TRAUMA RESIDENT HANDBOOK

Elvis Presley Memorial Trauma Center Department of Surgery Division of Trauma and Surgical Critical Care University of Tennessee Health Science Center Memphis, Tennessee

Contents
GENERAL POLICIES Trauma Service Policies Conferences and Clinics Service Assignments and Transfer Universal Precautions in the Trauma Rooms Criteria for Triage to Trauma Rooms Routine Trauma Labs Consults HEAD/SPINE Cervical Spine Clearance Spinal Cord Injury with Deficit Dermatomes Sensory Levels Classification of Spinal Cord Injury NECK Blunt Cerebrovascular Injury Penetrating Neck Injuries CHEST Blunt Aortic Injury Emergent Thoracotomy Hemothorax ABDOMEN/PELVIS Hemodynamically Unstable Blunt Abdominal Trauma Hemodynamically Stable Blunt Abdominal Trauma Antibiotics for Penetrating Abdominal Trauma Anterior Abdominal Stab Wounds Blunt Liver Injury Blunt Splenic Injury Pancreatic Injury Organ Injury Scales Management of Pelvic Fractures Tile Classification of Pelvic Fractures VASCULAR Ligate vs. Repair Neurovascular Injuries EXTREMITIES Fracture/Dislocations Muscles and Nerves Mangled Extremity Severity Score SURGICAL CRITICAL CARE Diagnosis & Empiric Therapy of VAP Risk Factors & Prophylaxis for DVT Herbal Supplements Ventilator Weaning Management of Hypertension Pharmacologic Agents Alcohol Withdrawal Sedation Stress Ulcer Prophylaxis ICP Management 4 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 37 38 39 40 41 42 43 44 47 48 52 53 54 55 56 58 59

Criteria for Triage to Shock / Trauma Room

Physiological Alterations
Trauma Score 13 Known GCS <14 Core temperature <28 C or <82 F Abnormal vital signs: SBP <90, pulse <60 or >120, respirations <10 or >30

Mechanism of Injury (assumes physiological stability) Strangulations/hangings GSW/SGW of head, neck, torso Penetrating injuries of extremities with neurovascular deficit Stab wounds of head, neck, torso Steering wheel/windshield deformity Fatality within the vehicle Rollovers/ejection from vehicle Pregnant patients when history is suggestive of major trauma Intoxicated patients when history is suggestive of major trauma Blunt trauma with complaints relative to abdomen or thorax Extrication time > 20 minutes Intrusion of space > one foot Falls > 15 feet Pedestrian struck Motorcycle crash

Anatomical Alterations
Airway obstruction Pelvic instability Significant bleeding Crush (major) injury CSF leak Flail chest Open long bone fracture Depressed skull fracture/scalp avulsion Maxillofacial trauma, severe Spinal cord injuries Subcutaneous emphysema, massive Tension pneumothorax Major amputations (not fingers/toes) Multiple long bone deformities

13

Routine Trauma Labs: Adult

The following laboratory tests should be ordered for all adult surgical trauma patients evaluated in the trauma rooms: CBC with differential Trauma BMP (to include total bilirubin, ALT, AST) P-amylase INR Lactate Arterial blood gas UA -- also UCG in female patients Type and screen. Type and crossmatch only for any patient who receives uncrossmatched blood (red tag) for resuscitation in Shock/Trauma, or any patient going directly to the OR from Shock/Trauma.

14

Cervical Spine Clearance

Blunt neck trauma

Awake, alert, no distracting injuries, asymptomatic, NEUROLOGICALLY NORMAL

Altered mental status, or multiple system injury, or awake with cervical pain or tenderness, or clinical signs of spinal cord injury

No neck pain AND No tenderness to palpation

AP, Lateral, Odontoid plain films

Poorly visualized area or abnormal C-spine cleared (document on chart), remove collar CT scan C-spine

Adequate, normal films

Normal

Abnormal

MRI of affected area

Leave collar on and consult Orthopedics (admission date an odd day) or Neurosurgery (admission date an even day) for evaluation

16

Spinal Cord Injury with Neurologic Deficit

Penetrating Blunt

Bolus methylprednisolone (Solumedrol) 30 mg/kg over 15 min (if within 8 hours from injury)

45 minute steroid free pause

Continuous infusion 5.4mg/kg/hr for 23-47 hours* 23 hours if started 0-4 hours after injury 47 hours if started 4-8 hours after injury

Obtain CT of affected area

Obtain MRI of affected area

Strict log roll Take off backboard Keep in cervical collar if cervical injury or altered sensorium

*In conjunction with Orthopedics/ Neurosurgery

Consultation: Orthopedics on odd admission date, Neurosurgery on even admission date

17

Dermatomes

18

Sensory Levels

19

Standard Neurological Classification of Spinal Cord Injury

KEY MUSCLES R C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4-5
TOTALS maximum 5 0

MOTOR

Elbow flexors Wrist extensors Elbow extensors Finger flexors (distal phalanx of middle finger) Finger abductors (little finger)

0 = total paralysis 1 = palpable or visible contraction 2 = active movement, gravity eliminated 3 = active movement, against gravity 4 = active movement, against some resistance 5 = active movement, against full resistance NT = Not testable Hip flexors Knee extensors Ankle dorsiflexors Long toe extensors Ankle plantar flexors Voluntary anal contraction (Yes/No)
+
50

=
100

MOTOR SCORE

NEUROLOGICAL LEVELS
The most caudal segment with normal function

COMPLETE OR INCOMPLETE?
Incomplete = Any sensory or motor function in S4-S5

SENSORY MOTOR

ASIA IMPAIRMENT SCALE

American Spinal Injury Association 1996

20

SENSORY
KEY SENSORY POINTS

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

Pin Prick L

0 = absent 1 = impaired 2 = normal NT = not testable

Any anal sensation (Yes/No)

TOTALS

+ 56

56 56

+ =

PIN PRICK SCORE LIGHT TOUCH SCORE

56

Max: 112 Max: 112

Maximum

ZONE OF PARTIAL PRESERVATION

Partially innervated segments

SENSORY MOTOR

21

Blunt Cerebrovascular Injury

Appropriate mechanism with Unexplained neuro deficit (inconsistent with CT) Horners syndrome LeFort II or III (unilateral or bilateral) Cervical spine injury, including transverse process fractures C-1 C-6 Neck soft tissue injury
CT angiogram 4 vessel cerebral angiogram

Carotid injury

Vertebral injury

Neurosurgery consult **In conjunction with Neurosurgery

Neurosurgery consult

Treatment**

Treatment**

Heparin** if no contraindication (preferred for carotid & complex vertebral injuries) Start @ 1000 units/hour NO bolus

Aspirin Plavix** (ASA only if vertebral occluded with back-fill)

Serial PTT, 1 value 4 hours after drip started then q8hrs Goal is 1.5-2.0 x normal

st

Repeat angiogram in 14 days and/or 6 weeks if necessary Conversion to Coumadin or antiplatelet therapy depending on pathology/clinical course for at least 6 weeks, follow up in Trauma Clinic and with Neurosurgery

22

Penetrating Neck Injury

Hemodynamically unstable Expanding hematoma Excessive bleeding Dysphonia* Dysphagia* Air leak from wound Tracheal deviation Retropharyngeal air* Platysma Violation DO NOT PROBE WOUND!

*May benefit from diagnostic test such as plain lateral c-spine X-ray, barium swallow, bronchoscopy, or laryngoscopy

To OR

Zone I

Zone II

Zone III

unstable

stable

unstable

stable

unstable

stable

To OR

To OR

To OR

4 vessel cerebral angio, +/arch angiogram, barium swallow

Injury

No Injury

TO OR

Observe

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Blunt Aortic Injury

Appropriate mechanism of injury

Chest CT

Positive

Negative

Mediastinal hematoma Control BP & HR

Control BP & HR*

Continue work-up for other injuries

Appropriate sedation

Arch aortogram

Positive Vascular Surgery and/or Thoracic Surgery consult

Negative Stop BP & HR control

Appropriate mechanism of injury includes high speed impact injuries (MVC, MCC, fall, decelerating blunt injury). *BP & HR goals: systolic BP 120 mmHg, HR <90. Obtain ECG prior to blockade therapy Medications: Esmolol: 0.5 mg/kg IV loading dose over 1 minute, then 0.05 mg/kg/min over 4 minutes, then 0.1 mg/kg/min; titrate to HR <90. Advantage: very short half life (9 minutes) Disadvantage: side effect of hypotension may require cessation of therapy Labetalol: 10-20 mg IV slowly followed by continuous IV infusion of 1-2 mg/min. Additional bolus dose of 20 mg may be given up to a total of 300 mg. Continuous infusion must be titrated to the desired endpoints. Advantage: blockade of and with single agent therapy Disadvantage: half life 5-8 hours Nitroprusside: 0.3 mcg/kg/min initial dose, then titrate to BP goal. Maximum dose is 10 mcg/kg/min. Advantage: extremely short half life Disadvantage: can increase dP/dT and cause reflex tachycardia. NEVER use without blockade therapy.

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Emergent Thoracotomy

Mechanism of Injury

Blunt

Penetrating*

No vital signs in route or in Shock/Trauma

Loss of vital signs in route or in Shock/Trauma

No vital signs or CPR > 20 minutes

Loss of vital signs in route or in Shock/Trauma

Pronounce

Cardiac ultrasound

Pronounce

Negative

Positive

Emergent thoracotomy

* Only for penetrating wounds to the upper abdomen or chest (cardiac box). Resuscitative thoracotomy for penetrating abdominal wounds without suspicion of cardiac injury is not indicated.

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Hemothorax Management
Place Chest Tube

Daily Chest X-Rays Yes 48 Hours Clot Resolved No Yes CT Chest

Remove Tube

Clot Resolved No

No

1) Residual clot > 500cc OR 2) Residual clot occupies >1/3 of thoracic cavity OR 3) Unchanged Yes Candidate for VATS? Yes No
2 1

Repeat CT Chest in 48 hours

VATS

Candidate for TPA infusion per chest tube? Yes

No

Place Second Chest Tube

Clot Resolved

Infuse TPA per chest tube q 24 hours x 3 days (check daily Chest x-ray) Daily Chest X-Rays Repeat CT Chest Yes 48 Hours Repeat CT Chest

Remove Tube

Clot Resolved No

Repeat TPA infusion x 3 days (check daily chest x-ray)

Clot Resolved

Repeat CT Chest

VATS Contraindications 1) Coagulopathy 2) Hemodynamic instability 3) Inability to tolerate single lung ventilation

TPA Infusion Protocol 1) Obtain HCT, PT, PTT prior to infusion (if abnormal consider not using rTPA) 2) Mix 4mg of rTPA (Reteplase ) in 50cc sterile saline. 3) Instill mixture into chest tube and flush tube with 50cc of sterile saline. 4) Clamp chest tube for 4 hours (observe patient for 10 minutes for problems with breathing). 5) Mobilize patient. 6) Check HCT, PT, PTT 1 hour after infusion (if significantly changed from baseline, consider stopping infusion)
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TPA Contraindications 1) Active bleeding OR 2) CVA in past 30 days OR 3) Intracranial hemmorhage OR 4) Intracranial Neoplasm OR 5) Coagulopathy OR 6) Pregnancy OR 7) Chest tube with air leak

Blunt Abdominal Trauma Hemodynamically unstable

Physical exam

F.A.S.T.

DPL

Large amount of fluid in abdomen

Scant/no fluid in abdomen

Grossly positive*

Microscopically positive for RBC*

Microscopically positive for WBC*

To OR

To OR

To OR

Consider DPL if unstable Continue search for other sources of hemorrhage

*Criteria for positive DPL: Grossly positive - >10cc blood RBC - >100,000 cells WBC - >500 cells at least 1 hour after injury

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Blunt Abdominal Trauma

Hemodynamically stable

Physical exam

Reliable, awake, alert, no distracting injuries

Unreliable, abnormal mental status, distracting injuries

Nontender

Tender CT scan

Observation period Remains nontender

CT scan

Normal

Abnormal2

Normal

Discharge1

Admit for 23 hour observation

Admit, follow protocols

Admit, treat other injuries

1 2

If any doubt, admit the patient for at least 23 hours May require DPL or other evaluation depending on findings

28

Antibiotics for Penetrating Abdominal Trauma

Penetrating abdominal injury requiring laparoscopy/laparotomy

Ertapenem 1 gram IV prior to skin incision

No hollow organ injury

Hollow organ injury

No further antibiotics

No further dosing

*For patients with penicillin allergy, give ciprofloxacin 400 mg IV every 12 hours (2 total doses for hollow organ injury, only the preop dose for no hollow organ injury) and metronidazole 500 mg every 6 h (4 total doses for hollow organ injury, only the preop dose for no hollow organ injury)

29

Anterior Abdominal Stab Wounds

Hemodynamically stable, nontender abdominal exam

Yes

No

Local wound exploration

To OR

Violation of anterior fascia

Definitely no violation of anterior fascia

Equivocal violation of anterior fascia

To OR for laparoscopy/ laparotomy

Discharge

To OR for laparoscopy/ laparotomy

For the cooperative patient, consider awake laparoscopy in Shock / Trauma

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Nonoperative Management of Blunt Liver Injury

Hemodynamic stability mandatory for nonoperative management

CT scan

Grades 1,2,3

Becomes unstable

Grades 4,5

Stable OR Admit to floor, observe, AM Hct

Stable

ICU * Abdominal pain, jaundice, unexplained signs of infection

*ICUserial Hct q6h, close observation Pseudoaneurysm Angiography for embolization

Stable, improving

CT scan Abdominal fluid collection Consider drainage Improved, unchanged

DC from ICU

Search other sources

Quantitation of hemoperitoneum
Small- perihepatic Moderate- Small + paracolic gutter Large-Moderate + pelvis Repeat CT 1 month

Outpatient management
Grade 1,2,3 Grade 4,5

Repeat CT 1 month if pain or jaundice Ad lib activity

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healed

Not healed

Light duty - repeat CT 1 month until healed

Nonoperative Management of Blunt Splenic Injury

Hemodynamic stability mandatory for nonoperative management
*ICUserial Hct q6h, close observation Age 50 CT scan Pseudoaneurysm

Becomes unstable

Age < 50

Angioembolization

Grade 3-5

Grade 1,2 ICU*

OR

Grade 1 Floor

Grade 2-5 ICU*

Large hemoperitoneum

Small, moderate hemoperitoneum Stable, improving

F/U CT 24 hours

Worse

OR

ICU*

Quantitation of hemoperitoneum:
Small perihepatic/splenic Moderate small + paracolic gutter Large moderate + pelvis

Floor

Stable

Unexplained blood loss

Consider splenectomy

OR

Outpatient Management
Grade 1,2 Grade 3-5

CT if clinically indicated

Healed

CT in 1 month

Not healed

Activity ad lib
32

Light duty, repeat CT in 1 month if indicated

Pancreatic Injury Management

Pancreatic Injury

Proximal to mesenteric vessels (right)

Distal to mesenteric vessels (left)

Duct injury

No

Indeterminate

Yes

Drain

Low probability

High probability

Resection + drainage

High probability of ductal injury: - direct ductal visualization - complete pancreatic transection - >50% pancreatic laceration - severe maceration - pancreatic fluid leak

33

AAST Spleen Injury Scale

Grade* Injury type
I II Laceration Hematoma III Laceration IV V Laceration Laceration Vascular Hematoma Laceration Hematoma

Description of injury
Subcapsular, <10% surface area Capsular tear, <1cm parenchymal depth Subcapsular, 10%-50% surface area; intraparenchymal, <5 cm in diameter Capsular tear, 1-3cm parenchymal depth that does not involve a trabecular vessel Subcapsular, >50% surface area or expanding; ruptured subcapsular or parecymal hematoma; intraparenchymal hematoma > 5 cm or expanding >3 cm parenchymal depth or involving trabecular vessels Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen) Completely shattered spleen Hilar vascular injury with devascularizes spleen

*Advance one grade for multiple injuries up to grade III

34

AAST Liver Injury Scale

Grade* Type of Injury
I II Laceration III IV Hematoma Laceration Laceration Laceration V Vascular VI Vascular Hematoma Laceration Hematoma

Description of injury
Subcapsular, <10% surface area Capsular tear, <1cm parenchymal depth Subcapsular, 10% to 50% surface area: intraparenchymal <10 cm in diameter Capsular tear 1-3 parenchymal depth, <10 cm in length Subcapsular, >50% surface area of ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma > 10 cm or expanding 3 cm parenchymal depth Parenchymal disruption involving 25% to 75% hepatic lobe or 1-3 Couinauds segments Parenchymal disruption involving >75% of hepatic lobe or >3 Couinauds segments within a single lobe Juxtahepatic venous injuries; ie, retrohepatic vena cava/central major hepatic veins Hepatic avulsion

*Advance one grade for multiple injuries up to grade III

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AAST Kidney Injury Scale

Grade* Type of Injury
Contusion I Hematoma Hematoma II Laceration III IV V Vascular VI Vascular Laceration Laceration Laceration

Description of injury
Microscopic or gross hematuria, urologic studies normal Subcapsular, nonexpanding without parenchymal laceration Nonexpanding perirenal hematoma confirmed to renal retroperitoneum <1.0 cm parenchymal depth of renal cortex without urinary extravagation >1.0 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravagation Parenchymal laceration exteding through renal cortex, medulla, and collecting system Completely shattered kidney Main renal artery or vein injury with contained hemorrhage Avulsion of renal hilum which devascularizes kidney

*Advance one grade for bilateral injuries up to grade III

36

Pelvic Fracture Management

Orthopedics consult Initial assessment & A-P pelvic x-ray

Exsanguinating hemorrhage (BP~ <70)

Marginal hemodynamic stability (BP~ 90-110)

Hemodynamically stable (BP~ >110)

Open

Closed fracture

fracture
OR Supraumbilical DPL, F.A.S.T

Supraumbilical DPL, F.A.S.T

Algorithm for stable blunt abdominal trauma

Positive

Negative

Positive

Negative

T-pod

T-pod

T-pod

T-pod

OR

CT

OR Continued hemodynamic instability

Angiography

37

Tile Classification of Pelvic Fractures

Type A Stable fractures A1 A2 A3
Fractures not involving ring; avulsion injuries Stable, minimal displacement; iliac wing, isolated rami Transverse fracture of sacrum

Type B Rotationally unstable, but vertically and posteriorly stable B1 B2 B3

External rotation instability; open book injury Internal rotation instability; lateral compression injury Bilateral rotationally unstable injury

Type C Rotationally, posteriorly, and vertically unstable C1 C2 C3

Unilateral injury; ileal fracture, SI disruption, sacral fracture Bilateral injury; one side rotationally unstable, one side vertically unstable Bilateral injury; both sides completely unstable

38

To Ligate or Not to Ligate Injury

Infrarenal vena cava Suprarenal vena cava Internal jugular vein Brachiocephalic vein Subclavian vein and artery Superior vena cava Carotid artery Mesenteric veins Repair Repair Repair Repair Repair Repair Repair Ligate Can ligate if isolated injury, but at least 50% Portal vein Repair mortality rate secondary to massive fluid sequestration in splanchnic vascular bed and bowel necrosis Right renal vein Popliteal vein Femoral vein Lobar bile duct Celiac artery Left gastric artery Common/proper hepatic arteries Right/left hepatic arteries Splenic artery Iliac vein - comm/ext Iliac artery - comm/ext Femoral/popliteal arteries Tibial arteries Brachial artery Radial/ulnar arteries Repair Repair Repair Ligate Ligate Ligate Ligate Ligate Ligate Ligate Repair Repair Repair Repair Repair Can ligate but need to ensure patency of other leg arteries Can ligate if distal to profunda brachi branch since the elbow has rich collateral blood flow Can ligate but need to ensure patency of other artery and palmar arch Especially if proximal to gastroduodenal branch Especially if portal vein is intact Short gastric a. from left gastroepiploic Cannot ligate - fewer collaterals than left renal vein Cannot ligate Can ligate

Best Mode of Action

Can ligate Cannot ligate - at least 50% mortality) Can ligate unilaterally Can ligate unilaterally Can ligate Can ligate in life-threatening situations Can ligate in life-threatening situations

39

Neurovascular Injuries Associated with Fractures or Dislocations

Orthopedic Injury Anterior shoulder dislocation Humeral shaft fracture Supracondylar humeral fracture Distal radius fracture Perilunate dislocation Posterior hip dislocation Supracondylar femur fracture Posterior knee dislocation Tibial plateau fracture Proximal fibula fracture Neurovascular Injury Axillary nerve, axillary artery Radial nerve Brachial artery Median nerve Sciatic nerve Popliteal artery Popliteal artery, tibioperoneal trunk Peroneal nerve

40

Fracture/dislocation of Extremity

Equal pulses, ABI .7

Pulse deficit, ABI < .7

Orthopedics consult, reduce injury

Orthopedics consult, reduce injury

Pulses still equal

Pulses equal

Pulse deficit

Orthopedics management of injury

Angiogram in operating room

41

Chart of Muscle Groups and Nerve and Nerve Root Supply

Muscle Cervical flexors Cervical extensors Trapezius Sternocleidomastoid Arm abduction 0 15o, supraspinatus 15 to 90o, deltoid >90o, trapezius & serratus anterior Biceps Forearm supination Forearm pronation Wrist flexors Wrist extensors Hand intrinsics Hip flexion Hip extension Thigh abduction Thigh adduction Leg flexion Leg extension Foot plantar flexion Foot dorsiflexion Great toe extension Foot inversion Foot eversion Rectal spinchters C4 C6 C5 C6 C5 C7 C5 C6 C5 C6 C6 C7 C6 C8 C7 T1 L1 L3 L4 S1 L4 S2 L2 L4 L4 S2 L2 L4 L5 S1 L4 L5 L4 L5, S1 L4 L5 L5 S1 S2 S4 Suprascapular Axillary Long thoracic Musculocutaneous Musculocutaneous Median Radial Median and Ulnar Femoral Sciatic Superior gluteal Obturator Sciatic Femoral Superficial peroneal and tibial Deep peroneal Deep peroneal Deep peroneal Superficial peroneal Pudenal Nerve Root C1 C4 C1 C4 Cranial nerve XI Cranial nerve XI Nerve

C7 C8, T1 Median

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Mangled Extremity Severity Score

Skeletal / soft-tissue injury
Low energy (stab; simple fracture; pistol gunshot wound) Medium energy (open or multiple fractures, dislocation) High energy (high speed RTA or rifle GSW) Very high energy (high speed trauma + gross contamination) 1 2 3 4

Limb ischemia
Pulse reduced or absent but perfusion normal Pulseless, paresthesias, diminished capillary refill Cool, paralyzed, insensate, numb 1* 2* 3*

Shock
Systolic BP always > 90 mm Transient hypotension Persistent hypotension 0 1 2

Age (years)
< 30 30-50 > 50 * Score doubled for ischemia > 6 hours 0 1 2

The MESS is the sum of scores from each category. Scores < 7 are associated with limb salvage, Scores > 10 are associated with primary amputation. Outcome is variable for scores 7-10.

43

Diagnosis of Ventilator Associated Pneumonia

Indications for bronchoscopy with bronchoalveolar lavage (FOB + BAL) - Patient must have at least three of the following: 1. 2. 3. 4. Fever (temperature > 100.5) or hypothermia (T < 96) Abnormal WBC (>10,000, <4,000, or >10% bands) Purulent sputum New or changing infiltrate on chest x-ray

BRONCHOSCOPY + BAL TECHNIQUE

1. Routine suctioning with in-line catheter of the upper airway until clear. 2. Increase FiO2 to 100%, change IMV rate if necessary. 3. Sedate patient as necessary. Pharmacologic paralysis is NOT necessary. 4. Advance bronchoscope into affected lung segment (as seen on CXR) or LLL (if bilateral infiltrates). DO NOT USE SUCTION OR CONNECT SUCTION LINE TO BRONCHOSCOPE. 5. Scope should be advanced to the smallest bronchial segment possible to perform BAL. 6. Use 100cc sterile nonbacteriostatic saline in 20cc aliquots. Inject 20cc then immediately aspirate and pool the effluent for quantitative cultures. 7. Follow up with chest radiograph.
8. Proceed to VAP Pathway for treatment.

44

Trauma ICU Ventilator-Associated Pneumonia Clinical Pathway Diagnosis and Empiric Management
Clinical Suspicion of VAP Fiberoptic Bronchoscopy with BAL Empiric antibiotic therapy based on timing of ICU admission

<7 days in ICU Ampicillin/sulbactam (Unasyn) 3g IV q6h *

>7 days in ICU Vancomycin 20mg/kg IV q12h * + Cefepime 2g IV q8h *

Preliminary culture results >24 hours

No growth to date

Insignificant (1-99,999 cfu/mL)

Significant (100,000)

Continue empiric antibiotic therapy

Discontinue antibiotic therapy**

Streamline antibiotic therapy**

Final culture results <100,000 cfu/mL >100,000 cfu/mL

Empiric therapy discontinued

Definitive antibiotic therapy (see Definitive Therapy Pathway for TICU)

Defined as the appearance of a new or changing infiltrate on chest radiograph and at least 2 of the following: o o Abnormal temperature (>38 C or <36 C); 3 3 Abnormal white blood cell count (>10,000 cells/mm or <4000 cells/mm or the presence of >10% immature bands); Macroscopically purulent sputum -If severe beta-lactam allergy, change: Unasyn to Levofloxacin 750 mg IV Q24H, Cefepime to Ciprofloxacin 400 mg IV Q8H; dosage adjustment may be necessary based on renal function **Continue to monitor for changes in Final culture results
45

Trauma ICU Ventilator-Associated Pneumonia Clinical Pathway Definitive Therapy

Early VAP? (7 days in ICU)

Yes

No

Continue Antibiotics for 7 full days

Repeat BAL on Day 4 of Adequate Antibiotic Therapy *

VAP pathogen(s) <10,000 cfu/mL?

Yes No

Discontinue Antibiotics

Continue Antibiotics for 10-14 days

* Adequate antibiotic therapy is antibiotic therapy with in vitro activity against the pathogen. Patients extubated or not eligible for repeat BAL should be treated for 7 full days (consider 10-14 days if Pseudomonas or not responding clinically) ** Consider treatment for 10,000 cfu/mL in severely injured patients with Pseudomonas and/or Acinetobacter Use final culture result. Continue antimicrobial therapy in patients with septic shock Pseudomonas requires a follow-up BAL regardless of being early or late VAP

46

Guideline for the Prevention of Venous Thromboembolism in Critically ill Patients Approved by Pharmacy and Therapeutics Committee May 2004
Baseline CBC, BMP, PTT, and PT/INR

Contraindication to heparin pharmacotherapy? [A]

examples include: Traumatic brain injury with progression on head Active hemorrhage CT >24h post-injury (consult neurosurgery) Recent hemorrhagic stroke Hx of Heparin-induced Thrombocytopenia (HIT) INR > 1.6 Epidural catheter present (consult anesthesia) PTT > 60 sec 9 Platelet count < 50 x 10 cells/L No

Yes

Sequential compression devices (preferred) or A-V foot pumps. Consider serial duplex ultrasound in high-risk patients

Primary risk factor present? [A]

Spinal cord injury Spinal column fractures Long bone fracture Pelvic fracture Sacral fracture

Acetabulum fracture Traumatic brain injury Laparotomy Age > 40 plus major surgery, cancer, history of

No

VTE, or hypercoagulable state

Unfractionated heparin 5,000 * units sq every 8 hours plus Sequential compression devices (preferred) or A-V foot pumps *Note: May not be indicated in burn patients unless other risk factors are present.

Yes

Operative acetabulum fracture?

N o

Enoxaparin 30mg sq every 12 hours plus Sequential compression devices (preferred) or A-V foot pumps

Yes Pre-operative > 24 h post-operative

Unfractionated heparin 5,000 units sq every 8 hours plus Sequential compression devices (preferred) or A-V foot pumps

Enoxaparin 30mg sq every 12 hours plus Sequential compression devices (preferred) or A-V foot pumps

Reevaluate all patients for continuation of venous thromboembolism prophylaxis upon ICU discharge

[A] Consider Inferior Vena Cava (IVC) filter in: High-risk trauma patients with significant bleeding risk or Patients with injury pattern rendering them immobile for prolonged period of time: a) Severe Traumatic brain injury b) Spinal cord injury with para- or quadriplegia c) Complex pelvic fracture with associated long bone fracture(s) d) Multiple long bone fractures

Evidence-based references Geerts WH, et al. Chest 2001; 119: 132S-175S. Available at http://www.chestjournal.org/cgi/reprint/119/1_suppl/132S (accessed 5/14/04) Rogers FB, et al. J Trauma 2002; 53(1):142-164. Also available at http://www.east.org/tpg/dvt.pdf (accessed 5/14/04) Modified 5/14/04

47

Natural Products with Potential to Act as Blood Modifiers

Natural Products THOUGHT to have Blood Modifying Effects
Herb
(other names)
Angelica root (Angelica archangelica, root of the Holy Ghost) Anticoagulant Antiplatelet

Effect

Ingredient(s) Responsible
Coumarin consitiuents

Comments
There is some evidence that the related Angelica species can inhibit platelet aggregation and lower prothrombin time when combined with warfarin. The coumarin constituents of related Angelica species can inhibit human platelet aggregation in vitro. The related species, Angelica sinensis, can lower prothrombin time in rabbits when coadministered with warfarin. Anticoagulant effects have been seen with excessive doses of anise. (Typical dose is 0.5-1 gram of the dried leaf or 50-200 mL of the essential oil.) Theoretically, excessive use of anise might prolong coagulation, increasing PT/INR and test results, due to coumarins contained in anise. Anticoagulant effects have been noted in vivo. Dong quai can potentiate the therapeutic and adverse effects of warfarin and antiplatelet drugs. The antithrombin activity of fish oil is due to prostacyclin synthesis, vasodilation, reduced platelet counts and adhesiveness, and prolonged bleeding time. The isolated fraction, fucoidin, has 4050% of the blood anticoagulant activity of heparin, and fucus can increase the risk of bleeding.

Anise (Pimpinella anisum, aniseed, sweet cumin)

Anticoagulant

Coumarin constituents

Asafoetida (Ferula assafoetida, assant, devils dung, fum, giant fennel) Dong Quai (Angelica sinensis, Chinese angelica, Danggui) Fish Oils (omega-3 fatty acids)

Anticoagulant Anticoagulant Antiplatelet Antiplatelet

Coumarin constituents Coumarin constituents Docosahexaenoic acid (DHA) Eicosapentaenoic acid (EPA) Fucoidin

Fucus (Fucus vesiculosis, bladderwrack, kelp, black tang, cutweed)

Anticoagulant

48

Natural Products with THEORETICAL Potential to Have Blood Modifying Effects

Herb (Other names)
Agrimony (Agrimonia eupatoria, agromonia, cocklebur) Arnica montana, leopards bane, wolfs bane, mountain tobacco) Aspen (Populi cortex, Populi folium)

Effect
Coagulant Anticoagulant Antiplatelet

Ingredient(s) Responsible
Vitamin K constituent Coumarin constituents Salicin

Comments
Excessive doses of agrimony could interfere with anticoagulant therapy. (Typical dose is 3 grams/day.) Arnica could potentiate the effects of anticoagulant and antiplatelet drugs. Salicin is a salicylate constituent. However, in vitro studies provide preliminary data that suggest salicin might not potentiate the effects of anticoagulant drugs. There is insufficient reliable information to determine if there is enough salicylate present in black cohosh to have significant effects. Excessive doses of bogbean can increase the risk of bleeding due to the hemolytic effects of an unknown constituent. (Typical dose is 1-2 mL of the 1:1 liquid extract in 25% alcohol TID or 1-3 grams of the dried leaf TID.) Excessive doses could increase the risk of bleeding. (Typical dose is 60-200 mg of the dried leaf TID.) Borage seed oil could prolong bleeding time. Bromelain could increase the risk of bleeding when used in combination with antiplatelets or anticoagulants. Capsicum has led to increased fibrinolytic activity and could prolong bleeding time. Celery could have anticoagulant effects due to the apiogenin constituent. Clove contains a volatile oil that consists primarily of eugenol. There is one case report of increased international normalization ratio (INR) with concomitant use of danshen and warfarin. Studies show that lectin can have agglutinating activity and could interfere with anticoagulant or coagulant therapy. Fenugreek could potentiate the effects of anticoagulant and antiplatelet drugs. The crude extracts can inhibit platelet aggregation and the neutrophil and platelet secretory activity. This could potentiate the effects of anticoagulant and antiplatelet drugs. Panax ginseng could decrease the effectiveness of warfarin and affect clotting time. Goldenseal could inhibit the anticoagulant effects of heparin. Aesculin may increase bleeding time due to antithrombin activity, which could increase the risk of bleeding when used concomitantly with anticoagulants or antiplatelets.

Black cohosh (Cimicifuga racemosa, baneberry, black snakeroot, bugwort) Bogbean (Menyanthes trifoliata, buckbean, marsh trefoil, water shamrock)

Antiplatelet

Salicylate

Bleeding risk

Unidentified constituent

Boldo (Peumus boldus, boldine) Borage Seed Oil (Borago officinalis, burage, starflower) Bromelain (Ananas comosus, bromelin) Capsicum (Capsicum frutescen, African pepper, cayenne, chili pepper) Celery (Apium graveolens, smallage, Apii fructus) Clove (Syzygium aromaticum, caryophyllus) Danshen (Salvia miltiorrhiza, red sage, salvia root) European Mistletoe (Viscum album, all-heal, devils fuge, drudenfuss) Fenugreek (Trigonella foenum-graecum, birds foot, Greek hay) Feverfew (Tanacetum parthenium, featherfew, midsummer daisy, bachelors button) Ginseng, Panax (Asian ginseng, Korean red, jintsam) Goldenseal (Hydrastis canadensis, yellow puccoon, eye balm) Horse Chestnut (Aesculus hippocastanum, escine, venostat)

Anticoagulant Anticoagulant Antiplatelet Antiplatelet Antiplatelet Antiplatelet Antiplatelet Anticoagulant

Coumarin constituents Gamma linolenic acid

Enzyme constituent Capsaicinoid constituents Apiogenin (coumarin) Eugenol Protocatechualdehyde 3,4-dihydroxyphenyllactic acid Lectin Coumarin constituents Crude extracts

Coagulant Anticoagulant Antiplatelet

Anticoagulant Antiplatelet Coagulant Anticoagulant

Active constituents Berberine Aesculin (coumarin)

49

Horseradish (Armoracia rusticana, pepperrot, mountain radish) Licorice (Glycyrrhiza glabra, sweet root) Meadowseet (Filipendula ulmaria, bridewort, dropwort) Northern Prickly Ash (Zanthoxylum americanum, toothache bark, pepper wood) Onion (Allium cepa)

Anticoagulant

Coumarin constituents

Antiplatelet Anticoagulant

Coumarin constituent Salicylates

Anticoagulant

Coumarin constituents

Peroxidase stimulates the synthesis of arachidonic acid metabolites, which could potentiate the anticoagulant activity of other drugs or natural products. Licorice has shown antiplatelet activity in vitro. There is insufficient reliable information to know if the side effects and toxicity normally associated with salicylates could occur. Excessive ingestion of northern pickly ash might potentiate anticoagulant therapy. Inhibits platelet aggregation in humans and could increase the risks of bleeding with antiplatelet drugs or natural products. There is one case report of increased INR associated with the use of warfarin and papaya extract. Excessive doses of passionflower could increase the risk of bleeding. (Typical dose is 0.5-1 mL of the 1:1 liquid extract in 25% alchohol TID or 0.25-2 grams of the dried plant.) Pau darco may potentiate the effects of anticoagulants and increase bleeding tendency. Excessive doses of plantain could interfere with anticoagulant therapy. (Typical dose is 2-4 mL of the 1:1 liquid extract in 25% alcohol TID or 2-4 grams of the dried leaf TID.) Salicin is a salicylate constituent. However, in vitro studies provide preliminary data that salicin might not potentiate the effects of anticoagulant drugs. Excessive doses of quassia could increase the risk of bleeding. Large amounts of red clover can increase the effects and bleeding risk of anticoagulant drugs or natural products. Large amounts of Roman chamomile could have anticoagulant effects. Large amounts of safflower could potentiate the risk of bleeding with anticoagulant drugs or natural products. Excessive ingestion of southern pickly ash might potentiate anticoagulant therapy. (Typical dose is 3-4 mL of the 1:1 liquid extract in 25% alcohol TID.) Multiple cases of decreased INR have been reported, although none have involved thromboembolic complications. Excessive doses of stinging nettle could interfere with anticoagulant therapy. Large amounts of sweet clover could potentiate the risk of bleeding with anticoagulant drugs or natural products. Large amounts of sweet vernal grass could potentiate the risk of bleeding with anticoagulant drugs or natural products. Tonka bean can contain up to 10%

Antiplatelet

Unidentified constituent Unidentified constituent Coumarin constituents

Papain (Carica papaya) Passionflower (Passiflora incarnata, Maypop, apricot vine) Pau DArco (Tabebuia impetiginosa, taheebo tea, ipes, lapacho) Plantain (Plantago major, common plantain, greater plantain) Poplar (Populus tacamahacca, balm of Gilead) (Quassia amara, bitterwood) Red Clover (Trifolium pratense, cow clover, trefoil, beebread) Roman chamomile (Chamaemelum nobile, English chamomile, garden chamomile, whig plant) Safflower (Carthamus tinctorius, saffron, zaffer) Southern Prickly Ash (Zanthoxylum clava-herculis, sea ash, yellow wood) St. Johns Wort Stinging Nettle (Urtica dioica, nettle) Sweet Clover (Melilotus officinalis, common melilot, hay flower, sweet lucerne) Sweet Vernal Grass (Anthoxanthum odoratum, spring grass) Tonka Bean (Dipterux

Risk of bleeding Anticoagulant

Anticoagulant Coagulant

Lapachol Vitamin K

Antiplatelet

Salicin

Anticoagulant Anticoagulant Anticoagulant

Coumarin constituents Coumarin constituents Coumarin constituents

Anticoagulant Anticoagulant

Safflower yellow Coumarin constituents

Coagulant Coagulant Anticoagulant Anticoagulant Anticoagulant Vitamin K Dicumarol Coumarin constituent Coumarin constituent
50

odorata, coumarouna, torquin bean) Turmeric (Curcuma longa, tumeric, Indian saffron) Wild Carrot (Daucus carota, Queen Annes lace, beesnest plant) Wild Lettuce (Lactuca virosa, green endive, lettuce opium) Willow Bark (Salix alba, white willow, silberweide) Yarrow (Achillea millefolium, thousand-leaf, wound wort) Antiplatelet Curcumin

Anticoagulant Anticoagulant Antiplatelet

Coumarin constituents Coumarin constituents Salicylate constituents

Coagulant

Achilleine

coumarin and theoretically potentiate the risk of bleeding associated with anticoagulant drugs or natural products. Curcumin has anti-inflammatory activity and could potentiate the antiplatelet activity of other drugs or natural products. Large amounts of wild carrot could potentiate the risk of bleeding with anticoagulant drugs or natural products. Large amounts of wild lettuce could potentiate the risk of bleeding with anticoagulant drugs or natural products. Data suggests irreversible inhibition of thrombocytes is unlikely and there might be no increase interaction with blood coagulants. There is some evidence to suggest that achilleine has decreased clotting time.

HERBS WITH ANTICOAGULANT/ANTIPLATELET POTENTIAL: Concomitant use of herbs that have coumarin constituents or affect platelet aggregation could theoretically increase the risk of bleeding in some people. These herbs include anise, arnica, asafoetida, bogbean, boldo, capsicum, celery, chamomile, clove, danshen, fenugreek, feverfew, garlic, ginger, ginkgo, Panax ginseng, horse chestnut, horseradish, licorice, meadowsweet, prickly ash, onion, papain, passionflower, poplar, quassia, red clover, turmeric, wild carrot, wild lettuce, willow, and others.

51

Weaning from Mechanical Ventilation

Daily screening
No Problem for which patient was intubated is controlled Yes SaO2 90% FiO2 0.5 PEEP 5 cm H2O Airway reflexes intact No vasopressors or significant sedation

Continue mechanical ventilation

No

Yes

Therapist to measure RR/Vt

No

RR/Vt < 105 breaths/min/L

Spontaneous breathing trial

Yes

RR > 35 breaths/min for more than 5 minutes

SaO2 < 90%

HR > 140 or 20% of baseline

Systolic BP > 180 or < 90 mmHg No Increased anxiety or diaphoresis Extubate

52

MANAGEMENT OF HYPERTENSION Diagnosis of Hypertensive Crisis Immediate control to minimize end organ damage (CNS - hypertensive encephalopathy; cardiac - AMI, BAI, dissecting aortic aneurysm; renal ARF) is necessary. Otherwise BP should be lowered slowly and cautiously. Management of Hypertension There are many causes of hypertension in ICU patients, common causes include: - underlying hypertension - cold, shivering - agitation - hypoxia, hypercarbia - pain - increased ICP - withdrawal - transducer height etc. Treat underlying causes prior to administration of antihypertensives Common intravenous antihypertensive agents:
Drug
Metoprolol

Action
-1 antagonist (min -2 antagonist) -1 antagonist (mod -2 antagonist) -1 antagonist -1 antagonist (min -2 antagonist) Exogenous source of nitric oxide Exogenous source of nitric oxide Direct arterial smooth muscle relaxation ACE Inhibition

Effect
Negative chronotropy Negative inotropy Negative chronotropy Negative inotropy Vasodilation

Dose
IVP: 2.5 to 15 mg slow IVP every 6 hours IVP: 5 to 20 mg slow IVP every 1 to 4 hours Bolus: 5-20 mg IVP Infusion: 0.5 to 4 mg/min (Titrate) Bolus: 250-500 mcg/kg slow IVP Infusion: 25-100 mcg/kg/min (Titrate) Infusion: 5 to 20 mcg/min (Titrate; max 400 mcg/min) Infusion: 0.1 to 10 mcg/kg/min (Start low and Titrate) IVP: 5 to 20 mg slow IVP every 4 to 6 hours IVP: 0.625 to 1.25 slow IVP every 6 hours

Comments
Half-life 4 to 6 hours Oral:IV conversion 2.5:1 No vasodilation Half-life 4 to 6 hours Monitor closely in asthmatic patient (beta2 antagonist) Half-life ~ 15 min No vasodilation Methemoglobinemia Headache Profound hypotension Cyanide toxicity Reflex tachycardia Intrapatient variability Reflex tachycardia Hyperkalemia Acute renal failure Angioedema

Labetalol

Esmolol

Negative chronotropy Negative inotropy Venous vasodilation (min arterial dilation) Arterial and venous vasodilation Arterial dilation Vasodilation (arterial > venous)

Nitroglycerin

Nitroprusside

Hydralazine

Enalapril

Oral antihypertensives can be used in patients with stable hemodynamics. Otherwise use of IV antihypertensives is more easily titratable in ICU patients. Note on choice of antihypertensives: avoid -blockers in patients with increased adrenergic activity (pheochromocytoma, use of sympathomimetic drugs such as cocaine, amphetamine etc) avoid -blockers in patients with poor LV function, also check for other contraindications (bronchospasm) nimodipine produces cerebral vasodilation, effect noticeable in areas of brain with restricted circulation than healthy areas, usually used in patients with vasopasm after subarachnoid hemorrhage nitrates and nitroprusside can produce cerebral vasodilation and hence should be avoided in patients with intracranial pathology prolonged nitroprusside administration can lead to acidosis and cyanide toxicity
53

1
Mechanically ventilated trauma patient requiring sedation

YES

3 2
Patient w/TBI, ICP, or requiring frequent neurologic examinations?

YES

Preferred - Propofol (Diprivan brand) continuous infusion1 PLUS Morphine sulfate prn pain/agitation 2 OR Alternative - Fentanyl continuous infusion 2 Titrate to Riker SAS of 4 May consider use of neuromuscular blocker to assist with ventilator compliance 7 Lorazepam prn agitation, THEN Lorazepam continuous infusion if dosing requirements are high 4 PLUS Morphine sulfate prn pain/agitation, THEN Morphine sulfate continuous infusion if dosing requirements are high2 Titrate to Riker SAS of 4 In refractory cases, may use Propofol (generic) continuous infusion1 PLUS Morphine sulfate prn pain/agitation2
REASSESS Pt every shift & as needed

REASSESS Pt every shift & as needed

4
Patient w/TBI, ICP, or requiring frequent neurologic examinations? NO

NO

5 Go to 12 YE S

6
Pt expected to require sedation for 24 hours?

YES

NO

REASSESS Pt every shift & as needed

8
Pt requiring sedation after 24 hours?

9
Preferred Midazolam prn agitation3 PLUS Morphine sulfate prn pain/agitation2 Alternative - Propofol (generic) continuous infusion1 PLUS Morphine sulfate prn pain/agitation2

10
Continued need for sedation past 24 hours? NO

YES

NO 11
Go to 12

Titrate to Riker SAS of 4

12
D/C Sedation Protocol, continue Morphine sulfate prn pain (or morphine sulfate 2 continuous infusion)
57

ICU Pharmacologic Agents

ATRACURIUM Half life: 20 minutes. Cleared in plasma via Hoffman reaction; therefore, suitable for
usage in renal failure. Titrate to 2/4 TOF. Dosage (continuous infusion): 0.1 mg/kg/h. Cost: $11.46/100 mg. 24-hour cost (70 kg patient): ~$19.00/day.

PANCURONIUM Half-life: 2 hours. May cause tachycardia. Titrate to 2/4 TOF. Dosage (continuous
infusion): 0.06-0.1 mg/kg/h. Cost: $1.79/10 mg. 24-hour cost: ~$28.00/day.

VECURONIUM Half-life: 1.5 hours. Clearance adversely affected by renal failure. Titrate to 2/4 TOF.
Dosage (continuous infusion): 0.01 mg/kg/h. Cost: $12.39/10 mg. 24-hour cost: ~$20.00/day.

MIDAZOLAM Short acting benzodiazepine. Duration of action: 2 hours. Excellent amnestic effect. Use
with caution in elderly; may cause hypotension/respiratory depression. Contraindicated in hepatic failure. Dosage (continuous infusion): 2 mg/h. Cost: $9.48/5 mg. 24-hour cost: ~$90.00/day.

LORAZEPAM Intermediate acting benzodiazepine. Duration of action: 8-20 hours. May cause
paradoxical reactions in the elderly. Prolonged use can lead to prolonged sedation. Dosage (continuous infusion): 1 mg/h. Cost: $15.89/40 mg. 24-hour cost: ~$8.00/day.

HALOPERIDOL Butyrophenone/antipsychotic. Does not cause sedation per se; does not cause
respiratory or cardiovascular depression. Mechanism of action is to cause affective dissociation. Does have limited anticholinergic effects; may cause dystonia/tardive dyskinesia. Should use Cogentin at regularly scheduled intervals. Half-life: 18 hours. Dosage: 5-10 mg/dose. Titrate to affect up to 50 mg/dose. Cost: $0.57/5 mg. Cost per dose: $0.57-5.70.

MORPHINE Opiate, the gold standard analgesic in the ICU setting. Has sedative as well as analgesic
properties. Metabolites accumulate in renal failure. Duration of action: 4-5 hours. Causes respiratory depression, histamine release, and hypotension. Dosage (continuous infusion): 2-4 mg/h. Cost: $5.76/100 mg. 24-hour cost: $3.00-6.00/day.

FENTANYL Short acting opiate. Duration of action: 1-2 hours. Sedative and analgesic effects. Causes
respiratory depression. Does not have histamine release. Much more stable than morphine from cardiovascular standpoint. Dosage (continuous infusion): 1-5 mcg/kg/min. Cost: $1.28/1000 mcg. 24-hour cost: $12.80-64.00/day.

PROPOFOL Lipid soluble, ultra-short-acting anesthetic. Prepared in lipid carrier. Duration of action: 15
minutes. Easily titratable. Lowers ICP. Should not be used in patients with hypertriglyceridemia. Exhibits three-compartment redistribution with prolonged use, leading to prolongation of action. Bolus doses may cause hypotension. Rare fatal reactions noted in children. Dosage (continuous infusion): 20-200 mcg/kg/min. Cost: $49.95/1000 mg. 24-hour cost: $100.00-1,000.00/day. ALL PATIENTS RECEIVING DIPRIVAN MUST HAVE DAILY SERUM LACTATE AND CPK CHECKED. IF EITHER RISES, STOP DIPRIVAN IMMEDIATELTY.
54

Alcohol Withdrawal Protocol

Patient with risk factors for alcohol withdrawal syndrome

Obtain: 1. liver function panel, INR/PT 2. BMP, magnesium, phosphorus, albumin 3. Blood glucose monitoring Provide: 1. Thiamine 100mg once daily IV/IM/PO 2. Folic acid 1mg once daily PO/IV 3. Multivitamin once daily or Cernevit 5ml in minimum 500ml IVF once daily 4. Adequate hydration

High clinical suspicion for withdrawal

Active withdrawal

Select desired therapy: Lorazepam (preferred) or ethanol drip Note: ethanol is contraindicated in patients with pancreatitis and liver disease

Transfer to monitored unit

Lorazepam 2-4mg PO/IV/IM q 6 hrs x 4 doses, then 12mg PO/IV/IM q 6 hrs 2 8 doses (3 day prophylaxis wean). Monitor vital signs and status q 4-6 hrs.

Ethanol 5% in D5W at initial rate of 50 ml/hr. Titrate for symptoms of early withdrawal. Wean over 3 days. Monitor vital signs and status q 4-6 hrs.

Lorazepam 2-4mg IV every 1 hr until lightly sedated and symptoms resolved. Monitor vital signs and status every hour

55

Sedation Protocol
1. (Diprivan): Begin with 0.5 mg/kg/hr, increase by 0.5 mg/kg every 5-10 minutes, up to 5 mg/kg/hr. Patients receiving propofol infusion should have serum triglyceride levels monitored every 4-7 days; propofol should be discontinued if serum triglyceride levels are 300. Patients with closed head injury being followed by the neurosurgical service may receive Diprivan brand propofol because it has been shown to decrease intracranial pressure. ALL PATIENTS RECEIVING DIPRIVAN MUST HAVE DAILY SERUM LACTATE AND CPK CHECKED. IF EITHER RISES, STOP DIPRIVAN IMMEDIATELTY. 2. Morphine sulfate: Standard regimen is 1-6 mg IV every 1-2 hours prn pain/agitation; alternative regimen is continuous infusion (100 mg/ 100 mL NS): start at 2-4 mg/hr. Patients with documented allergy to morphine sulfate and/or severe hypotension with morphine sulfate administration, may use fentanyl: load with 1-2 mcg/kg, then continuous infusion (1 mg/ 50 mL) at 0.5-5 mcg/kg/hr. 3. Midazolam (Versed): Standard regimen is 2.5-5 mg IV every 1-2 hours prn sedation. 4. Lorazepam (Ativan): Standard regimen is 1-2 mg IV every 1-2 hours prn sedation; alternative regimen is continuous infusion (20 mg/ 100mL NS): start at 1-2 mg/hr. Patients with Renal Insufficiency/Failure The preferred agents are lorazepam (Ativan) and hydromorphone (Dilaudid) 0.5-1 mg IV every 1-4 hours prn pain/sedation; continuous infusion to start at 0.5 mg/hr. AVOID meperidine (Demerol) and morphine sulfate because of increased potential for accumulation of renally excreted metabolites, normeperidine and morphine-6glucuronide, respectively. Riker Sedation-Agitation Scale (SAS) 1) Unarousable: Minimal or no response to noxious stimuli, does not communicate or follow commands 2) Very sedated: 3) Sedated: Arouses to physical stimuli but does not communicate or follow commands, may not move spontaneously Difficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off again, follows simple commands Calm, awakens easily, follows commands

4) Calm and cooperative: 5) Agitated: 6) Very agitated:

Anxious or mildly agitated, attempting to sit up, calms down to verbal instructions Does not calm, despite frequent verbal reminding of limits; requires physical restraint, biting ET tube

7) Dangerous agitation Pulling at ET tube, trying to remove catheters, climbing over bed rail, striking at staff, thrashing side-to-side

56

Patient Admitted to MICU/SICU/TICU

Stress Ulcer Prophylaxis

Yes

Evidence of active GI bleed

on admission

Treat active bleeding

*SRMD=Stress Related Mucosal Damage PUD=Peptic Ulcer Disease GERD=Gastroesophageal Reflux

No

Patient with SRMD, PUD, or GERD*

No

Yes

MAJOR RISK FACTORS

Severe Head Trauma Burns > 30% BSA Prior Organ Transplant Renal Failure Recent PUD (6 weeks)* Hypotension/Shock 1. Severe Sepsis 2. Major Surgery/Trauma No

Yes

IV PROTON PUMP INHIBITOR

i.e. Pantoprazole 40 mg IV every 24 hours

ORAL H2 BLOCKER Tolerating Tube Feedings or PO intake

i.e. Ranitidine 150mg PO BID (For Cr Cl < 50) 75 mg PO BID

OR
Oral Proton Pump Inhibitor i.e. Pantoprazole 40 mg every 24 hours

> 48h Mech. Ventilation OR Coagulopathy No No Prophylaxis Indicated Re-evaluate need for treatment

Yes

IV H2 BLOCKER
i.e.Ranitidine 50 mg IV every 8 hours (For Cr Cl < 50) 50 mg IV daily

Discontinue Therapy

On Transfer/Discharge OR Risk Factors Resolved

References
1. Cook DJ , Fuller HD, Guyatt GH et al.Risk factors for gastrointestinal bleeding in critically ill patients.N Engl J Med. 1994 Feb 10;330(6):377-81. 2. Levy MJ, Seelig CB, Robinson NJ et al.Comparison of omeprazole and ranitidine for stress ulcer prophylaxis.Dig Dis Sci 1997Jun;42(6):1255-9 3. CookD, HeylandD,Griffith L,et al:Risk factors for clinically important UGIB in patients requiring mechanical ventilation. Crit Care Med 1999;27:28122817 4. Jung R, MacLaren R. Proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients. Ann Pharmacother. 2002 Dec;36(12):1929-37 *Endoscopic or radiographic evidence of peptic ulcer disease in preceding 6 weeks ** Presence and persistence and severity of risk factors should be reviewed every24h This clinical practice guideline is a systematically developed algorithm intended to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. This guideline is not a fixed protocol that must be followed, but is intended for health care professionals and providers to consider. While it identifies and describes generally recommended courses of intervention, it is not presented as a substitute for the advice of a physician or other knowledgeable health care professional or provider. Individual patients may require different treatments from those specified in this particular guideline. 58

General Management Principles for Severe (GCS 3-8) and Moderate (GCS 9-12) TBI
Use very short-acting sedatives if needed, for frequent neurological exams Especially important in first 24 hours Sedation holiday for nursing neuro check unless otherwise ordered Convert field collar to Miami J until ligamentous injury can later be ruled out Insertion of intraparenchymal ICP monitor after coagulopathy (if present) corrected (Normal PTT and INR < 1.2 desireable, <1.4 occasionally still done) Avoid thrombocytopenia Serial INR (repeat 6-8 hours after injury, then every 24 hours for 48-72 hours) Rapid evacuation of mass lesions if indicated Rule out vascular injury/hypoxic or embolic mechanisms of brain injury Rule out intoxicants as contributors to neurological status Ensure adequate ventilation and oxygenation and prevent hypercarbia Elevate HOB to 30 degrees (reverse Trendelenberg if spine not cleared) Avoid hypothermia Avoid hyperglycemia and hypoglycemia (Goal Glucose 80-150) Early nutrition, enteral preferred DVT prophylaxis with TEDs and thigh-high SCDs if possible Delay subcutaneous heparin until 24-48 hours post-injury Delay Lovenox until cleared by NSR Seizure prophylaxis (Dilantin) x 7 days for EDH, SDH, IPH/contusion, depressed skull fx, penetrating injury, GCS < 10, sz within 24 hours of injury Avoid symptomatic anemia Maintain normal ICP and CPP within desired range For elevated ICP (> 20 mm Hg x > 5 minutes): Notify Neurosurgery First Tier Therapies: Ensure HOB elevated Ensure no compression from cervical collar and neck in neutral position Ensure ventriculostomy (if present) patent and functioning Sedation and analgesia with Diprivan Drip (discontinue if elevation of CPK or lactate) or Fentanyl or Morphine Drip or Intermittent Dosage Maintain Hyperosmolar Euvolemia A Catheter, Mannitol +/- Lasix, hypertonic saline boluses, serum Na and osmolarity every 6 hours No hyperosmolar agents if osmolarity > 320 Goal serum Na 145-155 usually Cerebral Perfusion Pressure Goals 50-70 mm Hg usually Neosynephrine preferred pressor if pressors needed Dopamine in low doses

59

General Management Principles for Severe (GCS 3-8) and Moderate (GCS 9-12) TBI (continued)
Second Tier Therapies: Cerebrospinal fluid drainage/Ventriculostomy Mild, temporary hyperventilation to pCO2 30-35 Intermittent paralytics Intermittent barbiturates Third Tier Therapies: Decompressive craniotomy Barbiturate coma

In general, these are used in somewhat of a step-wise progression by tier but simultaneously within tiers (and sometimes across tiers). The idea is to have standards for all but tailor the therapy to the individual patient's physiology and injury patterns. The first tier therapies are used on essentially everyone with a severe TBI. The second tier therapies may be used prior to some of the first tier therapies or never at all. The third-tier therapies may be used prior to any second tier therapies.

60