Trauma Care Protocols

And
Management Guidelines

IU/Wishard Trauma Center

Division of Trauma, Critical Care

and Emergency Surgical Services

Department of Surgery

Indiana University
School of Medicine
Wishard Health Services
 IU/Wishard Trauma Center
Trauma Care Protocols and Management
Guidelines

The following Trauma Care Protocols and Management

Guidelines have been collaboratively developed by
members of the Trauma Service. The Guidelines are meant
to serve as a framework for practice and in no way are
meant to replace sound clinical judgment.

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Trauma Surgery Faculty and Staff

Gerardo A. Gomez, M.D., F.A.C.S.

Associate Professor of Surgery
Chief, Division of Trauma, Critical Care and Emergency Surgical Services

Lewis E. Jacobson, M.D., F.A.C.S.

Associate Professor of Surgery

Clark J. Simons, M.D., F.A.C.S.

Assistant Professor of Surgery

Erik W. Streib, M.D.

Assistant Professor of Surgery

Thomas Z. Hayward, III, M.D., F.A.C.S.

Assistant Professor of Surgery

Teri Joy, R.N., B.S.N.

Trauma Nurse Coordinator

Wendy St. John, R.N., B.S.N.

Assistant Trauma Nurse Coordinator

Chris Scott, Pharm D

Clinical Pharmacist

Protocols edited by Erik W. Streib, MD

Revised June 2004

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Table of Contents
Trauma Faculty and Staff 3
Protocol: Trauma Resuscitation, Resuscitation Priorities 5
Protocol: Severe Head Injury 8
Protocol: Evaluation for Spine Injuries in Blunt Trauma 12
Protocol: Penetrating Neck Injury 15
Protocol: Evaluation and Management of Blunt Aortic 18
Injury (BAI)
Protocol: Hemothorax and Pneumothorax 20
Chest Tube Management
Procedure Guideline: Insertion of Chest Tube 24
Protocol: Blunt Abdominal Trauma 26
Protocol: Non-operative Management of Blunt Liver and 28
Spleen Injuries
Protocol: Pelvic Fracture 30
Protocol: Evaluation of Penetrating Abdominal Trauma 32
Protocol: Penetrating Extremity Trauma 35
Protocol: Hypothermia in the Injured Patient 38
Protocol: Ventilator Withdrawal Protocol (Part I) 41
Protocol: Symptom Control for Ventilator Withdrawal in 43
the Dying Patient
Protocol: Information for Patients and Families About 45
Ventilator Withdrawal

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PROTOCOL: Trauma Resuscitation
Resuscitation Priorities

OBJECTIVE:
The following outlines the priorities for managing the seriously injured or
potentially seriously injured patient according to ATLS guidelines. This is a framework
for the ongoing assessment and evaluation, although it must be recognized that deviations
will be necessary according to the patient’s status and ongoing re-evaluation. Patients
who are defined as having injuries or potential injuries for which these guidelines apply
are those who meet Code 77 or Trauma Alert criteria as defined in the “Triage/Trauma
Team Activation” Protocol, and are placed in the shock room.

GUIDELINES: The guidelines below lists priorities in the primary survey, resuscitation,
and secondary survey phases of trauma management as adapted from ATLS.

A. Primary Survey (Life Support)

1. Airway: guarantee patency and assure that the patient can protect his/her airway.
a. Possible C-spine injury – maintain in-line stabilization if intubation required.
b. Rapid Sequence Induction (RSI) is appropriate in most patients when needed,
possible exceptions below.
c. Anterior neck injury, stridor, but no acute airway obstruction: consider awake,
fiberoptic intubation or urgent surgical airway under local anesthesia in OR.
d. Anterior neck injury, stridor, and acute airway obstruction: consider emergent
surgical airway without prior attempts at intubation.
e. Head injury – intubate when GCS is less then or equal to 8, consider
neurosurgical evaluation prior to intubation when feasible.
f. Apnea – immediate orotracheal intubation with in-line stabilization, RSI
generally unnecessary.
2. Breathing: assess breath sounds bilaterally.
a. Assist ventilation if ventilatory effort is inadequate.
b. Verify ET tube position via auscultation and end tidal CO2 determination.
c. Tension Pneumothorax – immediate needle decompression, followed by tube
thoracostomy
d. Simple Pneumothorax – tube thoracostomy after X-ray confirmation.
e. Hemothorax – tube thoracostomy after fluid resuscitation, consider OR
thoracotomy for initial chest tube output > 1500 cc.
f. Confirm position and function of all chest tubes with CXR.
3. Circulation: assess for signs of obvious and occult shock via signs of adequate
organ perfusion (mental status, capillary refill, etc), vital signs, Arterial Blood
Gas (ABG) analysis.
a. Hemostasis – direct pressure to bleeding wounds; consider immediate, rapid
closure for intensely bleeding scalp wounds.

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 b. Treat Shock
i. Assess for etiology. Consider hypovolemic shock as most common cause.
Neurogenic shock considered if evidence of spinal cord injury. Shock state
should never be assumed to result from head injury.
ii. Initial therapy should consist of 2 liters of isotonic crystalloid solution,
failure to respond or shock state that is difficult to correct should illicit a
search for bleeding that requires operative or angiographic control. See
specific injury related Guidelines.
iii. Patients discovered to have sustained severe injury or who presented with
signs of shock and then responded to initial therapy need to be reassessed
frequently, this includes continuous monitoring of vital signs, continuous
attendance by nursing staff and trauma team MD during all transports and
while in radiology, and frequent ABG analysis (no less then hourly for
patients with base deficits < - 8) until a resolution of the shock state has
been assured.
iv. Cardiac Tamponade – consider diagnosis with shock that does not respond
to volume, especially in penetrating chest trauma, neck vein distension
may or may not be present. FAST may confirm diagnosis. Consider ED
thoracotomy with loss of vital signs; otherwise proceed emergently to OR
for pericardial window or sternotomy/thoracotomy.
v. Indications for ED Thoracotomy:
(a) Penetrating Chest Trauma and one of the following:
(b) Loss of vital signs (pulse) en route to ED, with electrical activity
on presentation. or
(c) Loss of vital signs or sustained BP <50 in ED.
4. Disability:
a. Calculate GCS. Consider Neurosurgery consult when GCS <14, consider
intubation when GCS <9.
b. See Head Injury Guidelines.
c. Assess for sensory and motor deficits.
5. Exposure:
a. Remove clothing, log roll to examine back, remove backboard when present.
b. Maintain normothermia – blankets, warm fluids, warm room.

B. Secondary Survey (head to toe exam, adjuncts)

1. Head/Maxillofacial – examine wounds, control bleeding, pupil exam, assess facial
stability.
2. Neck – examine for wounds, palpate for tenderness, deformity, etc…
3. Chest – examine for wounds, etc.., re-evaluate breath sounds.
4. Abdomen
a. See injury specific Guidelines.
b. Focused exam.
c. Consider FAST in blunt trauma.
d. Determine need for further evaluation (DPL, CT, laparotomy/oscopy.)
5. Pelvis – examine for wounds, assess for tenderness, avoid excessive
motion/compression, x-ray to diagnose fracture.

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 6. Extremities
a. Complete pulse exam.
b. Reduce fracture dislocations.
c. Splint as needed.
7. Spine – assess for tenderness or deformity.
8. Adjuncts:
a. Naso/orogastric tube – consider placement in all blunt trauma victims.
b. Foley – place after rectal exam, unless deemed unnecessary by team leader.
c. X-rays – team leader to determine need and timing of x-rays, in general lateral
c-spine, supine CXR and pelvic x-ray for blunt trauma.

C. After Stabilization:
1. Determine disposition: OR, radiology, ICU, Obs.
2. Determine need and sequence of advanced radiographic studies (plain film, CT,
angio.)
3. Consult specialty services.
4. Determine frequency of re-evaluation i.e. labs, x-rays etc…

D. Frequent Re-Assessment:
1. Vital Signs should be documented no less then every 30 min. until initial work-up
is complete and patient has stabilized.
2. Outputs (chest tubes, urinary) – to be recorded at frequent intervals.
3. Patients with shock/blood loss or high base deficit need serial determinations of
perfusion status i.e. ABG, Hb, Lactate.

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PROTOCOL: Severe Head Injury

OBJECTIVES:

1. Early diagnosis and management of severe traumatic brain injury.

2. Prevent causes of secondary brain injury during resuscitation (hypoxia,
hypovolemia, hypocarbia, anemia, hypo/hyperglycemia.)
3. To rapidly identify and treat mass lesions.
4. Indications for ICP/CPP monitoring and management of intracranial hypertension
(ICH.)

DEFINITIONS:
• Mild head injury: Glasgow Coma Scale* (GCS) score 14-15
• Moderate head injury: GCS 9-13
• Severe head injury: GCS 3-8
*After adequate cardiopulmonary resuscitation.

GUIDELINES:

A. Initial management (see flowchart.)

1. Primary and secondary survey as outlined in resuscitation section above.
2. Establish level of consciousness and any focal neurologic deficits.
3. Airway:
a. Intubate all unconscious patients (GCS < 9) to secure airway. Use sedation
and short acting neuromuscular blockade if necessary.
b. Maintain cervical spine immobilization in all unconscious or symptomatic
(neck pain or tenderness) patients.
4. Breathing: Oxygenation and ventilation.
a. Administer high flow oxygen to all patients with suspected head injury.
b. Monitor oxygen saturation.
i. Avoid hypoxia (SaO2<90% or PaO2<60 mmHg.)
c. Ventilation.
i. Avoid hyperventilation; unless signs of herniation are present (see below.)
ii. Maintain PaCO2 35-40 mmHg.
5. Circulation:
a. Prehospital: avoid SBP<90 mmHg.
b. Resuscitate to goal of mean arterial pressure (MAP)>90 mmHg to maintain a
presumptive cerebral perfusion pressure (CPP)>60 mmHg.
c. Fluids: infuse 0.9% NaCl and/or blood.
6. Recognize and treat herniation syndromes.
a. Signs:
i. Pupils: Anisocoria (asymmetric,) irregular, or sluggish reaction,
progressing to fixed, dilated, nonreactive.
ii. Motor: hemiparesis, decerebrate posturing, Babinski reflex.
iii. Progressive neurologic deterioration, not attributable to extracranial
causes.

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 b. Emergency treatment of herniation:
i. Hyperventilation.
ii. Mannitol, if not hypotensive.
c. In the absence of a herniation syndrome, do not initiate treatment for
intracranial hypertension, until CT scan is done or ICP monitor inserted.
7. Manage all wounds in a sterile manner.
8. Indications for head CT scan (without IV contrast):
a. Unconscious.
b. History of loss of consciousness.
c. Focal neurologic deficits.
d. Post-traumatic seizure.
e. Decreasing level of consciousness.
f. Penetrating injury.
g. Skull fracture.
9. Indications for neurosurgery consultation:
a. Moderate or severe head injury: GCS<14.
b. Post-traumatic seizure.
c. Unequal pupils.
d. Neurologic deficit.
e. Abnormal head CT scan:
i. Hematoma.
ii. Contusion.
iii. Edema.
iv. Compressed basal cisterns.
v. Fracture.
10. All head injured patients will be admitted to the trauma service for a minimum of
24 hours, or until all multisystem issues are resolved.

B. Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring.

1. Need for ICP/CPP monitoring will be determined by the neurosurgery service.
General indications:
a. Severe head injury (GCS 3-8) + abnormal CT scan.
b. Severe head injury + normal CT scan and at least 2 of the following 3:
i. Age>40.
ii. Unilateral or bilateral posturing.
iii. SBP<90 mmHg.
c. Inability to monitor neuro exam: prolonged sedation or anesthesia.
2. Technique:
a. ICP: Parenchymal ICP monitoring catheter (Camino) or ventricular catheter.
b. CPP: Arterial line needed for continuous monitoring
i. CPP = mean arterial pressure(MAP) – ICP

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C. ICP/CPP treatment (see flowchart.)
1. Parameters:
a. Normal ICP = 0-10 mmHg.
b. Treatment threshold > 20-25 mmHg.
c. Goal CPP = 60-70 mmHg.
2. Mannitol.
a. Initial evaluation: Use mannitol without ICP monitoring only if signs of
herniation or progressive neurologic deterioration, not attributable to
extracranial causes, are present.
b. For treatment of intracranial hypertension:
i. Effective doses range from 0.25-1 gram/kg, given by intermittent bolus
infusion Q 4-6 hrs.
ii. Euvolemia must be maintained. Foley mandatory. CVP monitor
recommended.
iii. Monitor serum osmolality. Do not exceed 320 mOsm/kg.
3. Barbiturates.
a. High dose barbiturates may be considered for hemodynamically stable,
salvageable, severe head injury patients with intracranial hypertension
refractory to maximal medical and surgical therapy.
4. Steroids.
a. Steroids should not be used in patients with severe head injury.

D. Early post-traumatic seizure prophylaxis (7 days):

1. Phenytoin(Dilantin) is indicated for:
a. Glasgow coma scale score < 10.
b. Cortical contusion.
c. Depressed skull fracture.
d. Subdural hematoma.
e. Epidural hematoma.
f. Penetrating head wound.
g. Seizure within 24 hrs. of injury.
2. Therapy should be instituted for 7 days.

E. Nutritional support.
1. Enteral feeds should be instituted within 72 hours of injury.
2. Goals:
a. kcal:
i. Nonparalyzed patient – replace 140% of estimated energy expenditure.
ii. Paralyzed patient – replace 100% of estimated energy expenditure.
b. Protein:
i. Use high protein formula = Crucial. Provides 25% of kcal as protein.
3. Administration:
a. Start via NGT at initial rate of 10 ml/hr increasing 10 ml/hr every 4 hrs. until
goal is reached.
b. Hold for residual > 100 ml, or if abdominal injury present or surgery required.

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 4. Parenteral nutrition
a. Use only if enteral feeds contraindicated or not tolerated.
b. Use same caloric requirements.
c. Give at least 15% of total kcal as protein.

References:
1. Brain Trauma Foundation, Inc. Management and prognosis of severe traumatic
brain injury. 2000. http://www2.braintrauma.org (also 2003 update on cerebral
perfusion pressure.) (accessed 6/10/2004.)

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PROTOCOL: Evaluation for spine injuries in blunt trauma

OBJECTIVES:

1. To identify patients at risk for spine injury after blunt trauma.

2. To outline the radiographic evaluation for suspected spine injuries.
3. To initiate the initial management and appropriate neurosurgical consultation in
patients with suspected spine injuries.

DEFINITIONS:

1. 3-view C-spine series:

a. Lateral Radiograph: must adequately visualize the base of the occiput to the
upper part of the first thoracic vertebra. Supplement with swimmer’s view if
needed to visualize the cervicothoracic junction.
b. Anteroposterior Radiograph: must reveal the spinous processes of C2-7.
c. Open Mouth Odontoid Radiograph: must visualize the entire dens and the
lateral masses of C1.
2. CT scan of C-spine: Helical CT scan with saggital reconstructions from skull
base through the upper part of the first thoracic vertebra.
3. Spinal Immobilization: Rigid C-collar, supine position, logroll precautions. An
effort should be made to carefully take the patient off of the back board early in
the evaluation and management, to prevent skin injury and discomfort.
4. Suspicious Mechanism:
a. Direct trauma to the neck or back.
b. Significant deceleration, examples:
i. Motor Vehicle Crash with high speed, rollover or ejection.
ii. Fall from height.
iii. Pedestrian or bicycle accident with history of significant impact.
c. Severe head injury from blunt trauma.

GUIDELINES:

A. Perform ABCDE’s, primary and secondary surveys. Secondary survey includes a

focused neurologic examination and palpation of the cervical, thoracic, and
lumbosacral spine, while maintaining spinal immobilization.

B. Further evaluation and management depending on presentation:

1. Asymptomatic Patient:
a. Neurologically normal.
b. Not intoxicated.
c. No neck pain or midline tenderness.

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 d. No distracting injury that would make it difficult for the patient to discern the
presence or absence of neck pain, e.g.:
i. Long bone fracture.
ii. Visceral injury.
iii. Large wounds or burns.
e. If above criteria are met, remove C-collar. If patient can demonstrate
voluntary flexion, extension, and rotation without pain they are clinically
cleared (without radiographic evaluation.) Document clinical clearance in the
medical record.
2. Symptomatic Patient:
a. Complains of neck pain or has midline tenderness on examination.
b. Obtain 3-view C-spine series.
c. Supplemental CT scan of C-spine if plain radiographs suspicious or
inadequate.
d. Abnormal radiographs.
i. Continue immobilization.
ii. Neurosurgical consult for injury management.
e. Normal radiographs.
i. Continue immobilization while symptomatic.
ii. Neurosurgical consult for further evaluation and management.
3. Neurologic Deficit Referable to a Cervical Spine Injury:
a. Maintain spinal immobilization.
b. Neurosurgical consult.
c. Obtain CT scan if stable. Further imaging per neurosurgery.
d. Methylprednisolone protocol to start within 8 hrs. of injury (discuss with
neurosurgeon.)
i. Methylprednisolone(Solu-Medrol) 30 mg/kg slow IV bolus.
ii. Methylprednisolone infusion 5.4 mg/kg/hr for 23 hrs.
4. Obtunded, Intubated, or Comatose Patient:
a. Maintain spinal immobilization. (ASPEN collar)
b. Obtain CT scan of C-spine.
i. Negative Æ remove rigid C-collar, apply soft collar until able to clear
clinically. Document radiographic clearance in the medical record.
ii. Abnormal Æ neurosurgical consult.
5. Intoxicated Patient:
a. Asymptomatic:
i. Immobilize until not intoxicated.
ii. Then, clear as above for asymptomatic patient.
b. Symptomatic:
i. Evaluate and manage as symptomatic patient above.
ii. Immobilize until not intoxicated.

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 6. Distracting Injury (With Mechanism Suspicious for Spine Injury):
a. Asymptomatic:
i. Obtain 3-view C-spine series.
ii. Supplemental CT scan of C-spine if plain radiographs suspicious or
inadequate.
(a) Negative Æ Clear C-spine and remove collar. Document clearance in
the medical record.
(b) Abnormal Æ Neurosurgical consult.
b. Symptomatic:
i. Evaluate and manage as symptomatic patient above.

C. Thoracic, lumbar, and sacral spine.

1. Initial evaluation and management as for cervical spine, above.
2. If unable to clear clinically, and symptoms or a suspicious mechanism exists:
a. Obtain anteroposterior and lateral radiographs of the vertebrae.
i. Normal:
(a) Asymptomatic Æ Clear spine, document clearance in the medical
record.
(b) Symptomatic Æ Neurosurgical consultation.
ii. Abnormal Æ Neurosurgical consultation.

References:
1. Hadley MN et al. Radiographic assessment of the cervical spine in asymptomatic
trauma patients. Neurosurgery 2002 Mar; 50(3):S30-35.
2. Hadley MN et al. Radiographic assessment of the cervical spine in symptomatic
trauma patients. Neurosurgery 2002 Mar; 50(3):S36-43.
3. Marion DW et al. Determination of cervical spine stability in trauma patients
(update of the 1997 EAST cervical spine clearance document.) www.east.org
2002. (accessed 8/26/2003.)
4. Keats TE et al. American college of radiology ACR appropriateness criteria:
cervical spine trauma. http://www.acr.org/cgi-bin/fr?tmpl:appcrit,pdf:0243-
246_cervicalspinetrauma_ac.pdf 1999. (accessed 8/26/2003.)
5. Hoffman JR et al. Selective cervical spine radiography in blunt trauma:
Methodology of the national emergency x-radiography utilization study
(NEXUS.) Annals of emergency medicine. 1998 Oct; 32(4):461-469.
6. Stiell IG et al. The Canadian c-spine rule for radiography in alert and stable
trauma patients. JAMA 2001 Oct; 286(15):1841-1848.
7. Hadley MN et al. Pharmacological therapy after acute cervical spinal cord injury.
Neurosurgery 2002 Mar; 50(3):S63-72.

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PROTOCOL: Penetrating Neck Injury

OBJECTIVES:

1. Provide an algorithm for the identification, evaluation and management of

penetrating neck injuries.
2. Outline indications for diagnostic testing.
3. Define indications for surgery.

DEFINITIONS:

1. Neck: The circumferential region bounded by the clavicles and base of the skull.
Generally divided into three zones.
a. Zone I: Extends from the sternal notch and clavicles to the cricoid
cartilage, encompassing the structures in the thoracic outlet.
b. Zone II: Extends from the cricoid cartilage to the angle of the mandible.
c. Zone III: Extends from the angle of the mandible to the base of the skull.
2. Penetrating injury: An open wound which penetrates deep to the platysma
muscle. This excludes superficial abrasions and lacerations of the skin and
subcutaneous tissues only.

GUIDELINES:

1. Primary survey and resuscitation

a. Airway: Airway compromise will be the most immediate life threatening
associated condition. Options for airway control:
i. Orotracheal intubation is preferred route.
ii. Emergency cricothyroidotomy in the E.D. if unable to intubate or
ventilate. Risk of releasing a contained hematoma.
iii. Surgical airway in the O.R. Tracheostomy under local anesthesia
if airway is patent, but threatened.
b. Breathing/Chest: Evaluate for associated chest injuries.
c. Circulation:
i. Control bleeding with direct pressure.
ii. Intravenous access preferred in extremity opposite from injury.
d. Disability: Assess for neurologic deficit.
i. Stab wounds/lacerations – if no neurologic deficit, no
immobilization required.
ii. Gunshot wounds/comatose patients – maintain immobilization
until fracture ruled out by x-ray.
iii. Combined blunt and penetrating mechanism (rare) – immobilize as
for blunt injury.
iv. If cervical collar used, remove and re-examine neck frequently.

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2. Secondary survey. Includes focused examination of head neck and chest.
a. Indications for emergent exploration in the O.R.:
i. Shock.
ii. Active bleeding.
iii. Expanding or pulsatile hematoma.
iv. Need for surgical airway.
v. Obvious tracheal or esophageal injury.
vi. Impaled object.
b. Determine if the platysma has been violated.
i. Do not probe neck wounds.
ii. Small wounds that appear superficial may be locally anesthetized
and enlarged to inspect the depth of penetration.
iii. Superficial wounds may be closed in the E.D. If large or complex,
operative closure is an option.
c. Determine zone of injury.
d. Obtain AP and lateral neck, and AP chest radiographs.
e. Examine for physical findings of significant injury:
i. Bleeding.
ii. Bruit or thrill.
iii. Dysphagia.
iv. Hoarseness or stridor.
v. Subcutaneous emphysema.
vi. Hematoma.
vii. Oropharyngeal bleeding.
viii. Hemoptysis.
ix. Neurologic deficit.
x. Absent or diminished pulses.

3. Evaluation and management of hemodynamically stable patients:

a. Zone I.
i. Asymptomatic + normal chest radiograph = observe.
ii. Positive findings:
1. Arteriogram
2. Esophagram +/- esophagoscopy
3. Consider bronchoscopy
4. Management directed by results
b. Zone II.
i. Asymptomatic + normal radiographs = observe.
ii. Positive findings:
1. Arteriogram
2. Esophagram +/- esophagoscopy
3. Consider laryngoscopy and bronchoscopy
4. Management directed by results

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 c. Zone III.
i. Asymptomatic + normal radiographs = observe.
ii. Positive findings:
1. Arteriogram
2. Consider direct pharyngoscopy and laryngoscopy
3. Management directed by results
d. Multizone injuries. Evaluate zone I and III injuries prior to operative
management of zone II.
e. Penetrating injuries involving violation of the oropharyngeal mucosa.
Treat with penicillin or similar antibiotic to cover oral flora.

References:
1. Azuaje RE, Glover J, Gomez GA, et al. Reliability of physical examination as a
predictor of vascular injury after penetrating neck trauma. The American Surgeon.
2003;69(9):804-7.
2. 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(1):41-8.
3. 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(3):483-9.
4. Barkana Y, Stein M, Scope A, et al. Prehospital stabilization of the cervical spine
for penetrating injuries of the neck – is it necessary? Injury Int. J. Care Injured
2000;31:305-9.

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PROTOCOL: Evaluation and management of blunt aortic injury (BAI)

OBJECTIVES:

1. To identify blunt aortic injuries in patients at risk.

2. To describe medical management guidelines.
3. To facilitate transfer for definitive surgical treatment, when indicated.

BACKGROUND:

A. Morbidity and mortality:

1. The majority of patients with BAI will die before reaching the hospital.
2. The remainder may die within a few days unless identified and treated.
3. BAI has a reasonably good expectation of survival if identified and treated in a
timely manner.
4. Most patients have associated injuries.
B. Mechanism: BAI results from rapidly decelerating mechanisms such as:
1. Motor vehicle crashes (any direction of impact.)
a. High speed (> 40 m.p.h.)
b. Roll-over.
c. Ejection.
2. Motorcycle crashes.
3. Pedestrian/bicyclist struck with significant impact.
4. Falls (> 10 ft.)
C. Diagnostic modalities:
1. Chest X-ray (CXR) is rapid, but less sensitive and specific compared to CT or
aortography.
2. Helical CT has a very high (reported to be 100%) negative predictive value.
3. Aortography remains the gold-standard test, but is invasive and time consuming.

GUIDELINES:

A. Initial management:
1. Primary survey and resuscitation. ABCDE.
2. Secondary survey – obtain portable AP CXR.
3. CXR findings suspicious for BAI:
a. Widened mediastinum.
b. Obscure/indistinct aortic knob.
c. Deviation of the trachea to the right.
d. Obliteration of the space between the pulmonary artery and the aorta (AP
window.)
e. Depression of the left mainstem bronchus.
f. Presence of a pleural or apical cap.
g. Deviation of the nasogastric tube to the right.
h. Widened paratracheal or paraspinous stripes.
i. Fractures of the first or second rib or scapula.

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B. Diagnostic imaging:
1. Obtain a helical CT scan of the chest to screen for BAI in the following
circumstances:
a. Significant decelerating mechanism of injury (see above.)
b. CXR with any of the above findings.
c. In conjunction with CT of the abdomen/pelvis for suspected blunt intra-
abdominal injury.
2. CT read as normal by radiology attending Æ no further testing required.
3. CT abnormal, equivocal, or radiology attending not immediately available:
a. Consult interventional radiology (IR) to evaluate for BAI.
b. IR fellow and/or faculty will review CT chest.
i. If over-read by IR faculty as normal Æ no further testing required.
ii. IR faculty will document CT findings in the medical record.
c. CT abnormal or equivocal Æ proceed to aortography.
4. Angiography:
a. Ensure that other potentially life-threatening injuries have been assessed and
managed.
b. Continuously monitor and control blood pressure (see below.)
c. Aortogram negative Æ Admit patient to trauma service.
d. Aortogram positive for BAI Æ Consult IU cardiothoracic surgery fellow at
Methodist hospital.
C. Treatment guidelines for suspected or confirmed BAI:
1. Blood pressure control
a. Insert arterial line for continuous BP monitoring.
b. Control BP and HR with Esmolol drip.
i. Endpoints: SBP < 110 mmHg, HR < 100.
ii. Loading dose 500 mcg/kg over 1 minute.
iii. Infusion starting dose 50 mcg/kg/min.
iv. Repeat loading dose and increase in increments of 50 mcg/kg/min, to
maximum 300 mcg/kg/min.
c. Control BP with Nitroprusside drip, if needed.
2. Insert central venous access for resuscitation and CVP monitoring.
3. Surgical repair.
a. Consult cardiothoracic surgery for prompt transfer and repair.
b. Initiate Aortic Injury Transfer Algorithm.
c. Delayed surgery and/or medical management may be acceptable if:
i. Unstable from intra-abdominal or severe head injuries.
ii. Require emergent laparotomy or craniotomy.
iii. Unable to tolerate emergency thoracic surgery.
iv. Elderly patient or other comorbidities.

References:
1. Nagy K, Fabian T, Rodman G, et al. EAST practice management guidelines
workgroup. Guidelines for the diagnosis and management of blunt aortic injury. 2000.
www.east.org (accessed 9/15/2002.)

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PROTOCOL: Hemothorax and Pneumothorax
Chest tube management

OBJECTIVES:
1. To identify patients with hemo- or pneumothorax following blunt or penetrating
injury.
2. To standardize the insertion and management of chest tubes.
3. To establish criteria for the safe and timely removal of chest tubes.

GUIDELINES:
A. Chest tube insertion protocol:
1. In all patients, assess the ABC’s and obtain an airway, if necessary. Recognize
the differentiation between airway and breathing (hemo/pneumothorax) problems.
Respiratory difficulties may resolve with appropriate management of the
breathing problem without the need for intubation.
2. Determine whether the patient is hemodynamically stable (normal) or unstable
(hypotensive or tachycardia) and whether the patient has respiratory distress.
3. If hemodynamically unstable or has respiratory distress consider:
a. Tension pneumothorax:
i. Absent breath sounds.
ii. Tympanitic to percussion on affected side.
iii. Distended neck veins.
iv. Shift of the trachea.
v. Decompress with needle thoracostomy to temporize.
vi. Insert large bore chest tube.
b. Massive hemothorax:
i. Absent breath sounds on affected side.
ii. Dull to percussion on affected side.
iii. Stabilize blood pressure with vigorous fluid resuscitation.
iv. Insert large bore chest tube.
v. Take immediately to OR if,
1. Initial drainage is > 1500 ml, or
2. Drainage continues at >200 ml/hr for 2-3 hours
4. If patient is stable and has little respiratory distress, obtain AP supine chest x-ray
(mark the entry and exit sites with radio-opaque markers).
5. If x-ray shows:
a. Pneumothorax Æ place large bore (≥36 Fr) chest tube.
b. Hemothorax Æ resuscitate the blood volume and place large bore chest
tube.
6. For patients with penetrating injuries, if initial chest x-ray is normal:
a. Observe for 6 hours and obtain repeat inspiratory and expiratory chest x-
ray (AP portable if intubated.)
i. If the 6hr film is negative consider discharge from the ED.
ii. If there is a significant pneumothorax or hemothorax or the patient
becomes symptomatic follow guidelines as above.

20
 7. For patients with tiny pneumo- or hemothorax, seen only on CT scan:
a. Observe for 6 hours and obtain repeat inspiratory and expiratory chest x-
ray (AP portable if intubated.)
i. If the 6hr film is negative consider discharge from the ED.
ii. If there is a significant pneumothorax or hemothorax or the patient
becomes symptomatic follow guidelines as above.
8. All chest tubes will be placed to -20 cm H2O suction.
9. Reassess ABC’s after chest tube placement prior to proceeding with primary and
secondary survey.
10. Obtain chest x-ray to check tube position, evacuation of hemo- or pneumothorax.
a. Complete evacuation:
i. Begin monitoring ongoing chest drainage or air leak.
b. Incomplete evacuation:
i. Check system.
ii. Consider need for additional chest tube.

B. Chest tube maintenance protocol:

1. All chest tubes will be placed to -20 cm H2O suction for the first 24 hours.
2. Scheduled chest x-rays:
a. Morning after insertion: confirm tube position, evacuation of hemo- or
pneumothorax.
b. Further scheduled chest x-rays not needed, unless:
i. Change in clinical condition.
ii. Change in chest tube management.
iii. Tube removal anticipated in next 24 hours.
3. Air leaks:
a. Monitor for leak daily.
b. Continue -20 cm H2O suction until air leak resolves.
c. Trial of water seal prior to tube removal:
i. Place chest tube to water seal for 4-6 hrs. (tell the nurse.)
ii. Obtain PA and lateral (AP portable if intubated) chest x-ray.
iii. If pneumothorax reoccurs, place back on -20 cm H2O suction for
24 hrs. and reassess.
d. For prolonged air leaks or bronchopleural fistula (discuss with Trauma
Faculty):
i. Check system.
ii. Consider need for thoracotomy, thoracoscopy, pleurodesis.
iii. Consider water seal or Heimlich valve.
4. Fluid drainage:
a. Monitor character and volume of fluid. Do this yourself, do not rely on
the nurses notes.
i. Output minimal?
1. Definition: <10 ml/hr for prior 6-8 hrs if acute; <100 ml/24
hrs if more chronic
2. If minimal, proceed to chest tube removal protocol
ii. Ongoing output? Continue to monitor daily.

21
 5. Analgesia:
a. Provide appropriate analgesia for chest tube discomfort and associated
injuries, to allow adequate volume expansion therapy.
b. Transition to oral analgesics as soon as it is feasible.
6. Volume expansion therapy:
a. Necessary to mobilize retained secretions and blood, and prevent
atelectasis.
b. Use the Respiratory Therapy Volume Expansion Protocol. Incentive
spirometry is the minimum and mandatory for all non-intubated patients.
7. Antibiotics:
a. The goal of prophylactic antibiotics in patients requiring a chest tube is to
reduce the incidence of empyema. Since antibiotics can not usually be
given prior to bacterial contamination from injury or chest tube placement,
their use is truly presumptive therapy, rather than prophylaxis. The goal
of this preventative therapy is the same as that of prophylaxis, and
therefore the same principle is applied.
b. A first generation cephalosporin (cefazolin 1 g intravenous) should be
given before, or as soon as possible after chest tube insertion, and
continued for no longer than 24 hrs.

C. Chest tube removal protocol:

1. Criteria for chest tube removal:
a. Resolution of air leak.
b. No recurrence after trial of water seal.
c. Minimal drainage.
2. Remove tube:
a. Cut suture around tube.
b. Rotate tube slightly to ensure free movement.
c. Remove quickly at maximal inspiration.
d. Simultaneously apply occlusive dressing (Xeroform© covered with 4x4
gauze to apply pressure.)
3. Obtain PA and lateral (AP portable if intubated) chest x-ray.
4. Pneumothorax after chest tube removal:
a. Observe for 6 hours and obtain repeat inspiratory and expiratory chest x-
ray (AP portable if intubated.)
i. If the 6hr film is stable or improved consider discharge.
ii. If there is a significant pneumothorax or hemothorax or the patient
becomes symptomatic follow guidelines as above.

References:
1. Luchette FA, et al. Practice management guidelines for prophylactic antibiotic
use in tube thoracostomy for traumatic hemopneumothorax: EAST practice
management guidelines workgroup. www.east.org.
2. Davis JW, Mackersie RC, Hoyt DB et al. Randomized study of algorithma for
discontinuing tube thoracostomy drainage. J Am Coll Surg. 1994
Nov;179(5):553-7.

22
3. Martino K, Merrit S, Boyakye K, et al. Prospective randomized trial of
thoracostomy removal algorithms. J Trauma. 1999 Mar;46(3):369-71; discussion
372-3.
4. Marshall MB, Deeb ME, BleierJI, et al. Suction vs water seal after pulmonary
resection: a randomized prospective study. Chest. 2002 Mar;121(3):831-5.
5. Kerr TM, Sood R, Buckman RF, et al. Prospective trial of the six hour rule in stab
wounds of the chest. Surg Gynecol Obstet. 1989 Sep;169(3):223-5.

23
PROCEDURE GUIDELINE: INSERTION OF CHEST TUBE

OBJECTIVE:
1. To outline indications for the insertion of a chest tube.
2. To provide a procedure guideline for the insertion of a chest tube (tube
thoracostomy) in the trauma patient.

GUIDELINES:
1. Indications:
a. Pneumothorax – all cases in trauma when diagnosed by chest x-ray.
b. Hemothorax – all cases – when diagnosed by chest x-ray.
c. Hemopneumothorax – all cases.
d. Subcutaneous emphysema of the chest all in a patient who has sustained
blunt chest wall trauma requiring ventilator support or general anesthesia.

2. Equipment:
a. A chest tube insertion tray (basic tray.)
b. A chest drainage system underwater seal.
c. Chest tubes, at least a 32 French, usually 36 French.
d. Skin preparation solutions and gauze.
e. Number 1 or O silk or Ethibond on a medium curved cutting needle.

3. Procedure:

The steps for inserting the tube are basically the same regardless of whether it is an
apical or basilar one but a basilar chest tube is usually placed for all traumatic
hemopneumothoraces. It should be inserted with the patient lying in the supine or
lateral decubitus position with the injured side up if possible. A size 36 Fr or larger
tube should be used. The objective is for the tube to lie in the paravertebral gutter
posteriorly just above the diaphragm. The skin incision should be a horizontal one
placed one intercostal space below the point of entry into the cavity (which is at the
5th or 6th intercostal space) in the mid-axillary line and the tract should be directly
posteriorly, cephalad and medially. Alternatively, the incision can be made so that the
tube enters the chest through the same intercostal space which the skin incision
overlies, only more posteriorly. Basic steps for insertion are as follows:
a. Prepare the skin over a wide area of the chest wall.
b. Drape the area with four towels or sterile barriers – not with just a single
fenestrated sheet.
c. Infiltrate the skin with a local anesthetic and block the intercostal nerves,
the pericondrium and the pleura, this often requires 20-30 cc of local
anesthetic. Parenteral analgesia is rarely needed with a proper local block.
d. Make a 2-1/2 to 3 cm long skin incision well into the subcutaneous skin

24
e. Insert a curved Kelly clamp or curved Mayo scissors and cut or separate
the tissues so as to create a tunnel or tract in the direction in which the
tube is to be inserted. Identify the intercostal space to be punctured. Use
a blunt tipped Kelly clamp or scissors to spread the intercostal muscles
and the pleura. Remove the scissors or clamp and explore the tract with
the gloved finger from time to time to make sure the tract is going in the
right direction.
f. After the pleural cavity has been entered, insert the gloved finger to
explore for adherent lung and then further enlarge the opening in the
pleura.
g. Select the tube to be used. Note the location of the holes and the distance
of the proximal hole to tip of the catheter.
h. Grasp the tip of the tube with a Kelly clamp so that the long axis of the
clamp is almost parallel to the long axis of the tube. Measure the distance
that you want the tube to extend into the chest and either note or mark the
proposed point of emergence of the tube with another smaller clamp
placed on the tube at this point. This point is generally no less then 10 cm
and no more then 14 cm.
i. Insert the tube into the chest using the Kelly clamp as a guide. Remove
the Kelly clamp as soon as the tube has reached the desired position in the
chest. Palpate to ensure that the tube has entered the chest.
j. Suture the tube to the skin with a suture of #0 or #1 silk or Ethibond.
k. Connect the tube to the under-water seal chest drainage apparatus and tape
the connection between the end of the tube and the plastic connector as
well as the connection between the plastic connector and the rubber tubing
of the chest drainage apparatus.
l. Place a dry gauze dressing around the tube.
m. Obtain a portable chest x-ray to check the position of the tube.

25
PROTOCOL: Blunt Abdominal Trauma

OBJECTIVES:

1. To identify patients at risk for intra-abdominal injury following blunt trauma.

2. To standardize the work-up for intra-abdominal injury in these patients.

GUIDELINES:

A. Initial evaluation
1. Perform ABC’s, primary and secondary surveys. Secondary survey should
include focused abdominal exam, rectal exam and back exam.
2. Patients who are neurologically normal, not intoxicated, have a normal
abdominal exam, and do not have a painful distracting injury (i.e. long bone
fracture, large wounds or burns) may be managed by serial examination.
3. Patients at risk for intra-abdominal injury may be characterized by the
following situations:
a. Obvious abdominal pain with or without peritoneal signs (positive or
equivocal exam.)
b. External signs of trauma (lacerations, contusions, seat belt signs.)
c. Rib fractures or mediastinal injury.
d. Pelvic fractures.
e. Thoracolumbar fractures.
f. Unexplained episodes of shock.
g. Gross hematuria, or microscopic hematuria in an unstable patient.
h. Mechanism of injury consistent with possible abdominal impact and one
or more of the following:
i. Altered sensorium secondary to head injury, intoxicants, etc...
ii. Focal neurologic deficit (spinal cord injuries.)
iii. Distracting injuries.
iv. A period of time when patient will be unmonitorable (anesthesia.)
4. Patients with obvious need for laparotomy (i.e. ruptured diaphragm or
peritonitis) need no further work-up.
5. In patients with unstable vital signs and source of hemorrhage is not obvious
(i.e. pelvic fxs., long bone fxs, hemothoraces, external hemorrhage,) perform
DPL* (or FAST exam.)
a. Positive DPL (or FAST) Æ Exploratory laparotomy
i. 5 ml gross blood.
ii. 100,000 RBC/mm3.
iii. 500 WBC/mm3.
iv. Bile, bacteria, or food particles.
v. Lavage fluid draining from chest tube or Foley.
b. Negative DPL Æ evaluate other causes of shock.

*FAST exam may also be used by experienced examiners. Negative findings should be viewed as
nondiagnostic.

26
 6. In patients with stable vital signs, at risk for intra-abdominal injury (as defined
above) and no other obvious need for laparotomy:
a. Consider FAST exam for evaluator experience and later CT correlation.
b. CT scan of abdomen and pelvis.
i. Scans should be performed with oral and IV contrast.
ii. Patients with gross hematuria or any pelvic fracture (except acetabular
fractures) should have simultaneous CT cystogram (delayed imaging
with instilled contrast.)
7. Evidence of liver or spleen injury:
a. See Non-operative management of blunt liver and spleen injuries.(Next
section)
8. Free fluid without solid organ injury Æ consider:
a. Exploratory laparotomy to rule out hollow viscous or mesenteric injury, or
b. DPL to characterize fluid.

References:
1. Hoff WS, et.al. EAST practice management guidelines work group. Practice
management guidelines for the evaluation of blunt abdominal trauma. 2001.
http://www.east.org (accessed 06/15/2004.)
2. American college of emergency medicine. Clinical policy: critical issues in the
evaluation of adult patients presenting to the emergency department with acute
blunt abdominal trauma. Annals of emergency medicine. 2004;43(2):278-290.
3. American college of radiology (ACR). “Imaging of blunt abdominal trauma,”
ACR appropriateness criteria™, 1999.
http://www.acr.org/dyna/?doc=departments/appropriateness_criteria/text.html
(accessed 06/15/2004.)

27
PROTOCOL: Non-operative management of blunt liver and spleen injuries.

BACKGROUND:

1. Non-operative management is the treatment of choice for blunt hepatic and

splenic injuries in hemodynamically stable patients.
2. Abdominal CT is the most reliable test to identify and assess the severity of
blunt hepatic and splenic injuries.
3. Injury grade, degree of hemoperitoneum, neurologic status, and/or the
presence of associated injuries are not contraindications to non-operative
management.
4. Angiographic embolization is an adjunct to non-operative management of
stable patients with evidence of ongoing bleeding.

GUIDELINES:

A. Obtain CT scan of the abdomen and pelvis with intravenous contrast.

1. Evaluate CT for evidence of contrast blush or vascular extravasation.
a. Contrast blush/extravasation present Æ angiography + embolization.
b. No contrast blush/extravasation Æ admission (see below.)
B. Admission guidelines:
1. Grade I injuries may be admitted to PICU, depending on patient condition and
associated injuries.
2. Grade II and higher injuries:
a. Admit to SICU.
b. Hourly vital signs and urine output.
c. Serial CBCs Q 6 hours, base deficit and/or lactate Q 4-6 hours until
normal.
d. NPO.
e. Bedrest.
f. Most patients should be monitored as above until proven to be stable for
24-48 hours.
g. Notify trauma faculty of any transfusion requirement.
h. Transfer to floor when stable for 24-48 hours and no other ICU issues
exist. Advance diet as tolerated, advance activity to ad lib.
C. Potential complications:
1. Liver injury:
a. Biloma or bile leak.
i. Obtain follow-up LFTs.
ii. Elevated bilirubin or alkaline phosphatase may indicate biloma and
prompt follow-up CT.
b. Abscess.
c. Delayed hemorrhage from hepatic artery pseudoaneurysm. May present
as upper GI bleeding due to hemobilia and require angiography +
embolization.

28
 2. Spleen injury:
a. Delayed bleeding from pseudoaneurysm. Consider follow-up CT day 3-7
post-injury for grade III or higher injuries.
D. Indications for angiographic embolization:
1. Hemodynamically stable.
2. Contrast blush or extravasation on vascular phase of CT scan.
3. Evidence of ongoing bleeding on serial CBCs.

References:
1. Alonso M, et. al. EAST practice management guidelines work group. Practice
management guidelines for the nonoperative management of blunt injury to the
liver and spleen. 2000. http://www.east.org (accessed 06/15/2004.)

29
PROTOCOL: Pelvic fracture

OBJECTIVES:

1. Timely diagnosis of pelvic fractures.

2. To employ methods of pelvic stabilization early, to minimize ongoing
hemorrhage.
3. To review options for controlling bleeding associated with major pelvic fractures.
4. To recognize and manage associated urologic injuries.

GUIDELINES:

A. Initial management:
1. Primary survey and resuscitation.
a. Consider pelvic fracture in any blunt trauma patient with evidence of life-
threatening hemorrhage and/or ongoing resuscitation requirements.
b. Obtain AP pelvis radiograph early in these patients.
2. Secondary survey:
a. Examine pelvis, but avoid excessive manipulation when attempting to
establish stability.
b. Examine genitalia and prostate (males) for evidence of urethral injury. Place
Foley if no signs of injury.
3. AP pelvis radiograph:
a. Stable fractures (ring intact) in hemodynamically stable patient:
i. CT abdomen/pelvis.
ii. Consult orthopedic surgery & additional imaging if needed.
b. Unstable fractures/ring disruption (significant diastasis of the pubic
symphysis, fracture through posterior elements, and/or vertical instability):
i. Temporarily stabilize pelvis with either a bed sheet tied tightly around the
pelvis as manual reduction of the fracture is performed, or PASG/MAST.
ii. Orthopedic consult for early stabilization.
iii. CT abdomen/pelvis if hemodynamically stable.
iv. Further resuscitation and evaluation for source of bleeding in unstable
patients.
B. Hemodynamically unstable patients with unstable pelvic fractures:
1. Evaluate for other sources of blood loss (the scene, chest, or long bone fractures.)
2. Evaluate for intra-abdominal bleeding:
a. Open supra-umbilical DPL (or FAST*.)
i. Grossly positive (5-10 ml blood) Æ emergency laparotomy with
placement of external fixation device.
ii. Evidence of intestinal injury Æ emergency laparotomy with placement of
external fixation device.
iii. Microscopically positive or negative Æ external fixation and
arteriography with embolization.
*FAST exam may be used by experienced examiners. Negative findings
should be considered non-diagnostic

30
C. External fixation:
1. Indications:
a. Patients with unstable pelvic fractures and hypotension or significant ongoing
resuscitation/transfusion requirement.
b. Patients with unstable pelvic fractures and an indication for urgent/emergent
laparotomy.
2. External fixation device should ideally be placed before surgery or
angiography/embolization to promote hemostasis. The bridging bars should be
angled inferiorly to avoid interference with laparotomy incision.
D. Emergency laparotomy:
1. Indications (same as indications for laparotomy in absence of pelvic fracture):
a. Evidence of life-threatening intra-abdominal bleeding and hypotension.
i. Grossly positive DPL is reliable. Diapedesis of RBCs across peritoneum
from retroperitoneal hematoma causes a high percentage of false positive
microscopic results.
ii. Ultrasound (FAST) is less reliable with severe pelvic fracture. Negative
results should be considered non-diagnostic.
b. Evidence of gastrointestinal perforation.
c. Intra-peritoneal bladder rupture.
E. Angiography/embolization:
1. Indications:
a. Patients with unstable pelvic fractures who have evidence of ongoing bleeding
after non-pelvic sources have been ruled out.
b. Patients with unstable pelvic fractures who are found to have bleeding in the
pelvis, which can not be adequately controlled at laparotomy.
c. Evidence of arterial extravasation of intravenous contrast on CT
abdomen/pelvis.
F. Evaluation of genitourinary and rectal injuries associated with pelvic fractures.
1. Urethra:
a. Examine for blood at urethral meatus, scrotal or perineal hematoma, or high-
riding prostate.
i. Positive Æ retrograde urethrogram.
ii. Negative Æ insert Foley.
2. Bladder:
a. Obtain CT cystogram at time of CT abdomen/pelvis, in stable patients
b. Obtain standard cystogram at the conclusion of angiography/embolization.
3. Vagina:
a. Pelvic examination to rule out vaginal laceration and open fracture.
4. Rectum:
a. Digital rectal examination with gross blood or palpable fracture fragments.
b. Rigid proctosigmoidoscopy.
c. Antibiotics for open fracture and fecal diversion.

Reference:
DiGiacomo JC, Bonadies JA, Cole FJ, et al. EAST practice management guidelines workgroup. Practice
management guidelines for hemorrhage in pelvic fracture. 2001. www.east.org (accessed 6/20/2004.)

31
PROTOCOL: Evaluation of penetrating abdominal trauma.

OBJECTIVES:

1. To provide a process for evaluating penetrating injuries to the abdomen.

2. To standardize the evaluation of hemodynamically stable patients based on
mechanism and location.

DEFINITIONS:
1. Anterior abdomen: The region of the abdomen bounded by:
• Superior – Nipples.
• Inferior – Inguinal ligaments and pubis.
• Lateral – Anterior axillary line.
2. Flank: The region of the abdomen bounded by:
• Superior – Sixth intercostal space.
• Inferior – Iliac crest.
• Lateral – Between anterior and posterior axillary lines.
3. Back: The region bounded by:
• Superior – Tip of scapula.
• Inferior – Iliac crest or buttock.
• Lateral – Posterior axillary line.

GUIDELINES:

A. Gunshot wound (GSW) to abdomen

1. Primary survey and resuscitation.
2. Secondary survey. Inspect entire patient including back and flanks, to avoid
missed injuries.
3. Mark all wounds with paper clips and obtain AP and lateral radiographs.
4. If hemodynamically unstable Æ go directly to OR for exploratory laparotomy.
5. If hemodynamically stable, management depends on whether peritoneal cavity
has been violated.
a. If peritoneal cavity has been violated (i.e. evisceration, peritoneal signs, or
based on trajectory,) proceed to emergent exploratory laparotomy.

b. If uncertain about peritoneal penetration, options include:

32
 i. Exploratory laparotomy.
ii. Laparoscopy (if peritoneum violated, convert to open.)
iii. Observation with serial abdominal examinations.

B. Gunshot wound (GSW) to pelvis.

1. Need to evaluate extraperitoneal structures:
a. Rigid proctosigmoidoscopy.
b. Cystogram.
2. If there is a possibility of peritoneal perforationÆDPL, laparotomy, or
laparoscopy.

C. Stab wounds
1. Primary survey and resuscitation.
2. Carefully examine patient so that no wounds are missed, especially in the
back and flank.
3. Indications to proceed to emergency laparotomy:
a. Hemodynamic instability.
b. Evisceration.
c. Impalement.
d. Peritoneal signs.
4. If hemodynamically stable, further management is dictated by the location of
the stab wound.
a. Stab wound to anterior abdomen:
i. If the wound lies over the chest wall, do not exploreÆObtain upright
CXR and perform DPL.
(a) CXR or DPL positive Æ Exploratory laparotomy.
(b) CXR and DPL negative Æ Admit to trauma service.
ii. If wound is not over chest wallÆ Explore locally.
iii. If local wound exploration confirms that there has been no penetration
of anterior fasciaÆclose the wound and patient can be discharged.
iv. If local wound exploration confirms penetration of the anterior
fasciaÆObtain upright CXR and perform DPL.
(a) CXR or DPL positive Æ Exploratory laparotomy.
(b) CXR and DPL negative Æ Admit to trauma service.
b. Stab wound to the flank:
i. If the wound lies over the chest wall, do not exploreÆObtain upright
CXR and perform DPL.
(a) CXR or DPL positive Æ Exploratory laparotomy.
(b) CXR and DPL negative Æ Admit to trauma service.
ii. If wound is not over chest wallÆ Explore locally.
iii. If local wound exploration confirms that there has been no penetration
of anterior fasciaÆclose the wound and patient can be discharged.
iv. If local wound exploration confirms penetration of the anterior
fasciaÆObtain upright CXR and perform DPL.
(a) CXR or DPL positive Æ Exploratory laparotomy.

33
 (b) CXR and DPL negative Æ Obtain CT abdomen/pelvis (to evaluate
retroperitoneum) and gastrograffin enema (to evaluate colon.) If all
studies negativeÆAdmit to trauma service.
c. Stab wound to the back:
i. Obtain CT abdomen/pelvis (to evaluate retroperitoneum.)

D. Prophylactic antibiotics for penetrating abdominal trauma.

1. Antibiotic choice:
a. Piperacillin/Tazobactam(Zosyn©) is the recommended drug.
b. If allergic or contraindicated, an agent or combination with similar broad-
spectrum aerobic and anaerobic coverage will be chosen.
2. Dosing and duration:
a. A single dose of antibiotic will be given preoperatively.
b. Absence of hollow viscous injury requires no further administration.
c. Antibiotics will be continued for only 24 hours in the presence of hollow
viscous injury.
d. Hemorrhagic shock:
i. Consider giving 2-3 times normal dose.
ii. Re-dose after each 10 units of blood product transfusion.
3. Availability:
a. Emergency Department: Pyxis© machine in shock-room hall storeroom.
b. Operating Room: Main OR Pyxis© machine.

Reference:
1. Luchette FA, Borzotta AP, Croce MA, et al. The EAST practice management
guidelines workgroup. Practice management guidelines for prophylactic antibiotic
use in penetrating abdominal trauma. www.east.org (accessed 6/30/2004.)

34
PROTOCOL: Penetrating extremity trauma.

OBJECTIVE:

1. Early identification and management of life and limb-threatening injuries due to

penetrating trauma.
2. Goal: Treatment of vascular injuries within 4-6 hours of presentation.

DEFINITIONS:

1. “Hard signs” of vascular injury:

a. Pulsatile bleeding.
b. Expanding hematoma.
c. Thrill or bruit over vessel.
d. Distal ischemia: pulseless, pallor, parasthesia, paralysis, pain,
poikilothermia.
2. “Soft signs” suspicious for vascular injury:
a. History of moderate bleeding.
b. Small, nonexpanding hematoma.
c. Injury in proximity to a major artery.
d. Diminished but palpable pulse.
e. Peripheral nerve deficit.
3. Extremity:
a. Lower: distal to inguinal ligament.
b. Upper: distal to deltopectoral groove.

GUIDELINES:

1. Primary survey and resuscitation. Control of external bleeding with direct

pressure.
2. Secondary survey with focused vascular and neurologic examination.
a. Palpate and mark pulses.
3. Immobilize associated fractures.
4. Mark wounds and obtain radiographs, if indicated.
5. Hard signs of vascular injury present:
a. Notify vascular surgery attending.
b. Proceed to emergency operation.
c. Consider operative arteriogram if:
i. Severe associated fracture.
ii. Chronic peripheral vascular occlusive disease.
iii. Shotgun wound or severe soft tissue injury.
iv. Other injuries requiring emergent operation, with abnormal API or
vascular exam.

35
 6. No hard signs of vascular injury.
a. Measure Arterial Pressure Index (API.) You can perform this test.5
i. Technique:
1. Lower extremity: The blood pressure cuff is placed just
above the ankle. Listen to the DP or PT arterial signal with
a Doppler. Inflate the cuff until the Doppler signal
disappears. Slowly deflate the cuff. The pressure at which
the signal reappears is the ankle pressure. The highest
ankle pressure (DP or PT) is divided by the highest brachial
pressure to give the API.
2. Upper extremity: The blood pressure cuff is placed distal
to the injury, above the wrist. Listen to the radial or ulnar
arterial signal with a Doppler. Inflate the cuff until the
Doppler signal disappears. Slowly deflate the cuff. The
pressure at which the signal reappears is the wrist pressure.
The highest wrist pressure is divided by the opposite
(uninjured) brachial pressure to give the API.
ii. Interpretation:
1. API > 0.95 is normal.
2. API < 0.95 is abnormal.
3. A difference of > 0.15 between opposite extremities is
abnormal (e.g. patient with chronic occlusive disease.)
4. May be used to follow patient non-operatively, or post-
operatively.
b. Abnormal API < 0.95
i. Notify vascular surgery attending.
ii. Arteriogram as soon as possible.
1. Surgical injury identified (e.g. bleeding, occlusion.)
a. Operating room.
2. Non-surgical injury identified (e.g. focal narrowing, small
intimal flap, small false aneurysm, a-v fistula.)
a. Observe.
3. Normal.
a. Discharge.
c. Normal API > 0.95
i. No further testing.
ii. Discharge with instructions, and follow up p.r.n.

References:
1. Dennis JW, Frykberg ER, Veldenz HC, et al. Validation of nonoperative
management of occult vascular injuries and accuracy of physical examination
alone in penetrating extremity trauma. J Trauma 1998 Feb; 44(2):243-253.
2. Conrad MF, Patton JH, Parikshak M, et al. Evaluation of vascular injury in
penetrating extremity trauma: angiographers stay home. American Surgeon. 2002
Mar; 68(3):269-274.

36
3. Gomez GA, Kreis DJ, Ratner L, et al. Suspected vascular trauma of the
extremities: the role of arteriography in proximity injuries. J Trauma 1986 Nov;
26(11):1005-1008.
4. Shakford SR, Rich NH. Peripheral vascular injury. Chapter 43. In Mattox KL,
Feliciano DV, Moore EE (eds.): Trauma, 4th ed. New York, McGraw-Hill, 1996.
5. Dickson, CS (ed.) Noninvasive vascular testing. Chapter 3. In Vascular surgery
combat manual. St. Louis, Quality medical publishing, 1996.

37
PROTOCOL: Hypothermia in the injured patient

OBJECTIVES:
1. To identify hypothermia early and take appropriate steps to reverse hypothermia
during resuscitation of the injured patient.
2. To prevent further hypothermia due to exposure and resuscitation.

BACKGROUND:
1. Causes of hypothermia.
a. Accidental:
i. Normal thermoregulation overwhelmed by environmental exposure.
ii. Mild to moderate exposure with abnormal thermogenesis due to shock,
medications, alcohol, drugs.
b. Therapeutic or induced.
2. Mortality is greatly increased in the hypothermic trauma patient. Significantly
greater than mortality of hypothermia or injury alone.
3. Hypothermia is associated with multiple adverse effects:
a. Coagulopathy.
b. Increased or decreased oxygen demand and decreased delivery.
c. Cardiac irritability and dysfunction.
d. Acidosis.
e. Altered drug metabolism.

DEFINITION:
1. Hypothermia:
a. Mild 35-33°C (95-91.4°F)
b. Moderate 32-28°C (89.6-82.4°F)
c. Severe <28°C (<82.4°F)

GUIDELINES:
A. Prehospital:
1. Remove wet clothing.
2. Cover with dry blankets.
3. Administer high flow oxygen.
4. Assess for pulse (up to one minute.)
a. Pulse present: continue assessment and transport.
b. Pulse absent:
i. Organized rhythm – no CPR.
ii. Asystole or ventricular fibrillation – CPR at normal rate.
B. Preparation:
1. Warm room temperature.
2. Warm crystalloid fluids and blankets available.
C. Initial Assessment:
1. Initiate ABCD’s.
2. Control of hemorrhage.
3. Infuse warmed crystalloids and transfuse blood products through Level 1.

38
 4. Expose and assess patient, then cover with warm blanket.
5. Measure vital signs and core temperature.
D. Hypothermia Management:
1. Mild Hypothermia: 35-33°C (95-91.4°F)
a. Passive external rewarming:
i. Remove wet clothing.
ii. Increase ambient room temperature.
iii. Decrease airflow to patient.
b. Active external rewarming:
i. Warm blankets, hot water bottles.
ii. Bair Hugger warming blanket.
iii. Warm water immersion. Impractical in most injured patients. Frostbitten
extremities should be immersed in 40°C circulating water bath.
iv. Overhead radiant heat lamps, primarily pediatrics.
c. Avoid “afterdrop phenomenon” with external warming by rewarming
<1.5°C/hr.
2. Moderate Hypothermia: 32-28°C (89.6-82.4°F)
a. Continue active external rewarming.
b. Active core rewarming.
i. Ventilator circuit humidification and warming (40-45°C.)
ii. Heat all IV fluids and blood with Level 1, blood warmer.
iii. Continuous Arterio-Venous Rewarming (CAVR) using Level 1
countercurrent heat exchanger and heparin-bonded circuit. The most
efficient method, short of cardiopulmonary bypass.
iv. Body cavity lavage:
1. Pleural and peritoneal. Practical mainly intraoperatively.
2. Gastric and urinary bladder lavage. May be done at bedside.
3. Severe Hypothermia: <28°C (82.4°F)
a. Pulse present.
i. Passive and active external rewarming.
ii. Active core rewarming (see above.)
b. No pulse.
i. Begin CPR at normal rate.
ii. CAVR if SBP > 60 mmHg.
iii. Consider cardiopulmonary bypass.
iv. No cardioversion/Defibrillation until temperature >30°C (86°F.)
v. Bretylium for ventricular arrhythmias.

References:
1. Gentilello LM, Moujaes S. Treatment of hypothermia in trauma victims:
thermodynamic considerations. J Intensive Care Med. 1995 Jan-Feb;10(1):5-14.
Review.
2. Gentilello LM, Jurkovich GJ, Stark MS, et al. Is hypothermia in the victim of
major trauma protective or harmful? A randomized, prospective study. Ann Surg.
1997 Oct;226(4):439-47; discussion 447-9.

39
3. Kurek SJ, EAST practice parameter workgroup for hypothermia. Practice
management guidelines for treatment of hypothermia in trauma patients: a
preliminary review. EAST Sixteenth scientific assembly. Fort Myers, FL.
January 2003

40
PROTOCOL: Ventilator Withdrawl Protocol (Part I)

Fast Facts, a project of the National Residence End-of-Life Curriculum Project, funded
by the Robert Wood Johnson Foundation, are distributed by e-mail every two weeks.
The complete collection of Fast Facts is available for downloading at
www.eperc.mcw.edu.

Once it is decided that further aggressive medical care is incapable of meeting the desired
goals of care for a ventilator-dependent patient, discussing ventilator withdrawal to allow
death is appropriate (see Fast Fact #16). Such a decision is never easy for family
members, doctors, nurses, and other critical care staff. All members of the care team
should be involved and appraised of the decision-making process and have the
opportunity to discuss the plan of care.

Options for Ventilator Withdrawal Two methods have been described: Immediate
extubation and terminal weaning. The clinician’s and patient’s comfort, and the family’s
perceptions, should influence the choice. In immediate extubation, the endotracheal tube
is removed after appropriate suctioning. Humidified air or oxygen is given to prevent the
airway from drying. This is the preferred approach to relieve discomfort if the patient is
conscious, the volume of secretions is low, and the airway is unlikely to be compromised
after extubation. In terminal weaning, the ventilator rate, positive end-expiratory
pressure (PEEP), and oxygen levels are decreased while the endotracheal tube is left in
place. Terminal weaning may be carried out over a period of as little as 30 to 60 minutes
or longer (see ref. 2. for protocol). If the patient survives and it is decided to leave the
endotracheal tube in place, a Briggs T-piece can be placed.

Prior to Immediate Ventilator Withdrawal

1. Encourage family to make arrangements for special music or rituals that may be
important to them. If the patient is a child, ask parents if they would like to hold the child
as he or she dies. Make arrangements for young siblings to have their own support if
they are present. (See Part III of this series for additional information for families)
2. Document clinical findings, discussion with families/surrogates, and care plan in the
patient’s chart.
3. The physician should personally supervise that all monitors and alarms in the room are
turned off. Ensure that staff is assigned to override alarms that cannot be turned off if
they are triggered.
4. Remove any restraints. Remove unnecessary medical paraphernalia (e.g. NG tube,
venous compression device).
5. Turn off blood pressure support medications, paralytic medication and discontinue
other life-sustaining treatments (e.g. artificial nutrition/hydration, antibiotics, dialysis).
Note: some families have difficulty of accepting discontinuation of
hydration/nutrition—these can be left in place if desire.
6. Maintain intravenous access for administration of palliative medications.
7. Clear a space for family access to the beside. Invite the family into the room. If the
patient is an infant or young child, offer to have the parent hold the child.
8. Establish adequate symptom control prior to extubation (See Part II in this series).

41
9. Have a syringe of a sedating mediation at the bedside (midazolam, lorazepam) to use
in case distressing tachypnea or other symptoms.

At the time of ventilator withdrawal

1. Once you are sure the patient is comfortable, set the FiO2 to .21; observe for signs of
respiratory distress; adjust medication as needed to relieve distress before proceeding
further.
2. If the patient appears comfortable, prepare to remove the endotracheal tube; try a few
moments of “no assist” before the endotracheal tube is removed.
3. A nurse should be stationed at the opposite side of the bed with a washcloth and oral
suction catheter.
4. When ready to proceed, deflate the endotracheal (ET) tube cuff. If possible, someone
should be assigned to silence, turn off the ventilator, and move it out of the way. Once
the cuff is deflated, remove the ET tube under a clean towel which collects most of the
secretions and keep the ET tube covered with the towel. If oropharyngeal secretions are
excessive, suction them away.
5. The family and the nurses should have tissues for extra secretions, and for tears. The
family should be encouraged to the hold the patient’s hand and provide assurance to their
loved one.
6. Be prepared to spend additional time with the family discussing questions or concerns.
After death occurs, encourage the family to spend as much time at the bedside as they
require; provide acute grief support and follow-up bereavement support.

Reference:
Adapted from: Emanuel, LL, von Gunten, CF, Ferris, FF (eds.). “Module 11:
Withholding and Withdrawing Therapy,” The EPEC Curriculum: Education for
Physicians on End-of-Life Care. www.EPEC.net: The EPEC Project, 1999.

Principles and practice of withdrawing life-sustaining treatment in the ICU. Reubenfeld

GD and Crawford SW, in Managing death in the Intensive Care Unit. Curtis JR and
Reubenfeld GD (eds) Oxford University Press, 2001 pgs: 127-147.

Von Gunten C and Weissman DE. Fast Facts and Concepts #33: Ventilator Withdrawal
Protocol, January, 2001. End-of-Life Physician Education Resource Center
www.eperc.mcw.edu

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PROTOCOL: Symptom Control for Ventilator Withdrawal in the Dying Patient

The most common symptoms related to ventilator withdrawal are breathlessness and
anxiety. Opioids and benzodiazepines are the primary medications used to provide
comfort, typically requiring doses that cause sedation, to achieve good symptom control.
Concerns about unintended secondary effects, such as shortened life, are exaggerated,
particularly if established dosing guidelines are followed (see Fast Fact #8). There is no
medical, ethical or legal justification for withholding sedating medication, when death
following ventilator withdrawal is the expected goal, out of fear of hastening death.
However, increasing doses beyond the levels needed to achieve comfort/sedation, with
the intention of hastening death, is euthanasia and is not acceptable/legal medical
practice.

Sedation should be provided to all patients, even those who are comatose. The dose
needed to control symptoms depends to some degree on the neurological status of the
patient and the amount of similar medication used up to the time of extubation. Patients
who are awake at the time of extubation or in whom significant amounts of opioids and
benzodiazepines have been used previously, will require greater dosages or change to a
barbiturate to achieve symptom control. Note: in all cases, a senior-level physician
should remain at the bedside prior to and immediately following extubation until
adequate symptom control is assured.

Medication Protocol
1. Discontinue paralytics; do not use paralytic agents for ventilator withdrawal.
2. Before ventilator withdrawal: Administer a bolus dose of morphine 2-10 mg IV and
start a continuous morphine infusion at 50% of the bolus dose/h. Also, administer 1 to 2
mg of midazolam IV (or Lorazepam) and begin a midazolam infusion at 1 mg/h. Note:
Sedation should also be administered to the comatose patient. For children, obtain dosing
advice from a pharmacist or pediatric intensivist.
3. Titrate these drugs to minimize anxiety and achieve the desired state of comfort and
sedation prior to extubation.
4. Have additional medication drawn up and ready to administer at the bedside so it can
be rapidly administered, if needed to provide symptom relief.
5. After ventilator withdrawal: If distress ensues aggressive and immediate symptom
control is needed. Use morphine 5 to 10 mg IV push q 10 min, and/or midazolam, 2 to 4
mg IV push q 10 min, until distress is relieved. Adjust both infusion rates to maintain
relief.
6. Remember that specific dosages are less important than the goal of symptom relief.
A general goal should be to keep the respiratory rate <30, heart rate <100 and eliminate
grimacing and agitation.

43
References
Adapted from: Emanuel, LL, von Gunten, CF, Ferris, FF (eds.). “Module 11:
Withholding and Withdrawing Therapy,” The EPEC Curriculum: Education for
Physicians on End-of-Life Care. www.EPEC.net: The EPEC Project, 1999.

Principles and practice of withdrawing life-sustaining treatment in the ICU. Reubenfeld

GD and Crawford SW, in Managing death in the Intensive Care Unit. Curtis JR and
Reubenfeld GD (eds) Oxford University Press, 2001 pgs: 127-147.

44
PROTOCOL: Information for Patients and Families About Ventilator Withdrawal

The physician’s counseling of families is a critical aspect of care for the dying patient
who is able to be removed from a ventilator. Ideally the family will be involved in the
decision to withdraw the ventilator and thus appraised of the goals of the care. Before
withdrawal, the following issues should be discussed.

Potential outcome of ventilator withdrawal

Assuming all other life-sustaining treatments have been stopped, including artificial
hydration and nutrition, there are several potential outcomes: rapid death within minutes
(typically patients with sepsis on maximal blood pressure support), death within hours to
days (see FF #3), or stable cardiopulmonary function leading to a different set of care
plans, including potential hospital discharge. If the latter possibility is realistic, future
management plans should be discussed prior to ventilator removal, since some families
may desire to resume certain treatments, notably artificial hydration/nutrition. Generally,
by the nature of the underlying illness and the established goals, it is fairly easy to predict
which category will be operative, but all families should be prepared for some degree of
prognostic uncertainty (see FF #30).

The procedure of ventilator withdrawal

Never make assumptions about what the family understands; describe the procedure in
clear, simple terms and answer any questions. Families should be told before-hand the
steps of withdrawal and whether or not it is planned/desired to remove the endotracheal
tube (see FF #33). In addition, they should be counseled about the use of oxygen and
medications for symptom control. Assure them that the patient’s comfort is of primary
concern. Explain that breathlessness may occur, but that it can be managed. Confirm
that you will have medication available to manage any discomfort. Ensure they know
that the patient will likely need to be kept asleep to control their symptoms and that
involuntary moving or gasping does not reflect suffering if the patient is properly sedated
or in a coma.

Explain how the family, clergy and others can be at the bedside before, during and after
withdrawal. If asked, explain that they can show love and support through touch, wiping
of the patient’s forehead, holding a hand and talking to him or her.

Support the decision

Even though a family is able to make a definite decision for ventilator withdrawal, such a
decision is always emotionally charged. Families will constantly second-guess
themselves, especially if the death appears to linger following ventilator withdrawal.
Physician support, guidance, and leadership is crucial, as the family will be looking to the
physician to ensure them that they are “doing the right thing.” Furthermore, it is common
for families to have concerns that their decision constitutes euthanasia or assisted
suicide—explicit counseling from a physician will be needed. Finally, support needs to
continue following death during the bereavement period (see Fast Fact #22).

45
References
Adapted from: Emanuel, LL, von Gunten, CF, Ferris, FF (eds.). “Module 11:
Withholding and Withdrawing Therapy,” The EPEC Curriculum: Education for
Physicians on End-of-Life Care. www.EPEC.net: The EPEC Project, 1999.

Principles and practice of withdrawing life-sustaining treatment in the ICU. Reubenfeld

GD and Crawford SW, in Managing death in the Intensive Care Unit. Curtis JR and
Reubenfeld GD (eds) Oxford University Press, 2001 pgs: 127-1

46