final readings by Attending Radiologists are different from wet readings, the radiologist will immediately notify the Trauma Fellow or Attending.

b.  Patients admitted as a transfer with outside CT scans or x-rays should have their films uploaded into the PACS system. A green request form must be filled out in order to have images uploaded to PACS. (see Appendix G Imaging Request)

c.  Final reads must be obtained from the transferring facility. However, an “unofficial” read of imaging studies may be obtained if an order is written and Radiology notified.

d.  A member of the house staff (or NP/PA) must accompany each trauma patient to the CT scanner.

e.  Use the American Association for the Surgery of Trauma-Organ Injury Scale (AAST- OIS) for documentation of all intra-abdominal injuries, wherever possible. These may be found at the following website: http://aast.org/Library/TraumaTools.aspx

C-Spine Workup and Management

(see Trauma Protocols & Guidelines Cervical and Thoracolumbar Spinal Precautions; also,

Appendix O Trauma Protocol Algorithms>C-Spine Evaluable/Inevaluable)

a.  Normal trauma routine for clearing the C-spine includes 3-4 plain radiographic views or CT of the C-spine, combined with clinical exam/clearance of the C-spine.

b.  Any  patient with:

i.             midline cervical pain or tenderness

ii.             a distracting injury or competing pain

iii.             intoxication (any intoxicating substance)

iv.             any head injury or impaired level of consciousness

v.             focal neurological deficit

SHOULD NOT undergo attempted clinical exam/clearance until sensorium is cleared (usually the next morning).

c.  A C-spine CT is the preferred imaging modality if the patient is scheduled to undergo another type off CT examination. In this subgroup, a cross table lateral C-spine plain film is mandatory prior to moving the patient to the CT scanner.

d.  Patients with any spinal fracture should have a radiologic exam of the entire spine.

e.  “C-spine precautions” includes:

i.             bedrest

ii.             head flat

iii.             C-spine immobilization in a rigid cervical collar (Philadelphia collar or Miami J) at all times

iv.             transport flat on a gurney

In some low risk patients, after T&L spines have been cleared, the senior physician may use his/her judgment and write the C-spine precautions order to include “HOB may be up 30 degrees.”

f.  “T-L spine precautions”

i.             bed flat (patient may be in slight reverse Trendelenburg)

g.  C-spine Clearance

Clinically clearing the C-spine involves performing a physical examination to rule out midline pain or tenderness with palpation. If the patient denies midline pain and tenderness with palpation, the anterior half of the collar may then be removed. The patient should then be given clear instructions to slowly move his/her head from side to side (without assistance) and then back to front and to stop at any time if he/she experiences any pain/discomfort.

h.  Patients who are intubated for a prolonged period of time or are unable/incapable of having their C-spine cleared clinically, should undergo MRI of the C-spine within the first 10 days of admission to rule out ligamentous injury. If the MRI does not demonstrate signs of ligamentous injury, the C collar may be removed.

i.  An order and progress note (documenting that the patient’s C-spine has been both radiographically and clinically cleared) must be written in order to clarify that the patient no longer requires C-spine precautions.

j.  Any patient with complaints of midline pain or tenderness of the C-spine should be kept in a Philadelphia collar (or changed to a soft collar) regardless of their radiographic exam results. The patient should be instructed to wear the collar until he/she returns to Trauma Clinic.

k.  Occasionally, the spine surgery service (either Neurosurgery or Orthopaedics) may request patient guiided flexion/ extension (“flex/ex”) views of the C-spine.

i.             The correct procedure for obtaining flex/ex views of the C-spine entails that:

1.  a physician from the requesting service must be present in the radiology suite to supervise patient movement during the study. (Include in the order and specify service and doctor with pager #.)

2.  the patient should be allowed to move his/her own neck in flexion/extension exams. If the patient experiences pain or tenderness, the exam should be stopped.

l.  Patients who require a Philadelphia collar for extended periods of time are at risk for skin breakdown. These patients may have a Miami J collar placed in lieu of a Philly collar.

Venous Thromboembolism (VTE) Prophylaxis

(see Trauma Protocols & Guidelines VTE Prophylaxis Protocol)

a.  Venodynes are not used if a patient is only admitted for an overnight admission.

b.  Venodynes should be ordered separately from ordering the Trauma Duplex Protocol.

c.  Trauma Duplex Protocol

i.             The Trauma Routine Duplex Protocol should only be ordered for patients with High Risk or Extreme Risk.

ii.             The patient will receive an initial screening Duplex in the first 48 hours of admission. A second will be done during the first week of admission by the Ultrasound Lab; serial duplexes will be done weekly thereafter. The results of the duplexes can be found in Epic under “Imaging”.

c.  Patients should receive appropriate pharmacologic DVT/PE prophylaxis according to protocol.<

d.  Patients with IVC filters still require Venodynes and weekly Duplex screening.

e.  When immobile patients are transferred to nursing homes, SNF, extended care facilities, etc., the discharge summary/orders should include recommendations for DVT prophylaxis-either low molecular weight heparin (i.e. Lovenox) or unfractionated heparin.

Extubation of Patients

a.  No extubations are to be performed after 1900 unless a Trauma Fellow or Attending agrees and is present.

b.  No extubations are to be performed in patients with a known history of a “difficult airway” or “difficult intubation” unless a Trauma Fellow/Attending or Critical Care Attending agrees and is present. (Includes patients who are status post anesthesia with difficult airway/intubation and/or significant soft tissue neck injury.)

c.  No extubations are to be performed in patients status postoperative neck surgery (spine surgery cases included) unless a Trauma Fellow/Attending or Critical Care Attending agrees and is present.

Tertiary Survey

a. The "morning after" head to toe physical re-examination must be done and documented by a physician or NP/PA. (see Appendix H Tertiary Survey of Trauma Patient)

Anemia in Non-Critically Ill Trauma Patients

a.  Patients with low hematocrits (<30%) on the medical-surgical ward who can tolerate oral intake should receive ferrous sulfate 325mg po tid and docusate sodium 50- 500mg po divided in 1-4 doses while in hospital.

b.  If eating normally at the time of discharge, patients should be instructed to take over the counter ferrous sulfate.

Trauma Deaths

(see Trauma Protocols & Guidelines Reporting Deaths, Complications, and M&M)

a.  A death packet must be filled out AND a discharge/death dictation must be performed for every patient who dies in the medical center.

b.  All trauma deaths in the OR are medical examiner’s cases. It is important to note the time of death and which surgeon pronounced the patient. Leave all lines/tubes in place.

c.  Notify the Medical Examiner’s Office (858-694-2895) of any death based on criteria in death packet

d.  Until a patient is declared brain dead, the Trauma Service writes all orders on patient; LifeSharing is an assistive service only.

Discharge Planning

a.  Every morning, the Chief or Senior Resident should review all patients who could be potentially ready for discharge that day. They should discuss with the Trauma Fellow/Attending any details that might be needed for discharge and ensure that all such concerns are addressed so as to facilitate an early, prompt, and safe discharge.

b.  Once the approval for discharge is given, the Senior Resident should contact the Junior Resident to get the process moving. Case Managers should also be notified so that they may assist in the process.

c.  The resident should also attempt to identify any patient who might be able to be discharged the following day and discuss these patients with the Fellow/Attending.<

d.  Discharge orders should be written by 10:00 AM so that the patient leaves the hospital by at 2:00 PM.

e.  All labs and x-ray orders are to have the words “PENDING DISCHARGE” if the patient’s dischharge is dependent upon the results of these tests.

Trauma Clinic Follow-up

a.  Appropriate trauma patients should be scheduled for at least one Trauma Clinic appointment upon discharge.

b.  Criteria for clinic appointments

i.             Patients with NO injuries DO NOT require Trauma Clinic follow-up. (Can suggest follow-up with PMD)

ii.             If the Trauma Service placed sutures/staples, follow-up in Trauma Clinic in 7- 14 days for removal. Alternatively, may follow-up with PMD for removal.

iii.             If the Trauma Service is caring for wound(s), follow-up in Trauma Clinic in 1 week for a wound check.

iv.             If patient had a chest tube inserted, follow-up in Trauma Clinic in 1 week for CXR.

v.             If patient sustained a minor isolated system injury and no other Trauma Service issues, follow-up should be with the appropriate clinic (Ortho, Neuro, Plastics, HNS).

These patients DO NOT require followup in Trauma Clinic.

vi.             If the patient is a Kaiser patient or on active military duty, follow-up should be with Kaiser or the Naval Medical Center San Diego (Balboa), respectively. These patients do not require follow-up in the Trauma Clinic.

vii.             If the patient had a retrievable IVC filter placed, follow-up in Trauma Clinic in 4-6 weeks.

viii.             Any patient that underwent an interventional procedure, including placement of a retrievable IVC filter, and all patients with any Anatomic Injury Severity score ≥3, should have follow-up arranged in Trauma Clinic.

ix.             Patients currently enrolled in clinical studies should also have follow-up arranged in the Trauma Clinic.

c.  For discharges on Monday/Tuesday→Appointment for same week Friday.

d.  For discharges on Wednesday or later→Appointment for next week Friday.

e.  Friday Trauma Clinic is run by the Trauma NP/PAs. However, Trauma residents may be required to attend if the clinic is particularly busy. Resident notes must be signed by the attending.

Trauma Protocols & Guidelines

Airway Management

Protocol:

Doc #1 is responsible for determining the necessity of obtaining an airway by means of intubation or cricothyroidotomy after discussion with the Trauma Fellow/Attending.

Anesthesia can be paged by accessing the code blue page beeper for Anesthesia (x2622) and should respond within five minutes.

The senior ED resident will be present with the trauma team prior to the patient’s arrival and will page his ED attending for the procedure.

Ultimately, the Trauma Fellow/Attending is in charge of the resuscitation and airway decisions.

Procedure:

a.  When a trauma patient arrives, Doc #1 in conjunction with the Trauma Fellow/Attending is in charge of the patient’s airway including decisions for intubation and adjunctivve management. Should Doc #1 ask for the patient to be intubated, either the ED resident with ED attending backup or Anesthesia covering the code pager (x2622) will proceed.

b.  ED residents will be scheduled for doing the resus suite intubations only when they are Doc #1 and provided a Trauma Attending is present. The ED attending will be paged stat to the resus suite to supervise the ED resident. The Trauma Attending will be at the bedside supervising patient management and decision making.

c.  If Anesthesia is to intubate, the Anesthesia code pager is paged. This code beeper is carried by the in-hospital Anesthesia resident or attending 24 hours a day. As a backup in the event that the Anesthesia code pager fails to get a response, the Anesthesia floor walker may be accessed by calling the OR front desk (x36040).

d.  Rapid Sequence Intubation Procedure:

(see Appendix I Rapid Sequence Intubation)

i.             All patients should be considered to require C-spine precautions and to have a full stomach.  Manual C-spine precautions will be held by Doc #2.

ii.             Cricoid pressure will be held until the tube placement is confirmed and the cuff inflated. The most senior surgeon available (usually the Trauma Attending/Fellow) will hold cricoid pressure.

iii.             Placement of the O2 sat monitor, EKG leads, and suction availability will be a priority for nursing.

iv.             A Trauma Attending will be at the bedside for all intubations and is in charge of the intubation procedure.

v.             In order to standardize stocked medications, the following will be used for intubation in the resus suite:

1.  Etomidate

2.  Succinylcholine or Rocuronium

These are available as an RSI kit in the Pyxis.

vi.             Oral intubation attempts should be limited to a total of 3. (For example, in the case of the ED rresident intubating, he can attempt twice and his attending could attempt once.)

vii.             When the intubator finds that the patient has a “difficult airway” (i.e. anterior airway or unable to have a good view due to secretions, blood, or edema, he/she should tell the team immediately. The resus nurse will respond by having the cricothyroidotomy set out and available.

viii.             The Trauma Attending will make the decision as to whether to do a surgical airway/cricothyroidotomy.

ix.             After intubation, physical exam in conjunction with a disposable CO2 detector and/or ETCO2 monitor will be used to confirm the adequacy of tube placement. Cricoid pressure must be maintained until confirmation of appropriate tube placement has been verified.

An NG tube and Foley catheter should be placed followed by a CXR to verify ETT and NG tube placement.

Repositioning of the ETT mandates confirmation of position radiographically prior to leaving the resuscitation room.

Chest Tube Insertion/Removal

a.  Only an R3 or above can place chest tubes in mechanically ventilated patients.

b.  All other chest tubes are to be supervised by an R3 or above.

c.  Conscious sedation may be administered to awake patients.

d.  Chest tube removal is a 2-person procedure requiring the presence of either an NP/PA or R3 and above.

Central Venous Catheter Insertion

a.  Residents must receive appropriate training before placing central lines independently.

i.            Learn ICU (SCCM)

1.  Self-pace Course UCSD registration:

http://sccmwww.sccm.org/LMS/NewUser.aspx?progid=886

2.  Pulmonary Artery Catheter Education Project (PACEP) http://www.pacep.org/

ii.             SICU Central Line Course http://trauma.ucsd.edu/Default.aspx?tabid=184

iii.             Ultrasound Course http://trauma.ucsd.edu/Default.aspx?tabid=175 username: ultrasound  password: UltraSound2008

UCSD Clinical Guidelines for the Management of Traumatic Brain Injury

A. Resuscitation and Basic Physiological Goals

The following physiological parameters should be maintained as part of goal-directed traumatic brain injury (TBI) treatment.

1.      Airway Management

i.  Patients with a GCS ≤ 8 should be intubated for airway protection

Patients with a Glasgow Coma Score (GCS) equal to or less than eight, and those unable to protect their airway, should undergo endotracheal intubation with in-line cervical spine immobilization. Rapid sequence intubation (RSI) is the preferred method. Intubation should be considered for GCS ≤ 10. An attempt to contact the neurosurgery team before intubation is preferable as it will allow for evaluation of the patient’s neurological status prior to the administration of sedation and paralysis.

ii.  Sedative and analgesic choices should include short acting agents through the initial resuscitation, as temporal assessment of neurological status is critical. In general the following agents are recommended:

·      Etomidate - sedation for induction (RSI)

·      Succinylcholine - paralytic for induction (RSI)

·      Propofol - maintenance of sedation, prevention of agitation. Propofol is not an induction agent and is to be discontinued if its use is causing persistent hypotension requiring vasopressor agents.

·      Benzodiazepines- (i.e. midazolam or lorazepam) can be utilized as an initial or substitute sedative agent for propofol.

2.      Oxygenation/Ventilation

i.  Avoidance of hypoxia

Efforts should be made to avoid hypoxia at all times.

·      Patients with TBI should have pulse oximetry maintained at a SaO2 ≥90% and an attempt for PaO2 ≥ 100 mmHg.

ii.  Ventilation

Hyperventilation should be intensively monitored during the initial resuscitation.

·      The target PaCO2 is 35-40 mmHg. An ETCO2 monitor and serial ABGs should

be used as needed should be used to prevent profound hypocarbia/ hypercarbia.

·      Therapeutic hyperventilation may be necessary for brief periods when there is acute neurological deterioration that coincides with a cerebral herniation syndrome or for refractory elevations in ICP (see Section III on management of ICP)

3.      Blood Pressure, Volume Resuscitation, Anemia, and Coagulopathy

i.  Blood Pressure

Systolic blood pressure (SBP) and mean arterial pressure (MAP) readings should be recorded from a functioning arterial line when present and from the non-invasive blood pressure (NIBP) cuff when an arterial line is not present or presumed inaccurate.

·      Any patient requiring with intracranial hypertension must have an arterial line for the purposes of both hemodynamic monitoring and blood draws. A systolic blood pressure (SBP) should be kept between 100 mmHg and 180 mmHg.

·      Recognize that lower blood pressures can represent a “relative” hypotensive state in TBI patients (especially with elevated ICP)

·      Normal Saline, PRBCs and plasma (when needed) should be used as the initial method of maintaining euvolemia to achieve the target blood pressure.

·      Assessment for implementation of vasopressors should be considered for treatment of refracttory hypotension only after appropriate volume resuscitation. Vasopressors or Inotropes including Phenylephrine (Neosynephrine), Levophed, Epinephrine, Dobutamine, and Vasopressin should not be used to counteract the hemodynamic effects of propofol.

ii.  Euvolemia

The primary target is euvolemia through resuscitation. In many cases, a central venous pressure (CVP) will need to be obtained. CVP or other types of invasive monitoring are mandatory in patients with severe TBI requiring ventriculostomy, intubation or in patients with hypotensive events requiring optimization of volume status.

iii.  Coagulation

Coagulation panels should be followed closely, particularly in patients on anti- coagulation medications or with pre-existing bleeding dyscrasias. It is acceptable to use a stricter transfusion criteria, such as a platelet count of ≥ 80 x 103/mm3.

·      The target INR is less than or equal to 1.3 and platelets should be maintained above 80 x 103 / mm3.

·      FFP, Vitamin K, prothrombin complex concentrate, Factor VII, or DDAVP should be administered, as clinically indicated, in order to correct coagulopathy irrespective of need for surgical intervention.

·      INR and platelet count should be corrected in anticipation of operative intervention or bedside procedures such as placement of ventriculostomy or

other ICP monitors.

4.      Imaging

i.  All patients with suspected TBI (i.e. LOC, significant mechanism) must undergo urgent CT of the brain (CTH) during the initial resuscitation barring emergent operative management. Timing of repeat imaging is suggested below. MRI brain scans should be utilized for assessment of ischemic CVA, DAI, tumor assessment or per research protocols. MRI can also be used to help determine potential for neurologic viability particularly in patients with a persistent vegetative state.

B.   Intracranial Pressure (ICP) Monitoring

All patients with signs and symptoms of increased intracranial pressure (ICP) and/or GCS ≤ 8 should receive a ventriculostomy (primarily) or other form of ICP monitoring.

ICP should be monitored in patients with TBI if the GCS is ≤ 8 following initial resuscitation and the admission CT scan of the brain is abnormal (hematomas, contusions, edema or compressed cisterns). All patients with suspected increased intracranial pressure and GCS ≤ 8 should receive a ventriculostomy as the primary ICP monitor unless the clinical situation mandates a sub-dural bolt device.

Contraindications for ventriculostomy include 1) coagulopathy 2) mass lesion with mass effect at the site of the ventriculostomy site.

1.      ICP monitoring should additionally be considered for those patients with a normal admission CT scan of the brain if two or more of the following criteria are met:

·         age > 40 y/o

·         unilateral or bilateral motor posturing

·         documented episode of hypotension (SBP <90mmHg)

In addition, ICP monitoring should be highly considered in all patients undergoing emergent surgical procedures (orthopedic repair, etc) in whom a moderate to severe brain injury is suspected (GCS 3-12) to guide appropriate intraoperative CPP management.

i.   Increased ICP is defined as ≥ 20 mmHg.

ii.    Prophylactic antibiotic use, and routine surveillance cultures for ICP monitors are not recommended, but its use is under the discretion of the trauma and neurosurgical teams.

iii.    Cerebral Perfusion Pressure (CPP) of ≥60mmHg should be targeted. Neosynephrine infusion or other vasoactive adjuncts may be used to improve the CPP in the euvolemic, resuscitated patient.

C.   Treatment of Increased Intracranial Pressure (ICP)

(see   Appendix   O   Trauma   Protocol   Algorithms>Intracranial   Hypertension) Treatment for intracranial hypertension should be initiated when the ICP ≥ 20 mmHg.

A leveled algorithm will be used for increased ICP.  Each level represents increased

levels of intensity for the treatment of elevated ICP, and patients should be initiated in Level I, then staged through Level 3. If the treatments in a given Level have not sufficiently lowered the ICP within 20 minutes of implementation, then advancement to the next Level should be promptly initiated.

Level 1

·         Head of patient’s bed to be placed at ≥ 30 degrees.

·      Sedation and analgesia using recommended agents (propofol, fentanyl, and versed) in intubated patients. Pain relief and sedation are appropriate initial modalities for treatment of intracranial hypertension.

·         Ventriculostomy – extra ventricular drain (EVD) is the preferred method of ICP monitoring. Other forms of ICP monitoring i.e. bolt placement, should be used when EVD is not technically or physiologically feasible.

·         Mannitol – 0.25-1.0g/kg; IV bolus x 1 dose for lateralizing lesions or blown pupil with impending herniation.

Level 2

·      Hyperosmolar therapy

o   Mannitol: intermittent boluses of mannitol (0.25 - 1gm/kg body weight) should be administered. Attention must be placed upon maintaining a euvolemic state when osmotic diuresis is instituted with mannitol. The serum sodium and osmolality must be assessed frequently (every 6hrs) and additional doses should be held if the serum osmolality exceeds 320mOsm/L. Maintain a serum OSM <320mOsm with targeted serum Na+ of <160mEq/L.

o   Hypertonic saline: Serum sodium and osmolality must be assessed frequently (every 6 hr) and additional doses should be held if the serum sodium exceeds 160mEq/L.

·      Neuromuscular paralysis: pharmacologic paralysis with a continuous infusion of a neuromuscular blocking agent should be considered if the above measures fail to adequately lower the ICP and restore CPP. The infusion should be titrated to maintain at least two twitches (out of a train of four) using a peripheral nerve stimulator. Adequate sedation must be utilized if pharmacologic paralysis is employed and can be confirmed with BIS monitoring.

Level 3

·      Patient with Level 3 intracranial hypertension should undergo imaging to determine the presence of cerebral sinus thrombosis.

·      Decompressive hemi-craniectomy or bilateral craniectomy should only be performed if Levels 1 and 2 are not sufficient.

·      Barbiturate coma: an induced coma is an option for those patients who have failed to respond to aggressive measures to control malignant ICP including decompressive craniectomy. The use of BIS monitoring or equivalent is needed for assurance of adequate sedation and coma. Side effects include sudden hemodynamic collapse and a high incidence of pneumonia. Appropriate volume resuscitation and hemodynamic monitoring is mandatory. Utilizing vasopressor therapy may be warranted.

D.   Adjunctive Medications and Prevention of Complications

1.  Antiseizure Prophylaxis

Phenytoin has efficacy in preventing early post-traumatic seizures in patients with traumatic brain injury. Keppra (Levetiracetam) is the preferred anti-seizure medication given its lower side-effect profile and less need for tight monitoring of serum levels.

Medication should be considered to be discontinued after 7 days if no seizure activity occurs, however, a longer duration should be considered in patients with temporal lobe injuries.

2.  Stress Ulcer Prophylaxis

Patients with significant traumatic brain injury requiring mechanical ventilation as well as those with coagulopathies or a history of gastric or duodenal ulcers should receive stress ulcer prophylaxis with an intravenous H-2 blocking agent or proton pump inhibitor.

3.  Deep Venous Thrombosis (DVT) Prophylaxis

All patients with significant traumatic brain injury requiring mechanical ventilation and sedation should receive DVT prophylaxis in the form of sequential compression stockings upon admission. Subcutaneous low molecular weight heparin (Lovenox) may also be initiated within 24 hours of admission, unless contraindicated due to evidence of bleeding, need for surgery, or indwelling intracranial monitor.

4.  Early Tracheostomy

Tracheostomy is recommended in ventilator dependent patients to reduce total days of ET intubation.   This is at the discretion of the trauma and neurosurgery service.

5.   Nutritional Support

Nutritional support should be initiated via enteral route within 48 hours post injury. Frequent assessment of residual volumes of gastric nutrition should be performed, as patients with TBI frequently do not tolerate intragastric feeding, and are at risk for emesis and aspiration. Efforts should be made to obtain small bowel feeding access (i.e. Cortrak).

E.  Surgical Management of TBI

1.   Epidural Hematomas

An epidural hematoma (EDH) of greater than 30 cm3 should be surgically removed regardless of GCS. Continued non-operative management should be considered in posterior EDH of venous origin. Patients with an acute EDH, GCS <9, and anisocoria should undergo emergent EDH evacuation. EDH of less than 5 mm midline shift in patients with GCS >8 and no focal neurological deficit can be closely monitored in an ICU with serial CT scans. Judicious use of narcotics and sedatives is important as not to alter the neurologic exam. Repeat CTH should be within 4-6 if patient are to be managed non-operatively.

2.   Acute Subdural Hematomas

Acute subdural hematomas (SDH) with a thickness of greater than 10 mm or 5 mm of midline shift on CT scan should be evacuated emergently regardless of the GCS (clinical judgment should be used in patients with significant underlying atrophy). A SDH less than 10 mm thickness and less than 5 mm midline shift should be evacuated emergently if the patient has: GCS decrease by 2 points, asymmetric pupils or fixed pupils, or ICP > 20 mmHg. Repeat CTH should be within 4-6 if patient are to be managed non-operatively.

3.   Subarachnoid Hemorrhage

All patients with GCS <9 and SAH should have ICP monitoring with an EVD as the preferred monitoring of choice. Repeat CTH should be within 4-6 if patient are to be managed non-operatively.

4.   Parenchymal Lesions

Intraparenchymal hemorrhage (IPH) causing progressive neurological deterioration, medically refractory ICP elevations, or significant mass effect should be emergently evacuated. Frontal or temporal contusions with IPH >3.0 cm3 and >5 mm shift or cistern compression in patients with GCS 6-8 should be evacuated. Normal ICP should not preclude operative evacuation since herniation can occur without intracranial hypertension. Repeat CTH should be within 4-6 if patient are to be managed non- operatively.

5.   Diffuse Medically-Refractory Cerebral Edema and Elevated ICP

Decompressive craniectomy for refractory elevated ICP (unilateral or bilateral) within 48 hours of injury should be considered. Ultra early decompressive craniectomy prior to ICP monitoring is not recommended, unless surgery is performed for a mass occupying lesion (hematoma) and the bone flap is not replaced.

6.   Depressed Skull Fractures

Open skull fractures depressed greater than the thickness of the inner and outer table should undergo operative management. Referable symptoms attributed to the fracture site are an absolute indication for operative management. Open depressed fractures that are less than 1cm depressed and have no dural penetration, no significant intracranial hematomas, no frontal sinus involvement, no gross cosmetic deformity, no pneumocephalus, and/or no gross wound contamination may be managed non- operatively. All open skull fractures should be treated with prophylactic IV antibiotics.

Management of Anticoagulated Patients

(see Appendix O Trauma Protocol Algorithms>Anticoagulation-No CHI/CHI)

The following procedure applies for all injured patients admitted on anticoagulants:

a.  Obtain appropriate labs

i.            PT/PTT/INR

ii.             Plavix assay

b.  Head injury, with CT findings or loss of consciousness or with significant facial trauma or head/scalp area trauma:

i.            All anticoagulants held

ii.             Repeat CT scan within 6 hours of admission

iii.             Consult Neurosurgery

iv.             Reversal Plan

1.  Admit to ICU

2.  Reversal of anticoagulation with FFP to INR of 1.3 or less

3.  If on clopidogrel (Plavix), consider:

·       platelet transfusion

·       DDAVP

4.  If head CT abnormal or INR is ³ 5 consider the following:

·       Vitamin K 10mg IV over 30 min*

·       Profilnine 25-50 IU/kg IV (range 25-100IU/kg); may repeat as necessary.

a.        Follow INR, PT, PTT

b.        If INR increases after initial reversal

i.               Continue q6h labs and FFP prn

ii.                Consider repeat dose of Profilnine

2. If repeat head CT is negative, discharge from closed head injury viewpoint and restart anticoagulation

*Care should be taken to AVOID administration of IV Vitamin K to patients receiving anticoagulation in the setting of a known mechanical valve due to the risk of valve thrombosis.

c.   Significant soft tissue injury (long bone/pelvic fracture with soft tissue damage), including chest, abdomen, and retroperitoneum:

i.                           Admission to IMU or ICU

ii.                             Hold anticoagulants

iii.                              Reverse anticoagulation (b. iv. Reversal Plan)<

iv.                            Follow hematocrits/hemoglobins

v.                          Repeat CXR for chest injury

vi.                            Consider repeating abdominal/chest CT in 12-18 hours if suspicious for retroperitoneal bleeding or parenchymal injuries

d.   Patients without significant injury, without loss of consciousness, and not requiring surgery or invasive procedures

i.                           Hold anticoagulants

ii.                             These patients do not require reversal.

Cervical and Thoracolumbar Spinal Precautions

Protocol:

In all cases of trauma team activations and admissions, spinal injury will be assumed

until proven otherwise in all patients, including those with:

a.  neurologic spinal or CNS deficits

b.  spinal pain and/or tenderness

c.  significant mechanism of injury, including (as examples):

i.             two or more proximal long bone fractures

ii.             evidence of high impact

iii.             victim ejection

iv.             comatose state secondary to head trauma or those patients requiring induced pharmacologic neuromuscular blockade

Patients arriving with suspected spinal injury and immobilization by a rigid cervical orthosis (i.e. Philadelphia collar) and/or spine board will not have them removed until appropriate clinical radiographic evaluations are obtained. If the patient is not immobilized upon presentation, appropriate immobilization will be applied.

Procedure:

a.  Patients admitted with suspected spinal injury or high index of suspicion, due to mechanism of injury or by physical exam, will have rigid cervical collars applied and a spinal board placed. These will not be removed until radiographic and clinical evaluations are completed. Special consideration regarding pain perception should be given to the intoxicated or drugged patient and to the patient with “competing” pain.

b.  Any patient with a high index of suspicion of spinal injury who is admitted via prehospital Emergency Medical System personnel, and does not have spinal precautions in place, will be audited by the Trauma Coordinator and forwarded to the Base Hospital Coordinator.

c.  A complete neurologic examination including motor/sensory/reflexes and rectal examination will be performed and documented. Presence or absence of the bulbocavernosus reflex will be noted.

d.  If possible, obtaining spinal x-rays and determination of the presence or absence of injury should be done prior to any surgical procedure. Should an emergency condition preclude complete evaluation, spinal immobilization will continue until evaluation is completed.

e.  Normal trauma routine for clearing C-spine includes 3-4 radiographic x-ray views or CT of the C-spine initially, combined with clinical exam of the C-spine.  A patient with

competing pain, and intoxicating substance on board or any head injury should not have the clinical motion exams attempted until sensorium is cleared (usually the next morning).

f.  Patients with any spinal fracture should have a radiologic exam of the entire spine.

g.  If a patient is undergoing a CT scan for evaluation of another injury, a CT C-spine should be obtained to rule out an injury. If not, appropriate cervical spine x-rays include a lateral (which is taken first, and has priority over other views,) A/P and open-mouth view. A/P and lateral of thoracic and lumber spine will be obtained when indicated.  Lateral cervical x-rays must visualize C7.  Swimmers views will be obtained where necessary, except in patients with high risk or severe pain.

h.  Cervical spine precautions for the Division of Trauma includes:

i.            bedrest

ii.             head flat

iii.            C-spine immobilization in a rigid cervical collar (Philadelphia collar or Miami J) at all times

iv.            transport flat on a gurney

In some low risk patients, after T&L spines have been cleared, the senior physician may use his/her judgment and write the C-spine precautions order to include “HOB may be up 30 degrees.”

i.  Physician’s orders will reflect cervical spine precautions as follows:

i.            Full Spine Precautions

CTL spine injury has not been cleared or an injury has been identified:

1.  patient requires rigid cervical collar at all times

2.  full log roll when moving the patient

3.  patient may not be placed on an air fluidized or air loss specialty bed

4.  mattress to remain flat at all times (reverse Trendelenburg acceptable)

5.  bedrest only

ii.             Partial Spine Precautions

Cervical spine has been cleared radiographically but patient is unable to cooperate with a physical exam and has a low probability of ligamentous injury:

1.  T & L spines are cleared

2.  patient should wear a rigid cervical collar at all times

3.  bed to remain flat at all times (reverse Trendelenburg OK)

Trauma resident may use judgment and write order for the HOB to be elevated up to 30° in low risk patients.

iii.            CTL Spines Cleared

Patient may be mobilized as appropriate

j.  Clinically clearing the C-spine includes examining the patient for midline pain or tenderness with palpation. If midline pain or tenderness is absent on examination, the patient should be instructed to slowly move his head side to side (without assistance) then to the back and then to the front and to stop at any time if he has any pain.

k.  After negative plain films and flexion extension films, if a patient complains of cervical pain or soreneess, they should be kept in a Philadelphia collar or Miami J and be seen in clinic.

l.  Discontinuing cervical spine precautions will be documented in the physician’s orders and progress notes.

m.  Any patient without a C-spine clearance order and/or progress note will have reinstitution of tthe rigid collar.>

Venous Thromboembolism (VTE) Prophylaxis Protocol

a.  Patient Groups

i.            Low Risk