I or II will have their initial x-rays evaluated by the radiologist and treating physician. The decision to discontinue immobilization will be made by the PGY 3 resident or above or the ED attending physician. It will be documented in the notes. If positive findings are noted, the Spine Service should be notified immediately. Only a physician can remove cervical collars on pediatric trauma patients. This will encourage residents to perform a clinical exam at the time of collar removal and it will eliminate concerns relating to telephone and verbal orders for collar removal to the nursing staff.

Consultation of Spine Service

There are two arms to the team a neurosurgical arm and an orthopaedic arm involved in the management of pediatric spine injuries. Either the Trauma Service or the Emergency Department will consult the Spine Service if there is any suspicion of pediatric spine or spinal cord injury. Every time a consultation is requested for suspected spine injury, the Neurosurgical Service and the Orthopaedic Service will communicate directly with one another in all cases. These opinions will be given to the leader of the managing team, which in most cases will be the Trauma Service. These consultations will be rendered within 2-3 hours of request and will not be delayed beyond that time. It is our intent that all cervical spines that can be cleared will be done so within 6 hours of presentation to the Emergency Department or Trauma Service except in comatose patients. Since static plain radiographs may be negative and flexion/extension x-rays may not be possible, a soft collar may be requested by the treating physician until the spine can be cleared with flexion/extension x-rays or MRI. If Neurosurgical and Orthopaedic opinions concur, the treatment plan will be promptly instituted. If there is a discrepancy between the two opinions, the Neuro-surgical and Orthopaedics teams will resolve the difference. Both teams will follow their internal chains of command, although complex decisions will often be made at the highest level of the chain. Because many of these patients will be admitted to the PIC, the Pediatric Intensive Care Team involved must also be notified of the Spine Services opinion. Therefore, it is the responsibility of the individual consultant teams to not only document in the chart but also to communicate directly with the trauma team, as well as the PIC staff, when patients are transferred to that unit. The Pediatric Spine Service, depending on the constellation of injuries and the best interest of the patient, will decide subsequent referral of the patient to the Pediatric Neurosurgical or Pediatric Orthopaedic Service. Both services will continue to see all patients admitted with spinal injury throughout the period of admission. If spinal surgery is required on any pediatric patient, it will be performed utilizing a team approach, again with Neurosurgical or Orthopaedic leadership, depending on the needs of the patient. This Pediatric Spine Service will be responsible for nursing education regarding the management of pediatric spine injury as well as the education of other involved surgical and medical services.
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Thoracic / Lumbar / Sacral (TLS) Spine Clearance in the Trauma Patient

Thoracic spine fractures occur at about the same rate as cervical spine fractures 2-5% of the blunt trauma population. While the majority of these patients present with pain and tenderness, a significant minority (which can approach 20%) do not have associated pain and tenderness at presentation. This may be due to a decrease in sensorium or distracting major injuries, which preclude a reliable physical examination. While the vast majority of patients with vertebral fractures who develop neurologic deficits will have them at the time of presentation in the trauma room, a few will develop them in a delayed manner. The purpose of these guidelines is to increase our detection of subtle TLS fractures and possibly prevent the development of late-onset neurologic sequelae. All patients with blunt injury should be suspected of having a cervical or thoracic spine injury. The cervical spine should be cleared according to our established protocol and the thoracic spine should be cleared as outlined. All patients should be kept on spine precautions, which include in-line immobilization of the cervical and upper thoracic spine during any procedures and logrolling. Only after the patient has had an evaluation as outlined and is without a TLS fracture should spine precautions be discontinued.

1. Cooper C, Dunham CM, Rodriquez A. Falls and major injuries are risk factors for thoracolumbar fractures: Cognitive
impairment and multiple injuries impede the detection of back pain and tenderness. J Trauma 1995;38:692-696. 2. Meldon SW, Moettus LN. Thoracolumbar spine fractures: Clinical presentation and the effect of altered sensorium and major injury. J Trauma 1995;39:1110-1114. 3. Reid DC, Henderson R, Saboe L, et al. Etiology and clinical course of missed spine fractures. J Trauma 1987;27:980-6. 4. Samuels LE, Kerstein MD. Routine radiologic evaluation of the thoracolumbar spine in blunt trauma patients: A reappraisal. J Trauma 1993;34:85-89.

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Standard Neurological Classification of Spinal Cord Injury

MOTOR
R L KEY MUSCLES

C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 `S1 S2 S3 S4-5

Elbow flexors Wrist extensors Elbow extensors Finger flexors (distal phalanx of middle finger) Finger abductors (little finger)
0 = total paralysis 1 = palpable or visible contraction 2 = active movement, gravity eliminated 3 = active movement, against gravity 4 = active movement, against some resistance 5 = active movement, against full resistance NT = Not testable

Hip flexors Knee extensors Ankle dorsiflexors Long toe extensors Ankle plantar flexors

Voluntary anal contraction (Yes/No) MOTOR SCORE

TOTALS
maximum 50

+
50

=
100

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Penetrating Neck Trauma

The optimal management of penetrating neck injury has been debated for the past 40 years. Early reports, influenced by military experience, recommended a policy of mandatory neck exploration. Given the anatomical proximity of critical structures in the neck and the disastrous potential of innocuous appearing injuries, many surgeons adopted this approach. On the other hand, the policy was questioned in civilian practice, driven by economic considerations and resistance to unnecessary surgery in 40-60% of patients. Selective management protocols have become widely accepted. Current debate focuses on the role of ancillary diagnostic tests in selective management protocols as the vast majority (>95%) of significant injuries are symptomatic.1-4 The debate continues because there has not been a definitive study proving that one approach is superior or more cost effective compared with another. The goal of this management guideline is to encourage timely exploration in symptomatic patients and to obtain appropriate diagnostic studies in asymptomatic patients. The critical maneuver in the management of these patients is the physical examination, as all decisions are made based on physical findings. There are several principles to bear in mind: 1. 2. 3. 4. Attending presence is required for GSW to the neck (and pediatric SW). Attending notification is required for SW to the neck. Penetrating neck wounds should not be probed. An adequate surgical exploration involves visualizing the wound tract, exploring the carotid sheath, and fully mobilizing the trachea and esophagus if there are signs of aerodigestive injury or if the trajectory of the wound is in proximity of these structures. The neck is divided into three anatomic zones: Zone I - (between the clavicle and the cricoid cartilage) Zone II - (between the cricoid cartilage and angle of the mandible) Zone III - (above the angle of the mandible)

5.

PHYSICAL EXAMINATION Positive Findings Vascular Exam: Aerodigestive Exam: Active Bleeding Hemoptysis/Hematemesis Hypotension Air Bubbling Large or expanding Hematoma Subcutaneous Emphysema Pulse Deficits Carotid, Brachial/Radial Hoarseness Bruit Dysphagia Neurologic Exam: Localizing Signs: Pupils, Limbs, CNs CNs: Facial Glossopharyngeal midline position of soft palate Recurrent Laryngeal hoarseness, ineffective cough Accessory shoulder lift Hypoglossal midline position of tongue Horners Syndrome myosis, ptosis Brachial Plexus: Median fist Radial wrist extension Ulnar abduction/adduction of fingers Musculocutaneous forearm flexion Axillary arm abduction
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Angiography or CTA Bronchoscopy Esophagoscopy Esophagography

1. 2. 3. 4.

Biffl WL, Moore EE, Rehse DH, et al. Selective Management of Penetrating Neck Trauma Based on Cervical Level of Injury, Am J Surg 1997;174:678-682. Demetriades D, Theodorou D, Cornwell E, et al. Evaluation of Penetrating Injuries of the Neck: Prospective Study of 223 Patients, World J Surg 1997;21:41-48. Gracias VH, Reilly PM, Philpott J, et al. Computed tomography in the evaluation of penetrating neck trauma: A preliminary study. Arch Surg 2001;136:1231-1235. Sekharan J, Dennis JW, Veldenz HC, et al. Continued Experience with Physical Examination Alone for Evaluation and Management of Penetrating Zone 2 Neck Injuries: Results of 145 Cases. J Vasc Surg 2000;32:483-489.

Rev. 7/27/07

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Penetrating Injuries to the Heart

Clinical signs of pericardial tamponade in penetrating cardiac injuries are the exception, rather than the rule.1 Signs are: hypotension, JVD, muffled heart tones, or pulsus paradoxus. Pericardiocentesis is unreliable in the acute setting of trauma with a 20% false positive and 20% false negative rate. The most sensitive test for post-traumatic tamponade is (subxiphoid) pericardial window. This requires general anesthesia in the operating room.3 In patients who do not require general anesthesia for surgery following penetrating trauma, the best non-invasive test for cardiac or pericardial injury is twodimensional echocardiography. This test is both sensitive and specific in the patients without hemothorax (100%/89%), yet is less accurate in the setting of hemothorax (56%/93%).4,5 Penetrating cardiac injuries can occur without entrance or exit wounds in the boxinjuries to the heart can occur from a transmediastinal gunshot wound. A small retrospective study on gunshot wounds reveal that 40% of these patients present in extremis with decreased blood pressure and require emergency operation, with 1/3 of these patients having cardiac injury. Approximately 60% of these patients present in stable condition, but anywhere from 20-50% of these patients have injuries to the heart, mediastinal vessels, bronchus or esophagus that will present in a delayed fashion. Evaluation of these injuries requires workup to include echo/pericardial window, angiogram, bronchoscopy and esophagoscopy / barium swallow.6

Borders of the box are: the suprasternal notch, the nipples, the costal margin. X = wounds that produce cardiac injuries (Nagy KK, J Trauma 1995)

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Penetrating chest trauma

NO Injury within the box (see figure) YES Patients require surgery (associated trauma) YES
NO

YES Operating room, or ED thoracotomy

NO

Subxiphoid window Blood Present NO YES

Echocardiography** Positive? YES NO

Median sternotomy

Admit & observe Treat hemo-, pneumothorax R/O other intrathoracic injuries

* SBP > 90 in adults (should be adjusted for age) ** Non-availability of 2-D echo warrants consideration of pericardial window. A negative 2-D is only 60% sensitive in the presence of a pneumo/hemothorax. Clinical suspicion of cardiac injury despite initially (-) echo should prompt a repeat echo or pericardial window. A cardiology fellow is always available in the ED and should be involved for all formal echoes.
1. Asensio JA, Stewart BM, Murray J, et al. Penetrating cardiac injuries. Surg Clin N Am 1996; 76:685. 2. Moreno C, Moore EE, Majune JA, et al. Pericardial tamponade. A critical determinant for survival following penetrating cardiac wounds. J Trauma 1994; 36:229. 3. Trinkle JK, Toon R, Franz JL, et al. Affairs of the wounded heart: Penetrating cardiac wounds. J Trauma 1979; 19:467. 4. Meyer D, Jessene M, Grayburn P. Use of echocardiography to detect occult cardiac injury after penetrating thoracic trauma: A prospective study. J Trauma 1995; 39:902. 5. Nagy KK, Lohmann C, Kim DO, et al. Role of echocardiography in the diagnosis of occult penetrating cardiac injury. J Trauma 1995; 38:859. 6. Richardson JD, Flint LM, Small MJ, Gray LA, Trinkle JK. Management of transmediastinal gunshot wounds. Surgery 1981; 90:671-676.

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Transmediastinal Gunshot Wounds (TMGSW)

Transmediastinal trajectory of a bullet should be considered in the following situations: 1. Entry and exit wounds on opposite sides of the thorax. 2. Single entry wound with x-ray demonstrating a missile on opposite side of the thoracic cavity or in close proximity to the mediastinum. 3. Multiple gunshot wounds to the thorax. The mediastinum contains the heart, great vessels, trachea and esophagus as well as major venous and neural plexuses. Significant injury especially to heart or great vessels often result in prehospital death or hemodynamic instability. There is little controversy regarding the management of unstable patients they should have emergent thoracotomy. However, stable patients could harbor occult injuries to critical mediastinal structures (heart, great vessels, trachea, esophagus). Consequently, patients have routinely been submitted to a battery of invasive diagnostic tests: echocardiography or subxiphoid pericardial window, arch aortography, bronchoscopy, esophagoscopy and/or esophagography.1 The latter two have been employed together in order to improve upon the sensitivity of each individual test. This array of tests can be expensive and time consuming. Furthermore, only a small percentage of hemodynamically stable, asymptomatic patients have clinically significant injuries.2 Helical CT of the chest has proven useful in demonstrating the trajectory of missiles in the thorax. 3,4 In the setting of a potential TMGSW, a CT scan may confirm a trajectory remote from the mediastinum, obviating further testing. On the other hand, proven transmediastinal trajectory mandates further evaluation. However, rather than performing all of the aforementioned tests, the investigations may be tailored to the specific clinical scenario. Trajectory near the pericardium warrants echocardiography or pericardial window. If CT suggests aortic injury, or if the trajectory is superior to the arch, arteriography remains the gold standard (TEE cannot be considered reliable enough). Bronchoscopy is indicated for pneumomediastinum, respiratory distress or bronchopleural fistula/massive air leak. Esophagoscopy has been reported to have 100% sensitivity for thoracic esophageal injuries. 5,6 In an awake, asymptomatic patient, barium esophagography is easier to obtain and may be adequate by itself. The cervical esophagus most difficult to reliably evaluate, and so both studies are warranted.

1. 2. 3. 4. 5. 6.

Richardson JD, et al. Management of transmediastinal gunshot wounds. Surgery 1981;90:671. Renz BM, et al. Transmediastinal gunshot wounds: A prospective study. J Trauma 2000;48:416. Grossman MD. Determining anatomic injury with computed tomography in selected torso gunshot wounds. J Trauma 1998;45:446. Stassen NA, Reevaluation of diagnostic procedures for transmediastinal gunshot wounds. J Trauma 2002;53:635 White RK, et al. Diagnosis and management of esophageal perforations. Ann Surg 1992;58:112. Flowers JL, et al. Flexible endoscopy for the diagnosis of esophageal trauma. J Trauma 1996;40:261.

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Vascular Exposures
Vascular exposures can prove especially challenging in the trauma setting, where proximal and distal control must be rapidly achieved in the face of active hemorrhage. Fundamental ATLS concepts should be followed, with the caution that normotensive resuscitation may not be attainable and in fact may increase hemorrhage, if a vascular injury is uncontrolled. Thoracic Vascular Injuries Resuscitative (left anterolateral) thoracotomy is indicated in patients in extremis. Transsternal extension with a right anterolateral thoracotomy (clam shell incision) is needed to control cardiac or right-sided injuries. In unstable patients, incisions are chosen based on the presumed injury. In stable patients, the incision is based on either the presumed (clinical exam) or the proven (angiogram) location of the injury. Unstable patients should be kept in a supine position to allow quick access to other body cavities. Injured Artery Ascending Aorta/Arch Descending Aorta Innominate Left Common Carotid Subclavian First Portion (Left) Incision (Depiction) Sternotomy (1) L 5th Interspace Thoracotomy (2) Sternotomy + R Cervical Extension (1+ 3) Sternotomy + L Cervical Extension (1+ 3) L 3rd Interspace Thoracotomy (2) or Trap Door (Partial Sternotomy + L Supraclavicular + L 3rd Interspace Anterolateral Thoracotomy + Division of Clavicle) (1 + 2 + 4) Sternotomy + R Supraclavicular (1+ 3) Supraclavicular + Infraclavicular (4+ 5) Infraclavicular + Supraclavicular (5+ 4) Infraclavicular + Supraclavicular (5+ 4) + Deltopectoral Groove Extension

(Right) Second Portion Third Portion Axillary

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.
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Abdominal Vascular Injuries

Inspect the retroperitoneum and act according to the guidelines in the Table and Figures below. If, at any point, patients SBP < 60 mm Hg, either compress the aorta or clamp it at the diaphragmatic hiatus (retract stomach laterally, divide lesser omentum, dissect hiatus, apply clamp).

Explore -Zone I, Expanding, or Penetrating Hematomas Do not explore - Blunt, Non-Expanding Zone II/III Hematomas

The three zones of the retroperitoneum

Zone Ia and II L injuries are exposed with a left medial visceral rotation

Zone II R and caval injuries are exposed with a right medial visceral rotation
1. 2. 3. 4.

Zone Ib and III injuries are exposed with a direct approach

Hoyt DB, et al. Anatomic exposures for vascular injuries. Surg Clin N Am 2001; 81(6): 1299. Mattox KL, et al. Retroperitoneal vascular injury. Surg Clin N Am 1990; 70(3): 635. Feliciano DV, et al. Abdominal vascular injury. McGraw-Hill, New York. In: Mattox KL, Feliciano DV, Moore EE(eds): Trauma, 2000. Yelin AE, et al. Vascular system: 207-262. Mosby, St Louis. In: Donovan AJ(ed): Trauma surgery: techniques in thoracic, abdominal and vascular surgery, 1994.

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Truncal Stab Wounds

The purpose of this algorithm is to guide the management of patients with stab wounds to the anterior abdomen, thoracoabdominal area, back, and flank. Back/Flank stab wounds are defined as those between the tips of the scapulae and posterior iliac crests, posterior to the mid-axillary line. Physical examination alone is unreliable in this group, and DPL is unable to evaluate the retroperitoneum. Triple contrast (oral, rectal, and intravenous) CT has a sensitivity of 89-100% and a specificity of 98-100% in diagnosing intra-abdominal and retroperitoneal injuries.1-4 Thoracoabdominal stab wounds are defined as those between a circumferential line connecting the nipples and tips of the scapulae superiorly, and the costal margins inferiorly. Occult diaphragmatic injury is problematic in this patient group.5 We have selected DPL as the preferred diagnostic modality to exclude diaphragmatic injury, with a RBC cutoff of 5000/mm3 chosen to balance sensitivity and specificity.6 Anterior abdominal stab wounds are defined as those anterior to the mid-axillary line, from the xiphoid process to the pubic symphysis. Although optimal management of stable patients with AASW is debated, we have adopted a protocol of serial clinical assessments to determine the need for laparotomy. Retrospective review of RIH data suggests that this is a safe and effective approach in our institution.7 Stab wounds may fall into more than one defined region, thus a combined work-up may be required. For these type of wounds, or in the setting of multiple stab wounds, exploration may be indicated. Consider penetrating cardiac injuries with epigastric wounds (see pages 50-51).
1. Easter DW, Shackford SR, Mattrey RF, et al: A prospective, randomized comparison of computed tomography with conventional diagnostic methods in the evaluation of penetrating injuries to the back and flank. Arch Surg 1991;126:1115-9. Himmelman RG, Martin M, Gilkey S, et al: Triple-contrast CT scans in penetrating back and flank trauma. J Trauma 1991;31:852-5. 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. 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. 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. Thompson JS, Moore EE. Peritoneal lavage in the evaluation of penetrating abdominal trauma. Surg Gynecol Obstet 1981;153:861-863. Tsikitis V, Biffl WL, Majercik S, et al: Selective clinical management of anterior abdominal stab wounds. Am J Surg 2004;188,807. Nagy K, Roberts R, Joseph K, et al: Evisceration after abdominal stab wounds: is laparotomy required? J Trauma 1999;47:622-4.

2. 3.

4. 5. 6. 7. 8.

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Blunt Cerebrovascular Injuries

Blunt cerebrovascular injuries (BCVI) have historically been considered rare, yet potentially devastating events. Early series reported mortality rates of 28%, with 58% of survivors suffering permanent severe neurologic sequelae.1 Given the dearth of experience with BCVI, there is essentially no Class I literature to guide management. The fundamental mechanisms of internal carotid artery (ICA) injury include: a) cervical hyperextension/hyperflexion with rotation, stretching the ICA over the lateral articular processes of C1-C3; b) direct cervical trauma; c) intraoral trauma; and d) basilar skull fracture involving the carotid canal.1 The vertebral artery is most commonly injured from C- spine subluxation and fracture, especially of the foramen transversarium and C1-C3.2 Regardless of the mechanism, the final common pathway of BCVI is intimal disruption. This provokes platelet aggregation with subsequent embolization or thrombosis; it also allows egress of blood with dissection or pseudo-aneurysm formation. A latent period between the time of injury and the appearance of cerebral ischemia is characteristic of BCVI, and relates to the pathophysiology (i.e., platelet plug formation and subsequent embolization or occlusion). 23-50% of patients first develop signs or symptoms >12 hours after the traumatic event.1 This has led to the adoption of screening protocols in many institutions. Screening has dramatically increased the recognized incidence of BCVI, but benefit in terms of stroke reduction has not been proven.4-7 Existing data does indicate that anticoagulation improves neurologic outcomes among symptomatic patients, and may prevent stroke in asymptomatic patients.5,8 Arteriography is the gold standard for diagnosis. Duplex ultrasonography is inadequate for screening.3 We have elected to screen asymptomatic patients for BCVI at RIH. The screening test will be CTA using the 16-slice scanner in the ED. ANY ABNORMALITY will be further investigated with 4-vessel cerebral arteriography, unless there is consensus among clinicians that it is diagnostic. Our screening criteria will be: SIGNS AND SYMPTOMS OF BCVI: a) Hemorrhage- from mouth, nose, ears- of potential arterial origin. b) Large or expanding cervical hematoma (consider surgery). c) Cervical bruit in a patient <50 years old. d) Evidence of cerebral infarction on computed tomography (CT) scan. e) Unexplained or CT incongruous central or lateralizing neurologic deficit, transient ischemic attack, or Horners syndrome. RISK FACTORS FOR BCVI: a) High risk associated injuries: GCS <6, petrous bone fracture, diffuse axonal brain injury, LeFort II or III fracture, and cervical spine injury. It should be noted, however, that at least 20% of patients with BCVI have none of these injuries.3 b) Mechanism compatible with severe cervical hyperextension/rotation or hyperflexion, particularly if associated with complex facial fractures; c) Diffuse axonal injury of the brain; d) Near-hanging, seat belt abrasion, or other soft tissue injury of the anterior neck resulting in significant cervical swelling; e) Basilar skull fracture involving the carotid canal; f) Cervical vertebral body fracture or distraction injury.
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Treatment strategies and treatment-related outcomes by injury grade are as follows:5 Grade I- Intimal Irregularity; Dissection/Hematoma with <25% Stenosis: 7% stroke rate. 57% heal, 8% progress on follow-up arteriogram. No significant difference in healing or progression whether treated with heparin, anti-platelet therapy, or untreated. Use antiplatelet therapy (ASA 325mg qd) unless there is absolutely NO contraindication to heparin. Grade II- Intraluminal Thrombus; Intimal Flap; Dissection/Hematoma with >25% Stenosis: 26% stroke rate. 8% heal, 43% progress on follow-up arteriogram. Consider repair, may be complicated by extension to base of skull. Anticoagulation with heparin recommended. Consider stenting for dissections that threaten to occlude lumen. Grade III- Pseudo-aneurysm: 26% stroke rate. Rare healing with anticoagulation, although it may prevent strokes. Repair if surgically accessible. Consider endovascular therapy for inaccessible lesions, but wait several days for injury to stabilize. Grade IV- Occlusion: 35% stroke rate (50% in ICA). Rare re-canalization with anticoagulation, but it may prevent stroke (all strokes were in untreated patients). Consider repair, but it may be complicated by extension to base of skull. Grade V- Transection: 100% stroke rate, mortality. Endovascular therapy may be the only useful intervention. Therapy should be individualized. Anticoagulation should be held until there is no presumed risk of intracranial or other life-threatening hemorrhage. Anti-platelet therapy may be a reasonable alternative to systemic heparin.11 Drugs of choice are heparin (no bolus; 15 U/kg/hr to target PTT 40-50 sec) or anti-platelet therapy (clopidogrel 75 mg qd or aspirin 325 mg qd). Anticoagulation should be administered following stenting. Follow-up arteriography is performed within 7-10 days, to evaluate efficacy of the initial therapy and plan further interventions.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Biffl WL et al. Blunt cerebrovascular injuries. Curr Prob Surg 1999; 36:507. Cothren CC et al. Cervical spine fracture patterns predictive of blunt vertebral artery injury. J Trauma 2003; 55:811. Biffl WL et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg 1999; 178:517. Kerwin AJ et al. Liberalized screening for blunt carotid and vertebral artery injuries is justified. J Trauma 2001; 51:308. Biffl WL et al. Treatment-related outcomes from blunt cerebrovascular injuries: Importance of routine follow-up arteriography. Ann Surg 2002; 235:699. Miller PR et al. Prospective screening for blunt cerebrovascular injuries: Analysis of diagnostic modalities and outcomes. Ann Surg 2002; 236:386. Mayberry JC et al. Blunt carotid artery injury: The futility of aggressive screening and diagnosis. Arch Surg 2004; 139:609. Fabian TC, et al. Blunt carotid injury: Importance of early diagnosis and anticoagulant therapy. Ann Surg 1996; 223:513. Biffl WL, et al. Noninvasive diagnosis of blunt cerebrovascular injuries: A preliminary report. J Trauma 2002; 53:850. Berne JD et al. Helical computed tomographic angiography: An excellent screening test for blunt cerebrovascular injury. J Trauma 2004; 57:11. Wahl WL et al. Antiplatelet therapy: An alternative to heparin for blunt carotid injury. J Trauma 2002; 52:896.

Rev. 10/24/07

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Blunt Aortic Injury (BAI)

BAI is the second most common cause of death in blunt trauma, following head injury. Deceleration forces (e.g., high speed MVCs, falls from heights) cause tearing of the aorta at points of fixation: ligamentum arteriosum (80-85%), diaphragmatic hiatus (10-15%), and ascending aorta (5-10%). 85% of fatalities occur at the accident scene. Of the remainder, 25% occur within 24 hours and another 25% within one week. The A-P CXR is a reasonable screening test for BAI. Findings suggestive of BAI (including widened mediastinum, indistinct aortic knob, depression of left main stem bronchus, deviation of NG tube, opacification of aortopulmonary window, widening of paratracheal/ paraspinous stripes, apical capping, scapular fracture or 1st/2nd rib fracture) should prompt chest CT. If suspicion of BAI is low, a widened mediastinum may be further investigated by upright CXR. However, if suspicion of BAI is high, as in situations where there has been a severe deceleration mechanism, chest CT is indicated regardless of CXR findings as the initial CXR may be interpreted as normal in up to 7% of patients with BAI.1, 2 Helical chest CT is a sensitive test for BAI, and its specificity approaches 100%.2, 3 Suspicious findings warrant arteriography (the gold standard). If CT is diagnostic of BAI the decision to proceed to aortography vs thoracotomy is the thoracic surgeons preference. Once BAI is diagnosed or strongly suspected, antihypertensive therapy should be instituted with the goal of SBP <110 and HR <100, to prevent aortic rupture.3 Esmolol is preferred initially. A loading dose of 0.5 g/kg over 30 sec is followed by infusion of 50 g/kg/min (increasing up to 300 g/kg/min as needed). If necessary, nitroprusside (2-5 g/kg/min) may be added. The optimal means of minimizing perioperative morbidity spinal cord ischemia, mesenteric and renal insufficiency is debated. Clamp-and-sew techniques can be relatively safe with cross clamp times <30 minutes.4, 5 However, as the crossclamp time is not always predictable, and paraplegia rates increase markedly after 30 minutes, many authors recommend some form of bypass.1 Partial cardiopulmonary bypass with either left atrial-femoral or femoral-femoral cannulation to maintain distal arterial perfusion, allows for prolonged crossclamping times without significant untoward effects.6, 7, 8 Multisystem injuries (90%) and brain injuries (50%) are commonly associated with BAI, and management must be prioritized. Severe brain injury, blunt cardiac injury, or pulmonary injury may be prohibitive risks to early repair. Nonoperative management (i.e. antihypertensive and other supportive therapy) should be considered, with potential delayed repair.9, 10 Low-grade blunt solid organ injuries may still be managed nonoperatively, but higher-grade injures represent a bleeding risk with heparinized bypass circuits.11 Endovascular stent-grafts may be considered on an individual basis.

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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Fabian TC, Richardson JD, Croce MA, et al. Prospective study of blunt aortic injury: Multi-center trial of the American Association for the Surgery of Trauma. J Trauma 1997;42:374-383. Dyer DS, Moore EE, Ilhe DN, et al. Thoracic aortic injury: How predictive is mechanism and is chest computed tomography a reliable screening tool? A prospective study of 1561 patients. J Trauma 2000;48:673-683. Fabian TC, Davis KA, Gavant ML, et al. Prospective study of blunt aortic injury: Helical CT is diagnostic and antihypertensive therapy reduces rupture. Ann Surg 1998;227:666-677. Razzouk AJ, Gundry SR, Wang N, et al. Repair of traumatic aortic rupture. A 25 year experience. Arch Surg 2000;135:913-919. Sweeney MS, Young DJ, Frazier OH, et al. Traumatic aortic transections: Eight year experience with the Clamp & Sew technique. Ann Thorac Surg 1997;64:384-389. Hochheiser GM, Clark DE, Morton JR. Operative technique, paraplegia and mortality after blunt traumatic aortic injury. Arch Surg 2002;137:434-438. Miller PR, Kortesis BG, McLaughlin CA III, et al. Complex blunt aortic injury or repair: Beneficial effects of cardiopulmonary bypass use. Ann Surg 2003;237:877-884. Szwerc MF, Benckart DH, Lin JC, et al. Recent clinical experience with left heart bypass using a centrifugal pump for repair of traumatic aortic transection. Ann Surg 1999;230:484-492. Wahl WL, Michaels AJ, Wang SC, et al. Blunt thoracic aortic injury: Delayed or early repair? J Trauma 1999;47:254-260. Symbas PN, Sherman AJ, Silver JM, et al. Traumatic rupture of the aorta: immediate or delayed repair? Ann Surg 2002;235:796.802. Santanielo JM, Miller PR, Croce MA. Blunt aortic injury with concomitant intra-abdominal solid organ injury: Treatment priorities revisited. J Trauma 2002;53:442-445.

Rev. 8/1/07

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Blunt Cardiac Injury

Blunt cardiac injury (BCI) is a common cause of scene death. Of those who present to the hospital, the injury can be minor and inconsequential, or may be the cause of inhospital mortality. The term blunt cardiac injury is preferable to older terms such as myocardial/cardiac contusion or concussion. Modifiers such as with ECG or enzyme changes, -with complex arrhythmia, -with cardiac failure, -with coronary thrombosis, with septal/free wall rupture may be added. The goal of this algorithm is not to identify all patients with a BCI: the diagnosis itself is of secondary importance. Rather, the goal is to identify the patients at risk for complications (dysrhythmia, cardiogenic shock, or structural injury) which may require treatment. BCI should be suspected in individuals who sustain major chest trauma. The initial evaluation should include an ECG as part of the secondary survey. Patients with shock from any cause, ischemic changes on ECG or significant dysrhythmia* are admitted to the ICU. If angina or ischemic ECG changes are noted, the routine r/o MI protocol should be followed. Nonspecific ECG findings are rarely associated with significant BCI; patients may be discharged after 24 hours of cardiac monitoring if no new symptoms occur. Patients with significant blunt chest trauma who are being admitted for associated injuries should have cardiac monitoring for 24 hours. While many patients will require admission for associated injuries, a subset of patients may not require admission. These patients can be safely discharged from the ED if the ECG at presentation and at 8 hours are normal, and if a Troponin I level at 8 hours is less than 1.5 ng/mL.
1. Biffl WL, Moore FA, Moore EE, et al. Cardiac enzymes are irrelevant in the patient with suspected myocardial contusion. Am J Surg. 1994;169:523-528. 2. Mattox KL, Flint LM, Carrico CJ, et al. Blunt cardiac injury. J Trauma. 1992;33:649-50. 3. Pasquale MD, Nagy K, Clarke J, et al. Practice management guidelines for screening of blunt cardiac injury. http://www.east.org/tpg/chap2.pdf. 1998. 4. Velmahos GC, Karaiskakis M, Salim A, et al. Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. J Trauma. 2003;54:4551.

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BLUNT CHEST TRAUMA WITH Substernal chest pain, dysrhythmia on ECG monitor, sternal/multiple rib fractures, pulmonary contusion, thoracic seat belt sign. 12-LEAD ECG dysrhythmia ischemic ANGINA / SHOCK

Admission for associated injury Normal EKG Tel x 24 hrs ECG in AM

ICU admission, R/o MI if angina/ischemia +/- cardiology consult New angina, dysrhythmia, shock

No new symptoms Abnormal 8 hr EKG or ii i No injuries requiring admission Normal ECG & Troponin at 8 hrs

Discharge

* Ischemic changes: ST elevation, depression, or T wave inversion in leads dysrhythmia: new atrial fib, new LBBB/RBBB, frequent PVCs/PACs heart block Echocardiogram may be obtained in selected patients in this group with refractory shock, new murmur, clinical suspicion of pericardial effusion/tamponade Anything other than normal sinus rhythm Rev. 8/1/07

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Rib Fracture Protocol: Adult

Multiple rib fractures (more than 4 ribs) in patients > 45 years of age have been associated with increased morbidity.1 Elderly patients ( 65 years) who sustain blunt chest trauma with 2 or more fractured ribs have twice the mortality and thoracic morbidity of younger patients with similar injuries. For each additional rib fracture in the elderly, mortality increases by 19% and the risk of pneumonia by 27%.2 Data suggests monitoring the respiratory function of both groups may improve patient outcome.

Pain Assessment:
Once significant accompanying injuries have been ruled out, the cornerstone of rib fracture management is pain control.3 Treatment of rib fractures should be focused on early and adequate pain relief to avoid complications from splinting; primarily atelectasis, retained secretions and pneumonia. Multiple rib fractures may result in flail chest, which in itself can result in respiratory failure. A review of studies from 1966-2002 comparing systemic opioids, transcutaneous electrical nerve stimulation and NSAIDS to regional analgesia therapy such as nerve blocks and epidurals conclude it is difficult to recommend a single method for pain relief in all clinical situations but demonstrate regional blocks to be more effective than systemic opioids with less systemic side effects.4 The use of epidural analgesia in one study showed a decrease in the rate of nosocomial pneumonia and shorter duration of ventilator days with patients having more than 3 rib fractures.5 It is assumed by most clinicians that once pain is under control, deep breathing and coughing is assured after patients have been educated on their importance; evidence shows the contrary. Egbert et al demonstrated that narcotics and pain may eliminate the sigh mechanism and result in a pattern of monotonous tidal ventilation.6 This data suggests that even in the setting of controlled pain, it is important to be regimented in coaching the patient on coughing and deep breathing. The patient should not have a sufficient amount of pain to interfere with the ability to perform a slow vital capacity (Fig. 1 below) and an effective cough. If so the covering MD should be made aware.

Adequate Slow Vital Capacity (SVC):

Fundamental respiratory principles tell us if patients, especially those who are sedentary, are unable to take deep breaths and cough; efficiency of ventilation and oxygenation becomes compromised. Bendixen et. al demonstrated that shallow tidal volumes lead to atelectasis and increased shunting.7 Figure 1 (below) demonstrates a cause and effect of atelectasis specific to those on narcotics and/or having thoracic pain.
Figure 1. Pathogenic mechanisms and sequelae of atelectasis. Atelectasis: Physiology and Treatment Bakow et al. Comprehensive Respiratory Care, 1995; pg. 676

Infection Tachypnea/Hypopnea Tissue hypoxia Hypoxemia Respiratory failure/death Lung collapse

Narcotics/Pain Monotonous ventilation Reduction in FRC

Airway closure V/Q mismatch

Sputum retention

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After pain assessment, the clinician should measure a slow vital capacity from the patient. The incentive spirometer will be used as a surrogate the goal being 10-15ml/kg of ideal body weight. Patients able to achieve this should continue to be monitored by using at least once a shift (results documented) with patient being instructed to use the device every 1-2 hours as well. Attention should be paid to declining (but still in normal range) results. For individuals who are unable to achieve 10-15 ml/kg, the clinician should identify if the patient is unable due to pain, technique or respiratory function. For pain, the results should be referred to the covering MD. For improper technique the clinician may have to resort to using alternative methods (incentive spirometer with mask) or devices. Alternative devices include TheraPEP (see procedure), in which the patient would be instructed to take a deep breath, then blow out slowly through a mouth piece. The device has a pressure indicator to assure slow exhalation and adjustable resistance to facilitate customizing the device to the patients ability. Also available is the Acapella (see procedure). This device also would have the patient take a deep breath and exhale through adjustable expiratory resistance but with an added vibratory effect. This effect helps to mobilize secretions. The disadvantage of both the TheraPEP and Acapella devices is that the clinician is blind to what volumes the patient is moving. For this reason it is important that the clinician monitor the exhalation time to assure it is appropriate (at least 3-4 seconds). If the patient is unable to use any of the aforementioned devices and/or they demonstrate sequelae of shallow tidal ventilation, the clinician will utilize a more invasive technique. EzPAP (see procedure) is a hand held device that will utilize 0-15 lpm of air or oxygen and a pressure monitor to facilitate a positive exhalation pressure (10-20 cm/h20). The goal of this device is to increase the patients functional residual capacity (FRC) and thus prevent/treat atelectasis. If this method of lung recruitment fails with the patient, the clinician will discuss the use of CPAP/BiPAP with the covering physician. If non-invasive ventilation is to be utilized, the patient should be transferred to a step down/ICU if appropriate for their clinical condition. The patients ability to maintain a SVC will still be monitored until it improves or they require mechanical ventilation.

Patient Ambulation:
Ambulation of the patient should be done as soon as possible with all patients. In one study, delayed ambulation after orthopedic surgery was related to the development of new onset delirium, pneumonia and an increased hospital stay.8 Ambulation will encourage deep breathing due to increased activity and also decrease the surface area of gravity dependant areas in the lung; both important factors in improving ventilatory distribution. As with breathing, movement should not be inhibited by excessive pain and the inability of ambulation (not limited by contraindication) should be discussed with the covering physician.
1 Morbidity from Rib Fractures Increases after Age 45. JB Holcomb et al. American College of Surgeons. Vol. 196, No. 4, April 2003; 549-555 2 Rib Fractures in the Elderly. EM Bulger et al. The Journal of Trauma: Injury, Infection and Critical Care. Vol. 48, No. 6, June 2000; 1040-47 3,4 Karmakar, MK, Ho, AM. Acute pain management of patients with multiple fractured ribs. J Trauma 2003; 54:615 5 Bulger EM et.al. Epidural analgesia improves outcomes after multiple rib fractures. Surgery 2004, Aug:136(2):426-30 6 Egbert LD. Effect of morphine on breathing pattern: A possible factor in atelectasis. JAMA 188:485-488, 1964 7 Bendixen H, Hedley-Whyte J, Laver MB. Impaired oxygenation I surgical patients during general anesthesia with controlled ventilation: A concept of atelectasis. N Engl, J Med 269(19):991-996, 1963 8 Hosamk Kaamel, Mohammad A. Iqbal Ratna Mogallapu, Diana Maas, Raymond G. Hoffman. Time to ambulation after hip fracture surgery: Relation to hospital outcomes, The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 58:M1042-M1045 (2003).

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Multiple Rib Fracture Protocol

For patients 45 and older with 4 or more rib fractures and patients 65 and older with 2 or more rib fractures
IS=10-15 ml/kg ? IS Monitored by Nursing (document results)

Effective ?

N Pain ? Y N Age > 65 or >3 rib fx?A Y Y Effective ? TheraPEP or Acapella N EzPAP

Non-invasive analgesia protocolB Anesthesia Consult 4-5657D N

Poor Technique ?

N Y N

Effective? (good cough, improved IS)

Continue and document

IS 10-15 ml/kg

N SaO2 PCO2 Retained secretions Y

Call HO Consider CPAP/BiPAP and ICU transfer

Suctioning may be used as a supplement to this protocol but should not be used to replace it.

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Blunt Abdominal Trauma: Adult

Only 5-10% of patients admitted to trauma centers with suspected abdominal injury (motor vehicle crashes, severe crush injuries, falls from heights >10 feet, or patients with abdominal tenderness) will have abdominal injury. The rate of abdominal injury is twice as high in patients with hypotension, severe head injury, or spinal cord injuries. Approximately half of these abdominal injuries can be managed non-operatively. The diagnostic challenge is to identify abdominal injuries efficiently and accurately. Physical examination alone may result in a significant number of missed abdominal injuries, with 10% of patients with no abdominal tenderness or abdominal wall bruising having an abdominal injury on CT scan. Complicating the evaluation of patients with blunt abdominal trauma is the presence of EtOH. However, one large study has found that the presence of EtOH (levels equivalent to legal intoxication) does not appear to affect the reliability of an abdominal exam until the EtOH causes obtundation (GCS <11). There are surrogate markers for abdominal injury in the absence of physical findings, such as chest injury and hematuria. The absence of abdominal tenderness and these two injuries has a negative predictive value for abdominal injury of >99%. Ultrasonography is user-dependant. If FAST results are equivocal, pursue alternative diagnostic maneuvers. CT Indications Spinal cord injury, GCS <9 Significant abdominal pain or tenderness Gross hematuria Pelvic fracture Significant chest trauma Myocardial or pulmonary contusion Multiple which is greater than 2 unilateral rib fractures Left lower (8-12) rib fractures First or second rib fracture Scapular fracture Mediastinal hematoma Unexplained tachycardia and/or transient hypotension (with normal ultrasound exams / DPL)
1. 2. 3. 4. Grieshop NA, Jacobson LE, Gomez GA, et al.: Selective Use of Computed Tomography and Diagnostic Peritoneal Lavage in Blunt Abdominal Trauma. J Trauma 1995;38:727-731. Fernandez L, McKenney MG, McKenney KL, et al. Ultrasound in blunt abdominal trauma. J Trauma 1998;45:841-848. Healey MA, Simons RK, Winchell RJ, et al. A Prospective Evaluation of Abdominal Ultrasound in Blunt Trauma Is It Useful? J Trauma 1996;40:875-885. Livingston DH, Lavery RF, Passannante MR, et al. Admission or Observation Is Not Necessary after a Negative Abdominal Computed Tomographic Scan in Patients with Suspected Blunt Abdominal Trauma Results of a Prospective, Multi-institutional Trial. J Trauma 1998;44:273-282.

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Blunt Splenic Trauma: Adult

Important Points:
ANY bout of hypotension (SBP<90), transient or otherwise, in the Emergency Department is strongly predictive of failure of non-operative management (NOM). Other predictors of failure of NOM include injury grade and amount of hemoperitoneum. Patients who fail NOM have a longer overall and ICU LOS than patients who are managed operatively from the start. 95% of NOM failures happen within 72 hours of injury, regardless of grade. Thus, there is little utility to monitoring NOM patients beyond 3-5 days unless they have another reason to remain hospitalized. NOM for stable patients consists of bedrest, telemetry monitoring, hemoglobin/ hematocrit checks every 6 hours, and frequent abdominal examinations for the first 24 hours after admission. A decrease in hemoglobin of 2g or a significant change in abdominal exam should prompt a repeat CT scan, unless the patient is hemodynamically unstable. There is no data to support empirically repeating CT scans while the patient is in the hospital. Patients with AAST isolated grades I-II injuries may be safely observed on the trauma ward. Splenic salvage is increased in patients with arterial blush, pseudoaneurysm, or A-V fistula who undergo angioembolization (EMBO). Some caveats are: o A-V fistula, pseudoaneurysm, or large amounts of hemoperitoneum seen on CT scan or angiogram are highly predictive of failure of NOM in EMBO patients. Patients with any evidence of post-EMBO bleeding or hemodynamic instability should have an immediate splenectomy. There is a significant failure rate of patients with AAST grades III-V injuries who undergo EMBO. A second try at EMBO is never indicatedpatients who fail need an operation.

o o

Splenectomized (and those who undergo main splenic artery EMBO) should have pneumococcal, meningococcal, and Hib vaccines. The optimal time is 14 days post splenectomy. If there is any concern about the patient not following up, vaccinate on the day of discharge from the hospital. There is little objective data about when it is safe for patients with NOM splenic injuries to return to full activity. There is some data that says that 84% of grade III-V injuries are healed by 37 days. If the patient wants to return to heavy activities such as contact sports, he should undergo a CT scan at 2 months post injury to document healing. For an adult who engages in only everyday activities, an empiric follow-up CT scan is not necessary.

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Blunt Abdominal Trauma

Hemodynamically Stable

Hemodynamically Unstable

CT scan

Laparotomy

Splenic Injury*

No blush or vascular injury

Blush, pseudoaneurysm, AV fistula

NOM

EMBO

*Patients with high-grade injury and/or large amounts of hemoperitoneum with blush or other evidence of vascular injury may be taken directly to the OR at the discretion of the trauma attending
1. Crawford RS, Tabbara M, Sheridan R, et al. Early discharge after nonoperative management for splenic injuries: increased patient risk caused by late failure? Surgery. 2007;142:337-41. 2. Haan J, Biffl W, Knudson M, et al. Splenic embolization revisited: a multicenter review. J Trauma. 2004;56:542-7. 3. Haan J, Boswell S, Stein D, Scalea T. Follow-up abdominal CT is not necessary in low-grade splenic injury. Am Surg. 2007;73:13-18. 4. Haan J, Marmery H, Shanmuganathan K, et al. Experience with splenic main coil embolization and significance of new or persistent pseudoaneurysm: re-embolize, operate, or observe. J Trauma. 2007;63:615-619. 5. Peitzman A, Heil B, Rivera L, et al. Blunt splenic injury in adults: multi-institutional study of the Eastern Association for Surgery of Trauma. J Trauma. 2000;49:177-89. 6. Savage SA, Zarzaur BL, Magnotti LJ, et al. The evolution of blunt splenic injury: resolution and progression. J Trauma. 2008;64: 1085-92. 7. Schurr M, Fabian T, Gavant M, et al. Management of blunt splenic trauma: computed tomographic contrast blush predicts failure of nonoperative management. J Trauma. 1995;39:507-13. 8. Smith J, Armen S, Cook C, Martin L. Blunt splenic injuries: have we watched long enough? J Trauma. 2008;64:656-665. 9. Smith HE, Biffl WL, Majercik SD, et al. Splenic artery embolization: have we gone too far? J Trauma. 2006;61: 541-5. 10. Watson GA, Rosengart MR, Zenati MS, et al. Nonoperative management of severe blunt splenic injury: are we getting better? J Trauma. 2006;61:1113-1119.

Rev. 6/4/08

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Renal Trauma
Ten percent of patients with blunt abdominal trauma are found to have a urogenital injury. Renal parenchymal injuries are the most common. Of these injuries, 7590% may be classified as minor (Grade I-III) and require no intervention. Work up and treatment of the remaining major renal injuries has been controversial but there has been increasing interest in non-operative management because of associated decreased transfusion requirement, shorter ICU stay, and increased salvage rate of the kidney. CT scan of the abdomen/pelvis is the test of choice for staging renal injury. Evaluation: Urine from the first post injury void should be evaluated on all patients with blunt abdominal trauma. Most patients with major renal trauma present with gross hematuria or hypotension, only 0.8 1.2% of major renal injuries have neither. Microscopic hematuria (Greater than 5 RBC/HPF): Rarely associated with significant renal system injury. Patients require observation and repeat UA later in the ER or hospital to demonstrate resolution, in order to rule out other sources of hematuria such as malignancy. Children with significant microscopic hematuria (Greater than 50 RBC/HPF) should undergo abdominal/pelvic CT with Cystogram as their risk for significant renal injury is higher than in adults. Gross hematuria: Patients require abdominal/pelvic CT with cystogram if hemodynamically stable. A retrograde urethrogram should be performed if there is blood at the meatus. Blunt vs. penetrating: Blunt injury and stab wounds may be worked up in a similar fashion. Gunshot injuries often skip CT scan staging and require exploration because of hypotension, massive injury and delayed complications secondary to blast effect.

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Management: Notify Urology Service. Patients with a major renal injury may be candidates for nonoperative management under these conditions: Stable hemodynamics, urine extravasation contained within Gerotas fascia, and no ongoing bleeding. Patients should be monitored in the TICU for the first 24 48 hours. Bed rest should continue for 24 hours after the cessation of hematuria. Other therapeutic interventions are: Angio-embolization: A two-unit transfusion limit (blood loss thought to be related to renal injury) will be set as a threshold to consider angiogram for embolization. Bleeding may manifest as expanding hematoma or persistent hematuria. Double J Stent: Patients with evidence of urinary extravasation on initial CT scan may warrant stenting. Plan re-evaluation with CT scan 48 hours post injury. Any patient with persistent urinary extravasation on repeat CT scan requires stenting. Less than 10% of patients require surgery for failure of stents to control urine extravasation. Percutaneous drainage: Urinoma and abscess may be a complication of non-operative management. Both may be treated with percutaneous drainage. Operative salvage: Patients taken to the operating room for hypotension before adequate staging of potential renal injuries may warrant exploration if there is a strong suspicion for renal injury. Otherwise, postoperative staging CT is recommended. Intra-op IVP has been used to assess contralateral kidney function yet less than 1% of patients with a palpable contralateral kidney have a non-functioning kidney. The one-shot IVP is not warranted. Intra-op considerations: Assess urinary extravasation by injection of methylene blue. Goals are debridement, homeostasis, watertight closure of the collecting system, reapproximation of the parenchyma, and drainage of the retroperitoneum. Often omentum is used to wrap the kidney after repair. Revascularization: Revascularization has been employed for traumatic renal artery occlusion. Salvage in this situation is rarely successful and should not be undertaken in the acutely injured patient. Fewer complications are seen if non-operative management is undertaken. However, the patient must be monitored for the development of renovascular hypertension.
1. Ahn JH, Morey AF, McAninch JW. Workup and Management of Traumatic Hematuria. Emerg Med Clin North America, 1998;16:146-164. 2. Altman A. Selective Nonoperative Management of Blunt Grade 5 Renal Injury. J Urology, 2000;164;27-31. 3. Haas CA, Dinchman KH, Nasrallah PF, et al. Traumatic Renal Artery Occlusion. J Trauma 1997;45:557-561. 4. Skinner EC, Parisky YR, Skinner DG. Management of Complex Urologic Injuries. Surg Clin North America 1996;76:861-878.

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Diagnosis of Blunt Bowel and Mesenteric Injury

Blunt injury to the bowel or mesentery (BBMI) is uncommon and can be difficult to diagnose. While some studies claim that diagnostic delay does not cause morbidity or mortality,1 a large multicenter series has reported an increased mortality when the diagnosis is delayed by as little as 8 hours.2 Therefore, it is important to identify those at risk and make the diagnosis early. CT scanning is the best noninvasive test for diagnosing BBMI.3,4 Oral contrast does not need to be routinely administered as it delays the evaluation and does not add to the specificity or sensitivity of the test.5 CT findings that suggest BBMI include free fluid in the absence of solid organ injury, bowel wall thickening, mesenteric fat streaking, mesenteric hematoma, pneumoperitoneum, and extravasation of IV or oral contrast. The findings of pneumoperitoneum or contrast extravasation mandate laparotomy. The other findings are suggestive but not specific for BBMI. Malhotra and colleagues3 found that in a patient with a single CT finding 35% had BBMI. Two findings were associated with BBMI in 80%. If more than two findings were present the rate was 100%. Thus, two or more of these findings mandate laparotomy. A single finding should prompt further evaluation. Options for further evaluation include serial physical exams, DPL, and repeat CT scan. Physical exam has been shown to have variable results in predicting a need for operation.1 Thus it should be supplemented by serial WBC and a delayed CT scan. DPL has a high sensitivity and negative predictive value but a positive predictive value of only 35%. In addition, it is invasive and carries a risk of complications.6 In patients who cannot be reliably examined, DPL should be considered. A positive DPL is defined as RBC >100,000/mm3, WBC >500/mm3 or the presence of bile, bacteria or particulate matter. Amylase >20 and Alkaline phosphatase >3 are useful adjuncts in equivocal tests.7 A low threshold for exploration should be used when the clinical picture is not improving.

1. 2. 3. 4. 5. 6. 7.

Fang JF, et al. Small Bowel Perforation: Is Urgent Surgery Necessary? J Trauma1999; 47;515-520. Fakhry SM, et al. Relatively Short Diagnostic Delays (<8 Hours) Produce Morbidity and Mortality in Blunt Small Bowel Injury: An Analysis of Time to Operative Intervention in 198 Patients from a Multicenter Experience. J Trauma 2000; 48:408-415. Malhotra AK, et al. Blunt Bowel and Mesenteric Injuries: The Role of Screening Computed Tomography. J Trauma 2000; 48:991-1000. Killeen KL, et al. Helical Computed Tomography of Bowel and Mesenteric Injuries. J Trauma 2001; 51:26-36. Allen TL, et al. Computed Tomographic Scanning without Oral Contrast Solution for Blunt Bowel and Mesenteric Injuries in Abdominal Trauma. J Trauma 2004; 56:314-322. Rodriguez C, et al. Isolated Free Fluid on Computed Tomographic Scan in Blunt Abdominal Trauma: A Systematic Review of Incidence and Management. J Trauma 2002; 53:79-85. McAnena OJ, et al. Peritoneal Lavage Enzyme Determinations Following Blunt and Penetrating Abdominal Trauma. J Trauma 1991; 31:1161-1164.

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Rectal Injury
The management of civilian rectal injuries has evolved from wartime experience. Fundamental principles included diversion of the fecal stream, debridement and closure of the rectal injury when possible, distal rectal washout, presacral drainage, and broadspectrum antibiotics. These principles, while reducing morbidity and mortality in high velocity injuries, have been modified over the past 20 years, as the majority of rectal injuries sustained in the civilian population occur from low velocity missiles.2 Rectal injuries should be classified as either intraperitoneal or extraperitoneal. Injuries to the anterior and lateral surfaces of the upper two thirds of the rectum are classified as intraperitoneal (serosalized), and those of the posterior surface as extraperitoneal (no serosa). Injuries to the lower one-third are extraperitoneal.2 Rectal injury needs to be ruled out in all transpelvic gunshot wounds and other penetrating pelvic injuries. Diagnostic modalities should include a digital rectal exam looking for gross blood, and a proctosigmoidoscopy. Intraperitoneal rectal injuries should be primarily repaired with or without fecal diversion.1,2 Recent studies have suggested extraperitoneal rectal injuries should be left untouched and only a diverting colostomy should be performed.2 These authors state that the primary repair of extraperitoneal rectal injuries is often difficult because of the confined pelvic space, the adjacent sacral venous plexus and urogenital structures, and the hypogastric nerve plexus.2 That being said, easily visualized injuries with minimal dissection should be primarily repaired.2 Distal rectal washout and presacral drainage, mainstay therapy for high velocity rectal injuries, has not shown any advantage in the management of civilian type rectal injuries and may be omitted.2,3 Broad spectrum antibiotics covering gram negative bacteria and anaerobes should be given. Finally, genitourinary tract injuries are among the most common injuries associated with rectal trauma. Hematuria should raise the level of suspicion and prompt further workup.2 Healing of rectal wounds may occur in up to 75% of patients ten days after injury. Some admission colostomy closure may be considered in patients with low grade or penetrating injuries. Healing should be demonstrated with a contrast enema to exclude stricture or fistula formation.
1. 2. 3. Navsaria PH, Edu S, Nicol AJ. Civilian extraperitoneal rectal gunshot wounds: Surgical management made simpler. World J Surg. 2007 Jun; 31(6):1345-51. McGrath V, Fabian TC, Croce MA, Minard G, Pritchard FE. Rectal trauma: management based on anatomic distinctions. Am Surg. 1998 Dec; 64(12):1136-41. Gonzalez RP, Falimirski ME, Holevar MR. The role of presacral drainage in the management of penetrating rectal injuries. J Trauma. 1998 Oct; 45(4):656-61.

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Unstable Pelvic Fractures

Hemodynamically compromised patients with pelvic fractures present a complex challenge to trauma surgeons. Fractured pelvic bones bleed briskly and can lacerate surrounding soft tissues and disrupt their extensive arterial and venous networks. The resultant hemorrhage and secondary coagulopathy can be lethal; to confound matters, the considerable force required to fracture the pelvis typically results in significant associated extrapelvic injuries. Collectively, these factors account for high rates of death and complications. From 1997-2001, pelvic fracture patients presenting to RIH with hypotension had a mortality of 36%; among those requiring laparotomy, it was 58%. Several groups have reinforced the concept of a multi-specialty approach to patients with pelvic fractures and significant hemorrhage. Although the fundamental objectives control of hemorrhage, restoration of hemodynamics, and prompt diagnosis and treatment of associated injuries have not changed, the means of achieving these goals have evolved significantly. 1,2 Maneuvers such as early mechanical pelvic stabilization3 and arterial hemorrhage control by means of interventional radiologic techniques4 are now recognized as pivotal components of the management scheme. Hemodynamically stable patients should undergo CT scanning of the abdomen and pelvis to detect occult injuries or contrast extravasation.5 The finding of contrast extravasation in the pelvis is highly suggestive of significant arterial bleeding that may require angiography and embolization.6,7 Ongoing transfusion requirements also constitute an indication for arteriography. The initial approach to hemodynamically compromised patients must be aggressive. Crystalloid resuscitation and transfusion of packed red blood cells should be instituted immediately; empiric administration of fresh frozen plasma (1:1) and plate-lets (5:5) may help prevent coagulopathy. Reduction of the pelvic volume is critical, and is achieved by prompt wrapping of the pelvis, and taping of the knees and ankles. The orthopaedic surgery attending is instrumental in determining whether application of an external fixation device and what device is appropriate.8,9 Identification of alternative sites of bleeding is central to the triage of these patients. Physical examination, chest x-ray, and ultrasonography will identify significant extrapelvic hemorrhage, allowing timely intervention. If ultrasonography is equivocal, supraumbilical DPL should be performed, and the patient taken to the OR if the aspirate is grossly positive. Patients who do not recover with mechanical pelvic stabilization, transfusion, and treatment of associated injuries have a high likelihood of harboring pelvic arterial hemorrhage. They should undergo prompt arteriography either in the operating room or the radiography suite. For this reason, vascular/interventional radiology should be alerted early in the course of these patients.

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1. 2. 3. 4. 5. 6. 7. 8. 9.

Biffl WL, Smith WR, Moore EE, et al. Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. Ann Surg 2001;233:843-850. DiGiacomo JC, Bonadies JA, Cole FJ, et al. Practice management guidelines for hemorrhage in pelvic fracture. EAST 2001. Latenser BA, Gentillelo LM, Tarver AA, et al. Improved outcome with early fixation of skeletally unstable pelvic fractures. J Trauma 1991; 31:28-31. Agolini SF, Shah K, Jaffe J, et al. Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma 1997; 43:395-399. Ballard RB, Rozycki GS, Newman PG, et al. An algorithm to reduce the incidence of false-negative FAST examinations in patients at high risk for occult injury. J Am Coll Surg 1999;189:145-151. Pereira SJ, OBrien DP, Luchette FA, et al. Dynamic helical computed tomography scans accurately detect hemorrhage in patients with pelvic fracture. Surgery 2000;128:678-685. Stephen DJG, Kreder HJ, Day AC, et al. Early detection of arterial bleeding in acute pelvic trauma. J Trauma 1999;45:638-642. Buckle R, Browner BD, Morandi M. Emergency reduction for pelvic ring disruptions and control of associated hemorrhage using the pelvic stabilizer. Tech Ortho 1995;9:258-266. Tucker MC, Nork SE, Simonian PT, et al. Simple anterior external fixation. J Trauma 2000;49:989-994.

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Mangled Extremity
Severe extremity injuries with significant damage to more than one tissue component (integument = skin + subcutaneous tissue, muscles, bone, nerves and vasculature) are often called mangled extremities. They typically require arterial repair to restore limb viability. Unlike a pure vascular injury, however (such as a knife or gunshot wound), the prognosis for restoration of function is poor. Particularly for mangled lower extremities, amputation must be seriously considered as a better alternative to attempted limb salvage, especially when risk of systemic complications is high or when the salvaged limb will be less functional than a prosthesis. The prediction of successful limb salvage in terms of patient morbidity and eventual acceptable limb function has been limited by the lack of class I data (well powered, randomized, prospective trial). Additionally, all of the scoring systems currently used are based on data from lower extremity injuries only. The NISSSA scoring system is a tool which emphasizes the important factors which impact limb salvage for mangled extremities: nerve injury, ischemia, soft tissue/contamination, skeletal trauma, presence of shock, and patient age. Using this scoring system, several retrospective studies have shown that limb salvage is nearly always possible with acceptable functional results when the NISSSA is <7 and that few limbs can be or should be salvaged when the NISSSA >10. Several surgical services must become involved immediately in the care of a patient with a mangled extremity. Attending surgeons from the Trauma Service, the Orthopaedic Service and, as required on an individual basis, Vascular and Plastic Surgery are essential during evaluation, decision making, and treatment. If the mangled extremity is ischemic, every effort must be made to expedite immediate operative intervention nonviable limbs rarely benefit from arteriography in the Radiology Department, although an OR arteriogram may be valuable. It is essential that the trauma attending be directly involved in the care of these patients, to have a direct dialogue with attending surgeons of other disciplines and to maintain the perspective of the entire patient. Time is of the essence! Unless adequately perfused, nerve and muscle become progressively unsalvageable after 4 to 6 hours.

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NISSSA Rating Criteria Type of injury N Nerve Injury Degree of Injury Sensate Dorsal Points 0 1 Description

No major nerve injury Peroneal (deep or superficial), femoral nerve injury a Plantar partial 2 Tibial nerve injury a Plantar complete 3 Sciatic nerve injury a I Ischemia None 0 Good to fair pulses, no ischemia Mild 1b Reduced pulses, perfusion normal Moderate 2b No pulse(s), cap refill, Doppler signals present Severe 3b Pulseless, cool, ischemic, no Doppler pulses S Soft Tissue (ST) / Low 0 Minimal to no ST contusion, no CON Contamination (CON) Medium 1 Moderate ST injury, low-velocity GSW, moderate CON, minimal crush High 2 Moderate crush, deglove, high velocity GSW, moderate ST injury, considerable CON Severe 3 Massive crush, farm injury, severe deglove, severe CON, requires softtissue flap S Skeletal Low energy 0 Spiral, oblique fx, no/minimal displacement Medium energy 1 Transverse fx, minimal comminution, small caliber GSW High energy 2 Moderate displacement, moderate comminution, high velocity GSW, butterfly fragment(s) Severe energy 3 Segmental, severe comminution, bony loss S Shock Normotensive 0 BP normal, SBP always >90 mm Hg Transient 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. bScore doubles with ischemia >6 h.
Bosse MJ, MacKenzie EJ, Kellam JF, et al. A prospective evaluation of the clinical utility of the lowerextremity injury-severity scores. J Bone Joint Surg Am 2001;83:3-14. Lin CH, Wei FC, Levin LS, Su JI, Yeh WL. The functional outcome of lower-extremity fractures with vascular injury. J Trauma 1997;43:480-485. McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: A retrospective evaluation of the Mangled Extremity Severity Score. J Orthop Trauma 1994;8:81-87.

1. 2. 3.

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To Ligate or Not to Ligate

Injury Infrarenal vena cava Suprarenal vena cava Internal jugular vein Brachiocephalic vein Subclavian vein and artery Superior vena cava Carotid artery Mesenteric veins Portal vein Best Mode of Action Repair Repair Repair Repair Repair Repair Repair Ligate Repair Can ligate if isolated injury, but at least 50% mortality rate secondary to massive fluid sequestration in splanchnic vascular bed and bowel necrosis Cannot ligate - fewer collateral than left renal vein Cannot ligate Can ligate Can ligate Cannot ligate - at least 50% mortality) Can ligate unilaterally Can ligate unilaterally Can ligate Can ligate in life-threatening situations Can ligate in life-threatening situations

Right renal vein Popliteal vein Femoral vein Lobar bile duct Celiac artery Left gastric artery Common/proper hepatic arteries Right/left hepatic arteries Splenic artery Iliac vein - comm/ext Iliac artery - comm/ext Femoral/popliteal arteries Tibial arteries Brachial artery Radial/ulnar arteries

Repair Repair Repair Ligate Ligate Ligate Ligate Ligate Ligate Ligate Repair Repair Repair Repair Repair

Especially if proximal to gastroduodenal branch Especially if portal vein is intact Short gastric a. from left gastroepiploic

Can ligate but need to ensure patency of other leg arteries Can ligate if distal to profunda brachia branch since the elbow has a rich collateral of blood flow Can ligate but need to ensure patency of other artery

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Trauma Scoring Systems

Multiple trauma scoring systems have been promulgated over the years. These scores were developed for trauma triage and others were used to evaluate and predict outcomes: Revised Trauma Score (1989) uses the initial respiratory rate, systolic blood pressure and GCS of the patient. The score has good inter-rater reliability. The higher the score is, the higher the probability of survival. The scores range from 0 to 7.8. Injury Severity Score (1974) is based on an abbreviated injury score (AIS). Each injury is assigned an AIS score, ranging from 1(minor) to 6(lethal). The highest AIS within each of six body regions head/neck, face, thorax, abdominal/pelvic contents, extremities, external structures is identified. The ISS = the sum of the square of the three highest of these scores. Scores range from 0-75; any AIS of 6 automatically results in ISS = 75. It does not consider age of physiologic status, and may misrepresent injury severity when injuries are confined to a single body region (e.g. in penetrating trauma). Below is an example of an ISS calculation: ISS BODY REGION INJURY AIS CODE HIGHEST AIS AIS2 HEAD/NECK: Cerebral contusion 140604.3 4 16 ICA: complete transection 320212.4 FACE: Ear Laceration 210600.1 1 CHEST: Rib fractures 450220.2 2 left side, ribs 3-4 ABDOMINAL: Retroperitoneal hematoma 543800.3 3 9 EXTREMITIES: Fractured femur 851800.3 3 9 EXTERNAL: Overall abrasions 910200.1 1 ISS=34 NISS (New Injury Severity Score) considers the three highest AIS scores, irrespective of body region. This improves its predictive power for penetrating injury. The TRISS Method is a logistic regression equation based on the Revised Trauma Score, ISS and age, It also allows for the difference between blunt and penetrating injury. The ASCOT a severity and characterization of trauma score is very similar to the TRISS method in that is uses the components of the Revised Trauma Score but in a separated manner of Glasgow Coma Scale, systolic blood pressure and respiratory rate and also uses a different scoring system for injury to the different body regions, analogous to the ISS, and also includes age. Predicted outcome is also based on logistical regression analysis. The APACHE II (Acute Physiology And Chronic Health Evaluation) is a predictor of mortality derived from a logistic equation utilizing both acute and chronic conditions. The acute physiology score includes 12 data points: temperature, mean arterial blood pressure, heart rate, respiratory rate, paO2, pH, sodium, potassium, creatine, hematocrit, white count, and Glasgow coma score (the acute score ranges from 0 to 72). The chronic score accounts for respiratory failure (asthma, COPD, aspiration), heart failure (valvular dx, CHF, CAD), liver failure, immunosuppression, age and operative status (elective, emergent, non-operative) For further details: Trauma Scoring Systems consult: www.trauma.org/scores/index.html For APACHE II calculation: http://www.sfar.org/scores2/apache22.html

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2 (Moderate) 3 (Serious) 5 (Critical) 6 (Nonsurvivable) Decapitation 4 (Severe) LOC: GCS 15 C-spine fracture Lac w/ blood loss >20% CHI GCS 9-14 ICA: intimal flap DAI with GCS <8 ICA: intimal flap with neurologic deficit Cord contusion with Paraplegia / quadriplegia or neurogenic shock Brain stem DAI Penetrating injury Deep tongue lac Zygoma fx T-spine fracture Rib fxs Brachial plexus injury >3rib fxs, or any hemo-/ pneumothorax Bronchus perforation Pulmonary contusion Iliac artery lac Bladder rupture Colon perforation Humerus fx Femoral a. lac Crushed / mangled extremity Liver deep lac Parenchymal disruption <75% of hepatic lobe Pelvis fx substantial deformation and displacement Diaphragm rupture w/ herniation Myocardial contusion with shock Maxilla fx LeFort III LeFort III w/ 20% blood loss Aorta transection Tension pneumothorax Kidney hilum avulsion Liver >75% destruction of lobe Pelvic fx w/ shock Aortic transection ruptured

The following are the AIS scores from the 1990 revision to give an idea of the scoring system for each involved area:

1 (Minor)

Head/neck

Superficial scalp lac

T R A U M A

Face

Cornea abrasion Mandible fx subcondylar

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Spleen subcapsular hematoma < 50% Brachial a. lac Radius fx closed Scapula fx Degloving injury Brachial plexus injury High voltage electrical injury w/muscle necrosis Burn 20-29% TBSA Inhalation injury Burn 30-40% TBSA

Chest

Chest wall contusion

H A N D B O O K

Abdomen

Abdominal wall contusion

Hepatic avulsion

Extremities / Pelvic

Skin/subcutaneous/ muscle laceration

External

Burn <10% TBSA

Burn 40-89% TBSA

Burn - >90% TBSA

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TICU Sedation/Analgesia
Analgesia and sedation of the critically ill patient is a vital component of critical care. Unchecked post-traumatic pain and anxiety can provoke a whole host of deleterious effects including: increased myocardial oxygen demands leading to ischemia, myocardial infarction and increased systemic oxygen consumption, increased minute ventilation and need for prolonged mechanical ventilation, increased ICP, and increased catabolism. Proper administration of analgesics and sedatives can help to lessen the likelihood of these undesirable events. A basic understanding of the pharmacologic properties of analgesic and sedative medications will lessen the likelihood of improper use. A brief description of these medications follows. The summary presented here is intended to function as a framework for selection of medications. The most correct regimen is ultimately determined by clinical acumen, as well as continuous reassessment of the patient. In the near future, the Trauma Service will draw up a detailed TICU sedation protocol, which will be nursing-driven, based on the Richmond Agitation and Sedation Scale (RASS). This protocol will strive for a RASS of -1 to -2 as a target (see next page), which the bedside nurse will achieve through the titration of appropriate analgesics and sedatives. In the interim, the following points should be observed: Analgesia 1. Fentanyl, hydromorphone, and morphine are recommended agents. Fentanyl has the most rapid onset. Fentanyl and hydromorphone are preferred if patient is hemodynamically unstable or has renal insufficiency. Fentanyl may accumulate and cause prolonged effects, especially in the elderly. 2. Scheduled doses or intermittent doses are preferred over continuous infusions. Sedation 1. The RASS sedation scale is used to assess agitation. 2. Propofol is preferred in the first 24-72 hours after injury if frequent neurologic assessment is necessary. Beyond 72 hours, intermittent midazolam or lorazepam should be strongly considered. Common adverse effects of propofol include bradycardia and hypotension and triglyceride levels must be checked after 2 days of propofol infusion. 3. Midazolam is an excellent agent in the acute setting, but may accumulate in fatty tissue and cause prolonged effects, especially in the elderly, obese, or renal failure patient. 4. Benzodiazepines should be used with extreme CAUTION in the elderly and are to be considered drugs of last resort. 5. Atypical antipsychotics may provide a valuable adjunct to control agitation, and may decrease the reliance on benzodiazepines. Paralysis 1. In general, the indications for chemical paralysis are exceedingly rare and include life-threatening ARDS with ventilator dyssynchrony, to decrease systemic oxygen consumption in cases of fixed cardiac output, or when patient or staff safety is compromised by extreme agitation (RASS +5) prior to the effect of longer acting sedatives/antipsychotics. 2. When using paralytics, the degree of neuromuscular blockade must be monitored. Check train of four (TOF) in facial muscles every 30 minutes during induction and once a shift after that. Titrate to 2/4 TOF. For 0/4 TOF,
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3.

hold drug until 1/4 twitches are visible, then restart drug at a 20% reduction in rate. For 4/4 twitches, re-bolus and increase infusion rate by 25%. Atracurium is cleared by Hoffmann elimination; thus, no renal or hepatic metabolism is required. Doses in excess of the recommended dose may be necessary. This is the drug of choice if there is any concern about renal or hepatic function.

Delirium 1. Delirium is an independent risk factor for increased ICU mortality 2. ICU delirium should be treated with an antipsychotic, such as haloperidol 3. In the future, the Confusion Assessment Model (CAM) will be utilized by the nursing staff to identify delirium.

Richmond Agitation Sedation Scale

Score +4 Term Combative Description Overly combative or violent. Immediate danger to staff. Pulls/Removes tubes or catheters. Has aggressive behavior towards staff. Frequent non-purposeful movement. Patientventilator dyssynchrony. Anxious or apprehensive but movements not aggressive or vigorous.

+3

Very Agitated

+2

Agitated

+1

Restless

0 -1

Alert & Calm Drowsy Not fully alert, but has sustained (>10 sec) awakening with eye contact, to voice. Briefly (<10 sec) awakens with eye contact to voice. Any movement (but no eye contact) to voice.

-2

Light Sedation

-3

Moderate Sedation Deep Sedation

-4

No response to voice, but any movement to physical stimulation. No response to voice or physical stimulation.

-5

Unarousable

Adapted from Ely EW, Truman B, Shintani A, et al: Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation Sedation Scale (RASS). JAMA, 289:2983-91, 2003.

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Ventilator-Associated Pneumonia
Ventilator-associated pneumonia (VAP) occurs in up to 68% of mechanically ventilated patients, with a mortality rate of nearly 50%. The incidence of VAP increases by approximately 1% per day in the intubated patient. VAP bundles have been shown to reduce the incidence of VAP, thus head-of-bed elevation greater than 30 degrees, minimization of sedation with daily interruptions and early discontinuation of mechanical ventilation as soon as possible are strategies demonstrated to reduce the rate of VAP. The diagnosis of VAP is controversial; however bronchoalveolar lavage (BAL) with quantitative culture appears to be the best strategy for diagnosing VAP. Recent prospective cohort and randomized controlled trials have demonstrated decreased mortality and antibiotic usage when BAL was used to diagnose VAP.1,2 Since BAL is an invasive procedure, the suspicion of VAP must warrant the risk of the procedure. Currently, the clinical pulmonary infection score (CPIS) is used as an indicator of patients with likely VAP and therefore warrant BAL. Patients with CPIS greater than or equal to 5 and/or clinical suspicion should undergo BAL. However, CPIS is only intended to be a rough screening tool and some literature suggests that is may be ineffective in predicting VAP in trauma patients, thus clinical suspicion must remain high and CPIS should not be used as the sole basis to exclude VAP as a source of sepsis.3 BAL is performed by wedging the bronchoscope into the affected segment, instilling and aspirating five 20 ml aliquots of non-bacteriostatic sterile saline. The scope should remain wedged throughout and the initial aliquot MUST be discarded. The remaining effluent is pooled and sent for BAL culture. Broad spectrum antibiotic coverage should be initiated immediately after BAL pending final culture results. Patients who have been in the hospital for 3 days or more should be started on empiric coverage for MRSA and gram negative rods. Recent studies have demonstrated that appropriate early empiric antibiotic coverage in patients with VAP reduces mortality and ICU length of stay.4,5 It is imperative that antibiotics be focused or discontinued as appropriate at 72 hours based on culture results. Quantitative cultures should be imminently available at RIH and bacterial counts will be reported as 103 or less versus 104 or more organisms/mL. VAP is defined as a count of 104 or more organisms/ml. Counts less than this are considered to represent colonization and antibiotics should be discontinued. MRSA & SPACE bugs (Serratia, Pseudomonas, Acinetobacter, Citrobacter & Enterobacter) should be treated for 15 days, while 8 days is sufficient for all others. Discontinuation of antibiotics after 3 days may be considered if CPIS <6 and suspicion of pneumonia is clinically resolved.6

Modified Clinical Pulmonary Infection Score (CPIS)

Temperature (oF) > 96.8 & < 101.2 > 101.2 & < 102 > 102.1 or < 96.8 Tracheal Secretions Absent Nonpurulent Purulent PaO2/FIO2 > 240 or ARDS < 240 & no ARDS X-ray Infiltrate None Diffuse / patchy Localized 0 points 1 point 2 points 0 points 1 point 2 points 0 points 2 points 0 points 1 point 2 points 82 WBC Count > 4,000 & < 11,000 < 4,000 & > 11,000 (>50% band forms) Culture < 105 cfu/ml > 105 cfu/ml Gram stain & Cx same Progression of infiltrate None Progression 0 points 1 point 1 point 0 points 1 point 1 point 0 points 2 points

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Mechanically Ventilated Patient Preventative Measures a Clinical Suspicion of pneumonia and/or CPIS 5 NO YES BAL b

No Treatment

Initiate Broad Spectrum Abx c <104 CFU/ml

Stop ABX

Check Culture & Sensitivities

Non-Resistant Organism

104 CFU/ml SPACE d De-escalate according to sensitivities for 15 days. Double cover pseudomonas if concomitant bacteremia

Resistant Organism MRSA Vancomycin for 15 days Goal trough >15-20 (15mg/kg dosing)

De-escalate according to Sensitivities, Tx for 8 days

Footnotes:

a. b. c. d.
1. 2. 3. 4. 5. 6.

Head of bed elevation at least 30 degrees, minimization of sedation, daily assessment for spontaneous breathing trial, chlorhexidine oral care. Discard first 20mL prior to sending pooled effluent for culture. <3 Days in hospital/Admitted from home Empiric coverage for community-acquired pneumonia. > 3 Days in hospital/nursing home patient/recent hospital admission Empiric coverage for MRSA/SPACE bugs. Serratia, Pseudomonas, Acinetobacter, Citrobacter, Enterococcus.
Heyland DK, et al. The clinical utility of invasive diagnostic techniques in the setting of ventilatorassociated pneumonia. Chest. 19999; 115:1076-1084 Fagon JY, et al. Invasive and non invasive strategies for management of suspected ventilator-associated pneumonia. Ann Int Med. 2000; 132:621-630. Croce M, et al, The futility of the clinical pulmonary infection score in trauma patients. J Trauma 2006; 60:523-7. Dupont H, et al, Impact of appropriateness of initial antibiotic therapy on the outcome of ventilator associated pneumonia. Intensive Care Med. 2001; 27:355-362. Kollef MH. Antimicrobial therapy of ventilator-associated pneumonia: how to select an appropriate drug regimen. Chest. 1999; 115:8-11. Singh N, et al. Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. Am J Respir Crit Care Med. 2000; 12:505-5111.

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Severe Sepsis and Septic Shock

Systemic inflammatory response syndrome (SIRS): Any patient with two or more of the following four criteria has SIRS: Temperature > 100.4 or < 96.8 Heart rate >90 Respiratory rate >20 or PaCO2 < 32 mm Hg WBC count >12,000 or < 4,000 Sepsis: SIRS + Infection Severe sepsis: Sepsis + Acute Organ Dysfunction Septic shock: Sepsis with Hypotension (SBP<90 or MAP<60) despite resuscitation Patients with severe sepsis or septic shock must be treated aggressively to optimize outcome. Fundamental principles include source control, resuscitation, antimicrobial therapy and other adjuncts.1 Early goal-directed therapy improves survival in severe sepsis and septic shock. This approach involves adjustments of cardiac preload, afterload, and contractility to balance oxygen delivery with oxygen demand within 6 hours.1,2 Vasopressin may be effective in supporting blood pressure in patients with refractory shock despite adequate fluid resuscitation and high-dose conventional vasopressors. Low-dose corticosteroid therapy (hydrocortisone 200-300 mg/day x 7 days) should be considered in patients with septic shock. Patients with severe sepsis should be tested for adrenal insufficiency; non-responders should receive steroid therapy.3 Hyperglycemia and insulin resistance are common in critically ill patients, even if they have not previously had diabetes. Tight control of blood glucose (80-110 mg/dl) has been shown to improve morbidity and mortality4. Emerging evidence supports the use of a target blood glucose of 150mg/dl, which seems to yield many of the benefits of tighter control without the adverse effects due to unintended hypoglycemia. The ultimate goal for target blood glucose remains elusive at present and may change in the near future as additional data become available. Activated Protein C should be considered in patients with severe sepsis or septic shock who have Apache II score > 24 or two-system organ dysfunction.5 Avoid its use in postoperative patients with single-system organ dysfunction, or those who have not had source control. Contraindications are listed at: www.fda.gov/cder/foi/label/2001/droteli112101LB.pdf. Hold for 2 hours to procedure/surgery; resume 12 hours after major surgery or immediately after minor surgery.
1. 2. 3. 4. 5. Dellinger RP, Carlet JM, Masur H, et al. Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004; 32:858-73. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368-77. Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. Jama 2002; 288:862-71. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001; 345:1359-67. PROWESS study group. Efficacy and Safety of Recombinant Human Activated Protein C for Severe Sepsis. N Engl J Med 2001; 344: 699-709.

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Severe Sepsis / Septic Shock

Initial Evaluation
H&P; CBC, Chem 7, ABG, Lactate Cultures, UA; Imaging as indicated

Broad Spectrum Antibiotics; Plan for Source Control Arterial and Central Venous Catheters

Aggressive Resuscitation
CVP 8-12 mmHg MAP > 65 mmHg UO > 0.5ml/kg/hr Give Hgb to 10 g/dl then crystalloid Targets:

Reassess
Vital signs, UO, ABG, lactate q 2hrs

Improving / Normal

Worsening

Glucose Control 80-110 mg/dl DVT/GI prophylaxis Semi-recumbent position for ventilated pts Lung protection ventilation for ARDS/ALI Consider Activated Protein C

Swan-Ganz Catheter C.C.O.

Cardiac Profile

PCWP NI, SVR N1/High C.O. low

PCWP low fluid PCWP > 12, SVR low agent (eg. Levo)

Cosyntropin Stimulation Test Draw Cortisol (time = 0) 250 meg Cosyntropin IV Cortisol at 30 and 60 min Increase meg/dl = non-responder Consider empiric hydrocortisone or Dexamethasone if critically unstable

Dobutamine Milrinone

If high dose pressors (eg, Levo 0.2 meg/kg/min)

Vasopressin 0.04 IU/min

Glucose Control 80-110 mg/dl DVT/GI prophylaxis Semi recumbent position for ventilated pts Lung protection ventilation for ARDS/ALI Consider Activated Protein C

Rev. 10/1/07

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DVT/PE Prophylaxis in Adults Following Multiple Trauma

The National Institute of Health estimates that approximately 20% of multiply-injured young people develop DVT.1 Accurate assessment of the risk of DVT is critical for proper prophylaxis (see below). All non-ambulatory trauma patients should be considered for prophylactic anticoagulation. Prior to anticoagulation, however, the relative risk of DVT must be identified as greater than that of potential bleeding complications. Absolute contra-indications to anticoagulation include acute neurotrauma (intracranial or intraspinal bleeding) as well as ongoing coagulopathy or bleeding. However, after mandatory consultation with spine service or neurosurgery, DVT prophylaxis may commence as early as 48 hours post injury. When indicated, anti-coagulation should be immediate and continuous. Duration of therapy is dictated by the period of immobilization. Importantly, therapy should continue through rehabilitation until ambulation is achieved. Patients with low risk for DVT/PE should have early ambulation instituted. The definition of ambulatory status is walks 200 feet 3 times daily. In moderate risk patients, low molecular weight heparin (LMWH) appears to offer a safer, more effective means of protecting against DVT than either unfractionated heparin or sequential compression devices (SCD).2 In this population, if anticoagulation is contraindicated, SCD should be used.3 Of note, there is currently no proven benefit to the simultaneous use of anticoagulants and SCD. Use of prophylactic IVC filters should be reserved for patients with multiple risk factors (i.e., high risk patients) for whom an extended period of immobilization is anticipated, or in the event of failure of or contraindication to anticoagulant therapy.4 If not contraindicated, concomitant use of anticoagulants following IVC filter insertion should be considered.5
1. 2. 3. 4. 5. 6. Consensus Conference, National Institutes of Health: Prevention of venous thrombosis and pulmonary embolism. JAMA 1986;256:744. Geerts WH, Jay RM, Code KI et al. A comparison of low-dose heparin with low molecular weight heparin as prophylaxis against venous thromboembolism after major trauma. N Engl J Med 1996;335:701-707. Knudson MM, Lewis FR, Clinton A, et al. Prevention of venous thromboembolism in trauma patients. J Trauma 1994;37:480-487. Greenfield LJ, Proctor MC, Rodriguez JL, et al. Post-trauma thromboembolism prophylaxis. J Trauma 1997;42:100-103. Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena cava filters in the prevention of pulmonary embolism in patients with proximal deep vein thrombosis. N Engl J Med 1998;338:409-415. Greenfield, EAST 1998.

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Risk Assessment6 Underlying condition Morbid obesity Malignancy Abnormal coagulation factors at admission History of DVT Iatrogenic factors Femoral line >24 hours 4 or more transfusions in first 24 hours Surgical repair >2 hours Repair or ligation of major vascular injury Injury-related factors Burn >20% TBSA AIS score >2 for chest AIS score >2 for abdomen AIS score >2 for head, or Coma (GCS <8 for >4 hours) Complex lower extremity fracture Pelvic fracture Spinal cord injury +/- paraplegia or quadriplegia Age 40-60 years 60-75 years 75 years

4 2 2 4 2 2 2 3 3 2 2 3 4 4 4 2 3 4

DVT/PE Prophylaxis LOW Risk < 3 Early Ambulation If early ambulation not possible SCD
Rev. 8/4/07

MODERATE Risk 3 5 LMWH Lovenox 30 mg SC q12h If contraindication for LMWH SCD

HIGH Risk > 5 LMWH Lovenox 30 mg SC q12h If contraindication for LMWH IVC filter

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Heparin-Induced Thrombocytopenia
Heparin-Induced Thrombocytopenia (HIT) occurs in up to 5% of patients receiving therapeutic or prophylactic doses of unfractionated heparin (UH). HIT generally occurs 5 to 12 days after initiation of UH /LMWH, however, patients with previous exposure to UH/LMWH may develop HIT within 24 hours of exposure to UH/LMWH and are at particularly high risk for thrombotic complications. Exposure to extremely small amounts of heparin, such as those used to coat central catheters or flush intravenous lines has been associated with HIT. The use of low molecular weight heparin (LMWH) reduces the incidence of HIT by up to 90%1,2. HIT is a clinical diagnosis that may be confirmed by laboratory testing. The American Society of Hematology has developed a 4Ts grading scale to determine the pretest probability of HIT3,4 (See Table). A score of 0-3 indicates a low risk for HIT (< 0.1%); 4-5 an intermediate risk (.1-10%); 6-8 indicates high risk (>10%). All patients receiving UH/LMWH should have their risk assessed daily. Patients at low risk (score, 0-3) may be continued on UH/LMWH with continued daily risk assessment. Patients at intermediate risk (score, 4-5) should have confirmatory ELISA testing. If the ELISA is negative the patient may continue on UH/LMWH with continued daily risk assessment. In high-risk patients (score 6,8) or intermediate patients with a positive ELISA all UH/LMWH must be immediately discontinued (including heparin flushes and heparin bonded central catheters) and alternative anticoagulation with direct thrombin inhibitors (DTI) initiated3-5 (See below). Several DTIs are available for treatment of HIT. Lepirudin and Argatroban are the only DTIs currently approved by the FDA for treatment of HIT although there is growing experience with Fondaparinux. Lepirudin (0.1 mg/kg/hour) is renally metabolized and is contraindicated in patients with renal failure. Argatroban (1 mcg/kg/min) is hepatically metabolized and is the alternate DTI of choice in patients with renal failure. The incidence of thrombotic complications in patients with HIT who are not on DTI is up to 6% per day.5-7 The timing and duration of oral anticoagulation needed following an episode of HIT is unclear but currently DTI therapy until the platelet count surpasses 150,000 followed by 6 weeks of Coumadin (5 days of Coumadin/DTI overlap recommended) is recommended. In patients with a documented thrombotic complication associated with HIT, 6 months of anticoagulation with Coumadin is recommended.5 Category Thrombocytopenia Timing of platelet count fall Thrombosis of other sequelae 2 Points >50% fall Days 5-10, or < 1 day if heparin exposure w/I past 30 days Proven thrombosis, skin necrosis, or, after heparin bolus, acute systemic reaction None evident 1 Point 30-50% fall > 10 Days or unclear (but fits with HIT), or < 1 day if heparin exposure w/I past 30-100 days Progressive, recurrent, or silent thrombosis; erythematous skin lesions Possible 0 Points <30% fall <1 day (no recent heparin) None

Other cause for thrombocytopenia * Table adapted from Warkentin et al.8

Definite

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1. 2. 3. 4. 5. 6.

Aster RH. Heparin-induced thrombocytopenia and thrombosis. N Engl J Med. 1995; 332: 1374-1379. Martel N, Lee J, Wells PS. Risk for heparin-induced thrombocytopenia with unfractionated and low molecular weight heparin thromboprophylaxis: A meta-analysis. Blood. 2005; 106: 2710-2715. Lo GK, Juhl D, Warkentin TE, et al. Evaluation of pretest clinical score (4 Ts) for the diagnosis of heparininduced thrombocytopenia. J Thromb and Hem. 2006; 4: 759-766. Rice L. Emerging treatment strategies for heparin-induced thrombocytopenia. Semin Hematol. 2005; 42: 1521S. Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia: Recognition, treatment and prevention: The seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest. 2004; 126: 311S-337S. Greinacher A, Eichler P, Lubenow N, et al. Heparin-induced thrombocytopenia with thromboembolic complications: Meta-analysis of 2 prospective trials to assess the value of parenteral treatment with lepirudin and its therapeutic aPTT range. Blood. 2000; 96: 846-851. Lubenow N, Eichler P, Leitz T, et al. The HIT investigators group. Lepirudin in patients with heparininduced thrombocytopenia results of the third prospective study (HAT-3) and a combined analysis of HAT-1, HAT-2 and HAT-3. J Thromb Haemost. 2005; 3: 2428-2436. Wartentin TE, Aird WC, Rand JH. Platelet-endothelial interactions: sepsis, HIT, and antiphospholipid syndrome. Hematology (Am Soc Hematol Educ Prog). 2003; 497-519.

7.

8.

Rev. 8/7/07

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Antibiotic Usage on the Trauma Service

Prophylactic antibiotics are often employed in trauma patients, for a variety of conditions in order to prevent infections and are frequently recommended by consulting services. The data to support many of these recommendations is weak or nonexistent, and drugresistant infections attributable to antibiotic overuse are becoming more common and far more virulent, even resulting in preventable deaths due to Clostridia difficile. The overall concept is that antibiotics cannot overcome poor wound management and if over-utilized will promote the emergence of bacterial resistance and super-infections. Open fractures: Bacterial wound contamination of open fractures can lead to cellulitis, osteomyelitis and bony nonunion. Open fractures are best managed by debridement of devitalized tissue with concomitant antibiotic therapy. Most studies on antibiotic therapy for open fractures are outdated and/or suffer from serious methodological flaws. There is adequate data to support the use of a short course of a first generation cephalosporin, along with appropriate surgical wound care. Currently, there is NOT adequate data to support coverage of gram-negative bacilli or clostridial species, nor the use of antibiotic impregnated beads. 1 Thus, all open fractures should be treated with cefazolin for no more than 48hrs. Closed fractures are treated like any other clean case and should receive no more than a single perioperative dose. Traumatic Hemo-pneumothorax requiring Tube Thoracostomy: carry an associated risk of 1-2% incidence of empyema, mostly dependent on the insertion conditions and complete evacuation of hemothorax 2 . Strict adherence to full barrier sterile precautions is an ABSOLUTE MUST. Presumptive antibiotics for the prevention of empyema and pneumonia are controversial. A recent prospective, randomized trial comparing cefazolin for the duration of tube placement versus cefazolin for 24 hours versus placebo failed to demonstrate a difference in pneumonia or empyema. 3 Although underpowered, this study argues strongly AGAINST the use of antibiotics in trauma patients who require chest tubes. EVDs: Adequate data is not available to support early cessation of antibiotics, however, there are small studies that suggest that the rate of ventriculitis is unchanged in patients who receive only pre-procedural antibiotics. 4 Until an adequately powered study is performed to show that this is indeed the case, patients with EVDs will receive a first generation cephalosporin for the duration that the drain is in place.

1 Hauser CJ, Adams CA, Eachempati SR: Surgical Infection Society Guideline: Prophylactic antibiotic use in open fractures: an evidence-based guideline. Surgical Infections, 2006: 7(4): 379-405. 2 Luchette FA, Barrie PS, Oswanski MF, et al: Practice Management Guidelines for Prophylactic Antibiotic Use in Tube Thoracostomy for Traumatic Hemopneumothorax: the EAST Practice Management Guidelines Work Group. Eastern Association for Trauma. J Trauma. 2000;48:753-7. 3 Maxwell RA, Campbell DJ, Fabian TC, et al: Use of Presumptive Antibiotics following Tube Thoracostomy for Traumatic Hemopneumothorax in the Prevention of Empyema and PneumoniaA multi-center Trial. J Trauma, 2004; 57: 742-9. 4 Alleyne CH, Hassan M, Zabramski JM: The efficacy and cost of prophylactic and periprocedural antibiotics in patients with external ventricular drains. Neurosurgery, 2000; 47(5): 1124-7.

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Facial Fractures: There is no prospective study demonstrating a decreased incidence of infections after closed facial fractures in patients who receive empiric antibiotics. There is one randomized study looking at patients with operatively managed closed facial fractures. 5 This study showed a lower risk of infections in patients who received one dose of cefazolin pre-operatively, and one dose eight hours later. Thus, it seems reasonable to give a first generation cephalosporin for no more than 24 hours, including mandibular fractures. Traumatic Pneumocephaly: As an isolated finding, there is no indication for prophylactic antibiotics in traumatic pneumocephaly. In the presence of a sinus fracture, however, a short course of antibiotics may be warranted. Again, there is no literature to support this, and is at the discretion of the trauma attending and neurosurgeons. Base of skull fractures: No evidence to support routine antibiotic prophylaxis or empiric therapy in cases without meningitis. Irrespective of CSF leak. Vascular Injury: st Single dose of 1 generation cephalosporin for 24 hours if synthetic graft used. A single dose is indicated in endovascular procedures. There is no benefit from graft antibiotic bathing, suction groin wound drainage and preoperative bathing with antiseptic agents. Burns: Systemic antibiotic prophylaxis is of no value in controlling burn wound sepsis, and might even favor the growth of P. aeruginosa in the burn wounds. Penetrating Abdominal Trauma: A single preoperative dose of prophylactic antibiotics with cefazolin or ampicillin/ sulbactam is standard of care for trauma patients sustaining penetrating abdominal wounds. These antibiotics should be given as soon as technically feasible once the decision to operate has been made. Perioperative antibiotics are intended to prevent wound infection; they DO NOT prevent intra-abdominal abscess or anastomotic breakdown. In the absence of established peritonitis no further antibiotics are indicated and antibiotics must be discontinued within 24 hours. Third generation cephalosporins, quinolones, metronidazole, and aminoglycosides should be avoided.

Chole RA, Yee J. Antibiotic prophylaxis for facial fractures. A prospective, randomized, clinical trial. Arch Otolaryngol Head Neck Surg, 1987; 113(10): 1055-7.

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Trauma in Pregnancy
1 in 12 pregnancies is complicated by trauma. Two-thirds are injured in MVCs, with falls and assaults the next most common. Up to 20% of pregnant women are victims of domestic violence. Trauma is the leading cause of non-obstetrical maternal death. Life threatening maternal trauma is associated with 50% fetal loss rate; less severe injuries still have fetal loss rates of up to 5%.1 Since minor injuries are much more common, most fetal losses result from relatively minor maternal injuries. Thus, special attention must be paid to the pregnant trauma patient, with a coordinated effort among emergency physicians, trauma surgeons, obstetricians, and sometimes neonatologists.2,3 INITIAL MANAGEMENT The highest priority in a pregnant trauma victim is to evaluate and stabilize the mother: AIRWAY- Special concerns for a pregnant patients airway include the increased risk for aspiration due to decreased GI motility and upward displacement of the gravid stomach. BREATHING- The fetal 02-hemoglobin dissociation curve is shifted to the left, so minimal decreases in maternal SA02 can significantly compromise fetal oxygenation. CIRCULATION- Physiologic changes in pregnancy (30-50% increase in blood volume, peripheral vasodilation) may result in delayed manifestation of shock. Supine positioning may lead to hypotension as the uterus compresses the IVC. This can be avoided by positioning the mothers right hip on a pillow or IV bag to displace the uterus to the left. GESTATIONAL AGE DETERMINATION Age may be estimated by the uterine fundal height: if it is below the umbilicus, the fetus is 20 weeks or less and is not viable; if it is above the umbilicus, the distance in cm from the pubis to the top of the fundus roughly correlates with the gestational age in weeks (+/- 2 weeks). Ultrasonographic measurement of biparietal skull diameter (BPD), abdominal circumference, and femur length provides a more accurate determination. BPD is the best single test, but the others allow estimation of fetal weight. DETERMINATION OF FETAL VIABILITY The survival of a neonate delivered at 21 weeks is 0%; at 25 weeks it is 75%. Difficult decisions must be made between 22 and 25 weeks. Even if the fetus survives, long-term morbidity is a problem. 50% of surviving newborns delivered at 25 weeks or less have disabilities in psychomotor development, neuromotor function or sensory/communication function, with one-quarter having severe deficits at 30 months of life.4 Pre-delivery decisions about neonatal management may be altered depending on postnatal age assessment, condition of the neonate at birth, and the newborns response to resuscitation. Counseling of parents and documentation of decision-making is CRITICAL! DIAGNOSTIC TESTING Exposure of a fetus to extremely large doses of ionizing radiation may have teratogenic, carcinogenic, or genetic effects. The rate of childhood leukemia increases from 1/3000 (background) to 1/2000 among children exposed in utero to ionizing radiation. The greatest potential risk of anomalies is during organogenesis in the first trimester. However, total exposure of less than 5 rads has never been associated with anomalies, growth restriction, or spontaneous abortions. This allows multiple diagnostic tests (Table 1).5 ACOG guidelines state that concern about possible effects of radiation exposure should not prevent medically indicated diagnostic x-rays from being performed
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on the mother.6 Shielding is reasonable if practical. There are no documented adverse fetal effects of MRI, but it is arbitrarily recommended to avoid MRI in the first trimester. Estimated Fetal Exposure For Various Imaging Methods Plain Films Cervical spine Upper or lower extremity Chest (2 views) Abdominal (multiple views) Thoracic spine Lumbosacral spine Pelvis Hip (single view) CT scans (slice thickness: 10mm) Head (10 slices) Chest (10 slices) Abdomen (10 slices) TYPES OF TRAUMA Blunt trauma may cause fetal death by maternal loss of life or direct fetal injury. More commonly, the uterus bears the brunt of the injury. Over 50% of fetal losses are due to placental abruption. Abruption typically occurs within 6 hours of the event. The classic triad of frequent contractions, bleeding and abdominal pain occurs in fewer than half of cases, and ultrasound will identify placental clot only 50% of the time. Thus, the only clues to abruption may be contractions and abnormal fetal heart tracing. Up to 2 L of blood can be sequestered retroplacentally, so if the mother is hypotensive without a source, consider abruption. Uterine rupture is not common and also may be hard to diagnose. The classic presentation is searing pain, abnormal fetal heart rate and transabdominal palpation of fetal parts. The mother may rapidly deteriorate, and there is a very high fetal loss rate. Fetal-maternal hemorrhage, defined by the presence of fetal blood cells in the maternal circulation, can lead to fetal anemia and fetal compromise. When Rh(+) fetal cells are exchanged with Rh(-) maternal blood, the mother will make immune globulins against Rh(+) blood cells. In subsequent pregnancies with Rh(+) children, hemolysis of fetal blood cells can potentially cause fetal death. To avoid these potential complications, all pregnant trauma patients with Rh(-) blood type should receive a vial of Rh immune globulin (RhoGAM) within 72 hours of the incident. The amount of blood exchanged can be estimated by the Kleihauer-Betke test, which is performed on maternal blood. Although the amount of blood exchange does not accurately predict fetal prognosis, additional vials of RhoGAM must be administered when there has been >30 ml hemorrhage. Penetrating trauma is associated with relatively high fetal loss rates due to umbilical cord, placental, or fetal trauma. Cesarean section is frequently necessary. The distended uterus may actually shield the maternal viscera and it displaces the bowels superiorly. Burns over 40 -50% BSA correlate with very poor fetal survival, prompting some to recommend Cesarean Section.7,8 Electrical injuries have not been well studied. The link between minor household electrical shocks and stillbirths is unclear, but fetal mortality is as high as 50-75% following significant electrical injury such as a lightning strike. Early fetal heart monitoring should be considered.7,8
93

Fetal dose (rads) 0.002 0.001 0.00007 0.245 0.009 0.359 0.040 0.213 Fetal dose (rads) <0.050 <0.100 2.600

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SURGERY ON THE PREGNANT PATIENT Surgery may be required to treat or stabilize a mother. General anesthesia has not been linked with any specific problems. It is important to maintain uterine perfusion by maintaining high maternal SA02, providing fluid resuscitation, operating in the left uterine displacement position, and avoiding vasopressors when possible. Fetal heart monitoring can be performed during surgery by placing the monitor in a sterile sleeve. PERIMORTEM CESAREAN SECTION Once there is maternal loss of vital signs there should be an immediate consideration for the performance of a Cesarean section if the fetus is viable. Survival is optimized if performed within 4 minutes. If the fetus is delivered >15 min after maternal death, fetal survival is only 5% and most of those survivors have severe neurological sequelae.3 DISPOSITION If a pregnant patient <22 weeks has been evaluated and treated and is ready for discharge, she should be instructed to contact her obstetrician within 24 hrs for a follow-up appointment. She should also be instructed to call if she develops any lower abdominal pain, bleeding, fluid loss or a decrease in fetal movement. If a pregnant patient with a viable fetus has been stabilized, she should undergo fetal monitoring for 4-6 hours for minor trauma, and at least 24 hours for major trauma. If the mother is stable for discharge from RIH the fetal monitoring can be arranged at W&I. Prior to discharge every pregnant trauma patient should have a blood type determination and receive RhoGAM if Rh(-).Tetanus toxoid is safe to administer in pregnancy. Local anesthetics, acetaminophen, and narcotics can be used when indicated. Nonsteroidal antiinflammatory agents should be avoided. Safe antibiotics include penicillins, erythromycins (excluding EES), cephalosporins, clindamycin and gentamicin Tetracyclines, chloramphenicol, and quinolones should be avoided. Mechanism for OB/GYN CONSULTATION Page the PGY-3 OB-GYN Resident in the ED at Women & Infants directly at 2741122 ext 1750 or have the operator page them at 274-1100. If the 3rd year cannot be located, have the in-house OB/GYN chief resident paged by the operator. If a prompt response is not achieved the Trauma Service should then page the in-house OB/GYN attending. Please provide the following information if it is available: Patients name and the name of their OB-GYN, a brief history, an estimation of the gestational age. At this point the OB resident will come to RIH to evaluate the patient, and will arrange for fetal monitoring if necessary.
1. 2. 3. 4. 5. 6. 7. 8. ACOG Educational Bulletin, Obstetric Aspects of Trauma Management. Number 251, Sept 1998. DAmico C. Trauma in Pregnancy. Topics in Emergency Medicine. 2002. Hanley M and Thomson C. Trauma in Pregnancy: Double Jeopardy. Emergency Medicine Practice, 5(1): 128, 2003. ACOG Practice Bulletin, Perinatal Care at the Threshold of Viability. Number 38, Sept 2002. Toppenberg K et all, Safety of Radiographic Imaging During Pregnancy. American Family Physician, 59(7) 1813-1818, April 1999. ACOG Committee Opinion, Guidelines for Diagnostic Imaging During Pregnancy. Number 158, Sept 1995. Gatrell C and Schwartz G. Trauma in Pregnancy . Principles and Practice of Emergency Medicine, 1999. Jagoda, A and Kessler, S, Trauma in Pregnancy. The Clinical Practice of Emergency Medicine. 2001.

Rev. 9/2/07

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Reporting Child Abuse and Neglect and Referrals to the Child Protection Program
All medical personnel in Rhode Island are mandated to report suspected child abuse or neglect to the Rhode Island Department of Children, Youth and Families (DCYF). Reports are made by calling 1-800-RICHILD. After calling the DCYF 'hotline', a form entitled "Physicians Report of Examination" (PRE) is filled out and forwarded to DCYF documenting the suspected abuse or neglect. The Child Protection Program (CPP) at HCH provides 24 hour-a-day physician coverage. The Child Protection physician on call is available for consultation when abuse or neglect is suspected. In many cases the CPP will take responsibility for reporting child maltreatment to the proper authorities and will coordinate the collection and documentation of forensic evidence. The Child Protection Program should be contacted in all of the following pediatric cases: 1. All unexplained head injuries, especially in children <2 years of age. 2. All unexplained fractures, particularly in nonambulatory children and in children <1 year of age; multiple fractures in the absence of major trauma. 3. All immersion, pattern injury, questionable burns in nonambulatory children, and unexplained burns. 4. All unexplained abdominal injuries. 5. All acute sexual assaults in children and adolescents (within 72 hours) that require immediate documentation of physical trauma by colposcopy. (Most sexual abuse cases > 72 hours post-assault can be referred to the Child Safe Clinic). 6. Other: a) All drowning in children <5 years of age. b) All cases where the child is suffering from exposure or starvation. c) All cases of significantly delayed or neglected medical care. d) Ingestion of drugs or alcohol suspected to be non-voluntary or caused by parental neglect, especially ingestion of illegal drugs in children. e) All cases of suspected Mnchhausen syndrome by proxy. f) All other cases where injuries have been purposefully inflicted on a child (e.g., pattern bruising such as slap marks, strap marks, or ligature marks). g) Chronic failure-to-thrive cases without medical cause. h) Cases of repeated episodes of infantile apnea where the child has been previously admitted to the hospital and whose medical work-up was negative. Also, cases of previously healthy children who experience apnea after nine months of age. i) All free falls >3ft. in children <1 year of age. j) Repeated admissions for trauma in children <2 years of age. k) All trauma cases where the injury is suspected to have occurred because of inadequate supervision or because of lack of provision for the child's safety. In any other case where the medical care provider has questions about whether or not abuse or neglect occurred, the CPP should be consulted. The CPP can be contacted at 4-3996 from 8:00 a.m. to 4:30 p.m. weekdays and through the page operator at 4-5611 from 4:30 p.m. to 8:00 a.m. and on weekends and holidays.
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Speech Language Pathology Services

Patients are referred to the Speech-Language Pathology Department via an order in POM when there are concerns regarding communication/cognition, feeding/swallowing, and/or voice. Patients injuries may lead to short or long-term loss of ability to speak/communicate, therefore referral to a speech-language pathologist (SLP) is indicated to evaluate for need and type of augmentative communication (communication board or electronic device), Passy-Muir speaking valve, or speech therapy. Head trauma can also lead to cognitive impairments (attention, memory) and/or aphasia in which case a speech pathologist may perform a cognitive/linguistic evaluation. Long term intubation, placement of a tracheostomy tube, and long term use of nasal tubes can all have a negative affect on swallowing function and therefore these patients should be considered for referral to Speech Language Pathology as well.

ASSESSMENTS
Speech-Language Pathology/ Feeding/Swallow Evaluation Clinical Swallow Evaluation: Patient is seen at bedside. A comprehensive swallowing evaluation is completed which includes an oromotor examination and administration of food and liquid consistencies. Based upon this assessment recommendations may be made for treatment and additional testing. Communication Evaluation: Voice, speech and language, and cognition are assessed. Recommendation regarding type of treatment or any additional assessment, which may include Passy-Muir valve evaluation, augmentative communication evaluation/treatment, videostroboscopy or clinical voice evaluation/treatment, will be made. Modified Barium Swallow (MBS) Examination is completed in the radiology department(s) along with a radiologist. Patient is seated upright and administered trials of various consistencies and is viewed under fluoroscopy. Evaluation is made of the oral phase and pharyngeal phases of the swallow. The pharyngeal phase of the swallow is assessed with regard to timeliness of the swallow, residue in the pharynx, symmetry of pooling/residue, premature spillage of bolus, number of swallows per bolus, presence or absence of laryngeal penetration, presence or absence of aspiration, patient response to laryngeal penetration or aspiration. Based on the examination, recommendations are made by the SLP regarding dietary textures, swallowing strategies, treatment and further testing. MBS is indicated to objectively assess the oropharyngeal swallowing mechanism and to assess for aspiration/risk of aspiration. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) A speech language pathologist completes examination at bedside. A flexible fiberoptic scope is placed into the patients nose and advanced to the level of the pharynx in order to assess structure and function. The patient is presented with trial of food and liquid of various consistencies. The pharyngeal phase of the swallow is assessed with regard to timeliness of the swallow, residue in the pharynx, symmetry of pooling/residue, premature spillage of bolus, number of swallows per bolus, presence or absence of laryngeal penetration, presence or absence of aspiration, patient response to laryngeal penetration
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or aspiration. Based on the examination, recommendations are made by the SLP regarding dietary textures, swallowing strategies, treatment and further testing. FEES is indicated to assess the pharyngeal swallow phase and to assess for aspiration/risk of aspiration. FEES may be recommended when positioning in or transport to radiology may be problematic, for assessment laryngeal competence (post intubation, tracheostomy), or assessment of secretion management. For some patients, both MBS and FEES may be indicated. Videostroboscopy/Comprehensive Voice Assessment A speech language pathologist completes examination in the videostroboscopy room on COOP-1. The examination is reviewed with an Otolaryngologist. A rigid scope is placed into the oral cavity to the level of the pharynx. If the patient is unable to tolerate the rigid scope orally, a flexible scope may be used nasally. The larynx is viewed under a constant and a stroboscopic light source. A comprehensive assessment of the laryngeal structures and function is completed. Based on the examination, recommendations are made by the speech language pathologist and Otolaryngologist regarding further testing and treatment. The Otolaryngologist may also suggest other medical or surgical intervention as indicated. Videostroboscopy is indicated when there is concern for laryngeal pathology. Videostroboscopy allows for more detailed evaluation of the anatomy and physiology of the larynx/vocal folds. Swallowing is not assessed during a videostroboscopy examination. Treatment/Therapy Based upon the results of the evaluations that have been completed, treatment goals will be established by the SLP to address voice, swallowing, communication and cognition/ language as indicated. RIH/HCH Speech-Language Pathology Department: Phone 444-5485/Fax 444-6212 Contacts: Anette Rogers, Manager, Speech-Language Pathology 444-4053 Moira McDonnell, Clinical Coordinator, Speech-Language Pathology 444-4047
Rev. 6/17/08

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Diagnosis of Brain Death: Adult

DEFINITION An individual who has sustained either: 1. IRREVERSIBLE cessation of circulatory and respiratory function, or 2. IRREVERSIBLE cessation of all function of the entire brain, including the brainstem, is dead. A determination of death must be made in accordance with accepted medical standards. The uniform determination of death act implicitly states two critical points: 1. CESSATION of function is recognized by appropriate clinical examination. 2. IRREVERSIBILITY is recognized by persistent cessation of function during an appropriate period of observation and/or trial of therapy. THE DIAGNOSIS OF BRAIN DEATH CAN BEST BE DETERMINED BY CLINICAL EXAMINATION ALONE, provided that complicating conditions are not present. CLINICAL CRITERIA FOR BRAIN DEATH DIAGNOSIS: Assuming that no complicating factors exist, the examination is as follows: I. ABSENT CEREBRAL FUNCTION: Includes no response to stimuli above the neck. II. ABSENT BRAINSTEM FUNCTION: Examination of brainstem function requires appropriate and adequate stimulation: a. ABSENT PUPILLARY LIGHT REFLEX: No atropine within 12 days. b. ABSENT CORNEAL REFLEXES: Includes bilateral stimulation. c. ABSENT VESTIBULO-OCULAR REFLEX: Must be tested with caloric stimulation. Patient should be in supine position with head elevated 30 degrees to allow for proper positioning of the horizontal semicircular canal. A minimum of 200 cc ice water instilled into each external canal with careful observation of the eyes for any movement as well as the extremities for presence of any vestibulospinal induced movement. d. ABSENT OROPHARYNGEAL REFLEX (gag reflex) e. APNEA: Appropriate testing for apnea is extremely important. Most patients with severe brain damage will have been hyperventilated for a period of time during the course of their therapy. Therefore, an appropriate period of time is required to allow for elevation of serum PaCO2. Hypercarbia with serum PaCO2 greater than 60 mmHg for 30 seconds has been determined as adequate stimulation for respiratory drive. To apnea test a patient, the patient should be ventilated on 100% FiO2 for 10 minutes. During this period, the minute ventilation should be adjusted so that the PaCO2 is in the low 40s. THE ARTERIAL BLOOD GAS (ABG) SHOULD BE DRAWN AT THE BEGINNING AND THE END OF THE APNEA TEST AND DOCUMENTED IN THE CHART. At the beginning of the apnea test, the patient should be put on 100% FiO2 blow by. After a period of five (5) to eight (8) minutes without any spontaneous respiratory effort, a second ABG is drawn and the patient is put back on the ventilatory assistance. If the patient does not tolerate the apnea test, as indicated by the development of hypoxia during the procedure (e.g., O2 saturation less than 80%) or hypotension
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(e.g., systolic blood pressure less than 70 mmHg), then the test should be terminated. In this circumstance it should be medically documented that the patient did not tolerate the performance of the apnea test and, therefore, requires a supplementary diagnostic study to confirm the absence of cerebral blood flow or electrical activity. PERIPHERAL NERVOUS SYSTEM ACTIVITY AND SPINAL REFLEXES MAY PERSIST AFTER BRAIN DEATH. TRUE DECEREBRATE OR DECORTICATE POSTURING, OR SEIZURES, ARE NOT CONSISTENT WITH A DIAGNOSIS OF BRAIN DEATH. IRREVERSIBILITY is recognized when: 1. 2. 3. The cause of coma is established and is sufficient to account for the loss of brain function. The possibility of recovery of any brain function is excluded. No reversible conditions exist such as sedation, hypothermia, hyper- or hypoglycemia or natremia, neuromuscular blockade, or presence of serum toxins or drugs. The cessation of all brain function, as outlined above, persists for an appropriate period of observation and/or trial of therapy.

EXAM INTERVAL: Identical examination, including apnea test, and documentation must be performed. NOTIFY THE NEW ENGLAND ORGAN BANK AT 1-800-4466362 WHEN THE FIRST CLINICAL BRAIN DEATH EXAMINATION IS PERFORMED. An observation period of at least 12 hours is required once an irreversible condition has been established (see below). The exam interval may be reduced to 3 hours if a confirmatory test is also obtained. For anoxic brain death, 24 hours is required. If no complicating factors exist and all criteria on exam as outlined above have been met on two consecutive examinations, the patient is pronounced dead BEFORE artificial means of support are terminated. The documented time of death is the second neurological examination, not when cardiac arrest occurs following removal of ventilatory assistance. COMPLICATING CONDITIONS IF ANY OF THE FOLLOWING FACTORS EXIST, THE CLINICAL EXAMINATION IS INVALID: I. DRUG AND METABOLIC INTOXICATION: Cessation of brainstem function secondary to sedatives, anesthetic agents, street drugs, paralysis with areflexia, or apnea secondary to disease such as peripheral nerve infectious process, myasthenia gravis, or neuromuscular blockade must be ruled out. Patients who have been given thiopental for ICP management or Valium for sedation or who have experienced alcohol overdose must have a negative urine and serum toxicology screen. II. ELECTROLYTE IMBALANCE: Hyperosmolar coma secondary to elevated glucose (>400), hypo (<125) or hyper (>160) natremia must be corrected. Hepatic encephalopathy with elevated serum ammonia or preterminal uremia can also cause deep coma. III. HYPOTHERMIA: Criteria for reliable recognition for brain death are not available for the hypothermic state. Core temperature must be greater than 34 C. ADDITIONAL DIAGNOSTIC TESTS THERE IS NO MEDICAL OR LEGAL REQUIREMENT TO PERFORM ANY SUPPLEMENTARY DIAGNOSTIC TESTS OTHER THAN TWO CONSECUTIVE EXAMINATIONS AS DESCRIBED ABOVE UNLESS COMPLICATING CIRCUMSTANCES EXIST.
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While electrocerebral silence verifies irreversible loss of cortical function in the nontoxic, normothermic patient, technically flat-line EEGs (using 2 micro V/mm gain and interelectrode resistance of 100 to 10,000 ohms) are extremely difficult to obtain in the ICU setting with a patient on multiple supportive machines. Furthermore, catastrophic posterior fossa events with massive brainstem destruction will usually not cause loss of cerebral blood flow and therefore cortical activity will still exist on EEG. Other tests are available that assess the cerebral circulation, although only in the hemispheres, including radioisotope bolus cerebral angiography, gamma camera imaging with radioisotope cerebral angiography, and transcranial Doppler ultrasonography. Absent cerebral blood flow as measured by these tests, in conjunction with the clinical determination of cessation of all brain function for at least 3 hours, is diagnostic of brain death. Complete cessation of cerebral blood flow to the normothermic adult brain for more than 10 minutes is incompatible with survival of brain tissue. Therefore, documentation of circulatory failure is evidence of brain death. Four-vessel cerebral angiography can be performed at anytime and used as a single confirmatory test of brain death. At a minimum, bilateral internal carotid and one vertebral artery must be injected. When faced with a trauma victim who has received large doses of pentobarbital, the clinical examination is invalid and the angiography may be necessary. If no flow exists, the patient can be declared brain dead at the time of angiographic documentation of no flow. CERTIFYING PHYSICIANS There shall be two certifying physicians, both licensed to practice medicine in the state of Rhode Island. The initial physician (Staff Association or House Staff Association member) will be on the service where the patient is hospitalized. The second physician will be a Staff Association member of the Department of Neurology or Neurosurgery. Physicians who are members of a Transplant Service are specifically excluded from making a determination of brain death. At anytime, during this evaluation for brain death, the family may elect to withdraw life support. Donors without a Heartbeat: Donation after Cardiac Death (DCD) Kidney transplantation offers patients with end-stage renal disease a significant survival advantage as compared with dialysis. Despite the success of kidney transplantation, however, fewer than 9000 cadaveric kidneys are transplanted each year in the United States (UNOS data). This is due to the limited number of suitable kidneys that become available each year. Despite concerted efforts to increase the rate of donation, the number of cadaveric kidney transplants increased by only 10 percent between 1991 and 2000, with most of the increase resulting from the acceptance of organs from donors over the age of 50. The shortage of suitable kidney donors is a global problem for the transplantation community. It is encouraging that in 2003-2004 the number of deceased donors in the United States increased nearly 10%, due in large part to the Collaborative Efforts promoted by HRSA, in which Rhode Island Hospital is a key participant. Using kidneys from donors whose hearts have stopped beating could expand the number of cadaveric kidneys available for patients who need a kidney transplant. While only 115 DCD were recorded in 2000, the number of DCD transplants has steadily increased and in 2004 20% of deceased donor kidney transplants in New England were from DCD. The incidence of delayed graft function (DGF) is double that of standard brain dead donors, but the long-term outcomes of renal function and allograft survival are identical.
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Early concerns about the diagnosis of death on the basis of the cessation of cardiac activity (cardiac death) and the logistics of family consent were addressed by the Institute of Medicine (IOM), which declared that DCD including the declaration of death after a period of 5 minutes of asystole is ethically acceptable. Every day, families consent to the donation of organs from a family member for patients who need transplants, thus transforming the personal tragedy of death into a gift of life for others. The successful transplantation of kidneys from donors without a heartbeat extends that opportunity to families that make the difficult decision to discontinue life support. DCD Procedure (Based on RIH Protocol): 1. Patients 4 - 60 years of age with irretrievable loss of brain function and an established cause of irreversible damage:

Trauma

Intracranial bleed

Ischemic brain injury

Brain tumor

2. Brain death criteria not fulfilled due to patient hemodynamic instability or persistent brainstem function (absent cortical function) 3. Family or appropriate decision maker and attending physician agree to: No further treatment Continued artificial support is unwarranted No resuscitation upon asystole (ORM order) 4. Family / decision maker and attending physician agree to withdrawal of support: (Usually in the form of extubation, discontinue vasopressors and IV fluids) 5. Otherwise suitable organ donor: Creatinine < 2.0 mg/dL or suitable liver function 6. Notification of potential donor to New England Organ Bank (NEOB) NEOB: (800) 446-6362 Invitation for NEOB to speak with family for donation consent 7. Obtain Medical Examiners permission for donation. 8. Consent obtained by NEOB for DCD organ and tissue removal 9. Notification of potential donor to:

NEOB technical staff

Transplant surgeon

O.R. Staff (Nursing)

10. Preparation for cold perfusion upon declaration of death in ICU or operating room 11. Systemic heparinization (30,000 Units I.V.) 12. Extubate the patient (performed by ICU staff, attending physician or designate). 13. Five-minute period of asystole (absence of electrical activity on cardiac monitor). 14. Declaration of death (performed by patients physician or designate). 15. Cannulation of the femoral artery and vein for cold perfusion 16. Transport the donor to the operating room (for donors extubated in the ICU or the ED): 17. Laparotomy and organ procurement 18. Back table flush, evaluation and storage of organs 19. Contact recipients for admission and transplantation 20. If the patient does not progress to asystole in 60 minutes, organ donation is abandoned and routine comfort measures continue.
Rev. 9/8/07

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Diagnosis of Brain Death: Pediatric

A determination of brain death must be made in accordance with accepted medical standards. The Guidelines for the Determination of Brain Death in Children implicitly states: 1. 2. Cessation of brain function is recognized by appropriate clinical examination. Irreversibility is recognized by persistent cessation of function during an appropriate period of observation and/or trial of therapy.

To declare brain death, there must be two certifying physicians, both licensed to practice medicine in the state of Rhode Island. The initial physician should be the attending physician of record or his/her designee. The second should be a staff member in the Department of Neurology. Physician members of a Transplant Service are excluded from making a determination of brain death. Two clinical examinations are required separated by an age-dependent interval (refer to Appendix A). I. II. Absent cerebral function Complete loss of responsiveness, vocalization and volitional activity Absent brainstem function A. Absent pupillary light reflex; no atropine within previous 12 hours B. Absent corneal and oculocephalic reflexes C. Absent oculovestibular reflex. Caloric testing is contraindicated in the presence of hemotympanum or perforated tympanic membrane. In the absence of all other brainstem function, if a bilateral exam is contraindicated, a unilateral exam will be considered diagnostic. A minimum of 25cc ice water should be instilled into each external auditory canal followed by a 5-minute period of observation for eye movement in each eye. D. Absent oropharyngeal reflex (gag reflex) E. Apnea (see Appendix B for definition and procedure) F. Absence of spontaneous and purposeful movement, excluding segmental myoclonus

III. Absence of complicating factors A. Drug and metabolic intoxication. Depression of brainstem function due to sedatives, anesthetic agents, street drugs, or neuromuscular blocking agents must be ruled out by serum/urine toxicology screen and peripheral nerve stimulation. B. Electrolyte imbalance. Hyperosmolar coma due to elevated glucose (>400 mg/dl), and hypo- (<125 meq/L) or hyper- (>170 meq/L) natremia must be corrected. Hepatic and uremic encephalopathy can also invalidate the clinical exam. C. Hypothermia. Rectal temperature must be >34 C/93 F. D. Hypotension. An acceptable, stable blood pressure must be present during the examination interval (refer to Appendix A for exam intervals). There is no medical requirement to perform any confirmatory diagnostic tests (such as serial EEGs or cerebral blood flow study) other than two physical examinations, unless complicating circumstances exist. If any of the conditions described in section III exist, the clinical examination alone is invalid.
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In the presence of drug and metabolic intoxication, electrolyte imbalance, hypothermia, or significant blood pressure instability, confirmatory tests are required. One of the following tests, in conjunction with the clinical suspicion of cessation of all brain function for at least three hours, is diagnostic of brain death. A cerebral blood flow or cerebral artery angiographic study is required in patients in pentobarbital coma. Documentation of body temperature >34o C/93o F is required at the time of the confirmatory test. Confirmatory tests include: 1. 2. 3. Electrocerebral silence on 2 EEGs in a normothermic/non-intoxicated patient Absence of cerebral blood flow on radionuclide study Absence of cerebral artery visualization on 4 vessel cerebral artery angiography

Appendix A: Exam Intervals The exam interval recommended to determine brain death is chronologic age-dependent: 1. Newborn through 60 days 48 hours 2. 61 days through 12 months 24 hours 3. 13 months through 12 years 12 hours 4. 12 years or older 6 hours Appendix B: Apnea Test The following conditions must be met prior to performing an apnea test: 1. Absence of spontaneous respiratory muscle activity 2. Rectal or esophageal body temperature above 34 C/93 F 3. No clinical or laboratory evidence of medications that affect the respiratory center or neuromuscular function (refer to section III A) 4. Endpoint: To confirm arterial pCO2 >60 mm/Hg and/or arterial pH <7.25 To perform an apnea test, the patient should be ventilated on FiO2 1.0 for 10 minutes. During this time, the minute ventilation should be adjusted so that the PaCO2 is in the low 40s and/or the pH is normalized. An arterial blood gas should be drawn at the beginning and end of the apnea test and documented in the medical record. The patient should be placed on continuous positive airway pressure (CPAP), FiO2 of 1.0 with end tidal CO2 monitoring. When CPAP is not feasible, the patient should be removed from the ventilator and a suction catheter providing an FiO2 of 1.0 placed through the endotracheal tube. The catheter delivering oxygen should remain in the trachea during the period of testing. After five minutes with no spontaneous respiratory effort, a second ABG should be drawn. If oxygenation and blood pressure remain stable, wait for ABG results; if unstable, resume mechanical ventilation. If the patient does not tolerate the apnea test, as indicated by the development of hypoxia or hypotension, the test should be terminated. In this circumstance, it should be documented that the patient did not tolerate the performance of the apnea test. The decision to obtain a confirmatory diagnostic study to confirm the absence of cerebral blood flow or electrical activity rests with the neurology and ICU attendings. This was prepared by the Pediatric Committee on Brain Death and finalized on 12/17/97.
Rev. 9/8/07

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Informed Consent and the Care of the Trauma Patient

The care of the injured patient presents many difficult and unusual challenges not limited to medical issues alone. Legal matters punctuate the care of trauma patients and cover a wide range of topics from concerns regarding informed consent, to medical futility and end of life care, to the concept of urgent medical necessity. Medical practitioners may find themselves in precarious and unfamiliar legal situations that may be stressful for the physician and ultimately may hinder the delivery of top-notch care. This section will serve to answer some of the more common questions regarding informed consent. Remember, it is essential that complex medico-legal decision be made with attending physician input and if possible, Risk Management as well. A Risk Manager is on-call 24/7 at 350-5274. Informed Consent: True informed consent involves a process whereby a medical professional describes a proposed therapy to a patient in laymans terms, states the risks and benefits of the proposed therapy and alternative therapies. The patients questions and concerns must be addressed and the medical professional has an obligation to ensure that the patient has a good understanding of the situation, and is able to participate in the process. In trauma patients altered mental status due to head injury, hypotension, shock, pain, alcohol or other substances frequently preclude informed consent. In these circum-stances and if time or the situation will allow, the medical professional has an obligation to contact next-of-kin NOK (including acquaintances) so that informed consent can be obtained as long as no urgent life-saving intervention is required. It is inappropriate to delay lifesaving interventions in order to contact NOK or obtain informed consent. Rhode Island law does not define the hierarchy of NOK for medical decision-making, so that a spouse, adult child, parent, etc. may serve in this capacity. (For more info see http://intra.lifespan.org/supportsvcs/Administration/Admin%20137.pdf ). Close friends or acquaintances may also serve as NOK and may be able to offer insight about a patients 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 patients wishes. However, the patients life should not be put at risk while this contact occurs. If NOK are not immediately available and a life-threatening condition exists, the physician should proceed with any necessary interventions. This may include the need to control the patient with physical or pharmacological restraints. The interpretation of a life-threatening injury is problematic and there is little guidance in the law as to what this encompasses, nor is it clear whether only the suspicion of a life-threatening injury would fall into this category. In situations where urgent action is required, it is imperative that the attending physician documents the urgency of the situation and that the procedure was done without consent on the basis urgent medical necessity. While an intoxicated individual may seem sensible as they vehemently refuse an operation, you must assess their capacity to understand the situation. If you have doubts about their capacity, consult with others on the team, especially the attending physician, and if time allows a Risk Manager.
Rev. 9/29/07

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Obtaining Consults on the Trauma Service

All consults must be cleared by a trauma attending prior to consultation with the exception of the following: 1. Neurosurgical consultation for head and spinal trauma. 2. Orthopaedic consultation for fractures. 3. Plastic Surgery consultation for facial fractures. 4. Ophthalmologic consultation for ocular trauma. 5. Echocardiography for penetrating trauma in the box. OT/PT Rehabilitation The Trauma Service will request Occupational/physical therapy consultation for any patient with: Major neurological deficit: significant brain injury, spinal cord of radicular injury or injury of the brachial or lumbosacral plexus Amputation proximal to the digits Fractures expected to delay recovery of ambulation or independent activities of daily living Burns Deconditioning If recommended by OT/PT, a rehabilitation medicine consultation will be requested by calling Dr. Mukands office at 456-4556 from Monday through Friday, 8:00am - 5:00pm as soon as possible after the patients admission and/or diagnosis. Name, diagnosis, and patient location will be helpful. Urgent adult rehabilitation medicine consultations can be requested by paging the Medical Director of Southern New England Rehabilitation Center, Dr. Mukand through the hospital paging operator. Adult patients with anticipated placement problems will have a prompt initial screening by personnel from the Southern New England Rehab Center with a note indicating how they do or do not fulfill admission requirements and what additional information needs to be obtained to make such a determination. Any questions concerning adult placement issues will be communicated through the Rehabilitation Community Liaison, Diane Ventrone, beeper 456-4541, to the Rhode Island Hospital Case Management staff. Weekend Pediatric PT/OT Coverage A therapist is available at Hasbro on weekends and holidays for priority patients who require PT/OT in order to be discharged over the weekend and for wound/burn patients in need of continuous whirlpool treatments. The Childrens Rehab therapist may be reached through the pager operator (4-5611) on Saturdays, Sundays and holidays from 8:am until noon. Please page the therapist during these hours with new priority referrals to ensure weekend service and discharge. Weekend faxed (444-4181) referrals will be acted upon on the next weekday unless the therapist has been paged.

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Speech/Language Pathology If one or more of these symptoms is present, referral to Speech/Language Pathology for a swallowing/dysphagia exam is warranted: 1. History of aspiration, aspiration pneumonia, recurrent bronchitis, chronic pulmonary disease. 2. Feeding refusal and/or poor appetite. 3. Presence of NG tube, G/J tube or NPO status, question of transition from NG, G/J tube to oral feeding. 4. Presence of dysphonia and/or laryngeal pathology. 5. Choking/coughing during or after meals. 6. Congested breathing post-feeding. 7. Recent intubation/extubation. 8. Decreased cognitive status interfering with PO intake. 9. Weight loss/failure to gain weight. 10. Patient and/or patients family complains of swallowing problem. 11. Swallowing difficulties noted with changing from one food consistency to another (e.g., from liquids to solids). 12. Presence of dysarthria and/or oral motor difficulty. 13. Wet, gurgle voice noted during and/or post-meals. 14. Weak or absent volitional cough. 15. Diagnosis of brainstem CVA. 16. Presence of tracheostomy tube and/or need for ventilatory support/question of tracheostomy tube weaning. 17. Patient and/or patients family report of lengthy meal times. 18. Patient avoids certain food consistencies (e.g., stringy, course textures). Urology 1. The timing of urologic consultation is dependent upon the patients overall status. Pre-operative urologic consultation should be obtained in those patients who are hemodynamically stable and present with gross hematuria or microhematuria with an established genital-urinary system injury. Intraoperative consultation should be obtained for established renal, bladder, urethral, ureteral and genital trauma if the overall status of the patient permits such consultation. 2. The work-up of blunt trauma patients with suspected GU injury should include the following: a) Patients with suspected urethral trauma with blood at the penile meatus, a high-riding prostate on exam or a significant pelvic fracture should have a cystourethrogram performed prior to placement of a Foley catheter. Such studies should be performed in conjunction with the Trauma Service, Urology Service and Radiology. b) Patients with suspected bladder rupture who will undergo a CT evaluation of the abdomen should have a CT bladder protocol followed. If the patient does not undergo CT scanning of the abdomen and a suspicion for bladder injury exists, the patient should have a cystogram. c) Patients with gross hematuria should have renal evaluation by CT scanning with IV contrast or an IVP. The Trauma and Urology Services should jointly manage any abnormalities detected on the above studies. d) The potential need for pelvic arteriography should be assessed prior to performance of these studies, as pooled contrast may confound attempts to angioembolization.
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Neuropsychology (Phone 444-4500, Pager 350-4042) Inpatient Consultation Subacute Cognitive Impairment Evaluate cognitive status after closed head injury including patients with: - Loss of consciousness > 20 minutes - GCS <13 - Head CT or MRI for skull fracture, contusion, hemorrhage or DAI - Significant retrograde or anterograde amnesia Evaluate cognitive status stable but has not returned to baseline (patients with GCS of 13-15 if they have): - Persistent concussive symptoms (e.g. headache, dizziness, nausea) - Any question of cognitive impairment - Any abnormalities seen on head CT or MRI - History of previous head trauma - Over the age of 50 Evaluate cognitive rehabilitation needs for discharge planning Provide education to patient and family about recovery from head injury (especially mild head injury/concussion) Evaluate decision-making capacity - Chronic, longitudinal, non-urgent Patients can be examined and/or educated as long as all the following are present: Patient can follow commands Patient can communicate (at least yes/no responses) Patient is not heavily sedated due to severe non-CNS injuries Outpatient Neuropsychology Referral Non-urgent evaluation of cognitive functioning following head injury of any severity 3-6 months s/p injury can provide recommendations for rehabilitation and compensation 6 months + s/p injury can address residual or persistent cognitive deficits Clinical Social Work: (Call 4-5711, or the page operator for CSW on-call) There is a CSW on-site from 8am-midnight, Monday-Thursday and there is 24 hour on-site coverage from 8am, Friday-11:59pm, Sunday. Consultation should be considered for: Supportive psychotherapy - Patients - Families Crisis intervention Grief/bereavement, anticipatory grief, death and dying Evaluation of coping behavior Initial diagnostic assessment of anxiety and depressive symptoms (SW can triage case to psychiatry if needed) Adjustment to illness for patient and/or family Vulnerability of patient - lives alone - social isolation - retardation - poor coping skills - physical disabilities

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Social Work: (continued) Consultation should be considered for: Family violence - child abuse* - neglect/abandonment* - domestic violence - exploitation - elder abuse - sexual abuse* Advocacy in hospital or community for patient and/or family - Cultural differences - Discrimination Patients HIV + or with AIDS Community violence - Gang fighting - Sexual assault Patient geographically distant from support system DCYF involvement*
*In conjunction with the Child Protection Team (CPT) for pediatric patients Rev. 7/16/08

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End of Life Issues

1. 2. 3. 4. 5. The Trauma Attending will be notified immediately of all deaths on the trauma service. All deaths on the trauma service are to be reported to the medical examiner. Death certificates are not to be filled out in cases that will be taken by medical examiner. The decision to institute comfort measures only (CMO status) or to withdraw support may be made only by the attending surgeon. In situations in which brain death determination must be made, please refer to the brain death protocols for pediatric and adult patients.

Is This Patient a Potential Organ Donor? According to the Centers for Medicare & Medicaid Services latest regulations (42 C.F.R., sec 283.45) and hospital policy, you MUST contact the New England Organ Bank if a patient has died in the hospital or if you answer yes to any of the following: Is death imminent following a severe neurological injury? Cerebral vascular accident (CVA)? Head trauma? Intracranial hemorrhage? Anoxic encephalopathy? Brain tumor (non-metastatic)? Does the patient exhibit early signs of brain death? Pupils fixed and dilated? No corneals? No withdrawal to pain? No gag? No cough? Is the patient ventilator-dependent with the likelihood of death upon extubation? YES to any of the above questions requires a referral to the: New England Organ Bank 1-800-446-6362
Rev. 7/11/07

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