DEPARTMENT OF SURGERY

Section of Trauma and Critical Care

PROTOCOL MANUAL

2011

Copyright 2011 Trauma Program Office

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TABLE OF CONTENTS
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SECTION 1: INTRODUCTION
Introduction 6

SECTION 2: ED POLICIES & PROCEDURES

Trauma Admission Policy 16
Adult Trauma Alert Policy 17
Adult Trauma Alert Activation Criteria 23
Pediatric Trauma Alert Policy 24
Pediatric Trauma Alert Activation Criteria 30
Trauma Resuscitation Roles & Responsibilities 31
Trauma Bay diagram 35
ED Trauma Labs 36
Care of Patient in Need of Immediate Surgery
When OR is at Maximum Capacity 37
Optimal Logistics of Initial Trauma Evaluation 40
Nursing Care Record: Trauma/Critical Care Policy 41

SECTION3: ED PROTOCOLS
ED Triage Algorithm 45
Termination of Resuscitation 46
ED Resuscitative Thoracotomy 47
I: Airway
ED Rapid Sequence Intubation 50
II: Head & Face
Indications for Head CT 56
Initial Management of Head Injury 57
Severe Closed Head Injury Algorithm 60
Facial Bone Fracture 61
III: Spine Evaluation
Spine Evaluation and Clearance 62
Cervical Spine Clearance Algorithm 63
Initial Management of Spinal Cord Injury 64
Critical Pathway of Removal of Backboard and Cervical Collar 65
IV: Blunt and Penetrating Neck Trauma
Blunt Cerebrovascular Injury Algorithm 66
Penetrating Neck Injury Evaluation 67
Penetrating Neck Algorithm 69
V: Thoracic Trauma
Blunt Cardiac Injury 70
Blunt Cardiac Injury Algorithm 72
Blunt Injury to the Thoracic Aorta 73
Blunt Thoracic Injury with Suspected Injury to Thoracic Aortic Arch
Or Arch Vessels 77
Suspected Thoracic Aortic Injury Algorithm 78
Penetrating Mediastinal Wound Algorithm 79
VI: Blunt and Penetrating Abdominal Trauma
Thoraco-Abdominal Stab Wound Algorithm 80
Diagnostic Evaluation of Blunt Abdominal Trauma 81
Blunt Abdominal Trauma Algorithm 83
GSW to Abdomen, Flank, or Low Back Algorithm 84
Evaluation of Genitourinary Trauma 85
Genitourinary Trauma Algorithm 86
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VII: Pelvis
Pelvic Fracture Radiologic Evaluation Algorithm 87
Pelvic Fracture Treatment Algorithm 88
VIII: Blunt and Penetrating Extremity Injury
Traumatic Peripheral Vascular Injury 89
Extremity Blunt Trauma Vascular Injury Algorithm 90
Penetrating Extremity Vascular Injury Algorithm 91
Open Long Bone Extremity Fracture Protocol 92
IX: Miscellaneous
Management of Injury in Pregnancy 93
Initial ED Management of the Pregnant Trauma Patient Algorithm 95
ED Evaluation of Burn Patients 96
Burn Service Care Algorithm 99
Burn Adult Resuscitation Algorithm 100
Massive Transfusion Protocol 101
Trauma Early Glutamine Administration & Enteral Feeding Algorithm 102
The Anti-Coagulated Trauma Patient 103

SECTION 4: ICU SPECIFIC PROTOCOLS

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Mechanical Wean / Extubation Guidelines 104

Ventilator Separation Protocol 106
Early Tracheostomy Protocol 107
Nosocomial Pneumonia Guidelines 108
Ventilator Associated Pneumonia Pathway 110
Analgesia & Sedation Guidelines 112
Neuromuscular Blockade Protocol 118
Abdominal Compartment Syndrome Assessment
and Monitoring Guidelines 127
Guidelines for Operative Procedures in the ICU 131
Burn ICU High Dose Vitamin C Orders 134
ICU Anemia Management Protocol 135

SECTION 5: ICU AND FLOOR PROTOCOLS

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Fifth Floor Quality Improvement Project 137

Fifth Floor Practice Standards 147
Logroll Guidelines 151
Fever Evaluation 154
Guideline for Rib Management 160
Chest Tube Management Guidelines 163
DVT Risk Factors 165
DVT Prophylaxis Algorithm 166
Therapy for Documented DVT/PE 167
Algorithm for Diagnosis & Treatment of Pulmonary Embolism 168
Stress Ulcer Prevention Guidelines 169
Calculation of Injury Severity Score 172
Guideline for the Maintenance of Endoscopic Feeding Tubes 173
Enteral Feeding: Verification & Maintenance
of Small-Bore Feed Tubes Policy 178
Bowel Regimen Protocol 180
Diarrhea Guidelines Algorithm 181
Constipation Guidelines Algorithm 182
Bladder Management Protocol for the Non-complicated Patient 184
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Bladder Management Algorithm 185

Central Venous Catheter, A-Line, PA Line Insertion,
Maintenance, Removal Guidelines 186
Hypnosedative/Alcohol Withdrawal Guideline 190
Use of Neuraxial Pain Control Methods for Trauma
and Acute Care Surgery 193
Pain Management Protocol for Hospitalized Patients 195
Rehabilitation Management Protocol 196

SECTION 6: DISCHARGE INSTRUCTIONS

Blue Surgery Discharge Follow-up Protocol 197
Discharge Home Instructions & Inter-Facility Transfer 198
Discharge Pain Medication Protocol 200
Discharge Pain Medication Algorithm 201

SECTION 7: WITHDRAWAL OF CARE/POTENTIAL ORGAN DONATION U/

Diagnosis of Death Policy 202

Notification of Coroner & Release of Medical Information Policy 205
Donation after Cardiac Death Policy 207
Organ & Tissue Procurement Policy 213
Potential Donor Management Guidelines 216
Withholding/Withdrawal of Care Policy 225

SECTION 8: DISASTER MANAGEMENT

Mass Casualty Response Plan Policy 233
Mutual Aid Plan Policy 239
Decontamination Plans for Chemical, Biological Agent,
Radiation Policy 243

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Revised 10/08

Preface
The Faculty and Staff of the Trauma Program at the University of Kentucky Hospital are pleased to
present the new Trauma Protocol Manual 2011. This latest revision has been updated and
expanded to include more resource material relevant to the variety of disciplines involved in the
care of the multi-injured trauma patient. The UK Trauma Program strives to deliver timely and
effective care to the injured patient utilizing evidence-based guidelines and protocols. This manual
outlines expectations and standards of care appropriate for Level 1 Trauma Center designation.

To further enhance trauma care internally and in our service region, the Trauma Protocol Manual
will be published on-line via the Department of Surgery Website, the Trauma Program Website and
the University of Kentucky CareWeb. These sites may be accessed at the web addresses listed
below. New and/or updated protocols/guidelines will be posted on the website. The UK Trauma
Program recommends periodic review of the site to monitor for latest revisions. The
protocols/guidelines are formatted so that they may be downloaded and printed. Hardcopies are
available in the Trauma Program Office (H213) or by calling 859-323-5022. Faculty and house staff
may obtain CD version by contacting Trish Cooper (3-5037) in the Trauma Program Office.

Please direct inquiries to Lisa Fryman, RN, Trauma Nurse Coordinator/Program Manager at 859-
257-1231 or [Link]@[Link]. Specific protocol discussion may be directed to Faculty by
calling 859-323-6346.

Dept of Surg, Trauma & Critical Care: [Link]/surgery/General/[Link]

Trauma Program: [Link]/TraumaServices
University of Kentucky CareWeb: [Link]/careweb

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SECTION 1: INTRODUCTION
BLUE SURGERY (TRAUMA/EMERGENCY) SERVICE

INTRODUCTION:
The Blue Surgery (Trauma/Emergency) rotation is sponsored by the Division of General Surgery,
Section of Trauma and Critical Care. The length of the rotation depends on the year of post-
graduate training. The rotation is designed specifically to provide all residents with experience and
didactic knowledge in comprehensive care of the injured adult (> 15 years of age) and adults
requiring emergent general surgical intervention.

ROTATION OBJECTIVES:

1. Provide clinical experience, instruction, and knowledge in the initial assessment/evaluation,

resuscitation, surgical intervention, and management of all injured adults.

2. Provide clinical experience, instruction, and knowledge in the initial assessment/evaluation,

resuscitation, surgical intervention, and management of adults with emergent general surgical
illness and/or requiring emergent surgical intervention.

3. Provide clinical experience, instruction, and knowledge in the management of critically ill
patients.

ROTATION REQUIREMENTS:

I. Patient Care Responsibilities

A. Trauma Patients*
The majority of trauma patients are admitted via the Emergency Department (ED). There will be
direct inter-facility transfer of injured patients from referring the referring hospital to the ICU or floor.
Occasionally, direct admits to the OR will bypass ED evaluation. Trauma patients can present as a
referral from another hospital and physician, direct from the accident scene via helicopter (scene
call), or unannounced by ground ambulance from Fayette County or the surrounding county EMS.
*Refer to attached "Trauma Admission Policy"

Trauma Expect: Patients referred and accepted by the trauma service from another hospital
(ground or air transport) are considered trauma expects. Trauma expects can be referred for EM
evaluation. Unless referred for EM evaluation, the Trauma/emergency surgery residents are
immediately responsible for supervision of trauma expect patient care upon that patient's arrival in
the ED.

Local EMS Transports: Patients transported by local EMS providers become the responsibility of
the Trauma/emergency surgery residents by one of two mechanisms:
1. Trauma consult called by the ED
2. Trauma Alert* called by ED.
*The Trauma Alert system is discussed below under a separate heading.

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Initial assessment and evaluation of the multiply injured patient should proceed according to ATLS
protocol. A review of your ATLS provider manual is highly recommended. Resident roles and
responsibilities during the initial evaluation are outlined in the attached documents. Role
assignment is pre-designated depending upon experience, skill proficiency, and resident knowledge
base. The chief surgical resident in house (PGY4 or PGY5) assumes responsibility for the timely
evaluation, management, and disposition of the trauma patient. This responsibility also includes the
timely notification of the attending physician. Patient disposition should be determined within 60
minutes of ED admission. The entire diagnostic evaluation/disposition should not exceed 120
minutes. Should it become obvious at any point during the initial evaluation that the patient will
require surgical intervention, it is imperative that the OR be contacted immediately. A surgical
resident will accompany hemodynamically unstable patients outside the ED for all diagnostic
procedures (i.e., CT scan, angiography, etc.). Physicians are not required to accompany "stable
patients". It is the responsibility of the ED nursing staff to insure that all trauma patients will be
accompanied by an RN during procedures done outside the ED. There is a policy that governs the
RN responsibilities for transport.

1. Trauma Alert System

The trauma alert notification system was designed to provide rapid and efficient mobilization of
personnel and resources essential for resuscitation, evaluation, diagnosis and treatment of the
multiply injured patient. The trauma alert system is divided into three levels in order to maximize the
efficiency resource allocation.

Trauma Alert
A trauma alert will be called based on the outlined mandatory and/or potential criteria (see attached
document). Patients receiving a trauma alert may be arriving via ground ambulance, air medical
transport, or could be present in the ED and experience an acute deterioration in condition.

Trauma Alert Red

A second level of trauma alert called 'Trauma Alert Red' is present in order to provide immediate
OR access for patients that have a high likelihood of requiring emergent life-saving surgical
intervention. 'Trauma Alert Red' is reserved for injured patients with a prehospital report of
hypotension following blunt injury and for patients who have sustained penetrating injury to the
neck, thorax and/or abdomen. An operating room will be held for 30 minutes after the trauma alert
red has been called. The chief surgical resident is responsible for the decision to release the OR
suite as soon as possible after patient arrival.

Trauma Alert Rotation

Responsibility for trauma alert resuscitations will alternate weekly between emergency medicine
and the trauma/emergency surgery service. The rotation schedule will be printed each month.
When emergency medicine is supervising trauma alerts, only a senior surgical resident needs to
attend the alert. This will allow the surgery team to be available in cases where immediate surgical
intervention is required. This rotation applies only to trauma alerts. The trauma team will respond to
all trauma alert reds and to all pediatric trauma alerts.

2. Trauma Labs
There is a document outlining laboratory values that will be ordered when ordering trauma labs. A
trauma panel is available. The labs ordered are based on the severity of the injuries. Blood Alcohol
and urine drug screens are mandatory. Any questions regarding the necessity for additional lab
values should be clarified with the chief surgical resident and communicated to the nurse. Refer to
policy on trauma labs in the ED Policies/Procedures Section.
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3. Documentation

Trauma Admit Form

The trauma admission form is to be completed IN FULL on ALL injured patients admitted to the
trauma service or receiving consultation from the trauma service. This includes ALL ED and
OPERATING ROOM MORTALITIES. Critical errors and frequently missing data are as follows:
1. Injury time.
2. Loss of consciousness.
3. Laboratory results including ETOH and urine drug screen results.
4. Procedures.
5. Primary diagnosis in detail (MVC is not considered an adequate medical diagnosis and
will not be accepted).
6. Trauma service admitting attending physician. The trauma attending on service not the
on-call attending physician should be listed as the admitting physician.
7. Referring physician and referring hospital.
8. For aeromedical scene work, the county where the scene work occurred.

The trauma admission form, upon completion, will be added to the medical record. This precludes
writing an admission narrative H&P. The original goes to the patient's medical record. The yellow
copy should be placed in the Trauma Coordinator's mailbox in the general surgery corridor. Any
missing trauma admit forms are the responsibility of the chief surgical resident on-call that day. Any
trauma admission form submitted incomplete will be returned to the chief resident for completion
within 24 hours. Missing data elements will be noted for completion. THE TRAUMA ADMIT FORMS
SHOULD BE COMPLETED IN LEGIBLE ENGLISH.

Documentation should not stop with the completion of the trauma admission form. Any and all
significant changes in patient condition while in the ED should be documented completely and
legibly in the medical record.

Daily Census
A daily census will be the responsibility of the off-going chief resident and his/her team. Updated
census information should be complete for morning rounds. All patients admitted to or consulted by
the service should be represented on the census. ED and OR mortalities should be listed on the
weekly M&M list.

Procedure Documentation
All procedures (deep lines, chest tubes, arterial lines, intubation, DPL, LP, cutdown, etc.) should
have a procedure note completed in SCM in detail.

a. The attending physician will be notified prior to performing a procedure. We realize

there are emergent situations that necessitate immediate performance of procedures
that would preclude prior attending physician notification.

b. Procedure notes should be completed for all procedures regardless of whether the
attending is present or absent. Procedures such as Intubation, bronchoscopy,
Groshong catheter removal, suture of lacerations, etc. should be documented. These
procedure notes are used to provide necessary and complete documentation in the
medical record for procedures performed.

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c. All procedures performed in the ED by trauma service residents should have a note
completed. There has been some confusion about procedures performed in the
Emergency Department after hours and on weekends. The supervising attending
physician for emergency department patients is the attending surgery physician
listed on the call schedule not the blue surgery attending on the service. There are
occasions when the blue service attending is present after hours and on weekends
and should be listed as the supervising physician. The latter circumstances should
be obvious.

A brief written note should appear in the progress notes that documents the procedure and
indicates that a more detailed note will follow. For all procedures the following information must be
provided:
Name: Diagnosis:
Reg Number: Indication:
Date of Procedure: Resident Surgeon:
Location: Attending Surgeon:
Service: (performing the procedure) Preparation:
Anesthetic:

Progress Notes and Medical Chart Documentation

Please remember that the medical chart is a legal document. Think before you write. Do not
ventilate disagreements in the medical record. The attending faculty assumes the liability for your
actions and your words. Daily progress, as well as any and all acute changes in patient condition
should be documented in the chart completely, accurately and legibly with the appropriate date and
time.

4. Trauma Admission Orders

Computer trauma order sets ARE TO BE USED FOR ALL trauma service patients. There are
formatted order sets for 1) ICU admission, 2) Mechanical Ventilation, 3) Admission to the FLOOR,
and 4) TRANSFER from the ICU to the FLOOR. REMEMBER, PATIENT ADMISSION AND/OR
TRANSFER CANNOT PROCEED WITHOUT COMPLETED ORDERS. PLEASE INSURE THAT
ORDERS ARE COMPLETED IN A TIMELY FASHION.

B. General Surgical Emergency Patients and UKMC Inpatient Consults

The vast majority of emergency general surgery patients are admitted via the UK Emergency
Department (ED). Occasionally, there will be direct inter-facility transfer from referring hospitals to
the ICU or floor that will bypass ED evaluation. Emergency general surgery patients present either
as:

1. A referral from another hospital and physician. *Trauma/Emergency Surgery residents are
immediately responsible for supervision of general surgery referrals accepted from another hospital
upon that patient's arrival in the UK ED.
* Patients accepted in transfer by other general surgery services (Green and Gold) or Green and
Gold patients that present in the ED for evaluation are and remain the primary responsibility of the
Green or Gold Surgery service chief resident.

2. A consult from the ED attending. The Trauma/Emergency Surgery service is responsible for the
evaluation of ALL general surgery UK ED** consults.

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**The Trauma/Emergency service should and will evaluate all ED general surgery consults. After
6:00 am and before 5:00 pm, it is permissible to triage appropriately to other general surgery
services (Green and Gold) but only after appropriate evaluation and reasonable diagnostic
possibilities have been established. The Blue surgery attending must approve the transfer. The
triage or transfer of service should be arranged between the chief surgical residents and/or between
service attendings not between junior house officers.

During regular working hours (8:00 am to 5:00 pm, Monday through Friday), all ICU surgical
consults and in house UK emergency consults (including emergent Kentucky Clinic consults) are
the responsibility of the Trauma/Emergency Surgery service. After regular working hours and on
weekends, in-house UK or in-house VA emergency general surgery consults and VA ED consults
are not the responsibility of the Blue Surgery service residents. These patients are the responsibility
of the General Surgery ESS resident. The only exception to these rules is elective general surgery
consults directed specifically to one of the Blue (Trauma/Emergency) Surgery attendings.

The chief surgical resident in house (PGY4 or PGY5) assumes ultimate responsibility for the timely
evaluation, management, and disposition of all general surgery emergency patients. This
responsibility also includes the timely notification of the attending physician.

NOTIFICATION OF CONSULTANTS
Consultant(s) evaluation is frequently required for the complete evaluation and treatment of the
multiply injured patient. Timely consultant notification and patient evaluation are necessary to
minimize emergency department length of stay and to insure high quality patient care. The Section
of Trauma and Critical Care has established the following guidelines. We expect the
Trauma/Emergency Surgery service residents to adhere to these guidelines. Consultants should be
notified promptly following completion of the secondary survey (<20 minutes after patient arrival) or
sooner if their services are required (acute neurosurgical, face team, cardiothoracic, or orthopedic
intervention). Consultants should respond to a page within 10 minutes. Consultants should be
present for patient evaluation within 20 minutes of notification. Consultation should be performed by
an upper level resident (PGY2 or higher) or faculty. Interns should not be notified for ED patient
evaluation unless all other members of the consultant team are involved in priority patient care that
precludes their presence.

TRAUMA SERVICE WARD

A single geographic location for all trauma patients will improve patient care, facilitate rounds,
reduce phone calls, and reduce housestaff workload. Fifth floor west has been designated as the
trauma/emergency surgery service ward. Overflow will be to the designated Orthopedic trauma
ward on 5 South. Patients with multi-system trauma and significant or predominant orthopedic
injuries should be admitted to 5 South. The admitting office is aware of the trauma service ward but
may need prompting or direction for admission to 5 West and 5 South.

ADMISSION OFFICE NOTIFICATION POLICY FOR THE BLUE SURGERY SERVICE

The decision regarding hospital admission, level of care (ICU, floor, telemetry), and admitting
service can be made rapidly (<20 minutes) for the vast majority of patients. With the exception of
patients taken directly to the OR, the trauma/emergency surgery service will insure that the
admitting process is initiated at the completion of the secondary survey or within 20 minutes of
patient arrival. Admitting office notification should occur as soon as possible for a patient taken
directly to the OR. Prompt notification of the admitting office will allow bed hunting/assignment to
proceed simultaneously with ED evaluation thereby avoiding needless bed assignment delays. A
working diagnosis, sex, and hospital area (ICU, telemetry, floor, etc.) are all the information needed
to initiate a bed search. Once a bed has been assigned and before the patient is transferred from
the ED, admitting must have the patient's name and the name of the admitting service attending
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physician. Admitting office notification can be accomplished in one of two ways: 1. You may give a
verbal order to the ED nurse caring for the patient; or 2. You may enter the information directly in
the computer. Do not call admitting because this is time-consuming and inefficient!

II. Call Coverage Responsibility

Call coverage teams will consist of Senior Surgical Resident (PGY 4 or 5), a midlevel surgery
resident (PGY2 or 3), and an intern. Night call and work hours will conform to the ACGME work
hours and night call standards. During some months additional senior, midlevel and first year
residents (EM, Pulmonary, Anesthesia, OB/GYN, PM&R, Family Medicine) will rotate on the
service. These additional resident resources will be integrated into the service to provide additional
coverage in compliance with ACGME work hour standards.

A. Referring Physician Calls

Receiving referring physician calls is a necessary part of resident education. Calls from a referring
physician (including UKMDs) are the responsibility of the chief resident (PGY 4 or 5). Any other
resident or intern receiving such a call should immediately forward the call to his/her chief resident.
The chief resident should gather the following information:
1. Physician/referring hospital name
2. Patient name/age
3. Chief complaint/mechanism and time of injury
4. Preliminary diagnosis
5. Vital Signs including EMV and fluid volume administered.
6. Mode of transport/ETA.
During the initial discussion with the referring physician, the chief can and should make appropriate
recommendations and suggestions regarding patient care prior to transport in order to ensure
optimal transfer (e.g. additional IV access, immobilization, splinting, mode of transport - ground vs
air medical).

After accepting patients for transfer*, the chief surgical resident will notify ED triage and relay the
following information on all expects:
1. Patient name/age/sex
2. Referring Physician and Hospital/ETA
3. Residents to be paged on arrival and pager number
4. Patient history/chief complaint
5. Specific diagnostics/interventions to be prepared
*The air medical dispatcher will contact ED triage for all patients being transported by the air
medical service.
Referring physicians should be treated in a polite and courteous manner. REMEMBER THAT THEY
ARE ASKING FOR OUR ASSISTANCE. MANY REFERRING HOSPITALS DO NOT HAVE THE
RESOURCES TO CARE FOR THESE PATIENTS. ALL patients referred by an outside physician
are to be accepted in transfer by the chief surgical resident unless otherwise instructed by the
Trauma/Emergency surgery service attending on call (NO EXCEPTIONS).

B. ICU Call
Primary ICU calls for Blue Surgery Service patients are the responsibility of the PG2 or PG3 on call.
The Critical Care Nursing Staff have been instructed to direct all calls to the PG2 or PG3 on call.
Interns receiving ICU calls will refer them to an upper level resident.

C. Floor Call
Primary floor calls are the responsibility of the Blue Surgery Intern on call. Questions or problems
regarding floor patients should be directed to the chief surgical resident on call.
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III. Patient Rounds

Patients rounds should occur twice daily on all Trauma/Emergency Surgical Service patients and
consults.

A. Morning Rounds
The chief surgical resident assumes primary responsibility for the timing and conduct of rounds. In
general, daily morning rounds begin at 6:00 am (7:00 am on weekends) in the Trauma ICU unless
otherwise notified. Residents from each call team are to be present for rounds. Given that this is not
always possible; a resident from each of the call teams should be present so that information
transfer occurs in an orderly fashion. The intensivist (Surgical Critical Care) residents will make AM
ICU rounds with the Blue Surgery Service.

B. Attending Rounds
Daily attending rounds will arranged between the faculty on service and the senior surgical
residents. Residents should present patient information in a clear, concise, and detailed format
facilitating the completion of rounds in a thorough but timely fashion.

C. Discharge Planning Rounds

Discharge planning with the Trauma Case Manager will occur Monday through Friday at 9:30am in
physician dining area. These rounds are mandatory for the surgical intern on-call. These rounds are
multidisciplinary, facilitate patient care, and insure timely patient discharge. The rounds will be done
in conjunction with the orthopedic trauma service case manager and social worker.

IV. Patient Discharges and Service Transfers

A. Hospital Discharge*
Patient discharge from the hospital should be timely and efficient. This process is facilitated by
discharge planning rounds. Timely and cordial interaction with the nursing staff that provide
discharge teaching and with the social worker who arranges extended care (i.e. Nursing Home,
Rehabilitation, Coma Center, Home Health, etc.) is critical. The Trauma Case Manager will be
responsible for coordinating discharge of the multiply injured patients. When patients are identified
for discharge, the nursing staff should be notified on the day prior to discharge. Discharge orders
and prescriptions will be completed the evening before or by 8:00am on the day of discharge. The
following critical errors are often made in patient discharges:
1. Patients are not scheduled for subspecialty appointments prior to discharge (i.e.
Neurosurgery, Orthopedics, ENT, Plastics, etc.)
2. Patients are not given adequate supplies or medication**. This is poor patient care, results
in unnecessary patient calls, and is unfair to the patient and their family. Please make sure
that patients are given adequate medication and supplies to make it to their first clinic
appointment. Pre-printed prescriptions should be used.
3. Appropriate labs and X-rays are not being ordered for the first clinic visit.
4. The first blue surgery clinic appointment should be scheduled 2-4 weeks following discharge
unless otherwise specified. Not all patients require a Trauma/Emergency Surgery service
clinic appointment. Please check with chief surgical resident, attending physician, or case
manager before scheduling a follow-up appointment.
5. The attending physician of record for the discharge summary is the attending on service
when the patient is discharged from the hospital.

*Please refer to the attached discharge documents and policies in this manual.

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**Trauma service residents will not prescribe narcotic pain medications after hours or on
weekends. Patients should be instructed to contact the clinic during regular working hours
for narcotic pain medications.

B. Service to Service Transfers

Multiple or single system injury patients can be transferred to an appropriate subspecialty service
when they are stable. Coordination of the transfer process is the primary responsibility of the chief
surgical resident. The Blue Surgery Service should function as a consultative service after transfer
of the patient when consultation is appropriate for good patient care. (See attached Trauma
Admission Policy)

V. Clinic Responsibility

A. Trauma/Emergency Surgery Clinics

There is one clinic for the service. The main clinic for the service is Tuesday 8:30 am – 12 noon.
Residents are expected to attend in accordance with the resident duty hour restrictions. All patients
seen by a resident should be staffed by an attending physician unless otherwise instructed.

B. Clinic Phone Calls

During weekday working hours, clinic phone calls will be referred to the Trauma Case Manager
(TCM). It is the Trauma Case Manager's responsibility to triage these phone calls appropriately.
Residents will be contacted by the TCM for prescriptions or medication** renewals. If the patient
needs to be seen by a physician, the TCM will notify the chief resident and the ED triage nurse.
During evening hours and on weekends all patient phone calls will be directed to the Chief surgical
resident on call.
**Trauma service residents will not prescribe narcotic pain medications after hours or on
weekends. Patients should be instructed to contact the clinic during regular working hours
for narcotic pain medications.

C. Elective OR Scheduling for clinic patients

The Surgical Residents are ultimately RESPONSIBLE for ALL ELECTIVE SCHEDULING OF OR
CASES FOR CLINIC PATIENTS.
1. All cases should be posted by completing the OR Case Posting form. The patient name,
procedure, estimated time, CPT code, and attending on service at the time of surgery are
the necessary information.
2. An 'Operating Room Case Posting Form' must be completed for all cases. This should be
given to the Surgery Clinic Staff who will complete the process.
3. Same Day Surgery Patients and Outpatients should have and H&P*, consent*, appropriate
preoperative labs*, and a referral to anesthesia clinic (when appropriate) prior to the day of
surgery. (*This should be given to clinic personnel).
4. Patients scheduled for elective admission prior to surgery can have H&P, consent, and
preoperative labs completed on the day of admission.
5. The Clinic should be notified regarding the booking of all elective cases, inpatient or
outpatient. This allows the clinic personnel to maximize utilization of our OR time.

VI. OR Scheduling

The Trauma/Emergency Surgery service has elective operating room time every Thursday and
Friday. Cases must be booked no later than 24 hours prior to Surgery. Do not wait until the last
minute to book elective cases. The chief surgical resident is responsible for checking, verifying, and
establishing case order. This should be accomplished along with the surgical attending on service.

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A. Emergent
The booking of emergent surgical cases is the primary responsibility of the chief surgical resident.

B. Elective*
The booking of elective surgical cases on Trauma/Emergency Surgery inpatients is the primary
responsibility of the chief surgical resident. *The clinic personnel must be notified about elective
inpatient booking so they can keep our schedule correct.
*Scheduling for clinic patients is covered under clinic responsibilities.

PERSONNEL
Trauma Nurse Coordinator (TNC)
Name: Lisa J. Fryman, RN
Phone: 859-257-1231
Pager: 330-6421

The TNC is responsible for program administration, quality assurance activities, and systems
problem solving. The TNC maintains and facilitates the trauma registry for the purpose of research
and quality assurance. Trauma admission forms should be forwarded to the TNC. The TNC also
coordinates ATLS and other education related activities. Clinically, the TNC evaluates quality of
care, especially during the initial assessment and resuscitative phase.

Trauma Case Manager (TCM)

Name: Amie Hawkins, RN and Darcy Tekulve, RN
Office: 859-323-5318

The TCM is responsible for:

1. Discharge planning
-determines patient disposition early and makes appropriate referrals to outside agencies
accordingly.
-directs consultation of Rehabilitation Medicine and Physical Therapy as necessary.
-along with nursing, identifies patients needing Home Health Referrals, outpatient equipment
needs, and teaching needs.
2. Liaison between the Blue surgery service and nursing
-keeps nursing abreast of the current plan of care and keeps medicine abreast of the nursing
plan of care.
-along with nursing, makes adjustments in the nursing plan of care to meet patient outcomes.
-during weekdays takes all patient clinic calls and triages appropriately.
-arranges for appropriate consults to PT, OT, RMS, and Psychiatry.
-develops and monitors protocols related to the care of trauma patients.
-assists interns in discharging patients by completing the discharge face sheet and arranging
clinic appointments.

TEACHING CONFERENCES

I. Trauma and Critical Care Conference

A. Trauma/Critical Care Conference*

There is a mandatory weekly trauma/critical care conference. All team members are expected to
attend unless patient care responsibilities preclude attendance. The conference schedule is
available from any of the trauma service faculty.

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LEGAL RESPONSIBILITY
Many trauma patients become involved in civil or criminal cases. Consequently, residents often
receive a subpoena to testify in these cases. Under most circumstances, the responsibility to testify
in court belongs to the attending faculty member that supervised the case. Please bring all
subpoenas involving testimony in these cases to the immediate attention of the Chief, Section of
Trauma and Critical Care or to the Chief, Division of General Surgery. All other medical
practice/legal issues should be brought to the immediate attention of the Chief, Division of General
Surgery.

TRAUMA/EMERGENCY SERVICE PROTOCOLS

There are a number of protocols that govern the treatment and care of Trauma/Emergency Surgery
Service patients. The surgical residents are expected to be familiar with these protocols and to
adhere to them. All of the protocols are contained in the attached package for your review.

15
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SECTION 2: ED POLICIES AND PROCEDURES

Trauma Admission Policy

This policy is designed to clarify protocols for trauma patient admissions to the University of
Kentucky Hospital. A major trauma patient is any patient with significant injury to two or more
systems or who, on the basis of mechanism of injury, has a high potential for injury to two or more
systems. Major trauma patients also include those with evidence of physiological compromise that
cannot be attributed to only or organ system.

All trauma patients with injury to more than one system, or who are otherwise included under the
definition of major trauma, will be admitted to the Trauma Service for a period of no less than
twenty-four (24) hours. Admission to Services other than the Trauma service does not preclude
close consultation with the Trauma Service; alteration in the condition of the patient will require
evaluation by the Trauma Service and any appropriate consultative service.

If after twenty-four hours the patient has a single system injury without injury to another system,
transfer to the appropriate service will be instituted. The Trauma Service may be requested to
function as a consultative service on the patient after transfer of the patient to another service.

16
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University of Kentucky / UK
HealthCare Policy #ED08-50
Policy and Procedure

Title/Description: Adult Trauma Alert ( patient >14 years of age)

Purpose: To effectively manage major trauma patients, the Trauma Alert Team must
assemble quickly and mobilize the resources essential to diagnosis and treatment.

Policy
Procedure
Persons and Sites Affected
Policies Replaced
Effective Date
Review/Revision Dates

PROCEDURE: To effectively manage major trauma patients, the Trauma Alert Team must
assemble quickly and mobilize the resources essential to diagnosis and treatment.
I. Criteria for Adult Trauma Alert
In order to ensure that critically injured patients receive appropriate medical care, the
Trauma Service has developed criteria to guide medical professionals in rendering trauma
care.
A. Mandatory Criteria
1. Trauma Alert Red

A Trauma Alert Red will be issued for any trauma patient:

Any with documented hypotension (Systolic B/P < 90)
GSW to neck, chest or abdomen.
GCS < 8 with mechanism attributed to trauma.
Patient with respiratory compromise or obstruction:
Indicates intubation of trauma patient from the scene
Includes intubated patients transferred from referring hospital
with ongoing respiratory comprise
Does not include intubated patients from referring hospital
who are stable from a respiratory standpoint
Transfer trauma patients receiving blood to maintain vital signs
Emergency Medicine Attending discretion

2. Trauma Alert

A Trauma Alert will be issued if a patient exhibits one or more of the following
criteria:

Any intubated trauma patient

Respiratory rate < 10 or > 30
Glasgow Coma Scale (EMV) < 12
Penetrating trauma to head
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 - 18 -

Stab wounds to neck, chest, abdomen, back or pelvis

Combination of 2nd or 3rd degree burn > 15% BSA and
multiple trauma
Spinal Cord Injury – Suspected or known
Pregnant trauma patient > 24 weeks gestation
Age > 65 with significant chest, abdomen, pelvic or extremity
injury
2 or more proximal extremity fractures, open fracture and/or
pelvic fracture
Amputation above ankle or wrist
Emergency Medicine Attending discretion

B. Potential Criteria (High index of suspicion for major injury)

The characteristics of the accidents or injuries listed below indicate that patient
condition may necessitate a Trauma Alert.

Evidence of high energy dissipation:

a. Falls > 20 ft.
b. Rollover MVC
c. Crash speed change > 40 mph
d. Motorcycle crash speed > 20 mph & separation of rider
e. Pedestrian struck by motor vehicle
f. Ejection of patient
g. Same vehicle occupant fatality
h. Intrusion into vehicle > 12 inches
i. Blast injury
Multiple system trauma involving more than one surgical specialty
Pre-existing cardiac, pulmonary, or systemic medical disease
Patient age > 55 years
Victim extrication time > 20 minutes
II. Initiation of Trauma Alert

A. The Trauma Service authorizes the following individuals to initiate a Trauma

Activation, if any mandatory or potential criteria are met during transport or upon
arrival:

Pre-hospital ambulance and Air Medical personnel

Emergency Department charge nurse
Surgical resident
Emergency Department physician, Trauma Service senior resident, or
attending may initiate a Trauma Alert at his/her discretion regardless of
mandatory criteria met.
B. Authorized personnel will initiate the appropriate Trauma Activation when:

A patient who exhibits one or more mandatory criteria is scheduled to arrive at

hospital < 15 minutes.
A patient who exhibits one or more mandatory criteria arrives without previous
notification.
A patient’s condition deteriorates acutely while in the Emergency Department.
18
 - 19 -

Only the Senior Trauma/Emergency Physician can deactivate a Trauma Alert and dismiss
Trauma Alert personnel from the Emergency Department. The Emergency Department
Charge Nurse will document Trauma Alert deactivation on the Nursing Care Record and will
ensure appropriate documentation on the Trauma Alert Log completed by the clerical staff in
order to prevent unwarranted patient billing.

III. Trauma Alert Activation Process

A. Notification

1. When authorized personnel request a Trauma Alert Red/Trauma Alert the ED

charge nurse will:
Notify the ED Patient Relations Assistant (PRA) of Trauma Alert
Red/Trauma Alert.
Document the patient’s name, time, and Trauma Alert indicator on the
Trauma/Critical Care Flow Sheet.

2. The ED PRA will call the paging operator via STAT number and instruct
him/her to issue a Trauma Alert or Trauma Alert Red supplying estimated time
of arrival (ETA) and brief patient descriptors for mechanism of injury.
Notify the Blood Bank by phone (Trauma Alert Red/Trauma Alert only)
Document all notifications in the Trauma Alert Log and denote Trauma
Alert Red or Trauma Alert.

3. When the paging operator receives instructions from the ED PRA, he/she will
activate the Trauma Alert pager system to notify Trauma Team members.

The Trauma Alert resuscitation management will be by Emergency Medicine

with Trauma Service chief resident available. All Trauma Alert Reds will be
managed by the Trauma Service.

B. The Trauma Alert Team consists of:

1. Emergency Medicine Rotation

Emergency Medicine Attending
Emergency Medicine Residents
Trauma Chief Resident
OB Chief Resident (OB cases only)
Emergency Department Nurses
Emergency Department Technicians
Emergency Department Paramedics
Radiology Technologist
Respiratory Therapist
CT Scan Technologist (notified)
Operating Room Charge Nurse (notified only)
Ultrasound Technologist

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2. Trauma Service Rotation

Trauma Attending (Trauma Alert Red only)
Trauma Chief Resident
Trauma Service Primary Call Resident
Anesthesiologist (Trauma Alert Red only)
Emergency Medicine Resident
Emergency Department Nurses
Emergency Department Technicians
Emergency Department Paramedics
Radiology Technologist
Respiratory Therapist
CT Scan Technologist (notified)
Operating Room Charge Nurse (notified only)
Ultrasound Technologist

IV. Trauma Alert Responsibilities

A. Trauma Team Physicians

When physicians assigned to the Trauma Team are notified that a Trauma Activation
is in effect they will:

Report to the ED within five minutes of notification.

Assume roles outlined in Trauma Resuscitation Roles and Responsibilities.

As the Trauma Charge Physician the Trauma Chief Resident/Senior Emergency

Medicine Physician will coordinate response activity.

The Trauma Service Primary Call Resident will notify capacity command center staff
of potential admission.

B. Trauma Alert Emergency Department Nurses

When a Trauma Activation is issued the ED charge nurse and primary patient care
nurse will:

Designate a Trauma Nurse #1 and a Trauma Nurse #2.

Designate a Trauma Nursing Care Technician.
Designate a Blood Bank runner.
Assign other personnel roles and responsibilities as designated in the Trauma
Resuscitation Roles and Responsibilities.
Assist with preparation of trauma resuscitation room for patient.
Document the names and arrival times of Trauma Team personnel.
Obtain Trauma Alert package with documentation forms.

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C. Trauma Alert Radiology Personnel

When a Trauma Activation is issued the Radiology technologist assigned to the team
will:

Deliver a portable Radiology machine to the Emergency Department within five

minutes.
Perform and process radiographs of trauma patients as quickly and efficiently
as possible.
Notify appropriate radiologist that the trauma patient’s radiographs are ready.
CT scan technologist will supply contrast for potential scanning and ensure CT
scan availability for the patient.

D. Blood Bank Personnel

When the Blood Bank is notified by the ED clerk that a Trauma Activation has been
issued Blood Bank personnel will:

Prepare in a cooler 4 units of 0 negative blood, 0 positive is acceptable for

males, within 10 minutes of notification.
Prepare requested number of units of type-specific blood within 15 minutes of
receiving patient’s Type & Cross sample. When type-specific blood is prepared
Blood Bank personnel will notify ED that blood is ready.
Prepare requested number of units of cross-matched blood within 45 minutes
after receipt of patient blood sample. When cross-matched blood is prepared
Blood Bank personnel will notify ED that blood is ready.

E. Operating Room Personnel

When the Operating Room is notified via the pager that a Trauma Activation has
been issued Operating Room personnel will:
Determine Operating Room availability.
Evaluate potential need for Operating Room Scrub and Circulating Teams.
Evaluate potential need for Anesthesiology Team (attending and senior
resident/CRNA).

In the event of a Trauma Alert Red, an operating room will be designated and held
for 30 minutes in anticipation of emergency operative intervention. The Attending
Anesthesiologist will respond to the Emergency Department within 5 minutes of
Trauma Alert Red notification to assist with airway management if necessary and to
evaluate the patient for pending operative intervention.

F. Laboratory Personnel
When the laboratory is notified by the ED clerk that a Trauma Activation has been
issued laboratory personnel will:
Expedite analysis of all trauma labs.
Call Emergency Department to report all panic level laboratory results. All other
laboratory results will be reported to the ED via the computer.

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G. Trauma Alert Respiratory Therapy Personnel

When a Trauma Activation is issued the Trauma Team Respiratory Therapist will:

Report to Emergency Department within 5 minutes of notification.

Assist physicians with airway management and ventilatory support.
Obtain, set up and manage ventilator.

V. Trauma Alert Quality Assurance

A. The Trauma Coordinator will review all Trauma Alert Red/Trauma Alert records for
completeness of information and for details of the response efforts (trauma
indications, arrival times of Trauma Alert Team members).

B. The Trauma Coordinator will submit a quarterly report and summary of all Trauma
Alerts to the Trauma Patient Care Committee.

C. The Trauma Coordinator will present specific issues or concerns related to a case(s)
for discussion and action planning.
If the committee determines that response was sub-optimal, the Chairman will notify
the department director or service chief of the area that delivered sub-optimal
service.
D. All Trauma Alert Red activations will be reviewed utilizing the following criteria:

Response of trauma team members

Appropriateness
Forward progress/conduct of resuscitation
Time to OR
OR preparedness
Patient outcome

Formerly ED08-101

Persons and Sites Affected

Enterprise Chandler Good Samaritan Kentucky Children’s Ambulatory Department ED

Policies Replaced
Chandler HP Good Samaritan Kentucky Children’s CH Ambulatory KC Other
Effective Date: 12/89 Review/Revision Dates: 02/10
Approval by and date:

Signature Date_______________
Name Penne Allison, RN, BSN, MSOM, Director
Signature Date_______________
Name Roger Humphries, MD Medical Director

22
 - 23 -

University of Kentucky Hospital

Level I Trauma Center

Adult Trauma Activation Criteria

Trauma Alert Red Trauma Alert

Criteria Criteria

One or more of the following: One or more of the following:

Confirmed SBP<90 at any time Any intubated trauma patient

Gunshot wounds to the neck, chest or abdomen Respiratory Rate <10 or > 30
GCS <8 with mechanism attributed to trauma GCS < 12
Intubated patients transferred directly from scene Penetrating head trauma
Patients with respiratory compromise or obstruction Stab wounds to neck, chest, back, abdomen or pelvis
- Includes intubated patients who are transferred from > 15% BSA with 2nd or 3rd degree burns and multiple trauma
another facility with ongoing respiratory compromise Spinal Cord Injury – Suspected or known
Does not include intubated patients from referring Pregnant trauma patient > 24 weeks
facility who are stable from a respiratory standpoint Age > 65 with significant chest, abdomen, pelvic or extremity injuries
Transfer trauma patients receiving blood to maintain 2 or more proximal extremity fractures, open fractures and/or
vital signs pelvic fractures
Emergency Medicine Attending discretion Amputation above ankle or wrist
Emergency Medicine Attending discretion

Potential Criteria
Age > 55 with significant mechanism of injury
Falls > 20 feet
Rollover MVC
Ejection of patient
Response/Resources activated:
Extrication > 20 minutes
Trauma Surgery Attending Motorcycle crash speed > 20 mph & separation of rider
Trauma Surgery Chief Resident Motor vehicle crash speed > 40 mph
Anesthesiology Attending Same vehicle occupant fatality
Emergency Medicine Resident Pedestrian struck by motor vehicle
ED Nurses Intrusion into vehicle > 12 inches
ED Technician Blast injury
ED Paramedics Multiple system trauma involving
more than 1 surgical specialty
Ultrasound Technologist
Radiology Technologist
CT Scan Technologist Response/Resources activated:
Respiratory Therapist
Blood bank cooler of uncross-matched blood Emergency Medicine Attending
Operating Room Charge Nurse notified Trauma Surgery Chief Resident
Operating Room made available Emergency Medicine Resident
Chaplain OB Chief Resident *if applicable
ED Nurses
ED Technicians
ED Paramedics
Radiology Technologist
Ultrasound Technologist
Respiratory Therapist
CT Scan Technologist
Blood Bank cooler of uncross-matched blood
Chaplain

Revised February 17, 2010

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 - 24 -

Revised August 2008

UNIVERSITY OF KENTUCKY HOSPITAL POLICY NUMBER: 08-102

CHANDLER MEDICAL CENTER FIRST ISSUED: 02/99
EMERGENCY DEPT. POLICY CURRENT AS OF: 10/08

SUBJECT: Pediatric Trauma Alert (patients < 14 years of age)

PURPOSE: To establish guidelines for rapid assembly and mobilization of resources prior to and
upon arrival of critically injured pediatric patients.
PROCEDURE: To effectively manage pediatric major trauma patients, the Pediatric Trauma Alert
Team must assemble quickly and mobilize the resources essential to diagnosis and treatment.

I. Criteria for Pediatric Trauma Alert

In order to ensure that critically injured pediatric patients receive appropriate medical care, the
Trauma Service has developed criteria to guide medical professionals in rendering trauma care.

A. Mandatory Criteria

Trauma Alert Red

A Pediatric Trauma Alert Red will be issued if any pediatric trauma patient exhibiting any of the
criteria:
Gunshot wound to the neck, chest, or abdomen
Hemodynamic instability (Systolic B/P<90 for child >1 year of age or Systolic B/P <80 for
child <1 year of age) after 2 boluses of 20ml/kg of lactated ringers (LR)
Any pediatric trauma patient receiving/having received blood transfusion to maintain vital
signs
GCS < 8 with mechanism attributed to trauma
Patient with respiratory compromise or obstruction
Indicates intubation of trauma patient from the scene
Includes intubated patients transferred from referring hospital with ongoing respiratory
comprise
Does not include intubated patients from referring hospital who are stable from a
respiratory standpoint
Emergency Medicine Attending Discretion

2. Trauma Alert

A Trauma Alert will be issued if a patient exhibits one or more of the following criteria:
Pediatric trauma score <13
Respiratory rate <10 or >30
Glasgow Coma Scale (EMV) < 10
Any intubated trauma patient
Penetrating trauma to head
Combination of 2nd or 3rd degree burn > 15% BSA and multiple trauma
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 - 25 -

Stab wounds to the neck, back, chest, abdomen or pelvis

Emergency Medicine Attending Discretion
Pediatric Surgery Attending Discretion

B. The characteristics of the accidents or injuries listed below indicate that patient condition
necessitate a Trauma Alert.

Age < 14 with significant mechanism of injury

Evidence of high energy dissipation:
a. Falls > 15 feet
b. Roll over MVC
c. Ejection of the patient
d. Motorcycle crash speed change > 20 mph with separation of rider
e. Motor Vehicle crash speed > 40 mph
f. Same vehicle occupant fatality
g. Pedestrian struck by motor vehicle
h. Blast injury
Multiple system trauma involving more than one surgical specialty
Extrication time > 20 minutes
Two or more proximal extremity fractures
Amputation above ankle or wrist level

II. Initiation of Trauma Alert

A. The Trauma Service authorizes the following individuals to initiate a Trauma Activation if any
criteria are met during transport or upon arrival:

Pre-hospital ambulance and Air Medical personnel

Emergency Department charge nurse
Surgical resident
Emergency Department physician, trauma service senior resident, or trauma
attending may initiate a Trauma Alert at his/her discretion regardless of
mandatory criteria met

B. Authorized personnel will initiate a Trauma Alert when:

A patient who exhibits one or more criteria is scheduled to arrive at hospital <
15 minutes.
A patient who exhibits one or more criteria arrives without previous notification.
A patient’s condition deteriorates acutely while in the Emergency Department.

Only the Senior Trauma/Emergency Physician can deactivate a Trauma Alert and dismiss Trauma
Alert personnel from the Emergency Department. The Emergency Department Charge Nurse will
document Trauma Alert deactivation on the nursing care record and will ensure appropriate
documentation on the Trauma Alert Log completed by the clerical staff in order to prevent
unwarranted patient billing.

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 - 26 -

III. Trauma Alert Activation Process

A. Notification:

1. When authorized personnel request a Trauma Alert Red/Trauma Alert the ED charge
nurse will:

Notify the ED Patient Relations Assistant (PRA) of Trauma Alert/Trauma

Alert Red.
Document the patient’s name, time, and trauma alert indicator on the
Trauma/Critical Care Flow Sheet.
Page the Pediatric Surgery attending, chief resident, and resident. Place
6661 for Trauma Alert Red & 6662 for Trauma Alert as return # to
communicate a pediatric trauma alert.
Page the Emergency Surgical Services (ESS) at #1234

2. The ED PRA will call the paging operator via STAT number and instruct him/her to issue
a Trauma Alert/Trauma Alert Red supplying estimated time of arrival (ETA), and brief
patient descriptors for mechanism of injury, and:

Notify the Blood Bank by phone (Trauma Alert Red/Trauma Alert only)
Document all notifications in the Trauma Alert Log and denote Trauma
Alert/Trauma Alert Red.

3. When the paging operator receives instructions from the ED clerk, he/she will activate
the Trauma Alert pager system to notify Trauma Alert Team members.

B. The Pediatric Trauma Alert Team consists of:

Pediatric Surgery Attending (Required for Trauma Reds)

Pediatric Surgery Chief Resident
Trauma Surgery Chief Resident
Anesthesiology Attending (Required for Trauma Reds)
Emergency Department Nurse(s)
Emergency Medicine Attending & Residents
Emergency Department Paramedics
Emergency Department Technician
Respiratory Therapist
Radiology Technologist
Ultrasound Technologist
CT scan Technologist
Blood Bank Cooler of Uncrossed matched blood
Operating room Charge Nurse notified
Operating room made available
Chaplain

The Pediatric Chief Surgery Resident and intern will respond within five minutes (15 minutes if out
of house). Because the Pediatric Surgery Chief Resident may take call from home, the Trauma
Service Chief Resident also responds to the Pediatric Trauma Alerts to provide direction of the
26
 - 27 -

resuscitation until the Pediatric Surgery Chief Resident arrives, or to provide assistance to the
Pediatric Surgery Chief Resident. Care of the patient and direction of the resuscitation will be
assumed by the Pediatric Surgery Chief Resident upon his/her arrival.

IV. Trauma Alert Responsibilities

A. Trauma Team Physicians

When physicians assigned to the Trauma Team are notified that a Trauma Activation is in effect
they will:

Report to the ED within five minutes of notification.

Assume roles outlined in Trauma Resuscitation Roles and Responsibilities.

As the Trauma Charge Physician, the Trauma Chief Resident/Senior Emergency Medicine
Physician will coordinate response activity. The Trauma Service Primary Call Resident will notify
capacity command center staff of potential admission.

B. Trauma Alert Emergency Department Nurses

When a trauma Alert is issued, the ED charge nurse and primary patient care nurse will:

Designate a Trauma Nurse #1 and a Trauma Nurse #2

Notify the Pediatric Charge Nurse of the patient’s pending arrival
Designate a Trauma Nursing Care Technician
Designate a Emergency Department Paramedic
Designate a Blood Bank Runner and send for blood when Trauma Alert Red or
Trauma Alert is initiated.
Assign other personnel roles and responsibilities as designated in the Trauma
Resuscitation Roles and Responsibilities
Prepare trauma resuscitation room for patient
Document the names and arrival times of Trauma Alert personnel

C. Trauma Alert Radiology Personnel

When a Trauma Alert is issued, the Radiology technician assigned to the team will:

Deliver a portable Radiology machine to the Emergency Department within five

minutes.
Perform and process radiographs of trauma patients as quickly as possible.
Notify radiologist that trauma patient’s radiographs are ready for evaluation.
The radiologist will respond within five minutes and assist with rapid interpretation of radiographs.

CT Scan technologists will respond within five minutes, supply contrast for potential scanning,
ascertain scanning needs, and ensure CT Scan and abdominal ultrasound availability for the
patient.

27
 - 28 -

D. Blood Bank Personnel

When the Blood Bank is notified by the ED clerk that a Trauma Alert has been issued, Blood Bank
personnel will:

Prepare four units of 0 negative blood (0 positive is acceptable for males)

within ten minutes of notification.
Prepare requested number of units of type-specific blood within 15 minutes
after receipt of patient blood sample, and notify ED when blood is ready.
Prepare requested number of units of cross-matched blood within 45 minutes
after receipt of patient blood sample, and notify ED when blood is ready.

E. Operating Room Personnel

When the Operating Room is notified via the pager that a Trauma Alert has been issued, Operating
Room personnel will:

Determine Operating Room availability.

Evaluate potential need for Operating Room Scrub and Circulating Teams.
Evaluate potential need for Anesthesiology Team (attending and senior
resident/CRNA).

In the event of a Trauma Alert Red, an operating room will be designated and held for 30 minutes
in anticipation of emergency operative intervention. The Attending Anesthesiologist will respond to
the Emergency Department within five (5) minutes of Trauma Alert Red notification to assist with
airway management if necessary and to evaluate the patient for pending operative intervention.

F. Laboratory Personnel
When the laboratory is notified by the ED clerk that a Trauma Alert has been issued, laboratory
personnel will:

Expedite analysis of all trauma labs.

Call Emergency Department to report all panic level laboratory results. All other
laboratory results will be reported to the ED via the computer.

G. Trauma Alert Respiratory Therapy Personnel

When a Trauma Alert is issued, the Trauma Alert Team Respiratory Therapist will:

Report to Emergency Department within five minutes of notification.

Assist physicians with airway management and ventilatory support.
Obtain, set up, and manage ventilator.

V. Pediatric Trauma Alert Quality Assurance

A. The Pediatric Trauma Coordinator will review all Trauma Alert Red/Trauma Alert
records for completeness of information and for details of the response efforts

28
 - 29 -

(trauma indications, person who initiated alert, arrival times of Trauma Alert, and
ancillary personnel).

B. The Pediatric Trauma Coordinator will submit a quarterly report and summary of all
Trauma Alerts to the Pediatric Trauma Patient Care Committee.

C. The Pediatric Trauma Coordinator will present specific issues or concerns related to
a case(s) for discussion and action planning.

If the committee determines that response was sub-optimal, the Chairman will notify
the department director or service chief of the area that delivered sub-optimal
service.

D. All Pediatric Trauma Alert Red activations will be reviewed utilizing the following
criterion:

Response of trauma alert members

Appropriateness
Forward progress/conduct of resuscitation
Time to OR
OR preparedness

All Pediatric Trauma Alert activations quality monitoring results will be forwarded to the Chief
of Pediatric Trauma.

Formerly 08-23

29
 - 30 -

University of Kentucky Hospital

Level I Trauma Center

Pediatric Trauma Activation Criteria

Trauma Alert Red Trauma Alert

Criteria Criteria

One or more of the following: One or more of the following:

Gunshot wounds to the neck, chest or abdomen. Trauma Score <13.

Confirmed age specific hypotension at any time. Respiratory Rate <10 or >30.
Any pediatric trauma who remains HDUS after 2 Glasgow Coma Score < 10.
Boluses of 20 ml/kg Isotonic Crystalloid. Any intubated trauma patient.
Any pediatric patient receiving/received blood transfusion. Stab wounds to the neck, back, chest, abdomen or pelvis.
GCS <8 with mechanism attributed to trauma. Penetrating trauma to the head.
Intubated patients transferred directly from scene. >15% BSA with 2ND or 3RD degree burns and multiple trauma.
Patients with respiratory compromise or obstruction Emergency Medicine Attending discretion.
Includes intubated patients who are transferred from Pediatric Surgery Attending discretion.
another facility with ongoing respiratory Age <14 with significant mechanism of injury.
compromise. Falls > 15 feet.
Does not intubated patients from referring facility who Rollover MVC.
are stable from a respiratory standpoint. Ejection of patient.
Emergency Medicine Attending discretion. Extrication > 20 minutes.
Motor vehicle crash speed changes >40 mph.
Motorcycle crash speed > 20 mph & separation of rider.
*HDUS (Hemodynamically Unstable)
Same vehicle occupant fatality.
Age SBP
Pedestrian struck by a motor vehicle.
<1 <80 Blast Injury
>1 80-89 Two or more proximal extremity fractures and/or open
fractures.
Amputation above ankle or wrist.
Multiple system trauma involving more than one surgical
specialty.
Response/Resources activated:

Response/Resources Activated:
Pediatric Surgery Attending
Pediatric Surgery Chief Resident Emergency Medicine Attending
Trauma Surgery Chief Resident Pediatric Surgery Chief Resident
Anesthesiology Attending Pediatric Surgery Attending -notified
ED Nurses Trauma Surgery Chief Resident
ED Technicians Emergency Medicine Residents
ED Paramedics ED Nurses
Ultrasound Technician ED Technicians
Radiology Technician ED Paramedics
Respiratory Therapist Radiology Technician
CT Scan Technician Ultrasound Technician
Blood Bank cooler of uncross-matched blood Respiratory Therapist
Operating Room Charge Nurse CT Scan Technician
Operating Room made available Blood Bank cooler of uncross-matched blood
Chaplain Chaplain

Revised August 2008

30
 - 31 -

UNIVERSITY OF KENTUCKY HOSPITAL NEW DOCUMENT #: 08-25

CHANDLER MEDICAL CENTER FORMER DOCUMENT#: 08-14
ISSUED: 6/91
EMERGENCY DEPT. POLICY REVISED: 6/93, 8/94, 7/97, 2/99, 5/00, 4/01,
1/05 & 5/08

SUBJECT: Trauma Resuscitation Roles and Responsibilities

PURPOSE: To establish guidelines for staff roles and responsibilities during trauma resuscitation
of the critically injured patient.

PROCEDURE:

Trauma Attending/Trauma Fellow

A. Provides guidance and oversees trauma resuscitation.

B. Performs and/or assist with procedures.

Trauma Team Leader

A. Assigned to the Trauma chief resident/Emergency Medicine Resident present or EM

Attending depending upon assigned rotation schedule. *Trauma Alert Red and
Pediatric Trauma Alert Red patients will be managed by the Trauma Attending or
Pediatric Surgery Attending with the assistance of Emergency Medicine Service.

B. Designated as Trauma Team Leader in charge of trauma resuscitation and decision-

making under the guidance of the Trauma Attending or EM Attending depending on
rotation schedule.

C. Responsible for:

Overall patient evaluation and management.

Ensuring completion of primary and secondary surveys.
Communicating assessment findings to recording RN.
Determining priority of procedures and necessary tests.
Determining need for and timing of operative intervention when indicated and
contacting the OR.
Determining the need for appropriate consultations.
Making physician assignments.
Dismissing ancillary personnel when services are no longer needed.
Deactivating Trauma Alerts when appropriate.
Ensuring traffic control.

D. The Trauma Team Leader may assume or delegate the role of evaluation and
management depending on patient acuity.

The Trauma Team Leader maintains responsibility at all times.

The Trauma Team Leaders’ role may not be delegated to first-year residents.

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 - 32 -

Emergency Medicine MD or MD #2

A. Assigned to the EM resident, Anesthesiology Attending or Trauma Resident.

B. Responsible for:

Airway management and assuring cervical spine immobilization.

Coordinates initial assessment.

Primary MD or MD #3

A. Assigned to second-most Senior Resident, preferably second-year or higher.

Responsible for:

Assisting Trauma Team Leader in patient evaluation and management.

Performs primary and secondary assessment.
Performing necessary procedures under the direction of the Trauma Team
Leader.
Coordinating orders.

MD #4

A. Assigned to third-most Senior Resident, preferably first-year or higher.

B. Responsible for:

Assisting in patient evaluation and management under the direction of MD #3.

Contacting CT Scan and Radiology Special Procedures, as needed, under the
direction of the Trauma Team Leader.
Coordinating orders and completing Trauma H & Ps under direction of MD #3.

Emergency Department Charge Nurse

A. Pre-notifies physicians, primary patient care nurse, circulating nurses and financial
counselor of impending arrival.
B. Responsible for:

Delegating responsibility of checking equipment and supplies within the

Trauma Resuscitation area.
Assisting with traffic control.
Acting as family liaison as needed.
Disseminating prehospital patient report to appropriate MD’s/RN’s.

Primary Patient Care Nurse

A. Prepares Trauma Resuscitation area prior to patient arrival, and ensures that needed
equipment/supplies are readily available.

B. Responsible for ensuring documentation from admission to time of disposition or

report to oncoming RN including:

32
 - 33 -

Notification and response times of all medical and ancillary personnel.

EMS/Air Medical report.
Mechanism/time of injury & patient history.
Vital signs; cardiac rhythm strips.
Ongoing assessment/re-evaluation.
Procedures performed by physicians.
Nursing process.

C. Directs nursing team members as needed and assumes overall nursing responsibility
for patient to include:

Assists with initial assessment.

Confirming labs are obtained and sent.
Ensures patient is placed on Cardiac monitor.
Monitors VS – Gives 5 minute updates.
Ensures PIVs are functional & insertion of additional IV’s as needed.
Obtains Labs from arterial puncture.
Accompanying patient outside the ED, as needed.
Ensuring initial notification of family and providing ongoing clinical updates.
Notifying Capacity Command Center of bed requirement as soon as possible.

Circulating Nurse/EM Paramedic

A. Responsible for:

Assisting with initial assessment.

Obtains first manual BP pressure.
Assists with medication administration.
Assisting physicians with procedures.
Assisting in removal of patient clothing.
Inserting additional peripheral IV’s and drawing labs.
Assisting with nursing procedures (e.g. nasogastric tubes, Foley catheters).
Assisting with administration of colloids/crystalloids (via fluid warmer, as
needed).
Paramedics will not administer colloids.

Emergency Department Nursing Care Technician

A. Responsible for:

Assisting in set-up of trauma resuscitation area.

Obtaining blood from Blood Bank as instructed.
Obtaining IV fluids and blankets from warmer.
Assisting in removal of patient clothing.
Processing lab specimens.
Obtaining additional supplies as directed by nurses.
Ensuring patient has an arm/wrist identification band.
Processing patient clothing/valuables.
Assisting with CPR, as needed.

33
 - 34 -

Assisting with patient transport.

Scribe or Documenting Nurse

A. Responsible for:
Documents Resuscitation.
Assists with crowd control.
Assists with procedures as needed.

Financial Counselor(s)

A. Pre-notifies Radiology, Respiratory Therapy, Operating Room, Blood Bank etc. prior
to patient arrival.
B. Identifies patient from EMS run sheet, Air Medical records, and/or patient’s family
and updates computer when possible.
C. Prepares lab slips, X-Ray requests, EKG requests and ID bracelets.
D. Secures patient valuables in ED safe.

Respiratory Therapy

A. Assists with airway management.

B. Ventilates patient.
C. Prepares, monitors and documents all required aspects of mechanical ventilation.
D. Assists during patient transport.

Radiology Technologist

A. Responsible for obtaining radiography studies in a timely manner as ordered.

Ultrasound Technologist

A. Performing Focus Abdominal Sonogram Test (FAST) as ordered in a timely manner.

34
- 35 -

35
 - 36 -

UNIVERSITY OF KENTUCKY HOSPITAL POLICY NUMBER: ED08-52CHANDLER

MEDICAL CENTER FIRST ISSUED: 06/91
EMERGENCY DEPT. POLICY CURRENT AS OF: 05/08

SUBJECT: Trauma Labs

PURPOSE: Describe a standard set of laboratory studies obtained for each trauma patient, and
to list specific additional studies for frequently encountered situations. We
understand certain cases may require additional studies, to be obtained at the
discretion of the treating physicians.

PROCEDURE:
Lab specimen should be obtained via a femoral arterial stick in patients that are:
(a) Unstable, (b) intubated, or (c) have major mechanisms of injury. Venous samples
are appropriate for patients that are: (a) Stable, (b) non-intubated, (c) have minor
mechanisms of injury, and (d) ALL pediatric patients.

Standard Lab Panel for Trauma Alert Red and Trauma Alert Patients
* ABG Panel (ABG, Hct, Na, K, iCa, Glu)
* Type and crossmatch (4 units packed red blood cells)
* Coags (PT, PTT, INR)

Additional Studies for Altered Mental Status (GCS ≤ 14) 1

* Serum alcohol level, urine screen for drugs of abuse

Female Trauma Patients of Child Bearing Age 2

* Urine pregnancy test
* If positive, Kleihauer-Betke test

1. Altered mental status is defined as GCS ≤ 14, not readily explained by pre-hospital
medication administration or shock.
2. Female trauma patients without history of prior hysterectomy (Refer to ―Evaluation and
Management of Injury in Pregnancy,‖ located in the protocol manual).

____________________________________ ________________________________
Medical Director, Emergency Medicine Trauma Program Director

____________________________________
Emergency/Trauma Services Director

Formerly 08-103

36
 - 37 -

UNIVERSITY OF KENTUCKY HOSPITAL NEW DOCUMENT #:08-14

CHANDLER MEDICAL CENTER FORMER DOCUMENT #:08-25
EMERGENCY DEPT. POLICY ISSUED: 9/93
REVISED: 3/00, 4/01, 1/05, 8/08

SUBJECT: Care of Patients in Need of Immediate Surgery When the Operating Room is at
Maximum Capacity
SEE ALSO: OR Policy, OR 01-09, OR Access for Trauma.
PURPOSE: To provide criteria and procedures to manage the needs of patients who require
access to the OR at times when the Operating Room is at maximum capacity.

CRITERIA:
Patients meeting the following criteria may access the Operating Room under this policy:

I. Acute Intracranial Bleeding - Rapidly progressing process or lesion leading to herniation or

paralysis (ex: acute subdural hematoma, acute epidural hematoma, acute intracerebral
hematoma, and/or acute spinal cord compression).

II. Exsanguinating Hemorrhage:

A. Penetrating neck or chest trauma

B. Blunt neck or chest trauma
C. Intraabdominal bleeding (ex: penetrating or blunt trauma, ruptured abdominal viscerae,
aortic, or iliac aneurysm)

III. Potential for Acute Arterial Hemorrhage (established diagnosis)

A. Traumatic thoracic aortic injury

B. Thoracic aortic dissection or aneurysmal rupture
C. Leaking abdominal aorta/iliac artery aneurysm

IV. Airway Emergencies Requiring Surgical Intervention

A. Traumatic disruption of airway

B. Airway compromise due to obstruction
C. Intrathoracic and/or lung hemorrhage with respiratory compromise

PROCEDURE:
In conjunction with the OR response, the staff in the ED will respond in the following manner:

I. Trauma Service Responsibilities

A. Senior most surgeon present

1. Responsible for determining priorities and management of patient care that
necessitates immediate OR access and policy activation.
2. Responsible for notifying OR clerk and charge nurse.
3. Responsible for notifying ED staff.
37
 - 38 -

4. Designates trauma team roles as scrub or circulator.

B. Remaining surgeons
1. Responsible for retrieving required carts: i.e. craniotomy, airway, chest,
abdominal or vascular depending on need.
2. Responsible for opening room, setting up sterile field, serving as scrub and
circulating personnel until OR personnel arrive.

C. Prior to entering OR room, all staff will apply head covering, mask, and shoe covers.

II. Emergency Department Staff

A. ED Charge Nurse
1. Responsible for determining need for Trauma Alert Red and for anticipating
necessity for accessing the Operating Room.
2. If aware of OR maximum capacity, assess ED staff, assignments and current
activities (if time allows).
3. Responsible for reassigning ED patients of primary patient care nurse if patient
going to OR (may also send NA if ED staffing allows).
4. Responsible for determining availability and need for additional resources.
5. Communicates need for respiratory therapist to accompany patient to OR.
6. Responsible for ensuring that blood bank delivers blood to OR.

B. Patient Care RN
1. Assumes nursing responsibility for the patient; delegates responsibility to others,
when available, to accomplish tasks.
2. The ED nurse will prepare the patient for transport and accompany the patient
immediately to the OR.
NOTE: Patients directly admitted to the OR via Air Medical Services will be
accompanied by the Air Medical staff who will continue resuscitation until relieved
by the ED nurse or OR personnel (i.e., Anesthesia).
3. The ED nurse will facilitate continued resuscitation in the OR until the call team
arrives. The ED nurse will be responsible for the following:

a. Monitoring and preservation of airway patency

1. Assisting with intubation or surgical airway as necessary
b. Continued volume resuscitation
1. Maintenance/titration of volume infusion rate (crystalloid and colloid)
2. Autotransfusion
c. Ongoing hemodynamic monitoring
1. Obtaining specimens for laboratory studies
2. Administration/titration of drugs
d. Assisting physicians with procedures
e. Documentation on ED Nursing Care Record

The ED nurse will remain in the OR until released by the anesthesiologist and/or the
arrival of the OR call team.

38
 - 39 -

Quality Monitoring:

**All cases will be reviewed by the Trauma Coordinator and the Multidisciplinary Trauma
Committee.

____________________________________
Emergency/Trauma Service Director
Medical Director, Emergency Medicine
REVIEWED: 8/97, 6/00; 8/08

39
- 40 -

40
 - 41 -

UNIVERSITY OF KENTUCKY HOSPITAL POLICY NUMBER: 05-04

CHANDLER MEDICAL CENTER FIRST ISSUED: 1/91
Emergency Dept. Policy CURRENT AS OF: 08/08

SUBJECT: Nursing Care Record: Trauma/Critical Care

SEE ALSO: 07-12, Nursing Care Record

Purpose:
Provision of guidelines for use of the trauma/critical care nursing record will allow a standardized
method for use of the assessment tool resulting in more effective utilization and accuracy of the tool
and the data collected.

Rationale:
Effective and timely management of the multiple trauma or critically ill patient demands a rapid,
organized, systematic approach to assessment, planning, implementation and evaluation. The
trauma/critical care nursing record provides the framework for organization of the approach and
provides a documentation tool to facilitate establishment of a permanent record of comprehensive
baseline and monitoring assessment data as well as facilitating the documentation of the
implementation and evaluation phases of the nursing process. The nursing record organizes
specific data points to assist in determination of patient status and detection of potential or actual
human response to illness.

Considerations

1. The trauma/critical care nursing record is included in the patient's permanent medical record.

2. Use of the assessment tool is initiated by the nurse when deemed appropriate. The tool must
be used with all critically ill or injured patients who require ongoing monitoring and are
classified as acuity Level I or II.

3. As assessments, interventions and/or evaluations are completed the corresponding time and
information will be recorded in the appropriate area.

4. Evaluative notes will be recorded under the Nursing Evaluation section of the nursing care
record.

5. The record must be signed and initialed by all nurses delivering care to the patient including
the recording nurse. Assurance of adequate signatures to document care provision is the
responsibility of the patient care nurse.

6. A mechanism for quality assurance will be implemented to audit charts for completeness.
Staff will receive feedback surrounding quality assurance audit filters regarding form
completion.

41
Requisites

1. Black or blue ball point pen essential.

2. Trauma/Critical Care Nursing Record (sample of form attached).

Procedure:

1. Legibly print patient name in addressograph area.

2. Record demographic information:

a. Classification
b. Time of arrival - in military time
c. Date
d. Age
e. Sex
f. Weight - in kilograms or pounds
g. Mode of arrival:
- If Air Med, specify: service.
- If Lexington Fire Department, specify unit number: EC-1, EC-5, etc.
- If ambulance, specify: Scott County, Jessamine County, etc.
h. Recording nurse Specify by name according to
i. Patient care nurse role assigned. Record MD
j. Circulating nurse names in appropriate areas.
k. Physician
l. Chief complaint/pre-hospital report - include as many details as are available
concerning:
1. Mechanism of injury: driver, passenger, restrained, unrestrained, ejected, roll-
over, speed traveling, air bag, etc. Description of injury, object (if available)
for penetrating trauma - caliber of gun, length or type of knife, removal of
impaled objects, etc.
2. Pre-hospital treatment: IV, intubation, immobilization, meds given and fluids
infused (type and amount).
3. Chief complaints: particularly important with non-trauma admits - e.g., MI, GI
bleeding to include duration of pain - treatment administered.
4. Injury time: Actual time of MVC, GSW, etc. This information is available from
patient, pre-hospital personnel, referring hospital, paperwork, etc.
5. Scene flight: Check box if patient arriving via helicopter directly from injury
scene.
m. Past medical history - check the appropriate box and include any other conditions
you identify.

3. Record information in boxes of trauma team response section.

a. If trauma activation is called, check the appropriate box for trauma alert, trauma
alert red or trauma consult.
b. For each team responder (e.g., trauma attending, trauma chief, trauma resident,
emergency medicine resident, anesthesia, neurosurgeon, U/S tech, RT, X-ray, etc.)
complete time called and time arrived section under each responder.
c. Complete name section under each responder by writing in responder's first initial
and last name.

4. Initial Assessment
 a. Complete initial assessment section by documenting the primary and secondary
survey findings. Document time assessment of system occurs in space provided.
All sections should be completed in full. If you are unable to assess a particular
area or it is not applicable document accordingly.

b. All trauma patients must have a completed Glasgow coma scores, pupil evaluation
& trauma score and on arrival and on discharge from the ED.

5. After completion of the initial assessment, shade injured areas on diagram using legend
at bottom of page.

6. Document lab draws with time, site, prep and person obtaining labs.

7. Vital Signs
a. Vital signs should have a PTA set documented. Then the frequency of the vital
signs should correspond to the acuity of the patient. Vital signs will include
Temp, BP, HR, RR, SpO2, GCS and pupils.

b. Critical Care monitoring should be documented every hour at minimum e.g. ICP,
CPP, CVP, PCWP, etc.

c. Intake and Output should be documented at regular interval or as ordered by MD.

d. Drips will be documented at regular interval for dosage and rate or when titrated.

8. Ventilator Settings will be completed initially and when changes occur.

9. Intervention
a. Procedures - record time of procedures, size of tubes & lines placed along with
sites and removal of backboard and/or changing of C-Collar in appropriate spaces.
Other procedure data can be entered in the nursing evaluation section.

10. Resuscitation Fluids

1. Record fluids patient received prior to arrival in shaded area.
2. Record all fluids patient receives by using
a. Time
b. Fluid Type
c. Crystalloids - liter number (#)
d. IV site
e. ―Y‖ for fluid warmer used
f. Colloids – document Type & unit number (#) & donor number (#)
g. Totals must be documented

11. Rhythm strip must be posted and interpreted for all patients with chest pain or a cardiac
event.

12. Medications
Document all medication administration by entering time administered, name of med, dose,
route, your initials and ordering MD.

13. Nursing Evaluation

Documentation of evaluation of patient response to interventions should be documented here.
Nurses and NCTs should include their initials after documenting and signature should be
legible. If additional space is needed use nursing continuation record.

43
14. Transport
Patient transports to diagnostics should be documented in this space.

15. Discharge Information

Document D/C vital signs, admitting service, total I&Os and disposition of valuables. Transfer
form should be completed if patient is transferred to another facility.

16. Notifications
All notifications should be documented by checking the box and inserting time notified in space
provided.

17. Signatures
All nursing staff involved in care of the patient should sign and initial the nursing care record. All
signatures should be legible.

18. Disposition
Document time report is called and last name of RN receiving report.

Time of actual patient movement from the department should be noted as well as destination of
patient. If "floor" is checked, enter room number.

19. Place patient stickers in upper right corner of patient chart on white and yellow sheets.
The white copy is to accompany the patient to the in-patient area and yellow stays in ED.

Formerly ED-07-13

44
SECTION 3: ED PROTOCOLS

45
 TERMINATION OF RESUSCITATION
ON THE BASIS OF PREHOSPITAL CRITERIA

Introduction:

The American College of Surgeons (ACS) position in resuscitative thoracotomy, taught in

Advanced Trauma Life Support (ATLS), is simple. In blunt or penetrating thoracic or abdominal
trauma, if a patient arrives pulseless and without signs of life, resuscitation ends and the patient
should be pronounced DOA (Dead on Arrival). Resuscitative thoracotomy has a poor salvage
rate with a high risk of iatrogenic blood borne pathogen exposure and/or injury to health care
provides. The patient should be pronounced DOA (Dead on Arrival) when any of the following
criteria are met:

1. Blunt Trauma whom arrives pulseless with no signs of life (patients > 15 years old).
2. Penetrating Trauma whom arrives pulseless with no signs of life with prehospital CPR >
15 minutes (patients > 15 years old).

Signs of Life:
1. Reactive pupils
2. Spontaneous movement
3. Organized ECG activity

Trauma Alert Activation should NOT occur initially for patients meeting the pre-hospital criteria.
The Emergency Department faculty will evaluate the patients immediately and determine the
following.

1. Pulselessness - if a pulse or any sign of life are detected, Trauma Alert Activation should
occur immediately.
2. Normothermic (T > 90 degrees F)

If all the above-mentioned physical findings are verified, the patient will be pronounced DOA
and no further resuscitation activity should ensue.

The ED Faculty should ensure completion of the Trauma Admission Form in its entirety,
completing under diagnosis ―Patient pronounced DOA‖ and noting any injuries diagnosed by
gross physical examination (e.g., femur fracture, penetrating head injury, etc.).

The pink copy of the Trauma Admission Form will be forwarded to the Trauma Coordinator for
entry into the Trauma Registry. The original copy will become part of the patient’s permanent
medical record.

References:
American College of Surgeons’ Committee on Trauma: Advanced Trauma Life Support, ed.8,
Chicago, 2008, The College.

Committee on Trauma: Resources for Optimal Care of the Injured Patient 2006. Chicago, 2006,
American College of Surgeons.
Revised 11/08

46
Revised 11/08

EMERGENCY DEPARTMENT RESUSCITATIVE THORACOTOMY

Purpose:
Emergency Department resuscitative thoracotomy may be necessary to salvage patients who
present in extremis and may otherwise die without aggressive therapy. Emergency Department
thoracotomy is not indicated in the resuscitation of all trauma patients who present in extremis.
The following protocol is intended to be a guide and is not intended to be all-inclusive or
exclusive. Additional patients not covered by this protocol who might benefit from Emergency
Department thoracotomy will be rare and case-specific. The procedure is performed in
conjunction with other resuscitative efforts and should not be employed in isolation. Under
certain conditions, resuscitative efforts might best be accomplished in the Operating Room. An
Emergency Department resuscitative thoracotomy should only be performed by general surgery
PGY-3, or higher, level residents or attendings.

Indications:

1) Penetrating thoracic trauma that arrive pulseless, with signs of life.

2) Penetrating non-thoracic, non-cranial trauma that arrive pulseless, with signs of
life.
3) Cardiac arrest in blunt chest or abdominal trauma after arrival in Emergency
Department with an obtainable blood pressure.
4) Suspected systemic air embolism.

Definitions:

1) Signs of life: reactive pupils, spontaneous movement, or organized ECG activity.

2) Aggressive fluid resuscitation: Packed RBC 2 units or Lactated Ringers 2 liters or
equivalent volume over 15 minutes.

Procedure:

1) Rapid bilateral antero-lateral Betadine or Chlorahexidine prep while thoracotomy

tray opened. Thoracotomy trays are located in Trauma Bay Omni cells.
2) Left antero-lateral thoracotomy incision located beneath nipple in males and in
inferior breast fold in females. Incision extends from left sternal border to anterior
border of latissimus dorsi and chest entered along the superior aspect of fourth
or fifth rib. Care must be taken to avoid injury to heart and lung. A right antero-
lateral thoracotomy may be preferred for primary right chest wounds.
3) Insert rib spreader with handle located toward table laterally.
4) Examine pericardium, if tense hemopericardium present (pericardium distended
with maroon discoloration) then proceed to step 7.
5) If systemic air embolism is suspected or massive hemorrhage from lung
parenchyma or hilum is present, then place Satinsky clamp across hilum
medially.
6) Retract left lung with left hand. Locate aorta by running right hand medically
along posterior chest wall. Aorta located along lateral aspect of vertebral bodies

47
 and will be postero-lateral to esophagus. Dissect around aorta inferior to
pulmonary hilum and apply aortic cross-clamp.
7) Enter pericardium by longitudinally incising pericardium anterior and parallel to
phrenic nerve. This is best accomplished by grasping pericardium with forceps
and cutting with Metzenbaum scissors. Pericardial incision is carried inferiorly to
diaphragmatic reflection and superiorly to level of superior pulmonary hilum. Care
must be taken to avoid injury to left atrial appendage and phrenic nerve. This is
best accomplished by lifting tip of scissors laterally as incision is made.
8) Manually lift heart from pericardial sac. If hemopericardium present, then
examine for cardiac perforation. Teflon pledgetted 3-0 prolene suture on a taper
needle is present in thoracotomy suture pack for repair of cardiovascular
wounds. If hemopericardium is not present, then begin open cardiac
compression. Aortic cross-clamping, if not previously performed, is indicated if no
hemodynamic response is noted.
9) Additional exposure may be accomplished by extending thoracotomy incision
across sternum into contralateral chest cavity.

Reference:

American College of Surgeons’ Committee on Trauma: Advanced Trauma Life Support,

ed.8, Chicago, 2008, The College.

Powell DW, Moore EE et al. Is emergency department resuscitative thoracotomy futile

care for the critically injured patient requiring prehospital cardiopulmonary resuscitation?
J Am Coll Surg. 2004 Aug; 199(2):211-5.

48
EMERGENCY DEPARTMENT TRAUMA THORACOTOMY TRAYS

TRAY #1

QUANTITY INSTRUMENT
1 - Finochietto – Buford Rib Spreader (10‖ Spread)
1 - Tuffier Rib Spreader
1 - 6 ¾‖ Curved Mayo Scissors
2 - 9‖ Metzenbaum Scissors
1 - #10 Disposable Blade
2 - 5 ½‖ Tissue Forceps
2 - 9‖ DeBakey Forceps
2 - 8‖ DeBakey Needle holders
4 - Vanderbilt Clamps
1 - Medium Satinsky Clamp
1 - 9 ½‖ DeBakey Aortic Clamp
8 - 5 ¼‖ Towel Clamps
1 - Liston Bone Cutter Straight
1 - Lebsche Sternal Chisel
1 - Hammer
4 - Surgeons Towels
1 - Teflon Sheet 6‖ x 6‖
10 - Laparotomy Pads

SUTURE BAG

QUANTITY SUTURE PRODUCT NUMBER

2 pkgs 2-0 Silk (SH-CR) 30‖ Ethicon #C01 6T
1 pkg Cotton Umbilical Tape 30‖ Ethicon #U-11 T
1 pkg Teflon Felt Pledgets ¼‖ Deknatel #K-705
1 pkg Teflon Felt Pledgets‖ Deknatel #L-705
6 pkgs 3-0 Prolene (SH) 36‖ Ethicon #8522H
4 pkgs 3-0 Prolene (SH)
with Teflon Pledgets
4 pkgs 4-0 Prolene (RB-1) 36‖ Ethicon #8557H
10 pkgs 2-0 Ticron (T-10) 30‖ D & G #3174-51

49
 RSI INTUBATION
Julia E. Martin M.D.
Assistant Professor
Department of Emergency Medicine

General information:

Airway control is always the most important objective in the initial resuscitation and stabilization.
It takes the highest priority in primary assessment. The trauma team must be prepared for any
airway emergency.

RSI involves the use of neuromuscular blocking agents and sedatives to facilitate endotracheal
intubation. Rapid Sequence induction technique is used to prevent regurgitation and aspiration
of gastric contents. Requires preoxygenation and denitrogenation by using 100% oxygen via
non-rebreather face mask to prevent apnea related hypoxia during the procedure. Once
paralytic is on board, mask ventilation is not attempted at this point. During induction, a skilled
assistant provides manual in-line axial stabilization of the head while a second assistant presses
the cricoid cartilage to prevent gastric aspiration. Cricoid pressure is maintained until the cuff on
the ET tube is inflated and tube placement is confirmed. Main disadvantage is once anesthesia
has been induced there is no turning back. The only contraindication to RSI intubation is a
practitioner who is not skilled in airway management. Indication for surgical airway is the
inability to intubate the trachea. In neck trauma, intubation may be difficult or impossible and
surgical airway may be required.

Short acting agents are used to allow patient to resume spontaneous respirations and to allow
close monitoring of neurological status. Oral endotracheal intubation is usually the preferred
method. If the head and neck are stabilized by an assistant there is almost no risk of spinal
cord injury by oral tracheal intubation.

Always anticipate vomiting. Even patients, who otherwise seem relatively unresponsive, may
vomit during attempted intubation without RSI. This may result in loss of airway control and
aspiration of gastric contents. Struggling patients increase muscle activity making hypoxemia
worse and increase ICP. As a general rule, presume all trauma patient’s have just eaten. Risk
for aspiration is greatest during anesthesia induction and instrumentation of the upper airway.
This risk is minimized by applying cricoid pressure.

Patients with severe closed head injury are of major concern because intracranial pressure can
rise precipitously during intubation. Rapid sequence induction of anesthesia and oral intubation
are now recommended for patients with head injuries to minimize the rise in ICP.

Remember, rendering patient apneic, when endotracheal intubation is beyond the skill of the
operator, may be rapidly fatal.

Indication for RSI Endotracheal Intubation of the Acute Trauma Patient:

Trauma patients with GCS < 8

Significant facial trauma with poor airway control
Airway obstruction
Closed head injury or hemorrhagic CVA

50
 Burn patients with airway involvement and inevitable airway loss
Class 3-4 hemorrhagic shock
Failure to maintain adequate oxygenation (PaO2 < 60 despite 100% FiO2)
Paralysis due to high spinal cord injury
Need for positive pressure ventilation
Blunt chest trauma with compromised ventilatory effort
Mandibular fractures with loss of airway muscular support

Evaluation:

―Talking patient‖ usually indicates airway is patient for the moment.

Respiratory distress associated with trauma to the upper airway is frequently made worse by
blood or gastric contents in the airway and requires prompt action. These patients are often
combative because of hypoxia.

When evaluating an awake patient with severe facial trauma ask them if they are getting enough
air. If they cannot answer, stick out their tongues fairly easily or are hyperventilating, they
should probably be intubated. In unconscious patients, it is probably best to intubate.

Tachypnea may be subtle but an early sign of airway or ventilatory compromise. Tachypnea is
often also associated with pain and/or anxiety.

Agitated and combative patients that are not hypoxic or have a significant head injury are better
managed with Haldol 5-10 mg.

Signs of Airway Obstruction:

Agitation = hypoxia
Obtudation = suggests hypercarbia
Cyanosis = hypoxia
Retractions and use of accessory muscles
Snoring, gurgling, stridor = partial obstruction at pharynx
Hoarseness = laryngeal obstruction

DRUGS:

Sedatives:
Versed:
Benzodiazepine
Rapid onset (1-2 min) and short duration (20 min)
Amnesic
Anticonvulsant
Muscle relaxant
Slight decrease in blood pressure and increase in pulse rate.
No increase in ICP.
Dose: 0.1 mg/kg

Etomidate:
Nonbarbiturate, nonnarcotic sedative-hypnotic induction agent.

51
 Good agent in multisystem trauma patient because it evokes minimal change in
HR and CO compared to Thiopental. (ideal agent in any patient in shock
including cardiogenic and septic shock)
Decreases ICP and IOP during procedure
Rapid onset (<1 min) and short acting (5 min)
Vomiting, esp. with combined with a narcotic
Dose: 0.3 mg/kg

Thiopental:
Ultrashort acting barbiturate sedative
Dose: 3-5 mg/kg
Onset 30-40 sec
Last 10 min.
Does not cause increase in ICP but can cause severe hypotension, therefore
avoid in multi-traumatized patients.
Can also induce bronchospasm.

Fentanyl:
Narcotic
Little or no histamine release
Rarely causes hypotension
Consider in head-injured patients as a premedication to prevent increase in ICP
(blunts pressor response)
Rapid injection may cause chest wall rigidity.
Dose: 3-5 mcg/kg
Onset in 2 min with 30-40 min duration.

Paralytic Agents:
Vecuronium:
Nondepolarizing agent
1/3 more potent and pancuronium and duration of action is 1/3 to ½ as long (25-
40 min vs Pancuronium which last 2-3 hours)
Onset 2-3 minutes
Dose not cause the degree of tachycardia seen with pancuronium.
No histamine release.
Defasciculating dose: 0.01 mg/kg
Paralytic dose: 0.1 mg/kg

Succinylcholine:
Depolarizing agent, which causes muscle fasciculations which can be prevented
by pretreatment with a non-depolarizing neuromuscular agent.
Rapid onset (30-60sec) with short duration of action (5-7 min).
Dose:
Adult: 1.5 mg/kg
Pediatric (<10 y.o): 2.0 mg/kg
Contraindications:
Burns > 7 days old
Extensive crush injuries > 7 days old.
Paraplegia > 7 days old.
Narrow-angle glaucoma

52
 Neuromuscular Diseases:
Guillain-Barre, myasthenia gravis, Multiple sclerosis, muscular
dystrophy, Parkinson’s disease.
Others susceptible to increased potassium:
Renal failure (no real evidence that RSI increases K+)
Rhabdomyolysis

Rocuronium:
Non-depolarizing agent
Onset < 1 min.
Duration 20-30 min.
Dose: 0.9-1.2 mg/kg
Expensive

Adjunctive:

Atropine:
Succinylcholine will cause bradycardia in infants and children therefore they
should be premedicated with atropine. Also pretreat any adult who is already
bradycardic.
Children < 8 y.o.
Dose: 0.01 mg/kg up to 0.5 mg (minimum dose of 0.1 mg)

Lidocaine:
Dose: 1.5 mg/kg
Some studies recommend intravenous Lidocaine to blunt the pressor response of
increased pulse, increased blood pressure, increased intracranial pressure,
and increased intraocular pressure associated with intubation, its
usefulness is controversial. However, because a single dose of lidocaine is
unlikely to cause harm, it seems reasonable to use in the patient who has a
known or suspected head injury.
Should be administered 2-3 min prior to intubation.

Procedure:
The 5 P’s of rapid sequence intubation:
Preparation
Preoxygenation
Pretreatment
Paralysis (with anesthesia)
Placement (of the endotracheal tube)

1. Preoxygenation with 100% oxygen for 3-5 minutes via NRB mask (or 3 vital capacity
breaths, avoid BVM if possible).
2. Secure IV’s, ECG, pulse oximeter.
3. Prepare intubation equipment: ETT with stylet, suction, BVM, laryngoscope.
4. Premedication:
Lidocaine (head injury) 1.5 mg/Kg
Vecuronium (defasciculating dose) 0.01 mg/Kg
Versed 0.1 mg/Kg
Atropine (peds) 0.01 mg/Kg
Etomidate 0.3 mg/Kg

53
5. Perform Sellick’s maneuver, maintain maneuver until after confirmation of tube placement.
6. Succinylcholine 1.5 mg/Kg (Peds: 2.0 mg/Kg)
7. Wait 30-60 sec, place ETT.
8. Confirm ETT placement by: listening for bilateral breath sounds, chest rise and fall, tube
fogging, & positive ETCO2. Final confirmation by CXR.
9. Release Sellick maneuver.
10. Secure ETT.

Basic RSI
Time (min)
-5.00 Preparation and Preoxygenation

-2.00 Administer Vecuronium 0.01 mg/kg IV

Lidocaine 1.5 mg/kg IV
(Fentanyl 3 mcg/kg IV)
(Atropine 0.01 mg/kg in kids < 10)

-1.00 Apply cricoid pressure and in-line cervical stabilization

-1.00 Administer Versed 0.1 mg/kg IV

or Etomidate 0.3 mg/kg IV

-55 sec Administer Succinylcholine 1.5 mg/kg IV (2mg/kg if <10 y.o.)

Intubate

RSI without Succinylcholine

Time (min)
-5.00 Preparation and Preoxygenation

-4.45 Lidocaine 1.5 mg/kg IV

(Fentanyl 3 mcg/kg IV)
(Atropine 0.01 mg/kg in kids < 10)

-4.45 Apply cricoid pressure and in-line cervical stabilization

-3.00 Administer Versed 0.1 mg/kg IV

or Etomidate 0.3 mg/kg IV

-2.45 Administer Rocuronium 0.9-1.2 mg/kg

Intubate

54
References:

Wilson R, Walt A. Anesthesia for the Trauma Patient. Management of Trauma pitfalls and
Practice, 2nd edition. Baltimore: Williams & Wilkins; 1996: 85-90,249-250.

American College of Surgeons. Airway Management. Advance Trauma Life Support. American
College of Surgeons; 1993:47-59.

Tintinalli J, Ruiz E, Krome R. Advanced Airway Support. Emergency Medicine a Comprehensive

Study Guide, 4th edition. New York: McGraw-Hill; 1996: 46-50.

Walker L. Using Rapid Sequence Induction to Facilitate Tracheal Intubation. Emergency

Medicine Reports. 1993;15:125-131.

Hardwood-Nuss A. Trauma Airway Management. The Clinical Practice of Emergency Medicine,

2nd edition. Philadelphia: Lippincott-Raven; 1996: 381-382.

55
56
 Initial Management of Head Injuries

Brain injury is the most common cause of death in trauma. Brain injury is divided into primary
and secondary forms. Primary brain injury, which occurs immediately upon impact, can be
reduced only through prevention initiatives. Secondary brain injury, which ensues within hours
to days later, results from a cascade of cellular events (intracellular calcium, cell membrane
permeability changes, depletion of cellular energy, free radical generation, cell signaling
molecules) that harms or even destroys neuronal tissue in and around the site of the primary
injury.

Secondary injury is exacerbated by 4 major factors: hypoxia, hypotension, hypercarbia and

intracranial hypertension. Additional factors which also affect secondary brain injury include:
hypocapnea, hyperthermia, glucose imbalance, acute hypo-osmolarity, electrolyte imbalance,
anemia, acid-base disorders and coagulopathy. Since secondary brain injury is a major
contributor to brain injury mortality and has a negative effect on neurologic outcome, clinicians
must work diligently to identify and treat causative factors. Airway maintenance, ventilation, CO2
control and restoration of circulating volume using isotonic fluid are essential initial treatments.
SBP < 90 and SaO2 < 90% must be strictly avoided in head-injured patients.

Intracranial pressure (ICP) elevations cannot be predicted by CT scan. ICP monitoring is

indicated in salvageable patients with GCS ≤ 8 and an abnormal CT scan. Some evidence also
suggests ICP monitoring is indicated in patients with a normal CT if GCS ≤ 8 and age > 40, SBP
< 90 or bi- or uni-lateral posturing. Though older devices were subarachnoid, subdural or
epiduraI, modern ICP monitors are intraparenchymal or intraventricular. ICP monitoring guides
therapy, and if an intraventricular catheter is in place, permits drainage. ICP monitoring also
predicts outcome, as patients who respond the therapy for intracranial hypertension have a
more favorable outcome.

Normal ICP is 0-15mmHg. Therapy should be initiated to lower ICP when it reaches 20mmHg.
More important than ICP is cerebral perfusion pressure (CPP), the difference between MAP and
ICP (CPP=MAP-ICP). CPP < 50mmHg must be strictly avoided and recommended CPP is 50-
70mmHg, though optimal CPP is unproven. CPP may be increased by lowering ICP or by
raising MAP.

ICP may be lowered by removal of noxious stimuli and adequate sedation. Morphine is sedative
and analgesic without increasing ICP. Midazolam may reduce MAP and raise ICP. Propofol is
the recommended sedative agent in brain injured patients because it lowers ICP. MAP can be
increased by use of alpha-adrenergic agents.

Alternative measures for brain oxygenation include jugular venous oxygen saturation (SjO2) and
brain tissue partial pressure of oxygen (PbrO2). If measured, interventions to increase cerebral
oxygenation when SjO2 drops below 50% and/or PbrO2 drops below 15mmHg.

Mannitol is a hyperosmolar plasma expander that also functions as an osmotic diuretic. Mannitol
expands plasma volume, reduces blood viscosity, increases cerebral blood flow and oxygen
delivery and because of its osmotic effects may reduce brain water and secondary brain injury.
Mannitol (0.25g-1g/kg) can be used to lower ICP based upon clinical signs alone (herniation or
progressive neurologic decline) or ICP monitoring. Clinicians must maintain adequate
intravascular volume in the face of mannitol therapy.

57
Hyperventilation has theoretical benefits in lowering pCO2 and thus cerebral blood volume which
lowers ICP. Hypocapnea can, however, produce cerebral ischemia and recent data indicate that
hypocapnea may be more harmful than hypercapnea. Moreover, prolonged hyperventilation is
probably ineffective because adaptation occurs and cerebral blood flow returns to baseline.
Current guidelines for CO2 control are to achieve a pCO2=35 and avoid hyperventilation to pCO2
< 35 mmHg for the first 24 hours post-injury. Hyperventilation may be used as a temporizing
measure only in cases of refractory intracranial hypertension.

Additional treatments for severe traumatic brain injury include barbiturates which are
recommended for refractory intracranial hypertension in hemodynamically stable patients.
Hemodynamic instability and severe ileus are side effects of this therapy. Steroids are
contraindicated for the treatment of traumatic brain injury. Anticonvulsants (phenytoin) may be
used to prevent early post-traumatic seizures and therapy duration is ≈ 7 days. Prophylactic
antibiotics are not recommended for indwelling ICP monitors. DVT prophylaxis is recommended
in patients with TBI, with compression devices initially and progressing to anticoagulants as
neurosurgery indicates is appropriate.

Pre-Hospital:

Ensure patent airway while maintaining cervical spine precautions (endotracheal

intubation using RSI protocol) if necessary.

Ventilate patient with 100% oxygen. Keep PaO2 > 60mmHg (Sat >90%).

Keep ETCO2 30-35mmHg during transport.

Establish adequate IV access.

Maintain mean arterial pressure (MAP) >90.

Mannitol may be given with ingoing signs if neurologic deterioration:

 Motor score < 3

 Decreasing motor score
 Lateralizing motor findings
 Pupillary changes (dilation or sluggish reactivity)

Sedation/Neuromuscular blockade can be useful in optimizing transport of head injured

patient. Both treatments interfere with neurologic examination and should be avoided if
possible.

Reassess neurologic status frequently.

Transfer should not be delayed for diagnostic testing.

Steroids have not been found to be of benefit to the head-injured patient and are not
recommended as therapy for severe head injury.

Initial Resuscitation of the Head Injured Patient

58
Insure patent airway (endotracheal intubation is indicated in patients with GCS < 8).

Maintain cervical spine immobilization.

Maintain MAP > 90 throughout patient course in attempt to maintain cerebral perfusion
pressure (CPP) 50-70mmHg. Insure adequate volume repletion before adding
vasopressors (CVP >12).

Maintain adequate circulating volume:

o NS preferred
o Monitor for signs of Diabetes Insipidus
o Place Foley catheter

Prophylactic anti-convulsants may be indicated.

59
 Severe Head Injury Management Algorithm
(GCS < 8)

Neurologic assessment
(GCS < 8)

Established definitive airway

Obtain ABG BVD 100% O2 or Mechanical Ventilation

CT Head
(see protocol)

Maintain PCO2 30-35

IVF NS (preferred)

MAP > 90

Decompress stomach
(Place NG/OG)

Insert Foley

Agitated/ Monitor Urine Output Lateralizing signs

PIP > 40 neurologic deterioration

Yes No Mannitol
¼ gm – 1

gm/kg

Consider Hold sedation

Sedation/
NMBA Monitor UOP

60
 FACIAL BONE FRACTURE
EMERGENCY DEPARTMENT RADIOLOGIC ALGORITHM

Indications:
1. Obvious facial bone fracture or fracture suspected on physical exam.
2. Facial bone fracture detected on head CT.
3. Facial bone fracture detected on radiograph from referring facility.

Upper and Mid- Lower Face

face (Mandible)

Axial Spiral CT
3mm Slices
Coronal
Reconstructions*

Upper and Mid-face Lower Face (Mandible)

Optional† Optional§
Coronal face, 3mm Panorex
Coronal orbits, 2mm

*Axial spiral CT with 3mm slices provides sufficient detail for diagnosis and treatment planning
for facial fractures (forehead to mandible).

†These films are not often needed urgently and should be obtained at the request or discretion
of the maxillofacial trauma consultant.
Facial plain films are sometimes helpful for treatment planning.
While (formal) coronal CT is usually only needed when coronal reconstructions
do not provide adequate detail for surgical treatment planning, an urgent coronal
CT may sometimes be needed to resolve an equivocal CT with regards to optic
nerve integrity or compression.

§Mandibular Panorex is a useful study in patients who can sit upright and cooperate with the
exam. Thus Panorex is not often logistically obtainable in multi-trauma patients and axial CT
with coronal reconstructions, which provides satisfactory detail for treatment planning, is the
usual diagnostic of choice.

11/08

61
 SPINE CLEARANCE
Basic Principles

General
1. Entire spine is immobilized during primary survey.
2. Radiographic clearance of the spine is not required before emergent surgical
procedures. Presence of a spinal column injury is simply assumed until excluded.
3. Secondary and tertiary exams include examination of the spine for tenderness as well as
testing all motor roots, sensation and reflexes.
4. Tertiary exams are performed only on alert and unimpaired patient without distracting
injuries.
5. If any spine fractures are found, entire spine must be radiographed.
6. For patients with radiographic injury spine consultation requested for focused pre-
operative evaluation regarding relative instability and severity of injury prior to intubation.
7. Patients remain on spine precautions until spine is cleared.

Cervical
1. C-spines are not cleared until after the tertiary exam is completed.
2. Cervical CT scan is the preferred radiographic modality when physical exam is not
adequate.
3. With impaired or unconscious patient, rigid collars are taken off within 2 hours and
replaced with semi-rigid pressure reducing collar.
4. Enter patients in cervical algorithm for C-Spine clearance.

Thoraco-Lumbar
1. CT scan of thoracic and lumbar spines if there are clinical findings on secondary or
tertiary exams or an unreliable exam. Multi-detector CT-scan with reformatted axial
collimation is superior to plain films.
2. Radiographic Thoraco-Lumbar clearance is not needed prior to OR for non spine
surgery. Thoracic & Lumbar clearance may however be required for some non supine
positioning in the OR, depending upon acuity and case type.
3. Tertiary exam is necessary to clear thoracic and lumbar spines.

8/08

62
63
 Initial Management of Spinal Cord Injury

1. Priorities: Airway, Breathing & Circulation

2. Maintain complete spine immobilization using:
a. Semi-rigid cervical collar
b. Modified logroll – maintaining spine in neutral position at all times
c. Remove patient from long board within 2 hours.
3. *If patient is hypotensive – determine cause and treat hypovolemia with fluids and
definitive surgical intervention as directed.
4. If hypotension due to Neurogenic Shock confirmed, consider inotropic agents to maintain
blood pressure (MAP 60 – 70mmHg).
*Effort must be made to reduce secondary injury.
*Methyprednisolone use – insufficient evidence to support routine use
5. Patient should be removed from long spine board & placed on pressure reducing surface
within 2 hours of trauma room arrival.
6. Radiographic studies to determine location of injury include:
a. Plain films
b. Spiral CT scan
c. MRI
7. Determine if injury is complete or incomplete and fracture is stable or unstable.
8. Fully document complete neurological exam during secondary survey & prior to OR if
possible.
9. Document level of sensory and motor function using dermatomes.

10. Obtain Spine Surgery (Orthopedic or Neurosurgery) consult.

11. Place urinary catheter to monitor urinary output & prevent bladder distension.
12. Place gastric tube to prevent gastric distension & aspiration.
13. Physical Medicine and Rehab consult on admission to begin a timely transfer to Acute
Spinal Cord Injury Rehabilitation.
8/08

64
65
66
 Penetrating Neck Injury Evaluation and Treatment Algorithm
University of Kentucky Hospital Trauma Center

Overview
The neck is divided into zones:
Zone 1-Clavicles to cricoid cartilage
Zone 2-Cricoid to angles of the mandible
Zone 3-Angles of the mandible to skull base
Management of patients with penetrating wounds to the neck has historically been determined
by zone of injury. Because zones 1 and 3 are challenging to expose surgically, patients with
injuries in zones 1 and/or 3 warrant thorough diagnostics because non-therapeutic surgery in
these areas is both difficult and morbid. Zones 1 and 3 should be approached surgically only if
an injury is felt to be present. However, zone 2 of the neck is easily exposed surgically.
Controversy has existed as to whether patients with zone 2 injuries should undergo exhaustive
diagnostics to exclude or characterize injuries in this area, or simply undergo neck exploration
with limited or no preoperative evaluation of the esophagus and cervical vasculature
(esophagography or esophagoscopy or both plus angiography).

Recently published studies have changed the management of penetrating neck trauma in 2
important ways. First, evidence suggests that for patients with no clinical evidence of vascular
injury (shown on the algorithm as ―Mandatory Criteria for Neck Exploration‖) then physical
examination has 100% sensitivity, thus definitively excluding vascular injury without any
angiography. This is most true if the injury is to Zone 2. The second major advance in the care
of these patients has been the advent of helical CT angiography as an alternative to
conventional catheter-based angiography, producing equivalent results.

Furthermore, the anatomic detail provided by the neck CT may permit the clinician to exclude
injury to the esophagus if the CT clearly shows a missile trajectory remote from the esophagus.
However, the precise role that CT will play in excluding injury to the esophagus in these patients
remains to be established. If the CT does not conclusively exclude injury to the esophagus,
contrast esophagography and/or esophagoscopy (or both) should be performed.

Summary
1. CT scan of the neck including CT cervical angiography is the initial diagnostic of choice.
2. Some asymptomatic patients may avoid angiography entirely.
3. Esophageal injury must be definitively excluded, which may require esophagography or
esophagoscopy or both.

References regarding the utility of CT/CTA for evaluating penetrating neck injury:

1. Gracias VH, Reilly PM, Philpott J, Klein WP, Lee SY, Singer M, Schwab CW. Computed
tomography in the evaluation of penetrating neck trauma: a preliminary study. Arch Surg
2001;136: 1231-5.
2. Mazolewski PJ, Curry JD, Browder T, Fildes J. Computed tomographic scan can be
used for surgical decision making in zone II penetrating neck injuries. J Trauma
2001;51:315-9.
3. Múnera F, Soto JA, Palacio DM, Castañeda J, Morales C, Sanabria A, Gutiérrez JE,
García G. Penetrating neck injuries: helical CT angiography for initial evaluation.
Radiology 2002; 224:366-72.

67
 4. Fergusion E, Dennis JW, Vu JH, Frykberg ER. Redefining the role of arterial imaging in
the management of penetrating zone 3 neck injuries. Vascular. May-jun 2005;13(3):158-
63. [Medline].

References demonstrating the diagnostic accuracy of physical exam for vascular injuries in
Zone II requiring intervention:

1. Nason RW, Assuras GN, Gray PR, Lipschitz J, Burns CM. Penetrating neck injuries:
analysis of experience from a Canadian trauma centre. Can J Surg 2001;44:122-6.
2. Sriussadaporn S, Pak-Art R, Tharavej C, Sirichindakul B, Chiamananthapong S. Selective
management of penetrating neck injuries based on clinical presentations is safe and
practical. Int Surg 2001;86:90-3.
3. Azuaje RE, Jacobson LE, Glover J, Gomez GA, Rodman GH Jr, Broadie TA, Simons
CJ, Bjerke HS. Reliability of physical examination as a predictor of vascular injury after
penetrating neck trauma. Am Surg 2003;69:804-7.
4. Osborn TM, Bell RB, Qaisi W, Long WB. Computed tomographic angiography as an aid
to clinical decision making in the selective management of penetrating injuries to the
nec: a reduction in the need for operative exploration. J Trauma. Jun 2008;64(6):1466-
71. [Medline].

68
69
 Blunt Cardiac Injury (BCI)

Blunt cardiac injury (BCI), formerly called myocardial contusion, encompasses a spectrum of
disease ranging from histologic injury to the myocardium without clinical manifestation to blunt
cardiac rupture.1 BCI contributes to 20% of prehospital deaths from blunt trauma.2 An exact
incidence of BCI does not exist because there is no ―gold standard‖ for diagnosis, i.e., the
available data are conflicting with regard to how the diagnosis should be made (ECG,
echocardiography, enzyme analysis, etc). This lack of a diagnostic standard makes the
literature difficult to interpret and leads to confusion in clinical practice.

The major priority is identification of patients at risk for adverse events resulting from BCI and
providing appropriate workup, monitoring and treatment. Conversely, patients not at risk can
potentially be discharged home. Patients with appropriate mechanism of injury and clinical
evidence of cardiac dysfunction (electrophysiologic or mechanical) can be considered to have
BCI.

BCI results from 5 possible mechanisms: direct pre-cordial impact, crush between sternum and
spine, deceleration or torsion causing a tear in the heart at a point of fixation, hydraulic effect
resulting in rupture from elevated intra-abdominal and caval pressure, and blast injury.3 Few
clinical signs are diagnostic of BCI. Chest pain is the most common finding, but dyspnea, chest
wall ecchymosis and rib fractures may also be present. Associated injuries include hemothorax,
sternal fracture and great vessel injury. Clinical signs consistent with BCI include dysrhythmias,
cardiac ischemia, low cardiac output and hypotension.4

Diagnostic tests include ECG, echocardiography, and enzyme analysis. Controversy exists
regarding the application of these tests. Frequency of diagnosis of BCI will be proportional to the
aggressiveness with which it is sought. Appropriate workup commands achieving a balance
between cost-effectiveness and information acquisition with attention to the clinical value of
information gained in changing patient management. Guidelines for using diagnostic tests are
as follows:

A. Level 1 evidence supports obtaining an ECG in the emergency department for at-risk
patients (described above).5 Using any ECG abnormality, including sinus tachycardia,
bradycardia conduction delays and PAC’s/PVC’s, the diagnostic sensitivity of ECG is
100%.6
B. Echocardiography is not effective as a screening tool and does not identify patients at
risk for complications.7 Transthoracic (TTE) or transesophageal echocardiography
(TEE) should be obtained in patients with evidence of hemodynamic instability or in
whom coincident coronary ischemia is suspected.
C. CK and CKMB fraction analysis is NOT indicated in suspected BCI because associated
skeletal and visceral injury creates serum CK abnormalities that contribute to an
unacceptable false-positive and negative rate.8 However, a body of evidence exists
suggesting some value to cardiac troponin I (cTnI) or troponin T (cTnT). That evidence
is as follows:
i. Diagnosis of BCI should not rely solely on cTnI or cTnT. ECG should be
included.
ii. Normal ECG and normal cTnI is 100% sensitive for BCI.9
iii. Abnormal ECG and abnormal cTnI is 100% specific for BCI.9
iv. cTnI is of little added benefit in patients with a markedly abnormal ECG
(diagnosis is already made).10

70
 v. Though the utility of cTnI in patients with normal ECG’s is limited, cTnI obtained
4-6 hours after the injury in patients with sinus tachycardia or non-specific EKC
changes or in older patients may give reassurance that the likelihood of BCI-
related complications is low. 10

References:

1. Mattox KL, Flint LM, Carrico CJ, Grover F, Meredith J, Morris J, et al. Blunt cardiac injury. J
Trauma 1992;33(5):649-50.
2. Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin 2004;20:57-70.
3. Fulda G, Brathwaite CE, Rodriguez A, Turney SZ, Dunham CM, Cowley RA. Blunt traumatic
rupture of the heart and pericardium: a ten-year experience (1979–1989). J Trauma
1991;31(2):167-73.
4. Miller FB, Shumate CR, Richardson JD. Myocardial contusion. When can the diagnosis be
eliminated? Arch Surg 1989;124(7):805-8.
5. Pasquale NK, Clarke J. Screening of blunt cardiac injury.1998. The Eastern Association for
the Surgery of Trauma. Available: [Link]
6. Fabian TC, Cicala RS, Croce MA, Westbrook LL, Coleman PA, Minard G, et al. A
prospective evaluation of myocardial contusion: correlation of significant arrhythmias and
cardiac output with CPK-MB measurements. J Trauma 1991;31(5):653-60.
7. Karalis DG, Victor MF, Davis GA, McAllister MP, Covalesky VA, Ross Jr JJ, et al. The role of
echocardiography in blunt chest trauma: a transthoracic and transesophageal
echocardiographic study. J Trauma 1994;36(1):53-8.
8. Fabian TC, Cicala RS, Croce MA, Westbrook LL, Coleman PA, Minard G, et al. A
prospective evaluation of myocardial contusion: correlation of significant arrhythmias and
cardiac output with CPK-MB measurements. J Trauma 1991;31(5):653-60.
9. Salim A, Velmahos GC, Jindal A, Chan L, Vassiliu P, Belzberg H, et al. Clinically significant
blunt cardiac trauma: role of serum Troponin levels combined with electrocardiographic
findings. J Trauma 2001;50(2):237-43.
10. Collins JN, Cole FJ, Weireter LJ, Riblet JL, Britt LD. The usefulness of serum Troponin
levels in evaluating cardiac injury [discussion]. Am Surg 2001;67(9):821-6.

Revised: 08/08

71
72
Revised 8/08
THE DIAGNOSIS OF BLUNT INJURY TO THE THORACIC AORTA
What diagnostic test is best?
Angiography, Transesophageal Echocardiography,
or Computerized Axial Tomography

Paul A. Kearney, M.D., F.A.C.S.

Associate Professor of Surgery
Chief, Section of Trauma and Critical Care
University of Kentucky Chandler Medical Center

Background
Blunt chest trauma with resulting aortic injury is a significant cause of death following high-
speed motor vehicle collisions.1-3 The vast majority of these patients (80%-90%) expire at the
collision scene.1-3 For the remaining 10%-20%, the mortality rate is high. Thirty percent expire
within 6 hours and 40%-50% within 24 hours of injury.1 The recent multicenter trial by the
American Association for the Surgery of Trauma reported an overall mortality of 31%, with 63%
of the deaths attributable to aortic rupture.4 Expeditious evaluation and timely surgical
intervention are essential for patient survival.

Screening
The goal of screening patients is to attain a zero nontherapeutic surgery rate without
overlooking any significant aortic or arch vessel injury. Mechanism of injury, clinical exam, and
the initial chest radiograph should reliably select patients who require further diagnostic
evaluation. Chest radiographs demonstrating mediastinal hematoma have good sensitivity
(93%) for aortic and arch vessel injury.5-7 When combined with mechanism of injury, sensitivity
rises to 98%.5 More importantly the negative predictive value of a normal upright chest
radiograph is almost 100%. A normal chest radiograph virtually excludes aortic and/or arch
vessel injury.5-7 Unfortunately, the specificity of an abnormal chest radiograph is only 10%-45%.
Since most mediastinal hematoma originates from thoracic vascular structures other than the
aorta, a definitive diagnostic test is required to establish the diagnosis of aortic injury.
Computerized axial tomography (CT) of the chest can be used to screen patients for
subsequent aortography.8-12 CT is more sensitive than chest radiograph in detecting mediastinal
hematoma.8,9 Screening thoracic CT is cost-effective and the negative predictive value of a
normal study is 100%.8-10 Consequently, CT can be used to reduce the negative aortogram rate
in patients with an abnormal chest radiograph.8-10

Diagnosis-Aortography
Many authors advocate the liberal use of aortography based on mechanism of injury and chest
radiographs.1,3,9,13 Using this approach, aortography yields positive results in only 10% of
patients. Although angiography remains the ―gold standard‖, the procedure is invasive and time
consuming, requires the use of intravenous contrast material and ionizing radiation, and can
result in false negative or false positive results.3,9,13,14 Transporting an injured patient to the
angiography suite is not without risk and interrupts the patient’s ongoing evaluation,
resuscitation, and treatment. On the other hand, when performed properly, aortography has a
sensitivity and specificity of 99%.9 Complications occur in less than 1% of patients.9

73
Aortography remains the only study that provides detailed images of the entire thoracic aorta
and the arch vessels.

Diagnosis-Transesophageal Echocardiography
Transesophageal echocardiography (TEE) provides high-resolution real-time axial and
longitudinal images of the aorta.14-18 TEE can accurately demonstrate injury to the thoracic
aorta.14-18 In our hands, TEE was more sensitive (100%) and specific (98%) than
aortography.14,15 TEE offers a number of advantages over aortography and CT scanning. The
study can be performed at the bedside, eliminating transport risks. Concomitant diagnostic and
therapeutic procedures can continue unhindered. TEE provides real-time images so that areas
of interest can be examined repeatedly in different planes. Simultaneous evaluation of cardiac
pathology and function can also be obtained. If urgent surgical intervention is indicated for other
injuries, TEE can be performed in the operating room without delaying TEE or the surgical
intervention. The study can be performed more rapidly than aortography making TEE ideal for
the evaluation of the unstable trauma patient with a number of diagnostic and treatment
priorities. Unfortunately, TEE requires the expertise of a well-trained and interested
echocardiographer. Airway compromise, esophageal pathology, and unstable cervical spine
fractures are contraindications to TEE. The depth and extent of injury are frequently difficult to
determine particularly when atherosclerotic disease diminishes the sensitivity of the
examination. In our experience, this has resulted in nontherapeutic thoracotomy.14 There are
blind spots related to the tracheal air column and the arch vessels simply cannot be imaged.

Diagnosis-Computerized Axial Tomography (CT)

CT scanning technology is advancing rapidly. Perhaps the most promising technology for a fast,
accurate, and less-invasive diagnostic test for detecting injuries to the thoracic aorta and arch
vessels is the newer generation helical CT scanner.9,19-21 Rather than providing indirect
evidence of aortic injury (detection of mediastinal hematoma), the helical scanners can provide
direct evidence of aortic injury obviating the need for confirmatory tests. Sensitivity, specificity,
and accuracy depend heavily on the technical skill of CT performance and the interpretative
expertise.9 Confirmatory angiography or TEE must be performed for indeterminate or equivocal
CT scan results. Although CT can be performed more rapidly than angiography, transport of the
injured patient to CT is not without risk and interrupts the patient’s ongoing evaluation,
resuscitation, and treatment.

Summary
Patients with suspected blunt injury to the thoracic aorta are a challenge for the trauma surgeon.
Multisystem trauma, critical illness, and hemodynamic instability in this patient group result in
diagnostic and treatment dilemmas. We employ a practical, evidence-based algorithm for the
screening and diagnosis of injury to the thoracic aorta. Both mechanism of injury and an
abnormal mediastinum on chest radiograph are required to trigger a diagnostic evaluation.
Every attempt is made to obtain an ―upright‖ AP chest radiograph to minimize distortion and
magnification. However, this is not possible in all patients. Widening of the mediastinum alone
is neither sensitive nor specific for mediastinal hematoma.5,6,7 Instead, we employ the criteria for
mediastinal hematoma (abnormal mediastinal silhouette) as defined by Mirvis and Ayella.6,7 No
further diagnostic evaluation is undertaken in patients with a normal chest radiograph, unless
there are compelling physical findings that suggest aortic or arch vessel injury (i.e. Pulse deficit,

74
unequal blood pressure/pulse measurement, unexplained hemodynamic instability, unexplained
neurologic deficit). Thoracic CT scan using the aortic protocol is performed. 9,19 A negative scan
yields observation. A scan positive for aortic injury prompts surgical intervention or appropriate
non-operative management. Patients with indeterminate scans undergo angiography or TEE to
establish or exclude the diagnosis.

REFERENCES:
1. Parmley LF, Mattingly TW, Manion WC, et al. Nonpenetrating traumatic injury of the
aorta. Circulation 1958;17:1086-1101.
2. Greendyke RM. Traumatic rupture of the aorta: special reference to automobile
accidents. JAMA 1966;195:527-530.
3. Culliford AT: Traumatic aortic rupture. In Hood RM, Boyd AD. Culliford AT (eds):
Thoracic Trauma. Philadelphia, WB Saunders, 1989, pp 224-244.
4. Fabian TC, Richardson JD, Croce MA, et al. Prospective study of blunt aortic injury:
multicenter trial of the American Association of the Surgery of Trauma. J Trauma 1997;
42:374-380.
5. Woodring JH. The normal mediastinum in blunt traumatic rupture of the thoracic aorta
and brachiocephalic arteries. J Emerg Med 1990;8:467-476.
6. Mirvis SE, Bidwell JK, Buddemeyer EU, et al. Imaging diagnosis of traumatic aortic
rupture: A review and experience at a major trauma center. Invest Radiol 1987;22:187-
190.
7. Ayella RJ, Hankins JR, Turney SZ, et al. Ruptured thoracic aorta due to blunt trauma. J
Trauma 1977;17:199-204.
8. Harris JH, Horowitz DR, Zelitt DL. Unenhanced dynamic mediastinal computed
tomography in the selection of patients requiring aortography for the detection of acute
traumatic aortic injury. Emerg Radiol 1995;2:67-76.
9. Patel NH, Stephens KE, Mirvis SE, et al. Imaging of acute thoracic aortic injury due to
blunt trauma: A review. Radiology 1998;209:335-348.
10. Mirvis SE, Shanmuganathan K, Miller BH, et al. Traumatic aortic injury: Diagnosis with
contrast-enhanced thoracic CT. Five year experience in a major trauma center.
Radiology 1996;200:413-422.
11. Demetriades D, Gomez H, Velmahos GC, et al. Routine helical computed tomographic
evaluation of the mediastinum in high-risk blunt trauma patients. Arch Surg
1998;133:1084-1088.
12. Dyer DS, Moore EE, Ilke DN, et al. Thoracic aortic injury: How predictive is mechanism
and is chest computed tomography a reliable screening tool? A prospective study of
1,561 patients. J of Trauma. 2000;48:673-683.
13. Kirsh MM, Behrendt DM, Orringer MB, et al. The treatment of acute traumatic rupture of
the aorta: A 10-year experience. Ann Surg 1976; 184:308-316.
14. Smith MD, Cassidy JM, Souther S, et al. Transesophageal echocardiography in the
diagnosis of traumatic rupture of the aorta. N Engl J Med 1995;332:356-362.
15. Buckmaster MJ, Kearney PA, Johnson SB, et al. Further experience with
transesophageal echocardiography in the evaluation of thoracic aortic injury. J of
Trauma 1994;37:989-995.
16. Vignon P, Gueret P, Vedrinne JM, et al. Role of transesophageal echocardiography in
the diagnosis and management of traumatic aortic disruption. Circulation 1995;92:2959-
2968.
17. Goarin JP, Catoire P, Jacquens Y, et al. Use of transesophageal echocardiography for
diagnosis of traumatic aortic injury. Chest 1997;112:71-80.
18. Mollod M, Felner JM. Transesophageal echocardiography in the evaluation of
cardiothoracic trauma. Am Heart J 1996;132:841-849.

75
19. Mirvis SE, Shannuganathan K, Buell J, Rodriquez A. Use of spiral computed
tomography for the assessment of blunt trauma patients with potential aortic injury. J of
Trauma 1998;45:922-930.
20. Gavant M. Helical CT grading of traumatic aortic injuries. Impact on clinical guidelines for
medical and surgical management. Rad Clinics of North America 1999;37:552-574.
21. Wicky S, Capasso P, Meuli R, et al. Spiral CT aortography: an efficient technique for
the diagnosis of traumatic aortic injury. European Radiology 1998;8:828-833.

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BLUNT THORACIC INJURY WITH SUSPECTED INJURY TO THE THORACIC AORTA OR
ARCH VESSELS

Patients who sustain blunt thoracic trauma are at risk for injury to the heart and great vessels.
Patients should be selected for additional diagnostic studies based on mechanism of injury and
evidence of mediastinal hematoma on chest radiograph. Every attempt is made to obtain an
―upright‖ AP chest radiograph to minimize distortion and magnification. However, this is not
possible in all patients. Widening of the mediastinum alone is neither sensitive nor specific for
mediastinal hematoma (5,6,7). Instead, we employ the criteria for mediastinal hematoma
(abnormal mediastinal silhouette) as defined by Mirvis and Ayella (6,7). No further diagnostic
evaluation is undertaken in patients with a normal chest radiograph, unless there are compelling
physical findings that suggest aortic or arch vessel injury (i.e. Pulse deficit, unequal blood
pressure/pulse measurement, unexplained hemodynamic instability, unexplained neurologic
deficit).

MECHANISM OF INJURY (History of significant deceleration)

1. High-speed MVC (>30-40mph)
2. Substantial vehicle deformity or associated fatalities
3. Unrestrained and/or ejection from vehicle
4. Pedestrian struck by vehicle
5. Falls > 10 feet
6. Hemodynamic instability

INJURY
1. Sternal and/or scapular fracture
2. Multiple rib fractures and/or flail chest

CHEST RADIOGRAPH (One or more of the following)

1. Upper mediastinal widening
2. Indistinct aortic contour
3. Obscuration of the aortopulmonary window
4. Widened left paraspinal stripe
5. Deviation of the NG tube or trachea to the right
6. Depression of the left mainstem bronchus
7. Left apical cap (apical capping)

* Isolated fractures of the first and second ribs without evidence of mediastinal hematoma do
not correlate with aortic or arch vessel injury and are not an indication for further imaging.

References:

1. Mirvis SE, Bidwell JK, Buddemeyer EU, et al. Imaging diagnosis of traumatic aortic
rupture: A review and experience at a major trauma center. Invest Radiol 1987;22:187-
190.
2. Ayella RJ, Hankins JR, Turney SZ, et al. Ruptured thoracic aorta due to blunt trauma. J
Trauma 1977;17:199-204.

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DIAGNOSTICS: ROLE OF DPL, CT, FAST (ultrasound)
05/08

The goal of the abdominal evaluation of multi-system trauma patients is the safe, accurate, and
timely determination of the presence or absence of intra-abdominal injury, particularly those
requiring surgical intervention. Physical examination can be unreliable in polytrauma patients,
particularly when the abdominal examination or the level of consciousness has been altered by
alcohol, drugs, central system trauma, or distracting pain. Diagnostic peritoneal lavage (DPL), CT
scan, and abdominal sonography (FAST) are the most frequently employed diagnostic studies
used for the abdominal examination of multi-system trauma patients. Each study has advantages
and disadvantages. The goal of this session is to integrate these complementary studies into a
rational diagnostic algorithm for the evaluation of the abdomen.

Introduced by Root et al. in 1965, DPL (Diagnostic Peritoneal Lavage) was the time-honored
standard for evaluation of the abdomen for many years. DPL is rapid (< 30 minutes) and safe (<
2% complication rate) with well-established standards for surgical intervention on the basis of cell
counts or the aspiration of free blood after lavage. Overall sensitivity is 98%, with a specificity of
98% and a diagnostic accuracy approaching 100%. The procedure is inexpensive and can be
performed at the bedside while other diagnostic and therapeutic interventions proceed. The
procedure is invasive. Previous abdominal surgery makes the procedure more difficult and may
enhance complications and diminish specificity. Pelvic fractures also diminish specificity.

DPL cannot evaluate extraperitoneal structures (thorax, retroperitoneum, and pelvis) and must be
supplemented with other diagnostic procedures. DPL is not organ specific. Therefore, a positive
study may lead to a non-therapeutic laparotomy for a trivial injury. In recent years, DPL has been
replaced by FAST in the unstable patient and has a limited role in the stable patient.

Abdominopelvic CT scanning for blunt abdominal trauma was introduced by Federle et al. in the
early 1980s and has gained wide popularity in the United States. CT scanning has a sensitivity of
96%, a specificity of 98%, and an accuracy of 97%. CT is organ specific, allowing the
identification and grading of injured organs and the quantification of intraperitoneal fluid or blood.
This allows for non-operative management of stable patients, thereby reducing the rate of non-
therapeutic laparotomy. Extraperitoneal injuries (thorax, retroperitoneum, and pelvis) can be
identified and graded. CT scanning is relatively expensive. Sensitivity and specificity depend on
quality of the scan and skill of the interpreter. Contrast aspiration and allergy may occur. Bowel
and pancreatic injuries may be missed. Even with the new, more rapid scanners, CT is time
consuming, and transport to the scanner interrupts other diagnostic and therapeutic interventions.
Consequently, CT is limited to hemodynamically stable patients. CT scan is the mainstay in the
abdominal evaluation of the stable blunt trauma victim. CT now has a role to play in the
evaluation of penetrating torso injury.

The use of ultrasound or FAST (Focused Assessment with Sonography in Trauma) in abdominal
trauma first evolved in Germany. FAST has been employed successfully at trauma centers in the
United States for over a decade. US is noninvasive, rapid (2 to 4 minutes), and relatively
inexpensive. The examination can be performed at the bedside, does not interfere with other
diagnostic and therapeutic interventions, and can be repeated as needed. The primary goal of
FAST is to detect free fluid in Morison’s Pouch, the pelvis, peri-splenic region and the
pericardium. The sensitivity of FAST ranges from 80% to 100%; the specificity, from 89% to
100%; and the accuracy, from 86% to 99%. Extraperitoneal structures can be imaged (thorax,
pericardium, retroperitoneum). The technique can be easily learned and performed by the

81
treating surgeon. Sensitivity, specificity, and accuracy of US clearly improve with experience.
Although extremely sensitive for peritoneal fluid, US is much less sensitive for specific organ
injury (liver, spleen, etc.). As is true of CT, US can miss bowel injuries. However, repeat
examinations mitigate the latter weakness, and organ-specific diagnostic sensitivity improves with
the experience of the examiner. Sensitivity, specificity, and accuracy also depend on image
quality. Obesity, bowel gas, and subcutaneous emphysema interfere with imaging.

References
1. Root HD, Hauser CW, McKinley CR, et al. Diagnostic peritoneal lavage. Surgery
1965;57:633-637.
2. Federle MP, Goldberg HI, Kaiser JA, et al. Evaluation of abdominal trauma by
computed tomography. Radiology 1981;138:637-644.
4. Kearney PA, Vahey T, Burney RE, et al. Computed tomography and diagnostic
peritoneal lavage in blunt abdominal trauma. Their combined role. Arch Surg
1989;124:344-347.
5. Hoffman R, Nerlich M, Muggia-Sullam M, et al. Blunt abdominal trauma in
cases of multiple trauma evaluated by ultrasonography: a prospective analysis
of 291 patients. J Trauma 1992;22:452-458.
6. Goletti O, Ghiselli G, Lippolis PV, et al. The role of ultrasonography in blunt
abdominal trauma: results in 250 consecutive cases. J Trauma 1994;36:178-181.
7. Forster R, Pillasch J, Zielke A, et al. Ultrasonography in blunt abdominal trauma:
influence of the investigator experience. J Trauma 1992;34:264-269.
8. Liu M, Lee CH, P’eng FK. Prospective comparison of diagnostic peritoneal
lavage, computed tomographic scanning, and ultrasonography for the diagnosis
of blunt abdominal trauma. J Trauma 1993;35:267-270.
9. Rozycki GS, Ochsner MG, Jaffin JH, et al. Prospective evaluation of surgeons’
use of ultrasound in the evaluation of trauma patients. J Trauma 1993;34:516-
527.
10. McKenney M, Lentz K, Nunez D, et al. Can ultrasound replace diagnostic
peritoneal lavage in the assessment of blunt trauma? J Trauma 1994;37:439-441.

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Genitourinary Trauma
5/08

Trauma to the GU tract is present in approximately 10% of all injuries. The following discussion
pertains to the evaluation and management of the stable patient.

Work-up of GU trauma begins with assessment of the urethra. Injuries of the female urethra are
rare. Urethral injuries are usually due to blunt trauma associated with pelvic fracture or
straddle-type injuries. The primary posterior site of urethral injury is the prostatomembranous
junction. The primary anterior urethral injuries are most commonly caused by straddle-type
injuries or perineal trauma. The location of injury is typically the bulbar urethra. Physical finding
of blood at the meatus, perineal hematoma or extensive laceration, a high riding prostate, or a
large hematoma found on rectal exam mandates a retrograde urethrogram prior to insertion of a
Foley catheter. Management requires suprapubic urinary diversion or endoscopic assisted
placement of Foley catheter.

Once urethral injury is ruled out, a Foley catheter should be inserted. It is essential to document
the color of the urine, as gross hematuria mandates further workup of the GU tract. Evidence
suggests the microscopic hematuria is not diagnostic for GU trauma and as such a urinalysis
should not be part of the workup.

If there is gross hematuria, evaluation of the remainder of the GU tract – kidneys, ureters (in
penetrating trauma), and bladder needs to be performed. This can be accomplished by various
imaging techniques. However, with the advancement of the CT technology, it has evolved to
become the standard of care. Therefore, for gross hematuria, a CT scan of the abdomen and
pelvis to evaluate the kidneys, as well as CT cystogram should be obtained.

The kidneys are the most commonly injured organs in the GU tract. Management depends on
hemodynamic stability and the grade of injury by CT scan. Most renal injuries do not require an
operation in a stable patient. However, incidental intra-operative finding of perinephric
hematoma should be explored if the mechanism is penetrating trauma.

A blunt ureteral injury is a case report! Most ureteral injuries are penetrating. They require
surgical intervention. Basic principles of ureteral reconstruction include debridement of
devitalized tissue, followed by tension-free anastomosis with absorbable suture in a spatulated
fashion over a double J stent.

Bladder ruptures can result from penetrating or blunt trauma. Extraperitoneal bladder rupture is
commonly associated with pelvic fracture; and intraperitoneal bladder rupture is a result of blunt
lower abdominal force on a full bladder. Classic physical findings of bladder rupture include
suprapubic pain, hematuria, and inability to void. A CT cystogram should be obtained.
Extraperitoneal bladder rupture is generally managed with Foley catheter drainage, and
intraperitoneal bladder rupture requires immediate surgical intervention.

85
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Traumatic Peripheral Vascular Injury

Any injured extremity should be thoroughly evaluated for a possible vascular injury. The
presence of obvious arterial injury from a blunt and/or penetrating mechanism rarely requires
imaging and should not delay emergent operative exploration. The presence of ―hard signs‖
strongly supports vascular injury and typically necessitates emergent repair. These ―hard signs‖
are:

1. Bruit/Thrill
2. Active/Pulsatile hemorrhage
3. Pulsatile/Expanding hematoma
4. Signs of limb ischemia and or compartment syndrome including the 5 "P's" - pallor,
paresthesias, pulse deficit, paralysis, and pain on passive extension of the compartment
(pain on passive extension is the earliest and most sensitive physical finding)
5. Diminished or absent pulses with + Doppler signals (this is not a sensitive prognostic
finding, as up to 30% of patients with major vascular injuries requiring repair have
normal pulses or Doppler signals distal to the injury due to collateral flow) [1]

The Arterial Perfusion Index, API, is a validated tool for screening for peripheral vascular
injury[2]. This is performed by placing a blood pressure cuff above the ankle or on the bicep of
the limb of concern. The systolic pressure is determined with a Doppler probe at the dorsalis
pedis or brachial artery. Repeat this procedure on the ipsilateral uninjured limb. The API is
calculated by dividing the systolic pressure in the injured limb by the systolic pressure in the
uninjured limb. An API < 0.9 has a sensitivity of 95% and specificity of 97% for a major arterial
extremity injury. In a study on blunt orthopedic extremity injuries the negative predictive value is
100% for an API > 0.9 to exclude an arterial injury.[3-5]

The purpose of these algorithms is to diagnose the occult injury early before irreversible tissue
ischemia is present. In patients where the ―hard‖ signs are NOT present it is imperative to
maintain a high suspicion of peripheral vascular injury in the injured extremity [2, 6, 7]. If ―hard
signs― are not present but peripheral vascular injury is suspected then expedient consultation
with Vascular Surgery is indicated and the use of imaging, per Vascular Surgery, should be
liberal to avoid missed injuries.

References:
1. Drapanas, T., et al., Civilian vascular injuries: a critical appraisal of three decades of
management. Ann Surg, 1970. 172(3): p. 351-60.
2. Bravman, J.T., et al., Vascular injuries after minor blunt upper extremity trauma - pitfalls
in the recognition and diagnosis of potential "near miss" injuries. Scand J Trauma
Resusc Emerg Med, 2008. 16(1): p. 16.
3. Mills, W.J., D.P. Barei, and P. McNair, The value of the ankle-brachial index for
diagnosing arterial injury after knee dislocation: a prospective study. J Trauma, 2004.
56(6): p. 1261-5.
4. Lynch, K. and K. Johansen, Can Doppler pressure measurement replace "exclusion"
arteriography in the diagnosis of occult extremity arterial trauma? Ann Surg, 1991.
214(6): p. 737-41.
5. Johansen, K., et al., Non-invasive vascular tests reliably exclude occult arterial trauma in
injured extremities. J Trauma, 1991. 31(4): p. 515-9; discussion 519-22.
6. Dennis, J.W., et al., Validation of nonoperative management of occult vascular injuries
and accuracy of physical examination alone in penetrating extremity trauma: 5- to 10-
year follow-up. J Trauma, 1998. 44(2): p. 243-52; discussion 242-3.

89
7. Gelberman, R.H., J. Menon, and A. Fronek, The peripheral pulse following arterial injury.
J Trauma, 1980. 20(11): p. 948-51.

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91
 Open Long Bone Extremity Fracture Protocol

Open long bone extremity fractures are associated with significant trauma. The expedient
management of these injuries ensures the best possible fracture treatment outcome. The
determination of the grade of open fracture is the responsibility of the orthopedic trauma service.
The extent of the type of open fractures often requires intra-operative evaluation.

Antimicrobial Treatment for Open Fractures Depending on Type

Open Fracture Antibiotic Antibiotic

Type Treatment Treatment if PCN
Allergic

Type I Kefzol 1 gm IV Clindamycin 600

q8h x 24h mg IV q6 x 24h
Type II Kefzol 1 gm IV Clindamycin 600
q8h x 24h mg IV q6 x 24h +
+ Gentamicin Gentamicin
4mg/kg/d x 48h 4mg/kg/d x 48h
Type III Kefzol 1 gm IV Clindamycin 600
Type A, B, & C q8h x 24h + mg IV q6 x 48 +
Gentamicin Gentamicin
4mg/kg/d x 48h + 4mg/kg/d x 48h
PCN 4 million U
q4h x 48h

If patient exposed to barn or farm wound contamination then add high dose PCN x 24 hours
(Type I and II) or 48 hours in Type III. If patient is has pen-allergy consider flagyl.

Open fracture management and evaluation, including antibiotics should be initiated as soon as
possible from the timing of wounding, not based on arrival to ER.

If a patient gets an operation on this open fracture after completion of the above duration of
antibiotics is given they should get only a perioperative dose.

Wound care for open long bone extremity fracture requires coverage of the wound with a
Hibiclens or Betadine soaked gauze.

Mandatory documentation of neurovascular exam is required in all extremity injuries pre and
post extremity fracture care. Frequent neurovascular examinations are required before and
after fracture management to detect extremity compartment syndrome. The LAST clinical
finding lost in developing compartment syndrome is the pulse. The body has evolved to perfuse
cells until the very end so it makes sense that the pulse is the last clinical finding to be lost in
developing compartment syndrome.

* All open fractures must be evaluated by the Ortho Trauma Service for proper management
(stabilization, wound care, further fracture grading, and definitive fracture management)

92
UNIVERSITY OF KENTUCKY HOSPITAL POLICY NUMBER: 08 CHANDLER
MEDICAL CENTER FIRST ISSUED: 05/07

Emergency Dept. Policy CURRENT AS OF: 08/08

Subject: Management of Injury in Pregnancy

Purpose: To establish guidelines for rapid assessment and treatment of critically injured
pregnant patients.

PROCEDURE: To effectively manage trauma patients that are pregnant, the Trauma Team
must mobilize the resources essential to diagnosis and treat both mother and fetus. For
purposes of this policy, a potentially viable fetus is one at 24 weeks gestation, although some
exceptions may exist.

I. Mechanisms of Injury

Motor Vehicle Accident

Assault
Domestic Violence
Other trauma, such as gunshot wound

II. Initial Evaluation and Management

1. If ≥ 24 weeks gestation, sustaining a traumatic injury, activate Trauma Alert

2. Page OB chief Resident
3. Place roll under the torso to give a gentle right-side-up position (10-15 degrees)
4. Early intubation when indicated
5. Chest x-ray and FAST completed during the primary survey
6. Consider avoiding the plain pelvic radiograph if:
a. Hemodynamically normal patient
b. No gross instability or tenderness on physical exam
c. Planned CT scanning would cover imaging of the pelvis
7. Simultaneous fetal assessment should be completed by the OB team
8. In the case of maternal shock with a positive FAST, where emergent laparotomy is
indicated, the fetal
assessment can be completed in the OR
9. If distress is identified in a potentially viable fetus, every effort should be made to expedite
transfer to the OR for emergent cesarean section via a midline incision
10. When significant mechanism or concern for associated intraabdominal injury are present,
exploratory celiotomy at the time of C-section is indicated

III. Diagnostic Studies

1. Lab studies:
a. Urine pregnancy or serum beta-HCG, especially with a questionable history
b. Clotting factors and plasma fibrinogen
c. Kleihauer-Betke test, especially when blunt uterine trauma is suspected

93
 2. Imaging
a. Avoid duplicating films
b. Shield the fetus whenever possible
c. See Appendix 1 for estimated fetal exposure

Appendix 1: Estimated Fetal Exposure for Various Radiographic Studies

Plain Films:
dose per exam (rad) Estimated Fetal
Lateral Cervical Spine 0.002
Chest 0.00007
Pelvis 0.040
CT Scans
Head <0.050
Chest <0.100
Abdomen/Pelvis 2.6

Summary

Focus all initial evaluation and resuscitation efforts on the mother.

1. Complete a primary survey before moving the mother from the trauma bay for any
reason.
2. Secondary survey should include simultaneous fetal evaluation.
3. Plan radiographic studies and avoid duplication. Shield the fetus whenever possible.
4. Emergent cesarean sections should be performed through a midline incision.

______________________________ ________________________________
Medical Director, Emergency Medicine Trauma Program Director

94
 UNIVERERSITY OF KENTUCKY HOSPITAL POLICY NUMBER: 08-55a
CHANDLER MEDICAL CENTER FIRST ISSUED: 05/07
Emergency Dept. Policy CURRENT AS OF: 08/08

Initial E&M of the Pregnant Trauma Patient

Traumatic injury in female with reported pregnancy at or beyond 24 weeks:

Trauma Alert activation, with simultaneous page of OB Chief Resident

Primary Survey
Roll backboard R-side up
10-15 degrees
PCXR
FAST

Unstable w/ Positive FAST

Stable Proceed emergently to MAIN
Complete Secondary Survey Unstable- No clear source
Complete Secondary Survey OR
Fetal evaluation in ED
Fetal evaluation in ED
Plan additional imaging, lab
studies

Fetal evaluation in OR

*FETUS IN DISTRESS*
Emergent C-section via
midline incision
(MAIN OR)
Trauma present for laparotomy
after delivery

*NORMAL FETUS*
Additional work-up as indicated
Fetal monitoring for at least 6
hours (or as directed by OB)

Initiate perimortem C-section

Maternal ideally within 4 minutes of
death/traumatic arrest maternal arrest (If gestational
age likely >24 weeks)

95
EMERGENCY DEPARTMENT EVALUATION OF BURN PATIENTS

Stabilization
A. Maintain airway - the supraglottic airway is extremely susceptible to obstruction from
edema as a result of exposure to superheated air. Assess for clinical signs of inhalation
injury:
- Facial burns/singeing of the eyebrows and nasal hairs
- Carbonaceous sputum and acute inflammatory changes in the oropharynx, raspy voice
- History of impaired mentation and/or confinement in a burning environment
- Assess for toxic inhalation, or carbon monoxide poisoning

B. Circulation
1. Replace volume based on Rule of Nines calculation. Follow the Parkland Formula (2 -
4cc x % TBSA burned x weight/kg = total to be administered in first 24 hours. Half should
be given in first 8 hours from time of burn and second half over next 16 hours) for
administration of fluid. The amount of fluid given should be adjusted according to
individual patient's response:

a. Adult UO: 0.5 – 1.0 ml/kg/hour

b. Child <30 KG: UO 1.0 ml of urine/KG/hour. It is necessary to administer Maintenance
IV fluid containing glucose in addition to burn formula

3. Initiate two large bore IVs; overlying burns shouldn't prevent IV placement (upper
extremities preferred)

Assessment

96
A. Assess for associated injuries
B. History - time and mechanism of the injury; enclosed fire, or if toxic chemicals involved
C. Assess burn
1. First degree: (Sunburns): characterized by erythema, pain, and the absence of
blisters – NOT COUNTED IN TBSA
2. Second degree: (Superficial Partial Thickness or Deep partial thickness):
characterized by a red or mottled appearance with swelling and blister formation. The
surface may have a weeping, wet appearance and is painfully hypersensitive
3. Third degree: (full thickness): skin appears dark and leathery; may also appear
translucent, mottled, or waxy white; the surface is painless and generally dry, but may
also be moist
D. Circumferential extremity burns:
1. Remove rings and bracelets and Assess distal circulation
2. Check pulses with a Doppler (absent pulse may indicate inadequate fluid
resuscitation)
d. Observe for cyanosis, impaired capillary refill, or progressive neurological signs (i.e.,
paresthesia and deep tissue pain)

E. Limb Escharotomy
Relieve compromised distal circulation in a circumferentially burned
limb by escharotomy, which can be done without anesthesia, due
to the insensitive full - thickness burn
1. The incision must extend across the entire length of the eschar
in the lateral and/or medial line of the limb including the fingers and
joints
2. The incision should be deep enough to allow the cut edges of
the eschar to separate

F. Thoracic Escharotomy:
Circumferential burns of the thorax occasionally impair respiratory
excursion. Bilateral, mid-axillary escharotomy incisions should be
considered

Special Burn Requirements

A. Chemical burns
1. Flush burns for at least 20 to 30 minutes; alkali burns require
longer irrigation
2. Brush dry powder off before irrigation
3. Alkali burns to the eye require continuous irrigation during the first eight hours

B. Electrical burns - frequently more serious than they appear on the surface
1. Initial care as above
2. Full spinal immobilization
3. EKG monitoring
4. Urinary catheter
a. Observe for myoglobinurea (due to rhabdomyolysis)
b. Increase IV rate fluid to ensure UO of at least 100 ml/hour
c. Consult Medical Control for Mannitol 25 GM IVP and IV infusion with 12.5 GMs of
mannitol/1000 cc NS to maintain the diuresis
C. Explosive Injuries –

97
Any patient involved in an explosion should be considered as having a mechanism for
traumatic injuries. Even if the patient states they were NOT thrown a distance. The force
of a flash flame explosion is enough energy to cause concussive type of injuries.

98
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102
 The Anticoagulated Trauma Patient

Warfarin use has been shown to increase the severity of head injury and a higher mortality rate.
Mortality of trauma patients with head injury while on warfarin ranges from 33% to 50%.i
Furthermore, it has been reported that the head injured patients on warfarin have an increased
risk of mortality from 2-fold to 4-fold, when compared with non-anti-coagulated patients with
similar degrees of head [Link]

As part of the trauma workup, one should always obtain an adequate history, which includes a
list of current home medication. Early identification of warfarin use has been shown to reduce
mortality on patients with intracranial hemorrhage from 48% to 9%.iii In the same study, mean
time to warfarin reversal (normal coagulation profile) was 1.7 hours in the early identification
group compared to 4.3 hours.

Another important aspect of the anti-coagulated patient is the decreased reliability of their
neurological exam. It has been shown that GCS of 15 and no loss of consciousness does not
reliably rule out intracranial pathology after trauma. Indeed, one study reported two anti-
coagulated patients with no loss of consciousness that eventually died from consequence of
intracranial hemorrhage.2 Therefore, all patients with known warfarin use should have a CT
scan of the head as part of their trauma workup regardless of their mental status.
1
Lavoie A, Ratte S, Clas D, Demers J, Moore L, Martin M, Bergeron E. Preinjury warfarin use
among elderly patients with closed head injuries in a trauma center. J Trauma. 2004
Apr;56(4):802-7.
1
Mina AA, Bair HA, Howells GA, Bendick PJ. Complications of preinjury warfarin use in the
trauma patient. Trauma. 2003 May;54(5):842-7.
1
Janczyk et al. Rapid warfarin reversal in anticoagulated trauma patients with intracranial
hemorrhage reduces hemorrhage progression and mortality. Abstract presented at AAST
annual meeting, September 30, 2004.

Phillip Chang, M.D.

Revised: 08/08
Known Warfarin use
yes no

Check Transfuse two units of Check

PT/PTT FFP & give 5mg of PT/PTT
Vitamin K IV before
results are available
CT of head
Warfarin reversal based
neg pos on lab values. If there is
evidence of warfain use,
Ct of head should be
Transfuse obtained
as needed

Close Neurosurgery
observation consult & check
fibrinogen level

103
 SECTION 4: ICU SPECIFIC PROTOCOLS
Revised: 08/08
University of Kentucky Medical Center
Acute Care Surgery (Blue) Service Intensive Care Unit
Mechanical Weaning/Extubation Guidelines

Critically ill trauma/surgical patients frequently require mechanical ventilation to maintain

adequate tissue oxygenation until they are able to take on the work of breathing without
assistance. Discontinuing ventilator support should be done at the earliest possible time after
the disease process has been adequately reversed. In the vast majority of cases, prolonged or
gradual weaning is unnecessary. Rather, patients should be assessed for eligibility for
separation from the ventilator and if appropriate, separated. The UK Ventilator Separation
Protocol is included in this manual for reference and should be ordered for all mechanically
ventilated patients. ―Weaning‖ is used to describe gradual removal of ventilator support and is
reserved for patient who cannot be discontinued from ventilator support without gradual
maneuvers. The weaning process must be tailored to meet each patients needs. There are no
dogmatic rules or hard and fast guidelines regarding the timing or duration of the process.
These are basic guidelines that should be followed.

*Nursing Guidelines:

Pre Extubation:

1. Adequate pain control [remember to decrease and/or withdrawal pain/sedation

medications to level of adequate pain control without over sedation].
2. Ensure complete reversal of NMBA if applicable [4/4 in TOF]
3. Assess for hemodynamic stability
4. Patient should be awake, alert and ideally follows commands
5. Correct acid/base and electrolyte abnormalities
6. Assess nutritional status [Is patient’s caloric need being met with dietary regimen]
7. Assess characteristics of secretions
8. Breathing through an endotracheal tube requires more respiratory muscle work
than atmospheric breathing following extubation, therefore limit CPAP trial to 30
minutes.

Extubation:

1. Separation criteria met prior to extubation

2. Cool humidified oxygen set up at the bedside
3. Suction out endotracheal tube and mouth prior to extubation
4. Deflate endotracheal tube cuff just prior to extubation
5. Racemic epinephrine available

Post Extubation:

1. Assess breath sounds q 4 hours and PRN

2. Assess for any signs of respiratory distress
3. Monitor vital signs and SaO2 per unit guidelines
4. Elevate head of bed or reverse Trendelenburg 30 degrees
5. Encourage incentive spirometry, deep breathing and coughing per unit guidelines

104
Post Extubation Therapy:

Breathing Exercises: The most effective method of preventing post-extubation pulmonary

complications is to encourage maximal voluntary deep breathing and coughing. Incentive
spirometry is perused to augment voluntary efforts.

Aerosol Therapy: Stridor - Upper airway stridor is best treated with nebulized racemic
epinephrine

Bronchoconstriction - Bronchodilators delivered via nebulized aerosol effectively reverse airway

constriction. Specific drugs have varying B1 and B2 effects that will influence the choice of a
particular medication. Patients that do not exhibit clinical evidence of bronchoconstriction will
not benefit from this therapy.

Secretions: Thick, tenacious, inspissated secretions can be effectively treated with

heated aerosol. Some patients may require the addition of a mucolytic
agent [Mucomyst] delivered per hand held nebulizer. A mucolytic agent is
an irritant that can cause bronchospasm and should be discontinued after
48 hours due to bronchorrhea.

Percussion and Postural Drainage: The indication for therapy is very narrow and specific.
A. Increased secretions or infiltrate on Chest radiograph
B. Atelectasis not responding to breathing exercises
C. Collapse of lung, lobe or segment.

In order to achieve maximum benefit, the patient must be able to cooperate with the respiratory
therapist. A large number of contraindications to this form of therapy, some of which are listed,
limit its use in the critically ill patient.

Contraindications: A. Unstable cardiac rate or rhythm

B. Congestive heart failure
C. Unstable neurologic status (aneurysm, increased ICP)
D. Abdominal distention and or obesity
E. Fractured ribs or flail chest
F. Bleeding diathesis

*Refer to Mechanical Ventilation by B. Boulanger, M.D., P. Kearney, M.D., G. Hale, R.R.T., J.

Coughenour, M.D., for more detailed information on mechanical ventilation.

References

Boulanger BR, Kearney PA, Hale G, Coughenour JC. Mechanical Ventilation: Division of
Surgery, Division of Trauma/Critical Care and the Department of Respiratory Therapy, 4th Ed ,
2008.

105
106
107
Nosocomial Pneumonia

The incidence of nosocomial pneumonia is high in mechanically ventilated patients. National

data indicates that critically ill patient intubated for greater than 24 hours are at 6 to 21 times the
risk of developing pneumonia (VAP). This risk increases by 1% every ventilator day. (Tablan et
al, 1994) Morbidity and mortality associated with the development of VAP is high, adding 5-16
hospital days and increased health care cost. (Kolef, 1993, Rello et al, 2002)

The Ventilator Bundle was developed to prevent adverse events that prolong the amount of time
a patient requires mechanical ventilation. The Ventilator Bundle consists of stress ulcer
prophylaxis, DVT prophylaxis, Elevation of the head of the bed (>30 degrees), antiseptic oral
care, as well as Sedation Weaning. This has been incorporated into the Trauma ICU Admission
Order Set.

VAP is suspected by:

1. Fever
2. Leukocytosis
3. Change in character and volume of sputum
4. New infiltrate on CXR
5. Increasing ventilator and/or oxygen requirements.

The diagnosis is confirmed by Protected Alveolar Lavage (PAL).

Protected Alveolar Lavage (PAL) Guidelines

The procedure is performed by trained respiratory technician, nurse and/or physician.

Technique:
1. Confirm physician order.
2. Gather necessary items/equipment.
3. Prepare the patient for the procedure by:
a. Adequate pre-oxygenation with 100 % FiO2.
b. Ensure patient is adequately sedated.
4. Using aseptic technique (mask, gloves, cap), advance the catheter out of the protective
sheath at the opened end and gently insert protected catheter through the endotracheal
tube or tracheostomy cannula into the pulmonary tract until resistance is felt.
5. Pull the set back 3-4 cm, remove the plastic spacer, and advance inner catheter to fully
expel the distal polyethylene glycol plug.
6. Instill 20 cc of non-bacteriostatic saline.
7. Aspirate lavage sample from the airway while maintaining catheter position
8. Remove catheter from the endotracheal tube with the syringe still attached.
9. Place sample in to specimen container without contamination.
10. Send specimen to lab without delay.
11. Return to previous ventilator settings.

108
References

Tablan, O.C., Anderson, L. J., Arden N.H., et al. (1994). Guidelines for prevention of nosocomial
pneumonia. Hospital Infection Control Practices Advisory Committee. American Journal of
Infection Control, 22, 247-292.

Kollef, M., (1993). Ventilator-associated pneumonia: a multivariate analysis. JAMA, 270, 1965-
1976.

Rello, J., Ollendorf, D.A., Oster, G., et al. (2002). Epidemiology and outcomes of ventilator-
associated pneumonia in a large US database. Chest, 122 (6), 2115-2121.

Attia, J., Roy, J.G., Cook, D.J., et al. (2001). Deep vein thrombosis and its prevention in
critically ill adults. Archives of Internal Medicine, 161, 1268-1279.

Mahul P., Auboyer, C., Jospe, R., et al. (1992). Prevention of nosocomial pneumonia in
intubated patients in respective role of mechanical subglottic secretion drainage and stress ulcer
prophylaxis. Internal Care Medience, 18, 20-25.

Drakulovic, M., Torres, A., Bauer, T.T., et al. (1999). Supine body position as a risk factor for
nosocomial pneumonia in mechanically ventilated patients: a randomized trial. Lancet, 354,
1851-1857.

Kress, J., Pohlman, A.S., O’Connor, M. F., et al. (2000). Daily interruption of sedative infusions
in critically ill patients undergoing mechanical ventilation. New England Journal of Medicine,
342, 1471-1477.

Schleder, B., et al. (2002). The effect of a comprehensive oral care protocol on patients at risk
for ventilator-associated pneumonia. Journal of Advocate Health Care, 4(1), 27-30.

Scannapieco, F.A. (1999). Role of oral bacteria in respiratory infection. Journal of

Periodontology, 70(7), 793-802.

Reviewed: 03/05

109
110
111
Reviewed 10/08

University of Kentucky Medical Center

Trauma Intensive Care Unit
Analgesic and Sedation Protocol

Introduction:

Injuries, surgical wounds, and the attendant critical illness are associated with moderate to
severe pain, as well as anxiety and agitation. Intense sympathetic and parasympathetic
responses can and do occur with pain and anxiety. When pain and anxiety are not promptly and
adequately relieved, excessive adrenergic activity and hormonal changes indicative of stress
occur. These physiologic stress reactions produce a marked increase in metabolism, cardiac
workload, and oxygen consumption that may compromise tissue oxygenation in the critically ill
patient. The goal is to provide effective, sustained pain relief and sedation with minimal side
effects.

Analgesia: Morphine is the analgesic drug of choice and may be used alone or in conjunction
with a sedative. Morphine may be given intermittently or as a continuous infusion. Continuous
intravenous infusion of morphine is preferable because it avoids peaks and troughs in blood
levels leading to over and under sedation. When pain control cannot be achieved with
morphine, fentanyl is an effective, inexpensive alternative.

Agitation: Haloperidol is preferred for agitation. Frequently, escalating doses are required to
reach therapeutic levels and clinical effect. Agitation can occur from inadequate analgesia.
Therefore, make sure analgesia is adequate before treating agitation. Although rare,
haloperidol can produce extrapyramidal symptoms, neuroleptic malignant syndrome, and
cardiac events, such as prolongation of QT interval and torsade de pointes.

Anxiety: Benzodiazepines are the principle class of drugs for treatment of anxiety. Short acting
agents may be used for patients undergoing ICU procedures (central venous access, intubation,
bronchoscopy, chest tube placement, tracheotomy, etc.). Benzodiazepines should also be used
to insure deep sedation for patients requiring neuromuscular blocking agents. Benzodiazepines
should not be used as first line drugs for treating agitation. However, agitation can result from
inadequate analgesia or severe anxiety. Benzodiazepines may be used for patients who do not
respond to haloperidol or for those patients in whom haloperidol is contraindicated.

This protocol is designed to provide effective and consistent pain management as well
as effective treatment for agitation and sedation.

112
113
Nursing Care:

1. Assess patients for subjective and objective signs of pain every 4 hours and PRN.

2. Utilize pain, sedation and anxiety scale as shown above.

a. Decrease pain/sedation medication rate and/or frequency as patient
requirements decrease.
b. AVOID OVER SEDATION

3. Document patient response to medication.

4. Use comfort measure in addition to medication regimen.

5. Always assess vital signs prior to medication administration.

a. Use extreme caution with borderline MAP and respiratory rate.

6. It is essential to taper high dose analgesic and sedation medications when

a. weaning patient for extubation.

7. Obtain new pain/ sedation orders after patient is weaned, extubated and no longer
a. receiving mechanical ventilation.

8. Monitor for extrapyramidal symptoms if patient is receiving haloperidol

9. Administer intermittent haloperidol slowly over 5 minutes if SBP is < 100.

Weaning guidelines for continuous infusion narcotic analgesics:

1. Weaning guidelines for Fentanyl:

> 2 weeks duration: 100 mcg/hr decreased twice daily
> 3 weeks duration: 50 mcg/hr decreased twice daily

2. Weaning guidelines for Morphine:

> 2 weeks duration: 2 mg/hr decreased every 6 hours
> 3 weeks duration: 2 mg/hr decreased every 12 hours

The weaning guidelines are to serve as parameters for weaning narcotics when patients have
been receiving narcotics for more than 2 weeks. These are not iron clad rules. Weaning from
narcotic analgesics may be individualized for the patient. Listed below are signs and symptoms
of withdrawal from narcotics that the critical care clinician should monitor for when weaning the
patient from narcotic analgesics.

Signs and symptoms of withdrawal:

agitation
tachycardia
tachypnea
tremors

114
 fever
increased lacrimation
diarrhea
nausea and vomiting

Daily Awakening Procedure:

For all patients meeting inclusion criteria, continuous infusion sedation medications will be
interrupted every day at 0800. Infusions are restarted at half the previous rates.
Infusions will be held until:
o Patient is awake and can follow commands (SAS = 4) with medical indication to resume
infusion
o Patient becomes agitated (SAS = 5-7) and requires resumption of sedation.

Inclusion Criteria for Daily Awakening:

o Patients initiated on continuous sedation > 48 hours
o Patients not concurrently receiving neuromuscular blocking agents
o Patients with stable hemodynamic/ventilatory status including:
 No evidence of ARDS (i.e. P/F ratio > 250)
 PEEP < 10 mmHg and pCO2 < 50 mm Hg
 MAP > 60 mmHg without use of vasopressor agents
 Patient not requiring use of rotobed

Exclusion Criteria for Daily Awakening:

o Patients initiated on continuous sedation < 48 hours
o Patients concurrently receiving neuromuscular blocking agents
o Patients with unstable hemodynamic/ventilatory status including:
 No evidence of ARDS (i.e. P/F ratio <250)
 PEEP > 10 mmHg and pCO2 < 50 mm Hg
 MAP < 60 mmHg without use of vasopressor agents
 Patient requiring use of rotobed

115
 Riker Sedation-Agitation Scale SAS
7 Dangerous Pulling at ETT, trying to remove catheters,
Agitation climbing over bedrail, striking staff, thrashing
side to side

6 Very Agitated Does not calm despite frequent verbal

reminding of limits, requires physical restraints,
biting ETT
5 Agitated Anxious or mildly agitated, attempting to sit up,
calms down to verbal instructions
4 Calm and Calm, awakens easily, follows commands
Cooperative
3 Sedated Difficult to arouse, awakens to verbal stimuli or
gentle shaking but drifts off again, follows
simple commands
2 Very Sedated Arouses to physical stimuli but does not
communicate or follow commands, may move
occasionally

1 Unarousable Minimal or no response to noxious stimuli, does

not communicate or follow commands

References

Jacobi, Judith, et al. Clinical practice guidelines for the sustained use of sedatives and
analgesics in the critically ill adult. Critical Care Medicine. 2002;30(1): 119

Riker, RR, et al. Prospective evaluation of the sedation-agitation scale for adult critically ill
patients. Critical Care Medicine. 1999 Jul;27(7):1325-1329.

Shapiro BA, Warren J, Egol AB, et al. Practice parameters for intravenous analgesia and
sedation for adult patients in the intensive care unit: An executive summary. Critical Care
Medicine. 1995; 23: 1596-1600.

Fox CA, Mansour A, Watson SJ. The effects of haloperidol on Dopamine Receptor Gene
Expression. Experimental Neurology. 1994; 130: 288-303.

Riker RR, Fraser GL, Cox PM. Continuous infusion of haloperidol controls agitation in critically
ill patients. Critical Care Medicine. 1994; 22: 433-440.

Guinard JP, Carpenter RL, Chassot PG. Epidural and intravenous fentanyl produce equivalent
effects during major surgery. Anesthesiology. 1995; 82: 377-382.

George KA, Wright PM, Chisakuta AM. Thoracic epidural analgesia compared with patient
controlled intravenous morphine after upper abdominal surgery. Acta Anesthesiologica
Scandinavia. 1994; 38: 808-812.

116
Ready LB, Oden R, Chadwick HS, et al. Development of an anesthesiology based acute
postoperative pain management service. Anesthesiology. 1988; 68: 100-106.

Uzbay T, Akarsu ES, Kayaalp, SO. Effects of bromocriptine and haloperidol on ethanol
withdrawal syndrome in rats. Pharmacology Biochemistry and Behavior. 1994; 49(4): 969-
974.

Sun K, Quinn T, Weissman C. Patterns of sedation and analgesia in the postoperative ICU
patient. Chest. 1992; 101: 1625-1632.

Malacrida R, Fritz ME, Suter PM, et al. Pharmacokinetics of midazolam administered by

continuous intravenous infusion to intensive care patients. Critical Care Medicine. 1992; 20(8):
1123-1126.

Singer M, Noonan KR. Continuous intravenous infusion of fentanyl: Case reports of use in
patients with advanced cancer and intractable pain. Journal of Pain and Symptom
Management. 1993; 8(4): 215-220.

117
Revised: 11/08

University of Kentucky Hospital

Trauma Intensive Care Unit
Neuromuscular Blockade Protocol

The use of neuromuscular blocking agents in the treatment of critically ill patients has increased
steadily over the past two decades. Increased use is largely due to advancements in medical
technology and a better understanding of the treatment of critical illness. Up to 8% of intensive
care patients who require mechanical ventilation may require neuromuscular blocking agents.
The decision to paralyze a patient should not be taken lightly. The benefits, however, outweigh
risks when consideration is given to the efficacy of short-term use of NMBA’s. Neuromuscular
blocking agents are indicated for the treatment of patients with severe acute respiratory failure
(ARDS), marginal tissue oxygenation ( VO2 or DO2), and severe agitation which compromises
patient safety.

To assess the depth of neuromuscular blockade, a peripheral nerve stimulator using Train-of-
Four stimulation will be utilized. Routine twitch monitoring is essential to ensure a consistent
and safe level of blockade while preventing prolonged neuromuscular blockade. Clinical
indicators should be utilized to assess effectiveness of blockade (e.g. PIP < 40, improved DO2,
ICP<15). Titrate to lowest dose of NMBA to achieve defined parameters. Since pain and
anxiety cannot be assessed easily, patients must receive scheduled sedation and analgesia.
The neuromuscular blockade will be discontinued every day to determine if the patient is
receiving adequate analgesic and sedation, and to evaluate if continued paralysis is needed.
The following protocol was developed to assist the physicians and nurses in critical care to
achieve optimal management of patients requiring NMBA’s.

118
NON DEPOLARAZING NEUROMUSCULAR
BLOCKING AGENTS
Intubated/Ventilator patients Only

I. Primary indications for the use of continuous infusion non-depolarizing

neuromuscular blocking agents (NMBA).

A. To enhance oxygenation during intermittent positive pressure ventilation.

Useful in patients with poor lung compliance (i.e., ARDS) or those who
compromise ventilation by using forceful expiratory musculature.

B. Hypermetabolic patients with marginal oxygen delivery and increased oxygen

consumption. High fever (>40C), shivering and extreme agitation.

C. Where control of continuous skeletal muscle fasciculation is unresponsive

to conventional therapy (i.e., tetanus).

D. Intracranial hypertension unresponsive to conventional therapy or when

conventional therapy is contraindicated.

II. Precautions and contraindications for the use of continuous infusion of NMBA:

A. Caution when used in patients with neuromuscular diseases (i.e., myasthenia

gravis, Eaton-Lambert syndrome), severe acidosis and hypothermia.

B. Caution when used concurrently with aminoglycosides, tetracyclines,

clindamycin, metronidazole, cyclosporin, vancomycin, steroids, calcium channel
blocking agents, magnesium salts, procainamide and quinidine due to their
potentiating effects.
[See Section VIII]

C. Caution when used in patients with renal, hepatic or pulmonary impairment, and
in geriatric or debilitated patients.

D. Avoid use in patients who have either experienced or have a family history of
malignant hyperthermia.

III. Vecuronium should be used as the drug of choice if neuromuscular blockade is

indicated. Cisatracurium is available as alternative agent, but must be ordered by an
attending physician because of status on formulary. Administer agents by controlled
infusion.

A. Vecuronium: mix 50 mg in 50 ml NS
Concentration: 1 mg/ml
Load: 0.08 - 0.1 mg/kg [use dry weight]
Infusion: 0.04 - 0.15 mg/kg/hr to maintain one detectable twitch

119
 by train of four monitor [1/4]
Start infusion @ 0.04 mg/kg/hr

B. Cisatracurium: Mix 200 mg in 250 D5W or NS

Concentration: 800 mcg/ml
Load: 0.2 mg/Kg [use dry weight]
Infusion: 1 - 10 mcg/kg/min to maintain one detectable twitch
by train of four monitor [1/4]
Start infusion @ 1 mcg/kg/min

[please note that infusion is in mcg/kg/min.]

IV. Nondepolarizing neuromuscular blockade can be reversed if clinically required if

spontaneous reversal of paralytic agent does not occur after agent is discontinued.

A. Neostigmine 2.5 - 5.0 mg plus glycopyrrolate 0.5 mg

B. Edrophonium 35 - 70 mg plus atropine 0.5 mg

If above regimens fail to reverse blockade, the following considerations must be

addressed.

1. 15 - 30 minutes is required to antagonize block.

2. Blockade may be too intense to be antagonized.
3. Respiratory acidosis prevents antagonism.
4. Possible drug interactions.
5. Organ system failure may decrease excretion of NMBA

V. Sedatives and or analgesics must be used concurrently with NMBA’s.

Refer to Pain/Sedation Protocol

VI. Adverse effects associated with NMBA.

A. Reactions associated with histamine release:

1. Bronchospasm
2. Flushing
3. Erythema
4. Hypotension
5. Tachycardia
6. Pruritis
7. Urticaria
8. Wheal formation

B. Cardiovascular effects including changes in:

1. Heart rate
2. Cardiac output
3. Cardiac filling pressure

120
 4. Mean systolic blood pressure
5. Mean arterial pressure
6. Systemic vascular resistance

C. Malignant hyperthermia

VII. Physiologic conditions that affect the amount of NMBA needed.

Requires Less NMBA Requires More NMBA

Acidosis Alkalosis
Hypothermia Hyperthermia
Hypocalcemia Hypercalcemia
Hypokalemia Hyperkalemia
Neuromuscular Disease Burns

VIII. Pharmacological agents that affect the amount of NMBA needed.

Requires Less NMBA Requires More NMBA

[potentate blockade] [antagonizes blockade]

Aminoglycosides Azathioprine
Beta-blocking agents Carbamazepine
Clindamycin Methylxanthines
Midazolam Phenytoin
Polymyxin
Procainamide
Quinidine
Tetracyclines
Vancomycin

IX. The efficacy of NMBA’s for altering oxygen consumption can be measured by
monitoring the following parameters:

1. Cardiac output/index
2. Venous oxygen saturation
3. Arterial oxygen saturation
4. Oxygen consumption

X. Depth of neuromuscular blockade should be monitored with a peripheral nerve

stimulator using the Train of Four (TOF) mode. An appropriate blockade is defined 1 - 2
twitches in the TOF. The following guidelines should be followed when initiating and
titrating for appropriate blockade:

1. Establish baseline by determining the lowest current that evokes a

4/4 response. Monitor TOF at 10 MA above baseline.

121
 2. Ulnar nerve is preferred site for assessing TOF.

Facial nerve and Superficial Peroneal nerve are alternative sites if both
upper extremities are not accessible.

3. If no response is elicited follow the trouble shooting algorithm. If medication is

excessive, the infusion should be held until one twitch is detected. Restart the
drip at the lowest dose per kg and titrate to 1/4 or 2/4 twitches.

4. Initially a TOF should be determined every hour until three consecutive TOF elicit
the same response. A TOF can be determined every 4 hours thereafter.
If the patient is demonstrating renal or hepatic insufficiency, the TOF should be
utilized every 2 hours.

5. 100 Hz should not be used unless attempting to determine level of excessive

neuromuscular blockade or sustained tetanus.

6. Refer to the Trouble Shooting Algorithm with 0/4 twitches.

7. Brow diaphoresis is indicative of inadequate blockade.

Nursing Care:

1. Lacrilube and artificial tears q 2 hours and PRN

2. Ensure complete eyelid closure to prevent scleral abrasions (use paper tape to
tape eyelid closed).
3. Oral Care q 2 hours
4. PT Consult for splints per physician’s orders
5. Consult PT when NMBA discontinued
6. Monitor skin integrity q 4 hours
7. Consider Kinetic Therapy
8. Deep vein thrombosis prophylaxis
9. Reposition q 2 hours
10. Passive range of motion q 4 hours
11. Change electrode placement q day and PRN to avoid skin irritation
12. Place new battery in TOF monitor prior to use.
13. Please evaluate the patient for adequate pain and sedation before increasing the
NMBA. The goal of therapy is to provide optimum ventilation and if this can be
achieved by increasing the amount of analgesia and/or sedative this should be
your first priority.

Refer to Trouble Shooting Algorithm

122
 Non Depolarizing Neuromuscular
Blocking Agents
Intubated/Ventilator Patients Only

Severe acute respiratory failure, marginal tissue oxygenation,

Hyperthermia/shivering, severe agitation, and increased ICP

Appropriate and Adequate Pain/Sedation

st
(Imperative that pain/sedation be addressed 1 )

Patient Responds

Increase in Sa02 and/or Sv02, Decreased ICP

YES NO

Maintain Adequate
Pain and Sedation Initiate Neuromuscular Blockade

Obtain Baseline TOF

Patients w/o organ Renal Failure Hepatic Failure

dysfunction

Vecuronium Vecuronium Cisatracurium

Titrate to 1/4 or 2/4 twitches

[75% to 90% blockade]
(If the patient shows any S & S of pain/agitation (dilated pupils, etc), consider increasing pain/sedation medication
before increasing or restarting the NMBA. Assessment for pain/sedation cannot be over emphasized and should be
ongoing)

Administer Benzodiazepines per protocol

Administer Narcotic Analgesic per protocol

Stop NMBA q am @ 0800 to assess adequacy of sedation/analgesic and to

determine if continued paralysis is needed.

Restart drip at previous rate if patient exhibits signs and symptoms of inadequate oxygenation. Notify H.O. if
the patient is severely compromised & requires a bolus.

123
124
 Trouble Shooting
Guidelines for
Neuromuscular Blockade

If unable to obtain twitch[0/4]:

check electrodes.
Good contact?

NO YES

Change electrodes

Good Lead Placement

NO YES

Change Lead Placement Site Edematous

NO YES

Check Battery Use Alternate Site

[refer to diagram]

Battery Good

NO YES

Change Battery Patient Dose Excessive

Stop NMBA and Check TOF in 1 hour

125
References

Jacobi, Judith, et al. Clinical practice guidelines for the sustained use of sedatives and
analgesics in the critcally ill adult. Critical Care Medicine. 2002; 30(1): 119

Riker, RR, et al. Prospective evaluation of the sedation-agitation scale for adilt critically ill
patients. Critical Care Medicine. 1999 July; 27(7): 1325-1329

Shariro BA, Warren J, Egol AB, Greenbaum DM, et al. Practice parameters for sustained
neuromuscular blockade in the adult critically ill patient: An executive summary. Critical Care
Medicine. 1995; 23: 1601-1605

Coursin DB, Meyer DA, Prielipp RC. Doxacurium infusion in critically ill patients with atracurium
tachyphlaxix. American Journal of Health-System Pharmacy. 1995; 52: 635-638

McCoy EP, Mirakhur RK, Connolly M, et al. The influence of the duration of control stimulation
on the onset and recovery of neuromuscular block. Anesth Analg. 1995; 80: 364-367

Kirkegaard-Nielsen H, Helbo-Hansen H, Severinsen IK, et al. Comparison of tactile and

mechanomyographical assessment of response to double burst and train-of-four stimulation
during moderate and profound neuromuscular blockade. Canadian Journal of Anesthesia.
1995; 42(1): 21-27

Gooch JL, Suchyta MR, Balbierz JM, et al. Prolonged paralysis after treatment with
neuromuscular junction blocking agents. Critical Care Medicine. 1991; 19(9): 1125-1131.

Helbo-Hansen HS, Bang U, Nielsen HK, et al. The accuracy of Train-of-four monitoring at
varying stimulating currents. Anesthesiology. 1992; 76(2): 199-203.

Jarpe MB. Nursing care of patients receiving long-term infusion of neuromuscular blocking
agents. Critical Care Nurse. 1992; 10: 58-63.

Davidson JE. Neuromuscular blockade. Focus on Critical Care. 1991; 18(6): 512-519.

Clarens DM, Kelly KJ, Gilliland SS, et al. A retrospective analysis of long-term use of
nondepolarizing neuromuscular blocking agents in the intensive care unit, and guidelines for
drug selection. Pharmacotherapy. 1993; 13(6): 647-655.

126
Intra-Abdominal Hypertension and Abdominal Compartment Syndrome
Assessment and Monitoring Guidelines

The abdominal cavity can be considered a single cavity and change in the volume of contents
will elevate abdominal pressures. Abdominal Compartment Syndrome (ACS) is a condition in
which the increased pressure in the anatomic space results in organ dysfunction. Undetected
increases in intra-abdominal pressure (IAP) can be life threatening. Identification of patients at
risk is essential to prevent hemodynamic and respiratory compromise from undetected ACS.
ACS is preceded by intra-abdominal hypertension (IAH) and organ dysfunction may precede
development of ACS.

Definition of ACS: Intra-abdominal pressure (IAP) > 20 mmHg (with or without an APP < 60
mmHg) in a minimum of three standardized measurements taken four to six hours apart plus at
least one new end-organ failure.

Definition of IAH: IAP > 12 mmHg.

I. Etiology of Increased IAP

Acute
A. Intra-abdominal Hemorrhage
Post resuscitation visceral hemorrhage
Hypothermic or consumptive coagulopathic bleeding
Rupture of abdominal aortic or visceral artery aneurysm
Post traumatic intra-abdominal hemorrhage
B. Retroperitoneal Hemorrhage
Blunt trauma (i.e., pelvic fracture, kidney laceration)
Hemorrhagic Pancreatitis
Ruptured abdominal aortic aneurysm
C. Accumulation of Fluid/Visceral Swelling
Septic shock
Peritonitis (i.e., perforated viscus, postoperative abscess)
Paralytic ileus
Bowel obstruction
Mesenteric venous thrombosis
Mesenteric ischemia/reperfusion
Pancreatitis
D. Other
Tension pneumoperitoneum
Intra-abdominal packing
Chronic
A. Ascites
B. Pregnancy
C. Large abdominal tumor/ovarian mass

127
II. Physiologic Consequences

Cardiopulmonary Effects
Increased IAP increases intra-thoracic pressure (ITP) which impedes venous return and
causes a number of physiologic derangements.

A. Pulmonary
Decreased compliance (see higher peak airway pressures)
Increased inspiratory pressure
Hypercarbia (decreased ventilation)
Hypovolemia (compresses SVC, decreasing preload = decreased CO)
Respiratory Acidosis (decreased FRC and TV = decreased ventilation)
Increased pulmonary vascular resistance (increases pulmonary shunt and
increases work on heart to generate same CO)

B. Cardiac
Decreased ventricular compliance (requires increased preload for same CO)
Increased CVP, PWP, PAP (Falsely elevated when euvolemic!)
Diminished venous return (compresses SVC/IVC)
Tachycardia (decreased preload, need increased HR to keep same CO)
Decreased cardiac output (seen when compensatory mechanisms fail)
Increased SVR
* Venous stasis may increase risk of DVT/PE

Renal Effects
Increased IAP compresses the inferior vena cava and renal veins. Direct extrinsic pressure on
the kidney creates a circumferential constriction. The combination of direct trauma,
hypoperfusion and venous backpressure can create an intra-renal compartment syndrome. As
a consequence, urine output diminishes.

Neurological Effects
By increasing ITP, increased IAP impedes venous outflow from the cerebral circulation.

ICP
CPP

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Gastrointestinal/Hepatic/Wound Healing
Increased abdominal pressure reduces blood flow to the abdominal viscera.
celiac and portal blood flow
mucosal blood flow
fascial blood flow- (increases risk of wound infection and dehiscence)
bacterial translocation

Multiple Compartment Syndrome

IAP -> ITP -> CVP -> ICP -> CPP
When ICP remains elevated despite maximal medical maneuvers, give
consideration to MCS which may require decompressive laparotomy
and/or decompressive craniotomy.

Grades of Intra-abdominal Hypertension (mmHg)

Normal = 0 – 11
Grade I = 12 – 15 (IAH)
Grade II = 16 - 20
Grade III = 21 – 25
Grade IV = >25

Please notify physician if IAP is > 12, or per physician’s orders. Profound physiologic
derangements can occur with IAH reforcing the need to recognize and treat IAH early
before ACS develops.

Abdominal Perfusion Pressure (APP) = MAP – IAP

Goal APP > 60 mmHg

III. Procedure for Measuring Abdominal Pressures

A. Supplies Needed

1. 500 ml Normal Saline

2. Transducer/pressure tubing
3. 60 ml syringe
4. 18 gauge needle
5. Providone-iodine swab
6. Alcohol Swab
7. Kelly
8. 4 x 4 gauze

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 B. Guidelines

1. Place patient in supine position

2. Clamp tubing of the indwelling urinary catheter distal to sampling port with
Kelly clamp, using 4 x 4 gauze to protect tubing.
3. Clean sampling port with providone-iodine/alcohol
4. Attach IAP monitoring device to foley
5. Insert 18-gauge needle into sampling port of bladder drainage system.
6. Attach 60-ml syringe to 3-way stopcock and withdraw 60 ml of normal
saline from the flush system.
7. Instill 60 ml of normal saline into the bladder
8. Using the proximal stopcock, level and zero the transducer at the
symphysis pubis. Please mark position if you are going to be doing more
intra-abdominal pressure measurements.
9. Measure abdominal pressure at end expiration (please note that the intra-
abdominal pressure waveform is a relatively flat line with excursion that
corresponds to respiratory cycle.
10. Record reading on flow sheet
11. Subtract NS instilled into the bladder from urine output
12. Label and date flush bag/transducer used for intra-abdominal pressure
readings if repeated measurements are ordered. Please ensure that the
flush bag/transducer is labeled for intra-abdominal pressure readings
only.

References
Scalea TM, et al. Increased Intra-abdominal, Intra-thoracic, and intra-cranial pressure after
severe rain injury: multiple compartment syndrome. J. Trauma 62(3):647-656, March 2007.
Malbrain ML, et al. Results from the International Conference of Experts on Intra-abdominal
Hypertension and Abdominal Compartment Syndrome. Intensive Care Medicine
2006;32(11):1722-1732 & 2007;33(6):951-962
Sugrue M. Abdominal compartment syndrome. Curr Opinion in Critical Care
2005;11:333-8.
Watson, RA, Howdieshell, RT. Abdominal Compartment Syndrome. Southern
Medical Journal. 1998; 91(4):326-332
Harrahill M. Intra-abdominal pressure monitoring. Journal of Emergency Nursing.
1998;24(5):465 – 466
Iberti, TJ, Kelly KM, Gentili, DR, et al. A simple technique to accurately determine Intra-
abdominal pressure. Critical Care Medicine. 1987;5(12):1140 – 1142
Iberti, TJ, Lieber CE, Benjamin, E. Determination of Intra-abdominal Pressure
Using a Transurethral Bladder Catheter: Clinical Validation of the Technique. Anesthesiology.
1989;70(1):47 - 50
Gallagher, John J. Ask the Experts. Critical Care Nurse. 2000;20(1):87 – 91.
Schein, M, Wittmann, DH. The Abdominal Compartment Syndrome Following
Peritonitis, Abdominal Trauma, and Operations. Complications in Surgery 1996; 15(5)

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 Guidelines for Operative Procedures in the Intensive Care Unit

I. Operative Procedures

A. Non-Emergent Procedures
1. Percutaneous Tracheostomy
2. Percutaneous Endoscopic Gastrostomy
3. Planned relaparotomy for the management of intra-abdominal sepsis
4. Planned relaparotomy for pack removal

B. Emergent Procedures
Note: Indicated operative procedure to sustain life when patient condition or time precludes
transport to the operating room.
1. Compartment Fasciotomy
2. Bedside Decompressive Laparotomy

II. Staffing Needs

A. Non-Emergent Procedures
1. Surgical Attending
2. Surgical Resident
3. RN
4. Other necessary staff based on procedure and need for anesthesia:
Percutaneous Tracheostomy – Respiratory Therapist
Anesthesia to be administered – Anesthesiologist
ICU tech to assist in obtaining supplies

B. Emergent Procedures
1. Surgical Attending
2. Surgical Resident
3. OR Safari team
4. Anesthesia resident
5. ICU RN

III. Monitoring Requirements

A. Non-Emergent and Emergent Procedures

1. Electrocardiogram
2. Pulse Oximetry
3. Arterial Blood Pressure

If indicated:
4. Train of Four twitch assessment
5. End-tidal CO2

Note: Adherence to strict nursing policies and procedures for monitoring will be maintained at
all times. Refer to Appendix A and Appendix B.

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IV. Administration of Medications

A. Non-Emergent and Emergent Cases

1. Surgical Attending
2. Surgical resident
3. Anesthesiologist
4. RN
Note: If anesthesia is to be administered, the RN will not administer.
RN will follow guidelines set forth for conscious sedation – See Appendix A and Appendix B

V. Supplies Needed

A. Non-Emergent Procedures

1. See Appendix C for Percutaneous Tracheostomy

2. See Appendix D for Percutaneous Endoscopy Gastrostomy

B. Emergent Procedures

1. Overhead OR light
2. See Appendix G for Compartment Fasciotomy
3. See Appendix I for Bedside Decompressive Laparotomy
4. See Appendix H for Minor OR Tray Supplies
Note: Supplies provided by OR Sterile per Safari Team

VI. Guidelines during procedure

A. Non-Emergent Procedures

1. Minimal traffic in and out of room other than indicated staff

2. Unit visiting may be closed as per Surgical Attending discretion

B. Emergent Procedures

1. Unit closed to visitors during operative procedure

References

Mayberry, J.C. (200) Bedside Open Abdominal Surgery. Utility and Wound Management.
Critical Care Clinics, 16 (1), 200, 151-172.

Porter, J.M., Ivatury, R. R., Kavarana, M. & Verrier, R. (1999). The Surgical Intensive Care Unit
as a Cost-Efficient Substitute for an Operating Room at a Level I Trauma Center. The American
Surgeon, 64, 328-330.

Waydhas, C., Schneck, G., & Duswald, K. H. (1995). Deterioration of respiratory function after
intra-hospital transport of critically ill surgical patients. Intensive Care Medicine. 21, 784-789.

132
Smith, I. Flemming, S., & Cernaiano, A. (1990) Mishaps during transport from the intensive care
unit. Critical Care Medicine, 18, 278-281.

Indeck, M., Peterson, S., Smith, S., et al. (1988). Risk cost and benefit of transporting ICU
patients for special studies. Journal of Trauma, 28, 1020.

Stiegmann, G., Goff, J., Van Way, C., et al. (1988). Operative versus endoscopic gastrostomy in
the intensive care patient. Critical Care Medicine, 16, 62-63.

Toursark, B., Zweng, T. N., Kearney, P.A., et al. (1994). Percutaneous Dilatational
tracheostomy: Report of 141 cases. Annals of Thoracic Surgery, 57, 862-867.

Hill, B. B., Zweng, T.N., Maley, R.H., et al. (1996). Percutaneous dilatational tracheostomy:
Report of 356 cases. Journal of Trauma. 32, 133-140.

Hwang, T.L., Chiu, C.T., Chen, H.M., et al. (1995). Surgical results for severe acute pancreatitis:
Comparison of the different surgical procedures. Hepatogastroenterology, 42, 1026-1029.

Tsiotos, G. G., Smith, C. D., & Sarr, M. G., (1995). Incidence and management of pancreatic
and enteric fustulas after surgical management of severe necrotizing pancreatitis. Archives of
Surgery, 130, 48-52.

Brant, C. P. Prieve, P. P., Eckhauser, M. L. (1993). Diagnostic laparoscopy in the intensive care
patient. Avoiding the nontherapeutic laparotomy. Surgical Endoscopy, 7, 168-172.

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HIGH DOSE VITAMIN C (Ascorbic Acid) Protocol

PLA – Burn ICU admission order set.

IV Meds

If > 30% TBSA burn (? depth) - High dose Vitamin C 66mg/kg/hr x 24 in LR

Calculation box

66mg/kg/hr X INSERT KG -> XX mg/hr/25mg/ml = Rate

ml/hr
Administer over 24hours then discontinue infusion

PHARMACY INSTRUCTIONS
1. 66mg/kg/hr x KG -> XX mg/hr/25mg/ml = Rate ml/hr

Rate ml/hr x 24hr L/1000ml = Total Dose = L/dose

2. Remove 50ml of LR from 1Liter bag

3. Add 50ml (25Gram vial) Vitamin C to 1 Liter of Lactate Ringers

4. Prepare entire total dose (24hr. infusion)

5. Cover each bag with an amber sleeve

6. Deliver entire total dose to the Burn ICU

Ex. 80kg pt. x 66mg/kg/hr = 5280mg/hr /25mg/ml = 211.2ml/hr

Total dose 5.069L/24hr period

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 ICU Anemia Management Protocol (Adults)

Patients commonly suffer from anemia on admission to the intensive care unit (ICU).
Additionally, anemia frequently develops or worsens during the course of a patient’s ICU
stay. Anemia can cause prolonged ICU stays, increase the costs of healthcare, and lead
to other negative patient outcomes. Anemia is usually treated in these patients but not
always in a cost-effective and resource-sensitive manner. In recognition of the ongoing
shortage in the nation’s blood supply, the cost of agents used to treat anemia, the
potential harmful effects of transfused blood products and the need to improve patient
outcomes, the Pharmacy and Therapeutics Committee recently approved the Adult ICU
Anemia Management Protocol.

Prevention

Minimize phlebotomy (avoid daily lab draws, obtain all blood needed at once, use
specimen tubes that can be used for multiple labs, add tests to blood already in
the lab when appropriate)
Adequate nutritional support

Transfusion of PRBCs

The protocol defines guidelines for blood transfusions. To receive PRBCs, patients must
meet one of three criteria presented in the Table. After the transfusion of one unit, the
average 70 kg adult will experience an increase in the Hgb by 1 g/dL. The goal after
receiving a transfusion is a Hgb 7 g/dL (Hct 21). If clinically indicated to monitor
response and further bleeding, blood counts should be collected 30 minutes after the end
of the infusion. Routine post-transfusion hematocrits are not mandatory. The most blood-
economical manner of monitoring hematocrit is with blood gas panels, which require only
1cc of blood (venous or arterial), are cost neutral compared to specific hemograms or
hematocrits and for which results are obtained more quickly by virtue of processing on the
blood gas analyzer.

Since 2001, almost all red blood cell units prepared and stored in the United States are
leukocyte-reduced.

Table. Indications for PRBC Transfusion

Variable Transfusion Trigger g/L*, Transfusion Goal g/L,
%HCT %HCT
Critical Illness (no active 70, 21 70-90, 21-27
hemorrhage)
Critical Illness & septic 70, 21 70-90, 21-27
shock (>6h)
Critical Illness & septic 80-100, 24-30 100, 30
shock (<6h)
Critical Illness with chronic 70, 21 70-90, 21-27
cardiac disease
Critical Illness with acute 80-100, 24-27 100, 30
cardiac disease

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 If the decision to transfuse PRBCs is made then 1 U should be given first to monitor for a
response as measured by hemodynamic status and measurement of Hg/HCT for
appropriate transfusion response. If an appropriate clinical response is not seen then
increments of 1 U of transfusion with monitoring for clinical/laboratory response.

Adapted from, “Hébert PC et al. Controversies in RBC Transfusion in the Critically Ill.
Chest. 2007. May;131(5):1583-90.

Epoetin Alpha (EPO)

EPO administration has demonstrated only a slight decrease in PRBC transfusion in

critical illness. This decrease was only appreciated in liberal transfusion models which are
not applicable today. In studies with strict transfusion models the decrease in the number
of PRBCs transfused was not statistically significant. EPO has been demonstrated to
reduce mortality in trauma patients however this inference is from largely retrospective
data. EPO was found to increase thromboembolic complications in trauma patients,
however, these findings occurred in patients that were not on medical thromboembolic
prophylaxis. EPO did show a mortality benefit with no increase in thromboembolic events
in those patients on medical thromboembolic prophylaxis. Further studies are needed to
determine the clinical benefit in trauma patients.

Adjunctive Medications

It is important for anemic patients to be placed on the appropriate adjunctive agents.

Patients being treated for anemia should also receive:

Folic acid 1 mg orally/per tube daily;

Cyanocobalamin (vitamin B12) 500 mcg orally/ per tube daily for five days,
then weekly;
Ferrous sulfate 325mg orally/per tube daily unless contraindicated.

Beta blockade to keep the heart rate less than 90 should be considered in patients with
known or suspected heart disease. The preferred agent is metoprolol starting at 12.5
mg orally/per tube twice daily, and titrated as tolerated to a maximum dose of 100 mg
twice daily. The patient must be adequately resuscitated and have appropriate pain
control before altering their physiology with beta blockade. Indicators of adequate
resuscitation are clearance of acidosis (normal lactate, base deficit and serum HCO3-),
normotension, adequate urinary output, and ScVO2, ScVO2 or StO2).

Revised 11/08

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SECTION 5: ICU and FLOOR PROTOCOLS

FIFTH FLOOR QUALITY IMPROVEMENT PROJECT

The goal of the Trauma/Emergency Surgery service is to provide cost-effective, high-quality patient
care. In order to achieve this goal a customer service model will be implemented. The physician/nurse
team will make excellent patient care the focus of their effort. This will be accomplished by the
development of ―best practice‖ models using evidence based clinical data. This will allow the
physician/nurse team to direct ancillary services in the most cost-effective manner for excellent patient
care.

General Guidelines for Patient Care

The very best way to care for patients is to understand physiology and pathophysiology. This allows
the clinician to understand the treatment being rendered. In general, if it sounds stupid it is stupid!
Remember that every beneficial intervention also has the potential to cause harm. When a treatment
or intervention is no longer required discontinue the intervention/treatment. Nasogastric tubes are
useful for gastric decompression and to prevent emesis associated with bowel obstruction, On the other
hand the tubes are uncomfortable and predispose the patient to sinusitis, GERD, and aspiration. Proton
pump inhibitors and H2 antagonists reduce the incidence of stress ulceration. However, they are
associated bacterial overgrowth in the stomach that may lead to nosocomial pneumonia. IV catheters
and fluids can be life saving but they are also associated with thrombophlebitis and infection. Foley
catheters may be needed for urinary retention or monitoring of intake and output. However, they are
associated with urethral strictures and infections. Phlebotomy for blood tests is a necessary part of
patient care. However, excess phlebotomy can and does result in anemia that can be harmful to
patients. Medications are extremely important for patient care but drug interactions and adverse
reactions can be harmful to patients. These are a few examples of the myriad of rather simple
interventions and therapies that can and do harm patients. Modern medical care is exceedingly
expensive. Ask yourself why a particular intervention, test, or medication is being used. Is this needed?
How does this benefit the patient? What is the harm? How much is this going to cost? What
information will I gain? Through rigorous self-examination the answer for many of these questions is
easier than you think.

Mobilization
There is clear, irrefutable evidence that extended bed rest is harmful to patients. Supine position and
lack of mobilization leads to reductions in pulmonary functional residual capacity, atelectasis,
diminished cough, and accumulation of dependent lung water. This makes the patient more prone to
pulmonary complications which are the most frequent cause of admission or readmission to the ICU in
the Medical Center. Bed rest also leads to rapid loss of muscle mass leading to de-conditioning which
may increase hospital length of stay, lengthen rehabilitation, or create the need for rehabilitation that
would have not been otherwise needed. Patients at bed rest are more prone to pressure ulcers, bowel
dysfunction, and venous thromboembolic disease.

A primary focus of patient care should be early mobilization of the patient. Weight-bearing status
should be determined within 24 hours of admission to the hospital. Ambulation of the patient should be
an immediate goal. If there are limitations on weight-bearing these should be identified and appropriate
resources (physical therapy, equipment, etc) should be applied immediately. At the very least, patients
should be out of bed and placed in a chair. This does not mean bringing the bed into a sitting position
but actually getting the patients out of the bed into a chair. If traction or hemorrhage risk mandates bed
rest, the patients should be nursed with the head of the bed elevated at least 30 degrees. When spine
precautions are in place the patient should be placed in reverse trendelenburg.

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Respiratory Function
Respiratory therapy is essential for acutely ill and injured patients. Many of our patients have co-
morbid lung disease and/or a history of heavy tobacco use. Lung function is further compromised by
bed rest, obesity, chest wall trauma, pain, surgical incisions, chest tubes, or via the use of cervical
collars, back braces, and/or traction. It is unrealistic to expect respiratory therapy service to assume
this task for most patients. Pulmonary toilet should be a major goal for excellent nursing care.

Prevention is the key element here.

Apply vigorous pulmonary toilet early! Use the respiratory therapist wisely. It is far easier to prevent
respiratory failure than to treat the consequences. Patients also require education as to their role in
pulmonary toilet. Patients often equate pain with further damage. They need to understand that
pulmonary toilet may cause pain but not harm. The simplest and best pulmonary toilet is to mobilize the
patient. This requires patient effort resulting in work of breathing that maintains respiratory muscle
function. Mobilization also shifts lung water, increases lung functional residual capacity, and reduces
atelectasis. Mobilization should be supplemented with education on maximum voluntary ventilation, as
well as coughing and deep breathing. Inspirometers and blow bottles can and should be used to
supplement coughing a deep breathing. Some patients may require bronchodilators and/or chest
physiotherapy. Occasionally expectorants are also required. Some patients may require nasotracheal
suctioning. Pain control is essential. Patients should be comfortable but not so somnolent that they
can’t actively participate in pulmonary toilet.

A word about supplemental oxygen

Supplemental Oxygen is expensive and unnecessary for most patients. Oxygen does not improve
respiratory failure! In fact, supplemental oxygen usually masks worsening respiratory function that
would respond to pulmonary toilet. Virtually all human beings have arterial desaturation when
recumbent or sleeping. Spot pulse oximetry in these circumstances is of no clinical value and
frequently results in unnecessary application of supplemental oxygen. Respiratory rate and effort
combined with auscultory findings, radiograph, and subjective patient complaints are much better
determinants of respiratory failure than arterial desaturation. In the latter circumstance, supplemental
oxygen should be used along with pulmonary toilet.

Central nervous system injury

Patients with head and/or spinal cord injury do not have normal pulmonary toilet. These patients rely
heavily on positioning, mobilization, and active pulmonary toilet to avert respiratory failure.
Nasotracheal suctioning along with chest physiotherapy, bronchodilators, and breathing exercises
should be used liberally in this patient group.

Tracheostomy
Tracheostomy is frequently required for the management of airway, pulmonary toilet, and/or respiratory
failure in patients with complex critical illness and/or injury. The vast majority of these are performed
percutaneously although some are still placed using the older, but still reliable, open surgical technique.
Regardless of placement technique, complications, daily tracheostomy tube/site care, and
downsizing/decannulation are the same.

Complications
Dislodgement: The most common early and lethal complication of tracheostomy is tube dislodgement.
In order to prevent this complication the tracheostomy tube is secured to the skin with sutures and fixed
in place with a secure neck strap. Sutures often give a false sense of security and will not in and of
themselves eliminate dislodgement. The most important defense against early dislodgement is a
secure neck strap and strict avoidance of undue tension and/or torque on the fresh tracheostomy. It
takes about four days after insertion to develop a mature tract. After four days, dislodgement rarely

138
results airway compromise and the tube can simply be reinserted through the neck. Prior to four days,
airway loss is likely and the patient may require endotracheal intubation to reestablish the airway. This
is a true emergency that requires the immediate attention of the surgical house staff. The patient can be
temporized with 100% oxygen delivered via bag valve mask and gentle occlusion of the tracheostomy
site.

Plugging: The most common intermediate complication of tracheostomy is mucous plugging. This will
be the most frequent problem encountered with ward patients. Secretions build up in the tracheostomy
tube lumen leading to sudden occlusion and airway compromise. Virtually all of the tracheostomy
tubes in use at UKMC have a removable inner cannula. The routine practice of maintaining cuff
deflation and routine inspection/cleaning of the inner cannula will prevent this complication.

Stenosis: Tracheal stenosis is a late complication of tracheostomy. Virtually all tracheostomies (85%)
are associated with some degree of tracheal stenosis. Only 1-2% of patients develop critical stenosis
that compromises the airway and produces clinical symptoms. The duration of endotracheal intubation
(> 11 days) prior to tracheostomy, technique used (open > percutaneous), higher placement (between
rings 1-2 vs. 2 or lower), and smaller airway (children, females) all increase the rate of clinically
significant tracheal stenosis. Almost all clinically significant stenosis occur within twelve weeks of
tracheostomy. The hallmark of clinically significant tracheal stenosis is respiratory distress and/or
stridor and wheezing when the tracheostomy tube is plugged or removed. If plug removal or
tracheostomy tube reinsertion alleviates symptoms the tube should remain in place until a diagnostic
evaluation can be performed.

Tracheal-arterial fistula: Small amounts of bleeding may occur simply from the irritation of suctioning,
site care and/or the tube itself. A rare but lethal complication of tracheostomy is tracheal-arterial fistula
that occurs from erosion of the tip of the tracheostomy tube into the great vessels of the upper thorax.
The hallmark of this complication is a ―herald bleed‖ defined as a moderate to large amount of bleeding
that stops spontaneously. If bleeding persists or produces airway compromise, the endotracheal tube
cuff can be inflated to tamponade bleeding and maintain the airway. Herald bleeding requires
immediate investigation!

Infection: Tracheostomy site infection is exceedingly rare. The presence of purulent, foul–smelling
secretions accompanied by an expanding zone of erythema establishes the diagnosis. Site care and
appropriate antimicrobial therapy are effective in controlling this complication.

Tracheocutaneous fistula: This is a rare complication of tracheostomy that is defined as a persistent

air leak present for more than one week after decannulation. While a small percentage of these will
close after 7 days most will require a surgical intervention to achieve closure.

Bronchorrea: Copious secretions usually indicate a residual or recurrent pulmonary problem.

Occasionally, these secretions are due to the endotracheal tube itself. The tube can and does irritate
the upper airway producing excessive secretions. Decannulation is the treatment of choice. If the
patient still requires a tracheostomy (coma), a drying agent such as robinol can be used.

Tracheostomy tube/site care

The tracheostomy tube and site should be inspected at least once daily. The site itself should be
inspected for purulence and erythema. Gentle cleansing with a small amount of soap and water
followed by a dry dressing provides ample site care. The inner cannula should be removed, inspected,
and cleaned as necessary to remove build up of dried secretions. The tracheostomy tape should be
snug enough to prevent excess movement of the tube but not so tight as to produce skin
breakdown/ulceration. The balloon should be deflated on cuffed tubes. Sutures, if present, can be

139
removed after six days. Tracheostomy bypasses the normal humidification provided by the
oro/nasopharynx so patients are prone to evaporative water loss and desiccation of the airway mucosa.
Humidified air or oxygen (if required) should be used at all times to prevent the latter complications.

Downsizing and decannulation

The general practice of downsizing a tracheostomy tube prior to decannulation is controversial. Be that
as it may, downsizing the tracheostomy tube prior to decannulation is the routine practice at UKMC.
The stated advantages are a reduction in size of the tract to reduce tracheocutaneous fistulas and to
detect tracheal stenosis prior to decannulation. After four days a well-established tract exists between
the surface and the trachea. Downsizing can proceed safely at this point. Decannulation should not
proceed until the patient is clinically stable. Respiratory failure should be stable or improving and
suctioning requirements should be nominal (>2-4 hours). The patient should have a vigorous cough
and be able to handle their secretions. There should be no residual airway issues. As a first step, the
plastic tracheostomy tubes (Usually Shiley occasional Portex or Bivona) are removed and replaced with
a 6mm metal tube (Jackson). These can then be plugged. If the patient tolerates plugging (see
complications: tracheal stenosis), has a good cough and minimal secretions, decannulation can
proceed. The tracheostomy site should be covered with an occlusive dressing. The patient should be
monitored closely over the next 24 hours for any evidence of respiratory distress. Closure of the tract
usually requires 24-48 hours. Comatose patients can be downsized but should not be decannulated.
This group of patients rarely has a good cough and cannot protect their airway. Consequently, they
remain at risk for aspiration and/or respiratory compromise.

Dysphagia and aspiration following tracheostomy

Dysphagia and/or aspiration following tracheostomy are very common. If managed correctly, this is
rarely a clinical problem and oral feeding can be safely resumed without an elaborate ritual. The
dysphagia team is seldom, if ever required. Almost 30% percent of normal individuals will have some
amount of aspiration on barium swallow. Contrast studies often overestimate the problem and lead to
unnecessary, complicated, and expensive solutions to a simple problem. Most patients who require a
tracheostomy have not had oral intake for some time. This is complicated by the fact that the
tracheostomy itself may interfere with swallowing. This is simply a problem of training/initiating a
swallowing bolus! To initiate oral intake, cuffed tracheostomy tubes should be deflated or downsized to
a smaller metal tracheostomy. Oral intake should never begin with liquids. It is much harder to develop
a swallowing bolus with liquids. The initial oral feeding challenge should be with thickened liquids
and/or solids. Most importantly, the patient should be sitting upright. Why don’t you try to swallow
liquids in a supine position! If the patient doesn’t succeed try, try again. Give the patient good
instructions and several attempts before conceding failure. Decannulation, if indicated, can also be
accomplished prior to another try. Only an occasional patient will fail and require an alternative feeding
access.

Intravenous Access
Three quarters (75%) of all hospital bactermia events are associated with intravenous catheters! There
is a general hospital wide practice to ―heparin lock‖ and keep both peripheral and central venous
catheters. Keeping multiple IV sites is simply not a good practice. Each and every IV site represents a
potential nosocomial infection site for patients. Both insertion technique and indwell time influence
subsequent thrombophlebitis. Many catheters are placed under less than ideal conditions and should
be removed as soon as possible. In all but the most unusual circumstances, a patient will require a
single functioning IV access site. Proper inspection and site care should be used to maintain function
and sterility. All other intravenous access sites should be removed.

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Wound Care
Wound care is much easier than most physicians and nurses think. The process has become
unnecessarily complicated, confusing, and expensive. The simple answer is soap, water, and gentle
handling of tissues. Astringents (peroxide, betadine, acetic acid, alcohol, Daken’s, etc.) should rarely if
ever be used in a wound. There is a widely held misconception that more frequent wound care
somehow makes wounds heal faster. This is simply not the case. Keeping wounds clean, moist, and
covered allows the body to heal the wounds considerably faster. Astringents, frequent dressing care,
and overzealous packing are more often responsible for delays in healing.

Wound Classification
Clean Wounds - These are surgical incisions that follow an elective surgical procedure that does not
involve the aerodigestive tract. Examples would be neurosurgical procedures, vascular procedures,
hernias, most elective orthopedic procedures.
Clean contaminated wounds – These are surgical incisions that follow an elective surgical procedure
that crosses the aerodigestive tract. Examples would be most ENT procedures, operations on the
gastrointestinal tract, or operation on the lung.
Contaminated wounds – These are incisions that follow an emergent surgical procedure where there is
obvious or potential infection. Examples would be perforations of the GI tract, strangulated hernias,
complicated soft tissue infections, open fractures.
Dirty wounds – This is really a matter of degree. The difference between contaminated and dirty
wounds is really the degree of contamination. Complex wounds with large devitalized areas, gross
fecal contamination, large amounts of purulent material, dirt, foreign bodies etc. are usually classified
as dirty.

Important Definition
Dehiscence refers to separation of the wound edges. Dehiscence can further defined as involving the
skin and subcutaneous tissue (superficial) or extending to the deeper layers (fascial dehiscence).
Evisceration refers to the protrusion of visceral contents through the wound. Not all dehiscence has
evisceration but by definition all eviscerations have dehiscence.

Wound management
Wounds are managed in one of three ways:
1. Primary closure of the skin and subcutaneous tissues (most wounds)
2. Delayed primary closure. Wounds are left open initially. The skin is then closed primarily
between day 3 and 4. Bacterial counts are lowest in the wound at this point and delayed primary
closure has the greatest success.
3. Healing by secondary intention. This technique applies for most open wounds.

Closed wounds
Wounds that have been closed primarily will seal within 36 hours. After that point it is very unlikely that
environmental contamination would compromise the wound. The general rule is to leave the surgical
dressing on for 24 hours. After that point the wounds can be covered with a light dry dressing to absorb
minor drainage, prevent irritation and for patient comfort. These wounds should be carefully inspected
at least once a day for signs of infection (redness, swelling, excessive tenderness, purulent drainage).
The subjective patient complaint of wound pain (fever may or may not be present) that increases or is
out proportion to wound size is often the earliest sign of surgical wound infection.

Open wounds
Contaminated or dirty wounds are often packed and left open. The main clinical reason for this practice
is the high incidence of wound infection if the wounds are closed. The wounds are generally packed
tightly to achieve hemostasis after the initial operative procedure. Unless there is a planned return to

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the operating room for exam under anesthesia, further debridement, and irrigation, these dressings
should be taken down and the wound examined at 24 hours. The first dressing change can be quite
painful and provisions should be made for adequate analgesia prior to proceeding. Most of the pain
emanates from the densely innervated wound edge and care should be taken in this area. If the
dressing is adherent gentle wetting with saline will facilitate removal and reduce discomfort. ―Clean
wound‖ care rather than ―sterile technique‖ should be the standard practice. At the first dressing
change the decision can be made to initiate saline wet to dry dressing or application of a vacuum
dressing. At this point a decision can also be made about washing/showering the wound with soap and
water. Dressing changes need only be once or twice a day and packing of the wound should be gentle.
Saline irrigation of the wound base is permissible. As mentioned previously, astringents should be
avoided and every effort should be made to avoid wound dessication by irrigating the wound in
between dressing changes if necessary. Regarding dressing fixation, the skin should be protected from
tape adhesives by using duoderm and Montgomery straps or by application of Bandnet dressing
(preferred). Absolutely every effort should be made to simplify wound care prior to discharge. Patients
should be given clear instructions on clean wound care, showering should be encouraged. When
possible, wounds can/should be dressed with tap water rather than sterile saline which is considerably
more expensive and unnecessary for most wounds.

Open wounds and evaporative water loss.

Open wounds can and do result in significant fluid & electrolyte disturbances. Dehydration from
evaporative water loss and malnutrition from protein loss are significant problems with large wounds.
This can be amplified if the wound is associated with an enterocutaneous fistula. The patients should
be assessed for signs of volume depletion such as excessive thirst, diminished skin turgor, and or low
urine output. Keeping the wounds covered and moist reduces evaporative water loss and may reduce
protein loss as well.

Wound infection
The earliest and most frequent sign of wound infection is excessive wound pain and tenderness. Low
grade fever, wound redness, and drainage often appear later and can be easily seen with a good exam
and dressing change. Wounds should be opened in the affected area to allow drainage, irrigation, and
gentle packing just like in open wounds. Wound culture and antibiotics are totally unnecessary except
in rare circumstances such as when patients exhibit signs of systemic illness and/or there is prosthetic
material in the wound. WARNING! When dealing with abdominal wall wounds, drainage may indicate
deep wound problems such as fascial failure and/or evisceration.

Gastrointestinal Tract
There is a widely held misconception that the gastrointestinal tract in quiescent following illness, injury,
and/or surgery. The gut plays an active role in overall host defenses, gastrointestinal stress ulceration,
and systemic inflammation. The historical term attached to the clinical problem of post operative gut
dysfunction was ― paralytic ileus‖. This has been shortened in modern medical terminology to ―ileus.‖
The traditional clinical practice is to withhold oral intake and maintain nasogastric decompression until
there was clinical evidence indicating return of bowel function (passage of flatus, bowel movement, or
audible bowel sounds). This practice is outdated and not consistent with what is currently known about
bowel function in illness. The stomach and small bowel function very well following illness, injury, and
/or operative intervention unless there has been mesenteric ischemia or long standing obstruction. The
actual root cause of the clinical entity referred to as ―ileus‖ is delayed return of colonic function.
Although ingrained in our medical terminology, ―ileus‖ is a misnomer and the proper term to use is
colonic pseudo-obstruction.

There are a number of clinical practices that either exacerbate or contribute to colonic pseudo-
obstruction. Chief among these are bedrest, narcotic administration (particularly epidural catheters), as

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well as fluid & electrolyte abnormalities. Depending on the clinical circumstances, the clinician also
needs to consider other contributing factors such as fecal impaction, resolving peritonitis, intra-
abdominal abscess, pneumonia, wound infection, retroperitoneal hematoma, and pseudomembranous
colitis. Mesenteric ischemia and early mechanical bowel obstruction, although rare, must also be
considered in the differential diagnosis.

For most patients, early mobilization, judicious use of narcotics, as well as attention to fluid &
electrolytes can mitigate or prevent pseudo-obstruction. Routine use of an effective bowel regimen
and/or early enteral nutrition is also effective depending on the patient and clinical circumstances.

The main risk to the patient with pseudo-obstruction is colonic ischemia and/or perforation which are
dependent upon the degree of colonic distention. Perforation/ischemia is much more likely when
colonic/cecal diameter is > 11cm. Under these circumstances, more aggressive management is
warranted. For most patients, the treatment of pseudo-obstruction is relatively straightforward. Bowel
rest, hydration, and correction of electrolytes are essential. Narcotics should be reduced as much as
possible. Depending on the clinical situation, other treatable contributing factors need to be rectified or
excluded. Nasogastric tubes are completely unnecessary for the vast majority of patients because they
are not effective in reducing colonic distention. NG tubes should be withheld unless the patient is
vomiting and/or has evidence of gastric distention on X-ray. A combination of stool softeners and
cathartics accompanied by a prokinetic agent (metaclopramide) are usually effective. Cathartics and
prokinetic agents are more effective when given orally but other routes of administration may be
necessary depending on the clinical situation. Rectal stimulation with a suppository and/or enema may
also produce results. For refractory patients or those with significant colonic distension, a
parasympathomimetic agent (neostigmine) can be administered IV with excellent results. Routine use
of neostigmine is precluded by side effects such as bradyarrythmias, bronchorrea, and diaphoresis.
Ideally, patients should be monitored during drug administration particularly if they have known cardiac
disease. Decompressive colonoscopy which is both diagnostic and therapeutic may be required for
patients with significant colonic distention.

Enteral Nutrition
Not all patients require early enteral nutrition. Well nourished patients who sustain mild to moderate
injury or those undergoing elective operations tolerate up to seven days of fasting with little or no
adverse consequences. However, patients with documented pre-injury or pre-operative malnutrition as
well as those patients with complex critical illness/injury clearly benefit from early enteral nutrition. In
fact, the evidence is clear and irrefutable. Infectious complications are significantly reduced in patients
who receive early enteral nutrition. Early enteral nutrition also maintains gut integrity, reduces the risk of
gastrointestinal stress ulceration, and increases the rate of wound healing.

Access routes
The main difficulty with early enteral nutrition is achieving and maintaining a reliable feeding access.
Gastric feeding is well tolerated and most patients can be fed in the stomach. Unfortunately tolerance is
an issue for some patients, monitoring may be difficult and the aspiration risk is higher than that for
post-pyloric tubes. As the patient improves clinically, aspiration risk declines and the need for post-
pyloric access diminishes. Three approaches are used to establish feeding access; nasoenteral feeding
tube, surgical jejunostomy, and percutaneous endoscopic gastrostomy (PEG). For the vast majority of
patients, a nasoenteral feeding tube is a safe, temporary access. These can be placed blindly, via
endoscopy, fluoroscopy, or at the time of surgical intervention. Since these tubes frequently become
dislodged they are often secured in place with a bridle. Nasoenteral feeding tubes are not a reliable
long term access and should be replaced with a jejunostomy or gastrostomy tube. When a patient has
significant foregut pathology, a surgical jejunostomy can be placed. This allows enteral feeding to

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proceed in the absence of an intact/functioning foregut. The most frequently utilized long term feeding
access is the PEG. This is a safe, effective way of delivering enteral nutrition for most patients.

Assessing enteral feeding tolerance

Continuous feeding is the only method used for post-pyloric nasoenteral and jejunostomy feeding
tubes. The small bowel will not tolerate bolus feedings. Continuous feeding is preferred for PEG
feedings but can be changed over to bolus feedings over time. Feeding intolerance manifests clinically
in a variety of ways. The key to delivering effective enteral nutrition is to be aware of the clinical
manifestations of feeding intolerance and to realize that signs of intolerance vary depending on the
feeding access used. Tube feeding reflux, high gastric residuals, vomiting, aspiration, abdominal
distention, and diarrhea are all signs of feeding intolerance.

Tube feeding reflux

In patients with a post-pyloric nasoenteral tube and a nasogastric tube, the first sign of intolerance can
be tube feeding reflux in the nasogastric aspirate. The first maneuver should be to confirm tube
positions with a radiograph. NG tubes can migrate distally and feeding tubes can be dislodged. Tubes
should be repositioned if necessary. Once tube position has been confirmed, then a downward
adjustment in rate and/or the addition of a prokinetic agent may be required. If reflux is significant and
accompanied by abdominal distention, the best course of action is to hold tube feedings for 12-24 hours
and reassess the patient. Sudden abdominal distention and reflux in a patient previously tolerating tube
feeds is a very worrisome finding that warrants further investigation.

High gastric residuals

In patients receiving continuous feeding via a PEG elevated gastric residuals are the first sign of
intolerance. Residuals should be monitored every 4-6 hours and should not exceed the sum total of the
tube feeding over that time period. When the residuals are elevated, feeding should be withheld and
rechecked after a period of rest. A prokinetic agent can be added with success in some patients. Again,
elevated residuals and abdominal distention in a patient that previously tolerated feeds should alert the
clinician to a change in clinical status that warrants investigation. Occasionally, patients will be fed into
the stomach using a small bore nasoenteral feeding tube. Residuals cannot be checked via these tubes
and no attempt should be made to do so.

Vomiting/Aspiration
Vomiting and/or aspiration may be the first sign of feeding intolerance. In the awake patient, complaints
of nausea will precede the event, so don’t ignore this complaint. This manifestation is more likely in
patients being fed in the stomach via PEG or nasoenteral feeding tube. Remember that post-pyloric
feeding reduces but does not eliminate vomiting/aspiration risk. The most prudent course of action is to
hold feedings. Depending on the clinical suspicion for aspiration, an evaluation by a physician is
warranted. Vomiting will usually dislodge a nasoenteral feeding tube, so replacement and/or
verification of position is warranted.

Abdominal distention
Frequently overlooked, abdominal distention and bloating are the earliest and most reliable signs of
intolerance. All patients receiving enteral nutrition should be evaluated daily. Not all patients require
and intervention but this should be noted and brought to the attention of the physicians caring for the
patient. Acute and/or significant distention may indicate mesenteric ischemia or colonic pseudo-
obstruction.

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Diarrhea
Diarrhea is probably the most frequent complication of enteral nutrition. Oddly enough tube feeding is
usually not the cause. Sorbitol containing medications are frequently to blame so a review of the
medication record is warranted. If indicated, clostridium difficile colitis should be excluded. Higher tube
feeding rates may produce diarrhea so a change in rate may be warranted. Anti-diarrhea agents can
be utilized if the problem persists. Changes in formula can be made. If the volume of stool exceeds
500-1000cc per day then holding the feeds may be necessary.

Tube maintenance
Enteral access tubes are expensive and vital to patient care. Every effort should be made to maintain
patency and protect against dislodgement.

Small bore feeding tubes

Standard nursing guidelines for small bore feeding tubes should be rigorously followed to prevent
clogging. The most effective way to maintain patency is to flush with tubes frequently with warm water
and to avoid medication known to clog these tubes. Whenever tube feedings are interrupted or
medications are administered, the tubes should be flushed with warm water.

PEG
These tubes can and do become clogged and or dislodged. One of the most important aspects of daily
PEG care is to assess the tube site and determine tube depth. Nurses should pay close attention to
the insertion site for redness, swelling, and/or tube feeding reflux. Following placement, PEG tubes are
secured in place using a silastic bumper. These bumpers are applied loosely to maintain the PEG at
the original depth of insertion which is charted in the endoscopic procedure note. Each PEG tube has a
centimeter marker on the side. The general depth for most patients is between 3-6 centimeters. The
depth at insertion should be recorded on the nursing assessment. If the depth marker is <3cm or >
6cm or there is tube feedings refluxing through the insertion site, feedings should be held and the
physician notified immediately. Remember, a sudden change in PEG feeding tolerance accompanied
by abdominal distention can indicate PEG tube migration or dislodgement.

Diarrhea
Not all liquid stools constitute diarrhea. Diarrhea is defined as frequent loose stools exceeding 1000cc
per day and/or producing fluid/electrolyte abnormalities. The clinical objective is to identify and remove
treatable causes of diarrhea. Medications are probably the most frequent cause of diarrhea. Drugs that
produce diarrhea such as prokinetic agents, oral macrolides, cathartics, and sorbitol containing elixirs
should be eliminated when possible. Adjustments in tube feeding rate and/or formula change may be
required. Clostridium difficile colitis should be excluded or diagnosed and treated. Diarrhea may
accompany a high-grade fecal impaction. Diarrhea may also be the only manifestation of intra-
abdominal infection. Surgical resection of the small or large bowel (ileocecal valve in particular) may
produce post-operative diarrhea. Diarrhea may follow resolution of pseudo-obstruction or surgical relief
of a mechanical small bowel obstruction. In general, treatment is defined by the cause. Medications
should be changed/eliminated. Fecal impaction should be cleared. With the exception of C. difficile
colitis, symptomatic relief can be provided with anti-diarrhea agents such as combinations of lomotil,
Imodium, paregoric, and narcotics.

Clostridium difficile (Pseudomembranous) Colitis

The Gram negative bacterium Clostridium difficile is part of the normal colonic flora in roughly 20-25%
of patients. The bacteria exist in small numbers in balance with other colonic flora and do not cause
any problems. Pseudomembranous colitis develops as a consequence of an overgrowth of C. difficile
allowing for increased toxin production and mucosal damage. The major mechanism is antibiotic
administration that alters/reduces colonic flora allowing room for increased growth of the drug resistant

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C. difficile bacterium. The disease can be produced by as little as one dose of antibiotics and most
often follows single dose antimicrobial administration for perioperative prophylaxis. There is some data
to suggest that mechanical bowel preparation/cleansing may produce the disease as well. The most
frequent offending antimicrobials are cephalosporin (Rocephin), Clindamycin, ampicillin, and
fluroquinolones such as levaquin. The primary manifestation of the disease is diarrhea which may
occur up to 14 days after the last antibiotic administration. Occasionally the patients will have
abdominal pain and distention. Rarely they will present with or have constitutional symptoms such as
fever and systemic toxicity that accompany the diarrhea and abdominal pain. The diarrhea associated
with the disease is quite distinct. The frequent passage of small amounts of foul smelling liquid stools
should raise clinical suspicion. The diagnosis is easily established by sending a stool specimen for
toxin assay. Cultures are of no value because the bacteria are normal resident flora in many patients.
First line therapy is metronidazole (flagyl) administered 7-10 days via the enteral route. Intravenous
flagyl is effective for patients who will not tolerate the oral route. Vancomycin given enterally is
reserved for patients who present with severe disease and/or fail on flagyl. Empiric therapy is
appropriate after stool cultures have been obtained and can be stopped if the toxin assay is negative.
Endoscopy to identify pseudomembranes is occasionally required to establish the diagnosis. Rarely, a
patient will develop toxic megacolon and require emergent surgical intervention.

Constipation
There is overlap between constipation and colonic pseudo-obstruction. Abdominal pain, distension,
nausea, and vomiting accompanied by absence of a bowel movement for more that several days are
the most common symptoms. Unfortunately these symptoms are identical to colonic pseudo-obstruction
so the diagnosis is difficult in the hospitalized patient. Narcotics, bedrest, dietary changes, fluid &
electrolyte abnormalities, particularly dehydration all predispose the patient to constipation. The key is
prevention. Early mobilization of the patient and adequate hydration are essential. Patients who require
pain medications should receive stool softeners as a routine. Once constipation develops attention
should be turned to correcting the problem. Fecal impaction should be excluded by rectal exam.
Remember that diarrhea may be a manifestation of fecal impaction. Stool softeners alone are usually
not enough. Unless the patient is vomiting, oral cathartics should be tried initially. Oral dulcolax tablets
and/or milk of magnesia (MOM) can be administered along with oral metaclopramide (reglan) 10-20mg.
Osmotic agents such as sorbitol or phosphate of soda are also effective particularly if administered with
dulcolax. These regimens can be repeated. If the patient is vomiting or does not respond to oral
therapy, digital rectal stimulation with a dulcolax suppository with or without enemas can be employed.

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 5th Floor Practice Standards

Mobilization Standards:
Patient will be out of bed to chair three times a day. Patient will also ambulate in hall
three times a day if patient is ambulatory.
1. For non-ambulatory patients: OOB three times a day. Bending the bed is not
equivalent to getting them out of bed. Getting them out of bed requires patient effort and
therefore respiratory and other muscle work. For bedridden patients, active/passive ROM will be
performed every 12 hours along with turning every 2 hours to decrease soft tissue injury.
Every patient should have incentive Spirometer when admitted unless specifically
contraindicated. Incentive Spirometer will be included in admission kit by nursing tech.
Incentive Spirometer will be used by every patient 10 times every hour while awake.
Turn/cough/deep breathe will be done for all non-ambulatory patients unless
contraindicated every 2 hours. The surgical literature clearly shows that pulmonary
complications are reduced by any method of pulmonary care that leads to maximum voluntary
ventilation on the part of the patient. Coughing, deep breathing, exertion, and incentive
Spirometer use should be encouraged and stressed.

IV Standards:
Nurse will have MD order prior to IV initiation.
1. Unless an emergency situation arises.
IV’s will not be heparin-locked for procedures.
1. Unless specifically ordered by MD
Each patient will have only one IV access.
1. Unless specifically ordered by MD.
2. Unless additional IV sites are needed for blood transfusions or non-compatible
drugs.
RN will attempt two IV sticks, if unsuccessful; will ask for assistance from one other RN.
If IV access is not acquired, RN will notify MD and suggest PICC or deep line placement.
IV’s and IV tubing will be changed every three days and more often as needed by night
shift RN’s.
RN will assess IV for patency, infiltration, infection every 8 hours and with medication
administration.
Patient may be heparin-locked with adequate PO intake, and IV will be d/c’d unless
patient has medication requiring IV, if so the IV will be heparin locked.

PICC line Standards:

PICC line therapy will be considered when IV initiation is difficult or impossible or when
long-term IV therapy is anticipated.
RN will acquire MD order prior to PICC line initiation. PICC line placement will be
performed by vascular access RN.
PICC line dressing will be changed 24 hours after PICC line insertion. Dressing will not
have gauze over insertion site so that it can be assessed for infection. After initial
change, PICC line dressing will be changed weekly using aseptic technique.
PICC line should be assessed every 8 hours.
Always use a 10 cc syringe for flushing a PICC line.
1. If patient is receiving infusion through PICC line, flushing every 12 hours is not
necessary.

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 Flush with 10cc of NS and 2cc of heparin in a 10 cc syringe every 12 hours.
After blood draw, lipid administration, blood transfusion, PICC line will be flushed with
20cc of NS.
RN is able to discontinue PICC line: pull line, measure length, assess condition (tip of
catheter) and document findings.

Diet Standards:
Diet will be as tolerated. (Progressing diet will be discerned by RN).
1. Unless specific diet is ordered by MD.
When a procedure is ordered, MD will specify post-procedure diet or NPO status.

Bath/Shower Standards:
Baths will be divided between days/evenings/nights.
1. Baths that are appropriate for night shift will be determined by the RN.
Appropriate patients will have a bath/shower every day.
1. If patient refuses bath, RN will be notified by NCT.
Oral care must be offered by NCT 3x’s/day (with am care, after lunch and after supper).
Oral care on NPO patients must be done at least 3x/day and more as needed (every 8
hours).
1. If patient refuses, RN will be notified by NCT.
Hair care will be done when blood or other debris is in hair.
Hair care will be offered by NCT when appropriate.
Male patients will be shaved daily unless patient has facial hair that they desire to leave
unshaved.
Denture care will be offered in morning and at night by NCT.

Oxygen saturations Standards:

Oxygen saturation will not be measured with vital signs except:
1. Unless specifically ordered by MD.
2. If O2 saturations ordered by MD to remain at a certain level, patient should be on
continuous pulse oximetry.
3. If patient returns to the floor from surgery on oxygen, aggressive pulmonary toilet
should be implemented. Patient should be kept on continuous pulse oximetry until
O2 sats remain above 92% on room air.
4. If patient symptomatic (SOB, chest pain, tachypnea) RN to obtain O2 saturation and
notify MD. Remember the most reliable indicator of respiratory distress is patient rate
and effort (are they using accessory muscles, are they tachycardic, are they having
trouble speaking, are they obtunded).

Intakes and Outputs Standards:

I & O’s will not be measured unless specifically ordered by MD except for:
1. I & O’s will be measured every 8 hours on each patient for the first 24 hours to
establish base line (per nursing practice guidelines).
2. I & O’s will be measured when a patient is on IV therapy.
3. I & O’s will be measured after discontinuing a foley catheter until patient voids.
4. I & O’s will be measured on patients that are on tube feedings.

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Foley Catheter Standards:
RN must have MD order for foley catheter to be initiated.
Foley catheter will be assessed for kinks and emptied every 4 hours.
Foley catheter will be discontinued the night before discharge.
1. Unless patient is to be discharged with foley catheter in place.
For total joint patients, foley catheter will be discontinued 2 days post-operative.
In and Out catheterization may be carried out by RN if patient has not voided 6-8 hours
after foley catheter has been discontinued. RN may repeat in and out catheterization a
second time. If patient has 400cc’s or more of urine out with catheterization, RN will
place catheter and notify MD.
Foley catheter care will be completed with bath every day and more often as needed.

Nasogastric Tube Standards:

RN may place NG tube if a patient has vomited 1000cc’s or more in 8 hours.
NG tube drainage should be measured every 8 hours (per nursing practice guidelines).
Assess nose/skin for breakdown around NG tube every 12 hours.

Chest tube Standards:

Chest tubes (site, tubing, drainage chamber) will be assessed every 12 hours.
Chest tube dressings will be changed every three days and more often as needed.
Chest tube should never be clamped (unless changing the collection chamber).
Chest tube cannot be disconnected from suction.
1. Unless specifically ordered by MD

Medication Administration Standards:

Medication will be administered by RN with MD order in accurate and timely manner. RN
must witness patient taking medication (do not leave medication at bedside).
Lidocaine (1cc-1.5cc) may be added to runs of potassium (10mEq/100cc).
1. Unless specifically contraindicated by MD.
These medications may be ordered by RN as needed under attending MD:
A. Bacitracin: apply to affected area BID and PRN.
B. Chloraseptic (for irritated/sore throats): 1-2 sprays every 2 hours PRN.
C. Tums (for heartburn/indigestion): 2 tabs every 6 hours PRN.
D. Benadryl (for insomnia and itching): 25-50mg PO every 6 hours PRN.
E. Tylenol (for headache): 325-650mg PO every 4 hours PRN.
1. Unless specifically contraindicated (patient allergic or intolerant of
medication)
2. Unless specifically contraindicated by MD.

Admission Standards:
New patients will be admitted during the shift on which they arrive.
1. Unless patient arrives to floor 30 minutes prior to end of shift (7am/3pm/7pm/11pm).
2. If patient arrives to floor one hour prior to end of shift (6am/2pm/6pm/10pm), patient
will be settled into room, vital signs assessed and admission paperwork initiated;
admission paperwork will be completed by next shift.
Patients should be reassigned when there are multiple discharges on one wing so that
admissions are evenly divided between RN’s.

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Discharge Standards:
Discharge will be completed in a timely manner upon completion of all discharge orders
and upon pending discharge being entered into the computer by MD or Patient care
facilitator. Foley catheter/IV/PCA will be discontinued the night before discharge.
1. If discharge orders and pending discharge are not completed 30 minutes prior to end
of shift, RN will be responsible for ensuring that IV is discontinued, patient has
transportation and belongings are collected. RN will initiate paperwork when
possible. Discharge paperwork and process is to be completed by next shift.

Transfer Standards:
Transfer paperwork of patients that are being transferred to another facility by 11am will
be completed by night shift RN. Report will be called by transferring RN.
Night shift RN will do as much preparation for transfer as possible (bath, dressing
change, IV discontinued). RN should also verify pending transfer order in computer/MD
chart and that discharge summary has been requested.

Report Standards:
Report MUST start at 7am/3pm/7pm/11pm. This is the beginning of the shift!
RN must pull up E-MAR and address any overdue tasks and both RN’s will check
orders in SCM to assure that they are up to date. This is the beginning of the shift!
Patient assignment will be done by the off going shift. (Night nurses will divide patient
for the day shift nurses and day shift nurses will divide patient assignment for night
nurses.) Patient assignment will be made with consideration of who had patient during
the previous shift, acuity level, # of patients being discharged).
Assessment Standards:
1. Nursing assessments will be done at the beginning of every shift
Except for patients needing more frequent assessment (per RN’s discretion)
2. Patients will be assessed upon arrival to floor from procedure, surgery or transfer
from ICU.

Vital Signs Standards:

Vital signs will be measured per routine. Routine vital signs are as follows: upon arrival
to floor vital signs will be measured every 4 hours times 24 hours
Every shift. (6a-2p-10p)
1. Unless specifically ordered by MD to be measured more often.
2. Unless patient has IV/epidural PCA.
3. If patient is transferred from another med/surg floor (7th or 8th) vital signs will be
measured as they were on transferring floor.
4. Vital signs will be measured more often as needed per RN’s discretion.

Blood Glucose Monitoring Standards:

Blood glucose will be measured on known diabetic patients as per protocol Unless MD
orders not to do blood glucose monitoring

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Logroll Guidelines

General rules:
1. Patients are transported to UK Hospital immobilized so must consider pre-hospital board
times (don’t forget referring hospital pre-transfer time as well), thus you may receive patient that
has had extended length of time on a board.

2. Evaluate your patient for risk factors associated with skin breakdown such as poor nutritional
status, circulatory impairment from cardiac or vascular disease, diabetes, lack of adipose tissue,
etc.

3. Hardboards should be utilized in the ICU/Floor for patient transfer and obtaining films only
and must be discontinued as soon as possible to prevent breakdown. Do not keep patient on a
board for any longer than necessary (2 hours is maximum time on board).

4. Document off/on board times.

5. Don’t use slider board to transfer the patient. Sliders are flexible devices that do not offer
appropriate spine immobilization.

6. Must reassess sensory/motor function with every turn, transfer and prn.

I. Pre-Log Roll Assessment:

A. Review Medical Diagnosis (Know your patient)
1. Clearance of spines per MD by radiologic evaluation
2. Level of SCI/stability of spine fractures
3. Other injuries

B. Review Medical Order for Activity

1. Spinal Precautions until spines clear
a. HOB flat or Reverse Trendelenburg (if not contraindicated)
2. Log Roll
3. Log Roll with cervical spine precautions

C. Determine number of staff required to perform logroll

1. Leader positioned at HOB
2. Assistants (1-2) for placement on hardboard, wound/skin assessment,
linen change
3. Assistants (3-4) positioned for turning
a. Additional staff may be required depending on patient size and/or
injuries
b. 1st assistant @ torso
c. 2nd assistant @ hips
d. 3rd assistant @ legs

D. HOB flat
1. maintained at all times
2. Reverse Trendelenburg may be used to elevate patient head after
logroll procedure completed

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 E. Inspect Cervical Collar
1. Correct size?
2. Appropriately applied/positioned?

F. Inspect cervical traction (if indicated)

1. Are weights secure and hanging freely?

II. Prepare for Log Roll :

A. Prepare patient for log roll turn
1. Explain procedure
2. Instruct patient to lay still, not to assist with turn
3. Ensure patient is in proper alignment prior to turn
4. Raise bed to approximate waist level of all participants

III. Log Roll Procedure:

A. Leader takes position at patient’s head
1. Position hands on each side of patient’s head
2. Place thumbs at the mandible bilaterally
3. Place fingers behind head at occipital ridge
4. Maintain firm, gently stabilization of neck throughout procedure

B. Leader to assess current motor and sensory function of patient

C. Leader directs assistants to turn patient (in unison on count of ―3‖) toward them
onto patient’s side
1. Leader monitors alignment (nose & umbilicus) continuously

D. Leader directs assistants on opposite side to proceed with turn

1. Placement of rigid backboard
a. position rigid backboard for contact with patient’s back
b. assess skin integrity while patient is on his/her side
c. change linen

E. Leader directs return to supine position on count of ―3‖

1. Patient should be gently rolled as a unit maintaining spinal alignment

F. Continue with patient care

1. Rigid backboard:
*Patient should be centered on board
If not centered, then:
a. Leader maintains cervical alignment as described
b. Equal number of assistants on either side of patient
c. On ―1-2-3‖ count, patient should be repositioned to
center of rigid backboard
2. Linen change:
a. Leader maintains cervical alignment as described and assess
spinal alignment
b. Assistants move to opposite side of bed
c. Repeat log roll procedure in opposite direction

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 G. Leader re-assesses sensory/motor function after all logroll procedures

IV. Transfer/Transport Guidelines :

A. Log Roll procedure is used at all times until spines are cleared by MD order
B. A rigid backboard is used at all times for transfers from one surface to another
until spines are cleared by MD order
1. Stretcher to stretcher
2. Stretcher to procedure/diagnostic table
3. Stretcher to bed
4. Bed to procedure/diagnostic table
5. Bed to bed

C. Slider boards must not be used to LIFT or TRANSFER patient. Slider is not a
rigid surface, thus not a suitable lifting or transfer device.
Exception: slider may be used under hardboard (not next to patient) to
reduce friction associated with movement from surface to surface.
D. Portable Diagnostic X-rays
1. Place patient on rigid backboard per log roll procedure
2. Leader and assistants lift patient on rigid hardboard in unison count ―1-
2-3‖
3. Pancake x-ray board is placed between bed and patient on rigid
backboard
4. Count ―1-2-3‖ in unison to lower patient/hardboard onto pancake board
5. Notify radiology that patient is ready for films
6. Patient remains on hardboard and pancake board until radiology
approves quality of films obtained

Patient should not remain on hardboard > 2 hours!!

7. Remove patient from pancake board

a. Leader and assistants lift patient on rigid hardboard.
b. Pancake board is removed
c. Leader and assistants lower patient in unison (still on hardboard)
to bed surface
d. Remove patient from rigid backboard using log roll procedure

References

Groeneveld, A, et al. Logrolling: establishing consistent practice. Orthopedic Nursing. 2001,

Mar-Apr;(20):45-9.

Hadley, MN. Cervical spine immobilization before admission to the hospital. Neurosurgery.
2002, Mar;(50):S7-S17.

Monhadevan, SV, et al. The evaluation and clearance of the cervical spine in adult trauma
patients: clinical concepts, controversies, and advancement, part 1. Trauma Reports. 2004,
July.

Emergency Nurses Association (2000). Trauma Nursing Core Curriculum:Provider Manual (5 th

ed). Park Ridge IL: 377-383.

153
 University of Kentucky Medical Center

Trauma Intensive Care Unit

Fever Protocol

Disordered temperature regulation is a common manifestation of critical illness. Hyperthermia

occurs secondary to heat generated by hypermetabolism which accompanies critical illness.
This is associated with altered central nervous system thermoregulation resulting in an upward
adjustment of the hypothalamic thermostat.

Fever has both beneficial and harmful effects. Fever is a beneficial survival mechanism that
enables the body to combat infection. Endogenous pyrogens stimulate production of T & B
lymphocytes which increases the body’s antibody production twenty-fold. The harmful effect of
fever is a result of increased metabolic activity which in turn increases oxygen consumption.
The goal of therapy should be aimed at allowing the body’s defense mechanism to help combat
the infectious organism without compromising tissue oxygenation. If the fever is not
compromising tissue oxygenation it is not necessary to treat fever.

Diagnosis and source of infection are often difficult to identify in the critically ill patient. Also,
there are many clinical conditions which produce hyperthermia that should be considered when
attempting to identify the source of fever.

The following algorithm was designed to assist the resident and the intensive care unit nurse in
clinical decision making for appropriate intervention and treatment of the critically ill febrile
patient Protocol for Fever

154
 Fever Evaluation
Temperature > 38.9 C [102 F.] or > 38.3˚C [101˚F] if patient is neutropenic

Greater than 48 hours post op

YES NO

Call House officer

1. Known source of temperature elevation
2. Antibiotic therapy initiated
3. Patient responding to antibiotic therapy

YES NO

Monitor and Notify Pan cultures in Past 96 Hours

House Officer on Rounds

YES NO

Blood Cultures * Pan culture**

(if not one in the past 24 hours)
Consider Other Sources***

Intravenous Lines in Place > 72 hours? Wounds?

If site is obviously infected change the Obtain a wound

line to a new site. Send intracutaneous specimen and
portion for a culture. send for C & S

****Ibuprofen 400-600mg po/per tube

Q 4 - 6 Hours PRN
if Temperature > 39.0 C [102.2 F.]

Temperature > 40 C. [104 F.]

Receiving NMBA

YES NO

External Cooling Call House Officer

155
Cannot use external cooling if not receiving NMBA or not properly sedated. Cooling may cause shivering, peripheral
vasoconstriction driving deep thermal temperature higher and a marked increase in oxygen consumption if not paralyzed or
adequately sedated.

*Blood cultures should be obtained from 3-4 different sites ~20-30ml. (No data to support waiting between draws)
**Pan cultures defined as sputum, blood and urine cultures.
***Special Considerations: Also, consider sinusitis or central nervous system infections [Refer to common source of
infections in ICU patient].
****Acetaminophen 650mg po/pr q4-6 hours PRN should be used for patients with renal insufficiency (Cr>1.5),
thrombocytopenia (<50,0000), a known bleeding diathesis, gastrointestinal stress ulceration, or a hypersensitivity to
NSAIDS.

Other etiologies of fever should also be investigated. Consider:

Alcohol withdrawal
Atelectasis
Deep venous thrombosis
Drug withdrawal
Drugs *
Hematoma
Neuroleptic hyperthermia
Pancreatitis
Subarachnoid hemorrhage
SIRS (secondary to shock, trauma)
Tissue necrosis
Transfusions

*Drugs:

Allopurinol
Antibiotics (penicillin, sulfonamide, cephalosporins)
Antihistamines
Barbiturates
Dobutamine
Hydralazine
Methyldopa
Procainamide
Phenytoin
Quinidine

156
Possible Sites of Infection Seen in the ICU Patient

Pneumonia: (The most common nosocomial infection in the ICU). Risk factors include
prolonged intubation, chest trauma and ARDS. Pathogens commonly found include: gram
negative enteric organisms (Hemophilus, Pseudomonas, and Enterobacter) and/or gram
positive organisms (Enterococcus, other strep species and Staphylococcus aureus).

Urinary Tract Infection: Pathogens commonly found include: E. coli, Enterococcus,

Klebsiella, Pseudomonas, Enterobacter, Proteus and Candida species.

Wound Infection: The wound may be erythematous with or without purulent drainage, or
subcutaneous crepitus. A surgical wound infection may not be clinically apparent until 5 to 7
days post-operatively.

Vascular Catheter Related Infection: The risk of line infection increases with the length of
time the vascular cannula has been in place.

Sinusitis: The risk factors include: nasogastric tube, nasotracheal tube, nasal packing, facial
fractures, recumbent positions, and high dose steroids.

Intraabdominal Infection: The risk factors include: peritoneal contamination by GI contents,

ascites, or presence of intraabdominal hematoma. If a patient develops bacteremia with
Klebsiella, Enterobacter, E. coli, B fragilis, or Enterococci species, an intraabdominal source
should be considered and investigated.

Acalulous Cholecystitis: Any critically ill patient is at risk. Contributing factors include:
opiates, fasting, TPN and shock.

Empyema: The risk factors include: pneumothorax, hemothorax, penetrating chest trauma,
unrecognized diaphragmatic perforation and pneumonia.

Tracheitis: Usually associated with tracheal intubation. Manifestations may include foul
smelling purulent tracheal secretions.

Fungal Infection: This is usually seen in immunocompromised patients or in patients who

have been critically ill for a prolonged period of time and have been on extended courses of
broad spectrum antibiotics.

Vascular Grafts: Manifestations of vascular graft related infections include: wound drainage,
wound infection, graft thrombosis, septic emboli and pseudoaneurysm.

Endocarditis: Central venous catheters can be an etiologic factor. Common pathogens

include: Staphylococcus and Streptococcus.

Mediastinitis: Can be seen after surgical procedures performed through a median sternotomy
and with injuries to the aerodigestive tract.

Central Nervous System Infection: The risk factors include CSF leak (following craniotomy
or basilar skull fracture), craniotomy, intraventricular catheter or penetrating spinal cord injury.

157
 Nursing Guidelines

The goal of therapy is to allow temperature elevation considering the possible benefits of
immune functioning, but be aware of the harmful effects that require
immediate interventions.

1. Tissue oxygenation: Keep SvO2 > 60, SaO2 > 90, in the absence of shivering
2. Hydration: Keep PCWP > 10, CVP > 8, UOP > 30cc/hr
3. Nutrition: Consult R.D. to ensure metabolic needs are being met with current feeding
regimen.
4. Pain/Sedation/Monitor for signs and symptoms of pain and assess need for sedation.
Adequate sedation will help control shivering and if unsuccessful will need NMBA.
5. External cooling should only be used if temperature is > 40 C. AND the patient is receiving a
NMBA or is properly sedated.
6. Antipyretics may be given if patient temperature is < 39.0 C. and adequate tissue
oxygenation cannot be achieved.
7. Rectal temperatures correlate most closely with core temperatures and should be used if
the patient does not have a pulmonary artery catheter, unless contraindicated or temperature
sensing Foley catheter.

External Cooling:
Hyperthermia is a natural adaptive mechanism in critical illness. Hypothalamic temperature
regulation is adjusted upward to accommodate the hyperthermia associated with
hypermetabolism and infection. Under these circumstances, attempts to lower temperature to
normal can be harmful because CNS autoregulation has been reset at a higher core
temperature. External cooling will produce increases in sympathetic tone that markedly
increase oxygen consumption. The body will attempt to restore temperature, during external
cooling by stimulating skeletal muscle, producing shivering, will increase tissue oxygen
consumption. External cooling will cause peripheral vasoconstriction. This will shunt heat
deeper and make it more difficult to cool. Recognizing the role of hyperthermia in critical illness,
a more permissive attitude is taken towards temperature elevation. Modest rise in core
temperature is monitored without treatment, and moderate temperature elevation (>102.2 ) is
treated with antipyretics. External cooling is reserved for extreme temperature elevation (>104 )
when compromise of tissue oxygenation and/or direct tissue damage may occur. More
aggressive temperature control can and should be employed when marginal tissue oxygenation
occurs with lower temperatures.

158
References
Rosenthal KE, Joshi, M. Evaluating the septic-appearing multiple trauma patient. Critical Care
Report. 1990; 1: 323-335.

Bruce JL, Grove SK. Fever: pathology and treatment. Critical Care Nurse. 1992; 12(1):40-49.

Wasserman MR, Keller EL. Fever, white blood cell count, and culture and sensitivity: their
value in the evaluation of the emergency patient. Topics in Emergency Medicine.
1989; 10(4): 81-88.

Robinson-Strane SR, Bublick JS. Dobutamine induced fever. Annals of

Pharmacotherapy.1992; 26: 1523-1524.

S, Livingston DH, Elcavage J, et al. The utility of routine daily chest radiography in the surgical
intensive care unit. The Journal of Trauma. 1993;35(4): 643-646.

Larach MG, Localio AR, Allen GC. et al. A clinical grading scale to predict malignant
hyperthermia susceptibility. Anesthesiology. 1994; 80(4): 771-778.

Haynes GR, Gottesman J, Dorman BH, et al. Postoperative hyperthermia in a patient

having critical brain resection. Southern Medical Journal. 1994; 87(3): 399-401.

Schmitz T, Bair N, Falk M, et al. A comparison of five methods of temperature

Measurement in febrile intensive care patients. American Journal of Critical Care.
1995; 4(4): 286-292.

Bessey PQ. Metabolic response to critical illness. Scientific American Medicine. 1994.

Revised: 12/08

159
 Guideline for Rib Fracture Management

Rib fracture repair has been selectively performed for more than 50 years; however,
clear operative indications have not been established yet. The long-term outcome of a
strictly nonoperative approach to flail chest, flail sternum, and rib series fracture may not
be optimal with the development of chronic pain, chest wall deformity, reduced chest
wall compliance and rib fracture nonunion.

In order to improve patient’s morbidity and mortality, indications for rib fracture repair
should be considered in patients with flail chest, flail sternum and painful movable rib
fractures refractory to conventional pain management1-7.

When considering rib fracture repair, anterior plating with bicortical locking screws or
locked intramedullary nails should be used. The anterior approach, which can be
performed in a minimal invasive technique, does not violate the pleural space. Further
locking screws, where the screw is threaded in to the plate improves fixation stability
especially in thin and osteoporotic bone2,4,7.

Conservative rib fracture management should be adequate with the use of PO/IV pain
medication as well as intercostal pain pumps6,7.

ORIF of rib fractures does not normally require an OnQ pump for post operative pain
management. PO/IV medication or IV PCA should be considered first for pain
management.

Rib series: > 6 fractured ribs. Consider ORIF repair for pain management only if
fractures occur at rib levels 3 – 7 with a failure of conservative pain management.

Flail chest: 4 consecutive unilateral ribs fractured in 2 or more places.

Sternal flail: sternum is dissociated from the hemi-thoraces of bilateral, multiple, and
anterior cartilage or rib fractures.

160
References:

1. Management of flail chest injury: Internal fixation versus endotracheal

intubation and ventilation. Ahmed et al. Journal of Thoracic and
Cardiovascular Surgery, 1995.
2. Operative chest wall stabilization in flail chest-outcomes of patients with or
without pulmonary contusion. Voggenreiter et al. J Am. Coll Surg. 1998.
3. Pulmonary function testing after operative stabilization of the chest wall for
Flail chest. Lardinois et al. European Journal of Cardio-thoracic Surgery 2001.
4. Surgical Stabilization of Internal Pneumatic Stabilization? A Prospective
Randomized Study of Management of Severe Flail Chest Patients. Tanaka et
al. Journal of Trauma, 2002.
5. Continuous Thoracic Paravertebral Infusion of Bupivacaine for Pain
Management in Patients with Multiple Fractured Ribs. Karmakar et al. Chest.
2003 Feb.
6. Pain Management in Blunt Thoracic Trauma. EAST guideline. Journal of
Trauma. 2005.
7. Rib Fracture Repair: Indications, Technical Issues, and Future Directions.
Nirula et al. World J. Surgery 2009.

161
162
 Chest Tube Management Protocol

A pneumothorax occurs when the resting negative pressure in the pleural space is lost,
leading to collapse of the ipsilateral lung. Pneumothoraces can occur spontaneously (primary
pneumothorax) after for example, a bleb rupture; or result from trauma (secondary
pneumothorax). In penetrating trauma, air can enter the pleural space from the atmosphere. In
blunt trauma, air escapes the pleura after barotrauma or laceration by a fractured rib. Signs and
symptoms of a pneumothorax can include: dyspnea, pleuritic chest pain, anxiety, cough, and
tachypnea. Large or symptomatic pneumothoraces are treated with chest tubes (tube
thoracostomies).
Chest tubes are removed when the pneumo/hemothorax has resolved and the amount
of pleural effusion is decreased. Traditionally, chest tubes are removed from suction when the
air leak has resolved. Chest tubes on water-seal with no air leak, less than 200cc drainage in 24
hours and minimal or no residual pneumothorax on CXR are considered for removal. A chest x-
ray is usually obtained 3-8 hours after placement on water-seal to identify any expansion of the
pneumothorax. Sometimes, a second follow-up radiograph would be taken the next morning
and if still negative, the chest tube is removed. If the initial chest x-ray on water seal shows
development of or significant expansion of the pneumothorax, the chest tube is placed back on
suction and/or reevaluated. An interval chest x-ray would follow.
There is emerging evidence to support a more rapid and systematic approach to chest
tube removal. Recent studies have determined which technique, water-seal or suction, allows
for shorter chest tube duration, when radiographs should be obtained, and finally, the optimal
time interval for identifying a recurrent pneumothorax on chest x-ray after placing a chest tube
on water-seal (Schulman 2005).
Some authors have suggested that the placement of chest tubes to water seal is
unnecessary, prolongs dwell time and that tubes on suction with no air leak may simply be
removed without a period of water seal. Martino et al. determined that there was no difference in
total chest tube dwell time between chest tubes placed on water-seal vs. those in which water-
seal was not used, although it appears that a short trial of water-seal allows for occult air leaks
to become clinically apparent and significantly reduces the need for another chest tube (Martino
1999). This water seal trial followed by a CXR is the practice of the Blue Surgery Service.
Recently, Schulman et al. studied the time interval for identifying a pneumothorax on
chest x-ray after placing a chest tube on water-seal (Schulman 2005) and from this work
formulated a new chest tube removal algorithm. This study concluded that a chest x-ray
obtained 3 hours after placing a chest tube on water-seal effectively excludes development of a
clinically significant pneumothorax. Their algorithm (modified below) will allow patients to
progress from water-seal to chest tube removal and discharge on the same day, enhancing
patient satisfaction with potential associated cost-savings (Schulman 2005).
Pizano et al. studied the time interval between the removal of a chest tube and a chest
x-ray (Pizano 2002) and concluded that a chest x-ray obtained within 1-3 hours after chest tube
removal effectively identifies a pneumothorax. These data add further support to Schulman’s
algorithm which uses a 3 hour time interval between chest tube removal and ―post-pull‖ CXR. In
addition, this study was conducted in mechanically ventilated patients suggesting that it is safe
to remove a chest tube from patients undergoing positive-pressure ventilation (Pizano 2002).

163
Chest tube removal algorithm (From Schulman CI et al. J Trauma 2005;59:92-95).

References

Kirsch TD and JP Mulligan. Tube Thoracostomy. Roberts: Clinical Procedures in Emergency

Medicine, 4th ed., Copyright © 2004 Saunders. P. 187-188.

Martino K, Merrit S, Boyakye K et al. Prospective randomized trial of thoracostomy removal

algorithms. J Trauma 1999;46:369–371.

Pizano LR, Houghton DE, Cohn SM et al. When should a chest radiograph be obtained after
chest tube removal in mechanically ventilated patients? A prospective study. J Trauma
2002;53:1073–1077.

Schulman CI, Cohn SM, Blackbourne L et al. How Long Should You Wait for a Chest
Radiograph after Placing a Chest Tube on Water Seal? A Prospective Study. J Trauma
2005;56:92-95

08/08

164
 © University of Kentucky Medical Center
Trauma Surgery Service
DVT Risk Factors

Underlying condition Weight

Inflammatory bowel disease 1

Varicose veins 2
Cardiac disease 2
Hormone (estrogen) therapy 2
Post-partum < 4 weeks 2
Obesity 2
Malignancy 2
History of thromboembolic disease 3
Acquired or congenital hypercoagulable state 3

Iatrogenic factors
Anticipated need for central line > 24 hours 1
More than 4 units transfused first 24 hours 2
Surgical procedure > 2 hours 2
Immobility > 72 hours 2
Immobility > 5 days 3
Repair of ligation of major venous injury 3

Injury related factors

Coagulopathy on admission 2
Intracranial bleed 2
Spine fractures 2
Coma (EMV < 8 for > 4 hours) 2
Complex lower extremity fractures 3
Pelvic fractures 3
Spinal cord injury with para or quadriplegia 3

Age
40 to 59 1
60 to 74 2
> 75 3

ABSOLUTE HIGH RISK CRITERIA

1. History of venous thromboembolism
2. Hypercoagulable state
3. Immobility > 5 days
4. Partial or complete spinal cord injury

165
DVT PROPHYLAXIS ALGORITHM

Low Risk 1 Elevate foot of bed. Encourage Ambulation

Moderate Risk 2-4 Elevate foot of bed. Encourage ambulation.

Low dose heparin (5000u SQ q8h.
Apply contraindication to heparin.
High Risk Patient > 5

Contraindication to Heparin
Active hemorrhage
Solid Organ injury
Intracranial Hemorrhage
Etc.
(Should be cleared by NS or appropriate service prior to admission)

NO YES

LOWER EXTREMITY CAN ACCOMMODATE SEQUENTIAL

COMPRESSION DEVICES (SCD)

YES NO

Apply SCD’s

Lovenox (Enoxaparin) Apply SCD’s to upper

30MG SQ every 12 hr or extremity if possible 40 mg SQ
once daily.
(Hold AM dose prior to discontinuation Risk of Hemorrhage Resolved
of epidural catheter on 48 hours post active hemorrhage,
morning of operation) solid organ injury, intracranial
hemorrhage, etc.

Discontinue SCD’s

*Patients who are non ambulatory at discharge should be maintained on Lovenox or switched to
low dose Coumadin to maintain INR at 1.5-2.0. (Follow Ortho recommendations on discharge for
Lovenox. If no Ortho recommendations then order X 2 weeks or until ortho clinic follow-up.)
** Routine Duplex Surveillance is no longer performed. Venous Duplex should be requested
when clinical suspicion for DVT is present.

166
THERAPY FOR DOCUMENTED DVT/PE

ANTICOAGULATION THERAPY FOR ACUTE DVT/PE

1. Unfractionated heparin
IV heparin bolus of 80units/kg followed by a continuous heparin infusion @18units/kg/hour.
The goal is prolongation of the PTT to twice control (+ 10%). Obtain PTT 6 hours
after initiation of therapy. Dose adjustments can be made per protocol.

Low molecular weight (fractionated) heparin (Preferred).

Enoxaparin (Lovenox) 1 mg/kg SQ bid or 1.5mg/kg QD. This will provide therapeutic
anticoagulation. Low molecular weight heparins do not effect PTT and therefore
measurement is not required. (Dosing in obese patients has not been established.
Caution should be used in patients with renal failure). Activated factor X levels must
be checked and this is not routinely required.

2. Begin warfarin (Coumadin) 10mg/day once therapeutic anticoagulation on heparin

(fractionated or unfractionated) has been achieved. Adjust dose to a target INR of
to 3.5 and then discontinue heparin (fractionated or unfractionated). Some patients
can be maintained on therapeutic anticoagulation with low molecular weight heparin.
Most patients will be converted to warfarin. Anticoagulation should be continued for
at least three months.

INDICATIONS FOR VENA CAVA FILTER PLACEMENT

Prophylactic IVC filter

The data are inconclusive regarding prophylactic filter placement.
Prophylactic filter may be considered in the following patients:
1. High risk patients with a contraindication to low dose heparin and unable to
wear compression stockings or foot pumps.
2. Documented DVT with free floating iliofemoral or vena cava thrombus.
3. Documented PE with hemodynamic compromise and a second PE
would be lethal.

Therapeutic IVC filter

1. PE on adequate anticoagulation.
2. Documented DVT/PE with contraindication to anticoagulation.
3. Documented DVT/PE with a complication of full anticoagulation.
4. Failure to achieve therapeutic anticoagulation.

167
168
Revised 10/08
University of Kentucky Medical Center
Trauma Service

Stress Ulcer Prophylaxis Guidelines

Incidence of Gastrointestinal Stress Ulceration

Clinically important stress-related mucosal bleeding affects up to 4% of critically ill patients, with
a mortality rate that approaches 50%.

Pathophysiology
The splanchnic hypoperfusion that causes stress-related mucosal damage in critically ill
patients is multifactorial and results from sympathetic nervous system activation,
increased catecholamine release and vasoconstriction, hypovolemia, decreased cardiac
output, and the release of proinflammatory cytokines.

Stress Ulcer Prophylaxis (SUP)

1) Histamine H2-receptor antagonists (H2RA) Preferred Agents
a. UK formulary –
i. PO - Famotidine 20mg tablets
ii. IV - Famotidine 20mg injection
2) Proton Pump Inhibitors (PPI)
a. UK formulary
i. PO
1. Pantoprazole 40mg tablets
2. Omeprazole/Sodium Bicarbonate 40mg packets
ii. IV
1. Pantoprazole 40mg injection

Recommended Prophylaxis at the University of Kentucky

Who Requires Prophylaxis

Prophylaxis for stress ulceration is not necessary in all patients. Only patients with one
or more of the following risk factors require prophylactic therapy:

1. Respiratory failure requiring mechanical ventilation > 48 hours.

2. Coagulopathy (platelet count < 5,000, INR > 1.5, aPTT>2X control)
3. Major Trauma (ISS > 16)
4. Major Burns (TBSA > 30%)
5. Major head and spinal cord injury
6. Stroke
7. Known history of peptic ulcer disease
8. Organ transplant recipients
9. Patients receiving NSAID’s or steroids

Other Considerations
Early enteral nutrition may be an important factor for preventing gastrointestinal mucosal
ischemia. Enteral feedings produce splanchnic vasodilation and increased mucosal blood flow
thereby preventing mucosal ischemia and its untoward consequences.

169
 UK Trauma Service
Stress Ulcer Prevention Guidelines

Hospital Admission

Screen for Risk Factors

Respiratory failure requiring mechanical ventilation > 48 hours.
Coagulopathy (platelet count < 50,000, INR > 1.5, aPTT >2x control)
Major Trauma (ISS > 16)
Major Burns (TBSA > 30%)
Major head and spinal cord injury
Stroke
Known history of peptic ulcer disease
Organ transplant recipients
Patients receiving scheduled NSAID’s or steroids

≥ 1 Risk Factor?

Yes No

Famotidine 20mg BID* No SUP necessary

Enteral Access Available? Consider switch to a PPI ONLY WHEN:

1. Current or recent upper GI bleed
2. Famotidine allergy
3. Ongoing treatment for H. pylori
4. Unexplained mental status changes
Yes No 5. Receiving PPI at home
Give PO Give IV

*For renal insufficiency/failure, adjust dosing according to pharmacy recommendations.

170
 Diagnosis and Treatment of Stress Related Mucosal Bleeding
Diagnosis
Endoscopy is the diagnostic modality of choice.

Overt Bleeding
Overt bleeding is defined as hematemesis, melena, hematochezia, gross blood >
(100cc) in the NG tube, or coffee ground emesis or nasogastric drainage.

Clinically Important Bleeding

Clinically important bleeding is defined as overt bleeding complicated by one or more of
the following within 24 hours of the onset of bleeding (in the absence of other causes):
1. spontaneous decrease of > 20 mmHg in the systolic blood pressure
2. an increase in HR > 20 beats/min
3. a decrease in [Hgb} > 2 gm/dl (Hct of > 8%)
4. subsequent transfusion where the Hgb & Hct do not rise appropriately for the number of
units transfused

Only clinically important bleeding warrants further investigation and if necessary

treatment. Endoscopy is the diagnostic modality of choice.

Treatment
Initial bolus of pantoprazole 80mg, followed by pantoprozole 8mg/hr continuous infusion
for 72 hours. Follow with once daily PPI for ___ months.

References

Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal bleeding in
critically ill patients. The New England Journal of Medicine. 1994; 330(6): 378-381.
Tryba M. Sucralfate versus antacids or H2-antagonists for stress ulcer prophylaxis: a
meta-analysis on efficacy and pneumonia rate. Critical Care Medicine. 1991; 19(7):
942-949.
Schepp W. Stress ulcer prophylaxis: Still a valid option in the 1990s? Digestion. 1991;
54: 189-199.
Pickworth KK, Falcone RE, Hoogeboom JE, Santanello SA. Occurrence of
nosocomial pneumonia in mechanically ventilated trauma patients: a comparison of
sucralfate and ranitidine. Critical Care Medicine. 1992; 21(12): 1856-1861.
Pemberton LB, Schafer N, Goehring, et al. Oral ranitidine as prophylaxis for gastric
stress ulcers in intensive care unit patients: Serum concentrations and cost
comparisons. Critical care Medicine. 1993; 21(12): 339-342.
Loperfido S, Monica F, Maifreni L, et al. Bleeding peptic ulcer occurring in
hospitalized patients: Analysis of predictive and risk factors and comparison with out-of-
hospital onset of hemorrhage. Digestive Diseases and Sciences. 1994; 39(4): 698-
704.
Cook D, Gordon G, Marshall J, et al. A Comparison Of Sucralfate And Ranitidine For
The Prevention Of Upper Gastrointestinal Bleeding In Patients Requiring Mechanical
Ventilation. The New England Journal of Medicine. 1998; 338(12): 791-797.

171
172
Revised: 09/08
University of Kentucky Medical Center

Trauma Service
Guideline for Maintenance of
Endoscopic Feeding Tubes

Early enteral nutrition is very important in the management of critically ill patients. Obtaining
and maintaining access to the GI tract is an essential component of patient care. The gastric
dysfunction that accompanies critical illness necessitates post pyloric placement of small-bore
feeding tubes to insure tolerance of enteral formulas and the administration of medication.
Reliable post-pyloric placement of feeding tubes using a blind technique is difficult. Surgical
and endoscopic methods are both difficult and expensive. Maintaining patency of these
important enteral access devices to insure continuous nutrient flow and to prevent costly tube
placement is essential for proper patient care.

These guidelines were developed to assist the clinician with medication administration,
maintenance of the feeding tube, and trouble shooting guideline when the feeding tube
becomes clogged.

Maintenance

Routine flushing with 20 - 30 ml of water before and after medications is essential for
maintaining patency, especially with medications containing sorbitol. If enteral nutrition is held
for any length of time the feeding tube should be flushed with 30 ml of water. Adequate flushing
of the feeding tube is the key to maintain patency and cannot be over emphasized.

Common Causes of Obstruction

1. Infrequent or inadequate water flushes pre/post medication delivery.

2. Viscous medications and tablet fragments may adhere to lumen wall causing obstruction
within 15 minutes to one hour.
3. Small caliber feeding tube collapse when aspirated. Do not aspirate small bore
feeding tubes!
4. Aspirated tube feeding formula mixes with gastric acid and coagulates, producing tube
obstruction.
5. Feeding flow rates less than 50cc/hr. may cause residue buildup and obstruction.
6. Viscous feeding formulas such as those containing additives like Promod.
7. Tube type effects patency. Silicone tubes have a higher obstruction rate than
polyurethane tubes.
8. Tube kinking from dislodgment.

173
Assessment of Small Caliber Feeding Tubes and Feeding Tube Regimen

1. Auscultation is not adequate to verify feeding tube location initially or during ongoing
assessment. An x-ray must be done to confirm position.
2. Monitor for potential regurgitation of tube feeding into the stomach by aspiration from the
nasogastric tube every 4 hours.
3. Change tube feeding canister every 24 hours, formula every 12 hours for canned
preparations, and every 6 hours if pre mixed by dietary.
4. Document cessation of tube feeding, amount given, versus the amount prescribed.

Administration of Medications

1. Consider whether medications should be taken on an empty/full stomach. If a patient is

receiving intermittent feedings schedule medications accordingly.
2. Check nasogastric or PEG residual prior to medication delivery. If residual is equal/greater than
75% of hourly rate, wait a short period and check again before giving medication.
3. Flush feeding tube with 20-30 ml of water pre/post medication.
4. Utilize liquid form of medications instead of tablets when possible.
5. Drugs designated SA, E.E.S., SL, XL, EC, LA, MT should never be crushed or dissolved
unless formulated for that purpose.
6. Never add medications to enteral formulas in tube feeding container. This practice may
cause coagulation and feeding tube obstruction.
7. Administer multiple medications separately to avoid drug interactions; Flush with 5ml of
water between medications, when possible.
8. Determine whether medication should be given in the stomach or small bowel. Drugs
such as sucralfate, antacids, iron salts, ketoconazole, should be administered via the
nasogastric tube to insure efficacy.
9. Phenytoin administrations; stop tube feeding one hour pre/post administration.
10. Some medications require special preparation to insure proper efficacy. If unsure of how
to administer the drug, please check with the pharmacist.

Nursing Guidelines

1. Ask pharmacy if medication is available in solution.

2. Always flush feeding tube with 20 - 30 ml of water pre/post medication administration.
3. Elevation of head of bed 30 is necessary when feeding tube is in the stomach.
Elevation is not necessary but is recommended when the feeding tube is in the post-
pyloric position.
4. Monitor the patient for diarrhea or constipation (refer to appropriate algorithm).
5. Send the patient to the operating room with enough formula for anticipated length of
case (May send 12 hours of formula in the container, if case is expected to go beyond
12 hours, please send cans of formula with patient).
6. The nurse should notify the patient’s primary service in the event the anesthesiologist or
consulting service requests that the tube feeding be stopped.

174
Troubleshooting Obstructions for Small Caliber Feeding Tubes

1. If a small caliber feeding tube becomes clogged, attempt unclogging with warm (not hot)
water or carbonated soda.
2. Pancreatic enzymes (Viokase) can be used to unclog tubes. Prior to administration of
above agent, aspirate tube-feeding formula using a 30 - 50 ml syringe. This will clear
tube up to the obstruction site. Clamp tube post administration for 15 minutes, and then
flush with water.
3. Due to rare instances of tube perforation, reinsertion of the stylet is not recommended
without the physician’s approval or supervision

See Clogged Feeding Tube Algorithm

175
 Clogged Feeding Tube

Slowly aspirate tube feeding formula using 30-50 syringe

Flush tube with 30 ml of warm water. Clamp tube for 15 minutes

Clogged Unclogged

Continue tube feeding

Administer the following:

Viokase + sodium bicarbonate (obtained from pharmacy)

Clamp feeding tube for 15 minutes

Clogged Unclogged

Raise HOB 30 degrees Continue tube feedings

Turn patient on side

Clogged

Is tube kinked? Obtain KUB, reposition tube

with MD order. Flush with 30 ml warm water

Clogged Unclogged

Consider tube replacement Continue tube

feeding

176
References

Byerly WG. Drug information questions and answers. Hospital Pharmacy Hotline. 1992; 5: 2.

Drug Information Center, University of Kentucky Medical Center. Pharmacy News for Nurses.
1992; 13(4):

Kohn CL, Keithley JK. Enteral nutrition-Potential complications and patient monitoring. Nursing
Clinics of North America. 1989; 24: 339-353.

Lehmann S, Barber J. Giving medications by feeding tube. How to avoid problems. Nursing
91. 1991; 21: 58-61.

Metheny N. Minimizing respiratory complications of nasoenteric tube feedings; State of science.

Heart and Lung. 1993; 22: 213-223.

Paauw JD, Fagerman KE, McCamish, et al. Enteral nutrition solutions. The American Surgeon.
1984; 50(6): 312-316.

Potts RG, Zaroukian MH, Guerrera PA, et al. Comparison of blue dye visualization and glucose
oxidase test strip methods for detecting pulmonary aspiration of enteral feedings in intubated
patients. Chest. 1993;103: 117-121.

Powell KS, Marward SP, Farrior ES, et al. Aspirating gastric residuals causes occlusion of
small-bore feeding tubes. Journal of Parenteral and Enteral Nutrition. 1993; 17: 243-246.

Thurlow PM. Bedside enteral feeding tube placement into duodenum and jejunum. Journal of
Parenteral Enteral Nutrition. 1986; 10: 104-105.

White WT, Acuff TE, Skyes TR, et al. Bacterial contamination of enteral nutrient solution: A
preliminary report. Journal of Parenteral and Enteral Nutrition. 1979; 3(6): 459-461.

Zaloga GP. Bedside method for placing small bowel feeding tubes in critically ill patients. A
prospective study. Chest. 1991; 100(6): 1643-1646.

177
UNIVERSITY OF KENTUCKY HOSPITAL POLICY NUMBER: HP08-39
CHANDLER MEDICAL CENTER FIRST ISSUED: 7/04
HOSPITAL POLICY CURRENT AS OF: 9/06

SUBJECT: Enteral Feeding: Verification and Maintenance of Small-Bore Feed Tubes in

Adults
SEE ALSO: NN08-03, Placement and Maintenance of Small-Bore Tubes (Adults)

INFORMATION
To facilitate delivery of enteral nutrition in adults, the Hospital has established guidelines for the
verification and maintenance of small-bore feed tubes.
Clinical Nutrition’s consultation service should be involved with all patients receiving enteral
nutrition, and will be responsible for ordering the feeds.

Confirmation of Tube Placement

Verification of small-bore feeding tube position requires initial radiographic confirmation with
KUB or lower chest x-ray prior to initiation of feeding.
Exception: Feeding tubes placed during laparotomy do not require radiographic confirmation. In
patients with surgical disruption between the GI tract and larynx, the physician may
document that radiologic confirmation of the feeding tube is not necessary.
1. The physician will notify the nurse of the location of the feeding tube and give an order
to begin enteral feeding.
2. The nurse should document the location initially on the nurses’ note and on the
patient’s care plan or the electronic Assessment and Intervention record, and should
document that tube feeding is started per physician’s order. This documentation is
required each time a feeding tube is inserted and with each time feeding started.
3. If tube is not in the small bowel as confirmed by x-ray, then nurse may reattempt
insertion twice. If tube continues to be in gastric position after both subsequent attempts,
the nurse will document and notify physician for endoscopic tube placement.

Administration of Formula (Open System)

Formula administration should be continuous via a feeding pump, unless otherwise ordered by
the physician. Bolus feedings should be avoided in the adult ICU patient. Cyclic administration
that delivers feeding over a few hours (either daily or intermittently during a 24-hour period)
using a feeding pump may be appropriate in some patients and should be ordered by the
physician.
Food coloring or dye on an on-going basis is contraindicated and should not be added to the
formula or container. Physicians may order food coloring added to tube feeding in specific
situations in which aspiration of tube feeding is suspected. Nurses should follow the guidelines
for use of food coloring in these instances.

Prevention/Assessment of Aspiration
For All Patients on Tube Feeding
1. Unless contraindicated (i.e., patient with cervical spine injury or subdural drain), elevate the
head of the bed to 30 to 45 degrees to reduce the risk of aspiration. Patients with spinal
injuries may be able to be placed in reverse Trendelenburg position at 30 to 45 degrees to
reduce the risk of aspiration.
Note: The nurse should verify head of bed elevation with the physician.
2 -- HP08-39, Verification and Maintenance of Small-Bore Feed Tubes in Adults

178
For Critically Ill Patients with One Major Risk Factor (refer to following list of risk factors),
it is recommended: • to provide all care listed above, • maintain tight glycemic control (blood
glucose between 80-110 mg/dl), and • use continuous infusions rather than intermittent boluses.

For Critically Ill Patients with Two or More Major Risk Factors (refer to following list of
risk factors), it is recommended: • to provide all care listed above, • that all feeding tubes be
in the small bowel, and • to use prokinetic agents (Metoclopramide).

Major Risk Factors • previous episode of aspiration • decreased LOC (sedation or elevation in
intracranial pressure) • neuromuscular disease • neuromuscular blocking agents • endotracheal
tube or intubation • vomiting • persistent high residuals For

Patients Receiving Gastric Tube Feeding

1. If the patient has any of the risk factors for aspiration listed above, tube feeding
tolerance should be assessed by checking residuals on gastric tube feedings every four
hours.
2. For gastric residuals of > 300 ml, hold tube feeding for 1 hour, then recheck residual.
If residual remains > 300 ml after 1 hour, then hold tube feeding, discard residual, and
notify service.
3. If second gastric residual is < 300 ml, resume previous tube feeding orders and return
residual to patient. If second gastric residual is > 300 ml, hold tube feeding and notify
service for specific orders (see Enteral Nutrition Physician/Patient Care Orders, form
J703).

Glucose Monitoring in Patients Who are Diabetic or Receiving Insulin

1. Fingerstick glucose should be monitored at least every six hours in diabetic patients or
in those receiving insulin.
2. Patients receiving insulin infusions require more frequent glucose monitoring, which
should be specified by the physician.

Approved by Karen Stefaniak, Chief Nursing Officer

Approved by Joseph Conigliaro, M.D., Associate CMO, Quality & Patient Safety Authorized by
Murray B. Clark, Jr., Associate VP for MC Operations

179
Revised 9/08
University of Kentucky Medical Center
Trauma Intensive Care Unit
Bowel Regimen Program

The injured/critically ill patient undergoes physiologic alterations in gut function. Gastric motility
slows; use of narcotics slows intestinal motility, warranting bowel function surveillance to ensure
timely identification and intervention of alterations. All trauma service ICU patients will be
started on a bowel protocol upon admission consisting of Docusate Sodium 250 mg twice daily
and Biscodyl suppository twice daily prn. Assessment of the patient should include bowel
patterns pre-injury, other medical conditions that predispose patient to alterations in bowel
function, medications,

High risk indicators: use of narcotic analgesia, lack of BM x 24 hours. Diarrhea and constipation
in critically ill patients may either be serious or benign conditions. There are many causes for
constipation such as improper diet, intestinal obstruction, tumors, excessive use of laxatives and
weakness of the intestinal musculature. What constitutes constipation is very subjective and
individualized. However, absence of stool > 3 days in patients receiving enteral nutrition should
be investigated and appropriate therapy initiated when indicated.

Diarrhea is common in critically ill patients, occurring in 24% of patients admitted to intensive
care units. Many factors contribute to diarrhea, such as infection, antibiotics, and drugs
containing sorbitol, bowel edema, inflammation, enteral feeding rate, and hyperosmolar enteral
feedings. Incomplete digestion may occur in patients who have had feedings withheld for
several days, therefore low rates with slow advance are recommended when beginning enteral
feedings. However, diarrhea associated with enteral feedings is usually seen in patients who
have gut atrophy from prolonged fast or patients on high hourly feeding rates (> 75 ml/hour).
Hypoalbuminemia (<2.5g/dl) and attendent bowel edema have been implicated as a cause of
diarrhea, but this association has never been firmly established.

Diarrhea associated with antibiotic therapy is usually benign, but can be serious. Antibiotic
therapy alters colonic flora which may allow overgrowth of pathogenic and or diarrheagenic
bacteria. Clostridium difficile is present in the normal colonic flora of some patients.
Overgrowth by toxigenic C. difficile can occur in patients receiving antibiotic therapy. C. difficile
infection can present as diarrhea that is mild to moderate or can cause severe colitis with
pseudomembrane formation. Pseudomembraneous colitis can lead to severe diarrhea,
hypovolemic shock, toxic megacolon, perforation and death. Specific findings of
pseudomembraneous colitis include watery, green, foul-smelling, non-bloody or bloody diarrhea,
cramping abdominal pain, fever (> 39.5 C) and leukocytosis. Stool specimen should be sent for
C. difficile toxin. C. difficile culture is a less efficient method and does not differentiate between
nontoxiocogenic colonic flora and toxic strains of C. difficile. Turnover time for the C. difficile
toxin assay is usually 24 to 48 hours. Severe diarrhea, abdominal distention, tenderness,
unexplained SIRS, megacolon on plain film and a high index of suspicion should prompt an
endoscopic evaluation to exclude pseudomembranes.

Treatment varies according to the severity of the illness. Enteral metronidazole is the first line
drug of choice. If a patient cannot tolerate oral medication intravenous metronidazole should be
given. Intravenous vancomycin is not effective in the treatment of C. difficile enterocolitis.
Enteral vancomycin is the drug of choice for severe colitis and treatment failures on
metronidazole.

180
181
182
Nursing Guidelines:
Diarrhea:

1. Document frequency and amount of stool

2. Inform physician of greater than 3 liquid stools day or greater than 500 ml for 2 consecutive
days
3. Use skin barrier or fecal bag to prevent skin breakdown from diarrhea stools
4. If oral medication is administered in the nasogastric tube clamp for at least 30 minutes
5. Flush feeding tube with 20 ml - 30 ml of water pre and post medication
6. Based on algorithm send stool specimen for C. difficile toxin per physicians order [turn around
time is usually 24 to 48 hours]
7. Notify H.O. if patient does not respond to antibiotic therapy within 48 hours or if diarrhea
returns < 72 hours after antibiotic stopped

Constipation:
1. Notify physician when patient who is receiving PO/enteral feeding has not had a stool for > 3
days
2. Ensure patients are receiving adequate hydration
3. Assess for medications or dietary intake (low residue, low fiber) that may contribute to
constipation
4. Lubricant should be used when manually removing impaction
5. Abdominal pain and/or distention may be a clinical manifestation of a serious problem

References
Thomspon, et al. (1992) cited in Powell, M and Rigby D. Management of bowel dysfunction:
evacuation difficulties. Nursing Standard. 2000; 14(47): 47-54.

Winney, J. Constipation. Nursing Standard. 1998; 13(11): 49-56

Sykes N. The treatment of morphine induced constipation. European Journal of Palliative

Care. 1998; 15(1):

Fekety R, Shah AB. Diagnosis and treatment of clostridium difficile colitis. JAMA. 1993; 269:
71-75.

Kelly CP, Pothoulakis C, LaMont JT. Clostridium difficile colitis. The New England Journal of
Medicine. 1994; 33(94): 257-262.

Hwang TL, Lue MC, Nee YJ, et al. The incidence of diarrhea in patients with hypoalbuminemia
due to acute or chronic malnutrition during enteral feeding. American Journal of
Gastroenterology. 1994; 89(3): 376-378.

Johnson, DA. Diarrhea in critically ill Patients. Problems in Critical Care. 1989; 3(3): 392-408.

183
Blue Surgery Bladder Management Protocol
for the Urologically Non-complicated Patient

UTIs account for 31% of nosocomial infections in US medical ICUs, thus it is essential to
understand the logistics of Foley monitoring and maintenance. The risk of bacteriuria from an
indwelling catheter is 3-10% per day. Daily assessment for the continued necessity of an
indwelling catheter and removal when they are no longer indicated are simple but important
steps to reduce infection, encourage a return to normal physiologic function, and improve
patient care.

Intermittent catheterization deals with draining the bladder at specific time intervals to simulate
normal physiologic function. An adult bladder holds approximately 400 ml of urine and voids 4-5
times/day. Intermittent catheterization should likewise be performed a 4-5 times/day with
adjustments based on volume drained. The total volume drained should not exceed 400 ml. If
volume drained is high, either the frequency of intermittent catheterizations should be increased
or fluid intake should be decreased.

Spinal Cord Injuries: According to several studies, intermittent catheterization is a better option
than indwelling catheterization for both male and female patients. Some studies show that for
patients who are undergoing catheterizations approximately 4 times/day, bacteriuria occurs at
an incidence of 1-3% per catheterization. Antibiotics are usually not required during intermittent
catheterizations unless the patient is in a high-risk population (immunosuppressed, internal
prosthesis, etc.).

Raymond et al. ―Neurogenic Bladder‖. eMedicine May 22, 2006.

Richards et al. Crit Care Med 1999; 27:887.

Saint et al. Arch Intern Med 1999; 159:80.

184
185
 University of Kentucky Trauma and Critical Care Recommendations for
Central Venous Catheter Insertion
Adapted from the American College of Surgeons Guidelines for Central Venous Access*

Indwelling vascular catheters are essential for patient care. All indwelling vascular catheters
have associated mechanical and infection risks. Catheters should be place when needed and
the insertion should be performed properly using strict aseptic technique. Catheter
maintenance should follow accepted guidelines including sterile technique for infusions, lines,
and hubs. Site inspection and care are essential for preventing infection. Catheters should
never remain in place for caregiver convenience and should be removed when no longer
needed.

Placement
1. Appropriately trained and experienced personnel identified to place CVC
2. Time out performed prior to procedure (patient ID, consent, site selection, diagnosis)
3. Choose the most appropriate site for CVC insertion based on patient’s needs
4. Full sterile precautions must performed on ALL non-emergent CVC insertions. This
includes sterile hat, mask w/shield, gown and gloves. A fully body sterile sheet is
applied after appropriate antisepsis.
5. Appropriate antisepsis is achieved with 2% chlorhexidine gluconate for 30 seconds and
then allowed to air dry. If this is not available, it is appropriate to use iodine, iodophore
or 70% ethanol, no organic solvents.
6. Choose a central venous catheter with the minimum number of lumens for your patient’s
needs.
7. All internal jugular and femoral lines should be placed under ultrasound guidance unless
emergent line placement is required.
8. If a CVC is malfunctioning then a new one may be placed by exchange over a guidewire
ONLY if there are no signs of bacteremia and/or infection
9. >3 needle sticks for access increases risk of insertion complications and consideration
should be given to more experienced personnel insertion and/or new stick site
10. After successful insertion a chlorhexidine impregnated sponge should be placed around
the catheter at the insertion site.
11. Position of CVC must be evaluated with a STAT chest x-ray. Correct CVC should have
the tip near the SVC and right atrial junction. All CXR should be evaluated for evidence
of pneumothorax.
12. If line is in satisfactory position the line needs to be cleared for use in SCM. Alert the
nursing staff that the line is ok to use and that the order for clearance is in SCM.
13. A procedure note is to be performed on all CVC insertion attempts, successful or not.
SCM has a procedure note dedicated to CVC insertion. This is the default and expected
method of procedure note completion. A brief note in the chart should indicate the
patient name, date and time with reference to the complete note in SCM.

Maintenance
1. The routine replacement of central lines does not prevent CRBSI and is not
recommended in the absence of CRBSI
2. The CVC site should be inspected daily and PRN
3. Before manipulation of any CVC proper hand aspesis should be performed by washing
with soap and water or alcohol scrub (even when gloves are worn)
4. Clean gloves should always be donned before CVC manipulation

186
 5. If CVC lumen access is attempted via the injection ports or caps then asepsis should be
applied to the ports/caps with 2% chlorhexidine gluconate or another appropriate
antisepsis
6. 2% chlorhexidine gluconate, iodine, iodophore or 70% ethanol (no organic solvents)
should be used for all CVC dressing care and dressing changes. All antisepsis should be
allowed to air dry before manipulation/dressing changes.
7. Use a sterile, transparent dressing over catheter site with clean gloves and a no-touch
technique. If the site is not dry, then apply a sterile dry gauze and change dressing when
it becomes saturated. Change to a transparent sterile dressing as soon as possible.
8. Sterile dressing should be replaced q7 days unless it becomes loose.
9. There is no indication for antimicrobial prophylaxis (systemic or local) with an indwelling
CVC.
10. Avoid anticoagulants for clot or CRBSI infection unless certain patient conditions
mandate their use
11. Use sterile NaCl (heparin if indicated) to flush and lock to maintain patency
12. The use of needle free connectors is encouraged to prevent needle stick injuries, and
aseptic technique should always be followed.

Catheter Related Infection and/or Complication Evaluation

1. The occurrence of fever should not prompt CVC removal. It is expected that clinical
judgment be applied. If patient demonstrates a strong suspicion of CRBSI then CVC
removal is considered.
2. If CRBSI is suspected or confirmed, the CVC or introducer should be removed. The line
should be cultured only if CRBSI is suspected.
3. The tip or intracutaneous segment only should be cultured.
4. If the patient demonstrates erythema or purulence at the catheter site, sepsis, + blood
culture results the CVC should be removed.
5. If the CVC that was exchanged demonstrates quantitative cultures suggestive of CRBSI
(>15 Colony Forming Units, CFUs) then the catheter should be removed and placed at a
new site.
6. 2 sets of blood cultures, one from a peripheral stick, in all patients with suspected CRBSI
7. After removal of CVC in patients with CRBSI, a non-tunneled CVC may be placed at a
new site after systemic antimicrobial therapy is begun
8. If after removal of CVC there is persistence of bacteremia and/or fungemia, lack of
clinical improvement (after 3 days of CVC removal and appropriate antimicrobial
therapy) then the clinician should seek septic foci (i.e. endocarditis, septic thrombi, and
mestastatic infections.
9. All institutions should have monitoring systems for outcomes, infections and
complication rates. They should also have systems in place if complications exceed the
standard of care to identify and correct these occurrences
10. Venous thrombosis, documented at insertion site, the CVC should be removed and
placed a new site if CVC is still needed.

Central venous, pulmonary artery, and peripheral venous lines placed outside the
Intensive Care Unit
All deep lines place outside of the intensive care areas must be changed to a new sight within
24 hours of admission to the unit. Exceptions to this policy are as follows:

1. Lines placed under aseptic conditions in the operating room, on the floor, or in another ICU
where sterility of the procedure can be documented.

187
2. All emergent lines, placed under non-sterile conditions, placed in the ED for emergency
resuscitation must be removed within 24 hours of admission to the ICU without exception.

Pulmonary Artery Catheter Important Notes

1. PAC should not be left in for > 10 days due to the significant risk of CRBSI
2. If the PAC is removed, under no circumstance should the introducer sheath be left in
place.
3. Guide wire PAC exchanges are only indicated for PAC malfunction only. If there are
extenuating circumstances then chief, fellow or attending approval is needed.

Insertion, maintenance, removal, and replacement of Arterial lines

Route of Insertion
1. The percutaneous route of arterial line placement is preferred to surgical cutdown.
a. Surgical cutdown for arterial cannulation should only be performed after approval by
the critical care attending.

Site of Insertion
1. The preferred site of arterial cannulation is the radial artery. Alternate sites of arterial
cannulation are for most patients listed in descending order preference.
a. Femoral artery*
b. Dorsalis Pedis artery*

*In patients with peripheral arterial disease, percutaneous femoral arterial cannulation has a
much higher complication rate and should be avoided. Dorsalis Pedis cannulation may lead to
inaccurate blood pressure measurements. Caution must be exercised in choosing the site of
arterial cannulation in this group of patients.

2. The complications associated with brachial artery and axillary artery cannulation are
higher than other routes.
a. Brachial artery: Used uncommonly because of the high complication rates. The major
complication is thromboembolic occlusion usually without ischemia.
b. Axillary artery: Limb threatening ischemia negligible. However,
catheter infection rate is much higher than other sites and line care
is difficult.

Insertion Procedure
1. The site chosen for arterial cannulation should be prepped and draped to create a sterile
field.
2. Sterile gloves and mask should be worn during insertion of the line.
3. The line should be sutured in place using aseptic technique.
4. At the completion of the procedure, a chlorhexidine impregnated sponge is applied to the
insertion site and covered with a sterile MVP (Tegaderm © or OP-Site ©) dressing.

Line Changes
1. The infection rate in percutaneously placed arterial cannulas are very low. Routine
catheter removal and change to a new site is unnecessary. Arterial cannulas can remain
at the original site of insertion until no longer needed.
Exception: Catheters should be changed to a new site when:
a. There is evidence of infection at the insertion site manifested as pain, redness,
swelling, or purulence. Catheters should always be cultured in this situation.

188
 b. There is evidence of ischemia distal to the site of insertion.
c. The catheter is implicated as a potential source of unexplained systemic
sepsis.

2. The decision to change the arterial line to a new site or to culture the catheter tip is left to
the discretion of the treating physician. It is recommended that catheter tips be
submitted for culture when there is evidence of infection at the site of insertion or when
the patient exhibits unexplained sepsis.

Reference

Freel AC, et al. American College of Surgeons Guidelines Program: A Process for Using
Existing Guidelines to Generate Best Practice Recommendations for Central Venous Access.
2008 June 19.

189
Revised: 11/08

University of Kentucky Hospital

Trauma Intensive Care Unit
Hypnosedative/Alcohol Withdrawal Prophylaxis

Introduction:

Alcohol abuse and/or addiction are frequent problems in the trauma patient population.
Acute alcohol withdrawal increases mortality and morbidity for the critically ill and/or
injured patient. It is essential that physicians and nurses obtain a thorough history to
ascertain if the patient has a history of alcohol abuse or dependency.

Symptoms of alcohol withdrawal begin 6 - 12 hours after cessation of alcohol and can be
difficult to differentiate from injury/illness related symptoms. Tremor, nausea, vomiting,
tachycardia, hypertension, diaphoresis, irritability and profound anxiety are frequently
seen. Seizures are the most life threatening symptom of alcohol withdrawal. Seizures
cause additional stress on body reserves which will further compromise the critically ill
patient. Delirium tremens is classified as the ―late‖ phase or major withdrawal.

Patients will often have a combined alcohol and hypnosedative abuse which requires a
different treatment approach to prevent withdrawal symptoms.

The goal of medical management is to recognize symptomatology of

hypnosedative/alcohol withdrawal and prevent progression into delirium tremens for
patients at high risk. Early pharmacological intervention is designed to prevent and/or
mitigate withdrawal symptoms thereby minimizing risk to the critically ill patient.

Criteria for Implementing Alcohol Protocol:

1. Alcohol level > 200 with GCS of 15

2. Alcohol level > 200 with prior history of Delirium
Tremens and/or prior enrollment in a detoxification program
3. History of Delirium Tremens or Detoxification program
with clinical manifestations of withdrawal

Criteria for Implementing Alcohol/Hypnosedative Protocol:

1. Above Criteria plus

2. History of daily use of benzodiazepines or barbiturates or
3. Positive drug screen with history of daily use.
4. Enter Chemical Dependency Consult.

Nursing Care Guidelines

Signs and Symptoms of Withdrawal: agitation, anxiety, tremors, nausea, vomiting,
hypertension, tachycardia, diaphoresis

190
[Differentiation from behaviors associated with closed head injuries, and
agitation/anxiety related to uncontrolled pain is essential]
1. Monitor vital signs q 1 hour x 24 hours
2. Monitor agitation/sedation level q 1 hour x 72 hours then q 4 hours and PRN

A. Diazepam Load and PRN Diazepam

Use PRN diazepam only if patient is having tremors

Use lower dose of haloperidol and diazepam for non-intubated patients

Assess and record the following vital signs parameters prior to each dose:

 Heart Rate
 MAP
 Respiratory Rate
 SpO2
 Level of sedation

Hold next dose and/or notify physician if :

 Heart rate < 60 [if a change from baseline]

 Respiratory rate < 16
 MAP < 60
 Sedation level > 4
 SpO2 < 92%

B. Carbamazepine:
Carbamazepine level prior to starting maintenance dose if patient is having signs
and symptoms of withdrawal Goal is to have level > 12.
Assess and record the following vital sign parameters prior to each dose:

 Heart Rate
 MAP
 Respiratory Rate
 SpO2
 Level of sedation

Hold next dose and/or notify physician if: Heart rate < 60 [if a change from
baseline]

 Respiratory rate < 16

 MAP < 60
 Sedation level > 4
 SpO2 < 92

191
C. Haloperidol:

1. Administer 10 mg IV over 1 - 2 minutes [administer over 5 minutes if SBP< 100]

2. Not to exceed 240 mg/24 hours.
3. Monitor for extrapyramidal symptoms and notify physician if symptoms observed.
4. Prolonged QT interval & incidence of Torsades des pointes is rare.
5. Monitor for signs and symptoms of rigidity, consult physical therapy if present

Sedation Status: Anxiety Scale:

Tremors
1 - Wide Awake 1 - No Anxiety 0-
Non Existent
2 - Drowsy 2 - Mild Anxiety 1-
Moderate
3 - Dozing Intermittently 3 - Anxiety 2-
Profound
4 - Mostly Sleeping 4 - Severe Anxiety
5 - Only Awakens When Aroused 5 - Extreme anxiety

References:
Ries, RK, Roy-Byrne, PP, Ward, NG, et al. Carbamazepine treatment for benzodiazepine
withdrawal. American Journal of Psychiatry. 1989; 146: 536-537.

Klein, EK, Uhde TW, Post RM. Preliminary Evidence for the utility of carbamazepine an
alprazolam withdrawal. American Journal of Psychiatry. 1986; 143: 235-236.

Butler D, Messsiha FS. Alcohol withdrawal and carbamazepine. Alcohol; 1986; 3: 113-129.

Denicoff KD, Meglathery SB, Post RM, et al. Efficacy of carbamazepine compared with
other agents; a clinical practice survey. Journal of Clinical Psychiatry. 1994; 55(2): 70-75.

Miller, R. Protracted alcohol withdrawal delirium. Journal of substance abuse and

treatment.1994; ll(3): 127-130.

Strasen, L. Acute alcohol withdrawal syndrome in the critical care unit. Critical Care
Nurse. 1982: 24-30.

Menza MA, Murray GB, Holmes VF, et al. Decreased extrapyramidal symptoms with
intravenous haloperidol. Journal of Clinical Psychiatry. 1987; 48(7): 278-280.

Fraser GL, Riker RR. Controlling severe agitation in the critically ill with intravenous
haloperidol. Hospital Pharmacy. 1994; 29(7): 689-691.

Skinner MH, Thompson DA. Pharmacologic considerations in the treatment of substance

abuse. Southern Medical Journal. 1992; 85(12): 1207-121

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Hyatt M. Anxiolytic Drug Abuse, Addiction and Withdrawal

Use of Neuraxial Pain Control Methods

For Trauma and Acute Care Surgery

Julie McWhorter, MD, Department of Anesthesia and

Jeffrey Coughenour, MD, Department of Surgery,
Section of Trauma and Critical Care

The use of Anti-Xa levels is not predictive of the risk of bleeding.

Antiplatelet or oral anticoagulant medications used in combination with LMWH may increase
the risk of spinal hematoma.
Patients who present with chronic use of Coumadin should be off therapy for 4-5 days prior
to neuraxial procedures. An INR should be checked and should be <1.5. If therapy is
reinstituted with an indwelling epidural catheter, INR should be monitored closely. The
catheter can be removed at any time assuming the INR is <1.5. The site should be
monitored for 24 hours after removal for complications.
NSAIDs pose no significant added risk of bleeding or spinal hematoma after neuraxial
procedures.
GP IIb/IIIa antagonists (Ticlid, Plavix) should be discontinued for 14 days (Ticlid) and 10
days (Plavix) respectively prior to procedures. Administration of platelets may be of
assistance in urgent situations, but no clear risk stratification has been established.
Patients taking herbal medications pose no increased risk from neuraxial procedures, unless
they are taken in conjunction with other conventional anticoagulants.
No specific consensus statement exists regarding risk and the use of direct thrombin
inhibitors and fondaparinux.
Spines should be evaluated and cleared. Method of evaluation and a negative tertiary exam
should be documented by the Trauma, NS, or Ortho spine service.
Prophylactic Lovenox should be held at least 12 hours prior to epidural placement.
Epidural catheters may be placed in intubated patients. Some attending anesthesiologists
are less comfortable with this as the ability to determine development of a neurologic deficit
is difficult. Therefore placement may be on a case-by-case basis.
Literature clearly supports placement of epidural catheters for pain control and improvement
of pulmonary mechanics in the setting of rib fractures.
Pre-operative placement of epidurals for thoracic operations and many abdominal
operations is associated with lower incidence of DVT, quicker return of bowel function,
improved pulmonary toilet, improved pain scores and increased ambulation postop.
Contrary to popular belief, Foley catheters are unusually required for thoracic epidurals.

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 Minimum time from Minimum time from last dose
last dose to catheter to catheter removal
placement/spinal
injection
Standard Anticoagulants
Warfarin INR < 1.5 Avoid use while
Heparin, full dose IV/SQ INR < 1.5 catheter in place
Heparin prophylaxis (BID, TID) No restrictions
Newer Anticoagulants
Xigris (Drotrecogin Alfa) 24 hours
Arixtra (Fondaparinux) 24-48 hours Avoid use while
Lovenox (1 mg/kg BID) 24 hours catheter in place
Lovenox (30 mg SQ BID) 10-12 hours
Lovenox (40 mg SQ QD) 10-12 hours 10-12 hours
Direct Thrombin Inhibitors
Argatroban aPTT < 40 Avoid use while
Lepirudin aPTT < 40 catheter in place
Antiplatelet Agents
ASA/NSAIDs No restrictions
Plavix 7 days Avoid use while
Ticlid 14 days catheter in place
Thrombolytic Agents
TPA (full dose for stroke, MI, etc.) 10 days Avoid use while catheter in
place
TPA (2 mg for catheter clearance) No restrictions

References:
University of Washington Medical Center, Nursing Epidural Policy and Procedure
[Link] Accessed May 14, 2008
Second ARSA Consensus Conference on Neuraxial Anesthesia and Anticoagulation, Reg
Anesth Pain Med 2003;28:172-97

05/08

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SECTION 6: DISCHARGE INSTRUCTIONS

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 Discharge Instructions

D/C Home:

Please be thinking ahead of time on patient’s D/C home plans. Please inform the bedside RN of
D/C plans so home care instructions can be completed. If the pt. needs home health or home
equipment, please contact patient care facilitator assigned to Blue Surgery for this before the
day of D/C. The Care Facilitator will contact you if they need written prescriptions for any of the
Home Health/DME orders. On the weekends, the weekend social worker can set up Home
Health; the patients do not need to be kept over the weekend for home health needs only.

Next, complete the following:

1. Complete the UK Discharge Orders form (H341) fully

2. Controlled substance prescriptions must be written on a separate (green) prescription pad.
Record type and amount of any controlled substance prescription on the white medical
record copy, of form H341, in order to have documentation of all meds given to pt. at D/C
3. Make sure the need for all f/u appointments have been documented on form H341 (may
need to call consulting services to find out if /when they need to see pt. back)
4. Write ―D/C to home‖ order in routine MD orders
5. Complete an automated D/C summary*

*For patient’s who live out-of-state, you will need to do a STAT D/C summary to send
with the patient in case they can find a local MD to provide their follow-up care.

Inter-Facility Transfers:

Such as to: Acute Rehab, Subacute Rehab, ECF, or Hospital to Hospital

The Social Worker for our service can assist you with inter-facility transfers. If you suspect the
pt. will need some type of placement, contact the S.W. on pager number found on Blue Surgery
Census. Inform the pt./family that they may have some rehabilitation needs and that our S.W.
will come by to talk with them. Please never tell a pt./family we will send them to a specific place
(such as Cardinal Hill). Many factors need to be looked at before a pt. can go to a facility and
not all pts. are candidates for CHH.

Once a facility has accepted the pt. please complete the following:

1. Complete a STAT D/C summary. This will have to go with the pt. It takes several hours to
get this done so please plan accordingly.
2. Complete the UK Discharge Orders Form (H341). This form still needs to be completed
except for the prescriptions, since the list of meds are in the D/C summary. Please make
sure you write for all needed F/U appointments on the form so the clerk can schedule these
before the pt. is transferred.

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3. There is an Inter-Facility Form (J076) that has to be completed prior to transfer. This form
has 2 pages. You are responsible for completing the M.D. section on page 1 and the Risk &
Benefit section on page 2
4. Write an order ―Transfer to _______‖ in routine M.D. Orders
Subject: Physician responsibility in completion of Inter-Facility Transfer Form (J076) that
must be completed by the physician prior to transfer of patient to another facility
that will assume care of the patient.

Patient Condition (page 1, gray section)

Includes:
Diagnosis/initial impressions
Current condition/observations
Treatment rendered
Current medications
ATTENDING PHYSICIAN SIGNATURE AND DATE

Transfer Information (last section of page 1)

The physician completing the Inter-Facility transfer form MUST WRITE THE NAME OF
THE RECEIVING PHYSICIAN on the appropriate line.

Authorization of Transfer (page 2, gray section)

Includes:
Risks of transfer
Benefits of transfer
Condition of patient at time of transfer
Attending physician’s signature and date

NOTE: ―See H & P‖ cannot substitute completion of the form by a physician.

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 Discharge Pain Medication Algorithm
Outpatient Surgery, Including Laparoscopy-8 Day Taper

Lortab 5/500mg or Percocet 5/325mg

1 PO q4hr PRN x 2 days then
1 PO QID PRN x 2 days then
1 PO TID PRN x 2 days then
1 PO BID PRN x 2 days and stop
Disp #30
Tylenol and/or Motrin thereafter unless contraindicated

Long-Bone & Pelvic Fractures and Ribs-20 Day Taper (until ortho follow-up)
Percocet 5/325mg
1-2 PO q4hr PRN x 5 days then
1-2 PO QID PRN x 5 days then
1-2 PO TID PRN x 5 days then
1-2 PO BID PRN x 5 days and stop
Disp #150
Tylenol or Motrin thereafter unless contraindicated

Soft-Tissue Trauma, Laparotomy & Non-Long Bone Fractures-16 Day Taper

Percocet 5/325mg
1-2 PO q4hr PRN x 4 days then
1-2 PO QID PRN x 4 days then
1-2 PO TID PRN x 4 days then
1-2 PO BID PRN x 4 days and stop
Disp #100
Tylenol or Motrin thereafter unless contraindicated

Lortab is available as 5/500mg. Therefore, tapers with Lortab must not exceed 2 tabs
q6hr so that total Tylenol dosage does not exceed 4g/day.

Instruct the patient that they may take ibuprofen 600mg QID with Percocet or Lortab but
that Tylenol/acetaminophen should not be taken with Percocet/Lortab. Discharge Pain
Medication Protocol

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201
SECTION 7: WITHDRAWAL OF CARE/POTENTIAL ORGAN DONATION

UNIVERSITY OF KENTUCKY HOSPITAL POLICY NUMBER: HP06-19

CHANDLER MEDICAL CENTER FIRST ISSUED: 2/85
HOSPITAL POLICY CURRENT AS OF: 10/07

SUBJECT: Diagnosis of Death

SEE ALSO: Hospital policy HP06-27, Organ and Tissue Procurement for
Transplantation

INFORMATION
In order to ensure appropriate patient care and abide by KRS 446.400 as it defines and
applies to a patient's death, staff physicians of the University of Kentucky Hospital
should follow these established guidelines in determining death.

Ordinary Circumstances
In ordinary circumstances, the signs of death are:
1. Unresponsiveness,
2. Absence of pulse and heartbeat,
3. Absence of spontaneous respiratory movement and all other movement, and
4. Absence of reflexes.

Cerebral Death
Cerebral death is defined as the absence of cortical and brain stem function.
Certification of signs of cerebral death shall be attested to and documented by a
member of the active medical staff.

Diagnostic Clinical Criteria of Cerebral Death

Currently acceptable clinical criteria for determination of cerebral death in the presence
of cardiac activity and relatively normal blood pressure, whether or not artificial means
are used to maintain the circulation of oxygenated blood, include:
0
1. Absence of hypothermia (body temperature 32 C), neuromuscular blockade,
shock, significant levels of sedative and central nervous system depressants in
the patient's serum (e.g., Phenobarbital, benzodiazepines), and severe metabolic
disturbance (e.g., hyperosmolar coma, hepatic encephalopathy).
2. Cerebral unconsciousness and motor unresponsiveness to stimuli which are
normally intensely painful. True decerebrate or decorticate posturing or seizures
are inconsistent with the diagnosis of cerebral death.
3. Absence of spontaneous movements for an observation period of at least one
hour, except for spinal reflex activity.
4. Absence of reflexes which involve cranial nerves. The pupils must be fixed at
midpoint or larger in diameter and nonreactive to sharp changes in the intensity
of incipient light. No ocular responses or eye movements to head turning or
irrigation of ear with ice water.
5. Absence of corneal reflexes.
6. No gag, cough, or retching reflex in response to bronchial stimulation with
suction catheter.

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 7. No respiratory movements when the patient is disconnected from the
mechanical ventilator. Adequate testing for apnea is very important. An accepted
method is ventilation with pure oxygen for a 10-minute period before withdrawal
of the ventilator, followed by passive flow oxygen. A 10-minute period of apnea is
sufficient to attain hypercarbia (60 Torr or greater) which adequately stimulates a
respiratory effort. Testing or arterial blood gases can be used to confirm this
level. Any spontaneous breathing efforts indicates that part of the brainstem is
functioning and that the patient is not brain dead.
In the absence of confirmatory tests, the seven conditions described above must
persist unchanged for at least six (6) hours. A confirmatory test may shorten the
observation period.

Confirmatory Testing for Determination of Cerebral Death

An additional confirmatory test is recommended for determination of cerebral
death a) when the preceding reflexes cannot be adequately assessed and
documented or b) in children under the age of five.
Currently acceptable confirmatory tests performed under a staff physician with
appropriate privileges include:
1. Angiography, which reveals absence of cerebral circulation.
2. Cerebral nuclear scan, which demonstrates absence of cerebral circulation.
3. Transcranial doppler study, which demonstrates absence of cerebral
circulation.
Angiography, cerebral nuclear scan, or a transcranial doppler study which
demonstrates the absence of cerebral circulation is a definitive test of cerebral
death. A waiting period is not required.
4. An EEG, which demonstrates isoelectric activity, provided that severe
hypothermia, neuromuscular blockade, shock, significant levels of sedative or
central nervous system depressants, or severe metabolic disturbance are
absent. A waiting period is recommended when EEG is used a confirmatory test
(See Special Circumstances below).

Special Circumstances
• In cases of anoxic brain death, with demonstrated electrocerebral (EEG) silence
but without radiologic, nuclear scan, or doppler demonstration of absence of
cerebral circulation, a six-hour period of observation and repeat examination,
excluding apnea testing, is required.
• In cases of children under the age of one year, where absence of cerebral
circulation has not been demonstrated, a 72-hour period of observation and
demonstrated isoelectric activity
on EEG at the end of the observation period is required.
• In cases of children age one through five, where absence of cerebral circulation
has not be demonstrated, a 24-hour period of observation and demonstrated
isoelectric activity on
EEG at the end of the observation period is required.
• In cases of gross anatomical brain injury, the period of observation for the
persistence
of clinical criteria for cerebral death may be reduced to one hour.
Gross anatomical brain damage may be appropriately assessed by physical
examination or craniotomy or by cranial MRI or CT studies, interpreted by a staff

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 radiologist, that indicate that the brain is irreparably damaged, extruded, divided,
or destroyed.

Pronouncing Death
In all cases, the patient’s physician will arrive within one hour to pronounce a
patient dead.
Notification of death must be provided to Admitting within one hour of
pronouncement of death.

Pronouncing Death in Cases in Which Artificial Ventilation is Employed

In cases in which artificial ventilation is employed, the fact of death and the
presumptive cause of death should be determined by scientific evidence which,
in the opinion of the physicians making the determination, is current, acceptable,
and adequate to demonstrate irreversible cessation of cerebral and brain stem
function.
The pronouncement of death in these cases will be made on the basis of the
foregoing criteria by no fewer than two active medical staff physicians, one of
whom may include the attending physician interpreting the confirmatory test. The
time of death will be determined by the physicians who attend the patient death
or, if none, by the physicians who certify the death.
When possible, the surrogate or legally responsible family member(s) will be
informed before cessation of artificial ventilation.

Organ Donation
In the case of potential organ donors:
• All criteria of HP06-27, Organ and Tissue Procurement for Transplantation,
must be met.
• Legally responsible family member or designated health care surrogate must
provide
witnessed informed consent for specific donation.
The two physicians determining death must not be involved in determining the
suitability of the donor and must not be members of the surgical team performing
the transplant.

Approved by Richard Lofgren, M.D., Chief Medical Officer

Authorized by Joseph O. Claypool, FACHE, Hospital Director

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UNIVERSITY OF KENTUCKY POLICY NUMBER: HP05-25
CHANDLER HOSPITAL FIRST ISSUED: 5/85
HOSPITAL POLICY CURRENT AS OF: 3/08

SUBJECT: Notification of Coroner and Release of Medical Information/Specimens

SEE ALSO: KRS 72; Hospital policies HP05-37, Accounting and Tracking Disclosures of
Protected Health Information; HP06-01, Medico-Legal Specimens

INFORMATION and INSTRUCTIONS

Conditions That Require Notification of Coroner

"Coroner's case" means a case in which the coroner has reasonable cause for believing
that the death of a human being within their county was not natural (homicide, suicide,
accident, under suspicious circumstances) or poses a threat to the public health.
According to KRS 72.020 and KRS 72.025, the attending physician, designee, or any
person finding or having possession of the body of any deceased person must notify the
coroner whenever the death:

• Appears to be caused by homicide or violence.

• Appears to be the result of suicide.
• Appears to be caused by drugs or poisons in the body.
• Appears to result from a motor vehicle accident in which the operator of the motor
vehicle left the scene of the accident or in which the body was found in or near a
roadway or railroad.
• Occurs during a motor vehicle accident and an external examination of the body
reveals no lethal traumatic injury.
• Occurs while the person is in a state mental institution or hospital and there is not
previous medical history to explain the death.
• Occurs while the person is in a penal institution or otherwise in police custody, except
pursuant to a death sentence.
• Appears to be caused by fire or explosion.
• Appears to be caused by physical abuse, including when the death of a child appears
to indicate child abuse prior to the death.
• Appears to be caused by drowning.
• Occurs as a result of an accident.
• Appears to be caused by sudden infant death syndrome.
• Occurs at the work site when industrial toxics may have contributed to the cause of
death or when there is no apparent cause of death.
• is sudden and unexplained.
• Human skeletal remains are found.
• A person under the age of 40 dies and there is no medical history to explain the death.
• The body is to be cremated and there is no medical history to explain the death.
• The decedent is not under the care of a licensed physician and there is no medical
history to explain the death.
• When post-mortem decomposition of a human corpse exists to the extent that external
examination of the corpse cannot rule out injury or where the circumstances of death
cannot rule out the commission of a crime.
• When the manner of death appears to be other than natural.

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In recognition of an Attorney General's Opinion (OAG 62-964), University of Kentucky
Hospital also requires that:
• Deaths that occur in the operating room or PACU in which the operation was
necessitated by violence -- accidental or otherwise -- be reported to the coroner.

2 -- HP05-25, Notification of Coroner and Release of Medical

Information/Specimens Instructions for Notifying the Coroner

The law places responsibility for reporting to the coroner the types of death listed above
with the attending physician. As a result, University of Kentucky Hospital requires that:
1. The attending physician will
A. determine whether each death is a coroner's case,
B. notify the coroner and document the notification in the appropriate section of
the
Notification of Death form, if death is determined to be a coroner's case,
C. complete and sign the Notification of Death form and submit it to Admitting
within one hour of time of death.
2. The admitting clerk will verify that the coroner has been contacted when the Admitting
Department receives the Notification of Death certificate on a coroner's case. (The
Capacity Command Center fulfills the role of Admitting when Admitting is closed.)

Note: If "coroner's case" is checked in the Notification of Death section and the
Coroner/Medical Examiner Section has not been completed and signed, the
admitting clerk will contact the coroner immediately. The coroner should be called
in any case in which doubt exists as to whether the death represents a “coroner’s
case.”

Releasing Information and Specimens to the Coroner

In accordance with KRS 72.415, University of Kentucky Hospital does not require written
permission to release medical information, specimens, objects, clothing, or other
evidence concerning a coroner's case to the coroner. When patient information is copied
from the medical record, however, Medical Records or other Hospital personnel who
prepare the information or pull the files, specimens, objects, clothing, or other evidence
must document coroner receipt on form J100, Record of Possession of Medico-Legal
Specimens, and file the form in the administration section of the patient's permanent
medical record.
• During regular business hours, the coroner should contact Medical Records to request
medical information or other requested items needed for a coroner's investigation.
• After regular business hours, the coroner should contact the Emergency Department or
Admitting to obtain medical information needed for a coroner's investigation.
• The coroner should contact Clinical Lab’s Special Chemistry department to obtain
specimens needed for investigations (24 hours a day).
The staff member who releases medical information, specimens, objects, clothing, or
other evidence to the coroner will document the release.
Disclosures of protected health information are included in HP05-37, Accounting and
Tracking Disclosures of Protected Health Information per HIPAA.

206
Approved by Richard Lofgren, M.D., Chief Medical Officer
Approved by Kathleen Kopser, Interim Chief Nursing Officer
Authorized by Murray B. Clark, Jr., Associate VP for MC Operations
UNIVERSITY OF KENTUCKY HOSPITAL POLICY NUMBER: HP06-26
CHANDLER MEDICAL CENTER FIRST ISSUED: 10/07
HOSPITAL POLICY CURRENT AS OF: 10/07

SUBJECT: Donation after Cardiac Death

SEE ALSO: KRS 311.241, KRS 311.992; Hospital policies HP06-17,
Withholding/Withdrawing Potentially Life-Sustaining Treatment; HP06-19, Diagnosis of
Death; HP06-21, Donation of Body Parts; HP06-27, Organ and Tissue Procurement for
Transplantation; HP06-33, Advance Directives; HP07-03, Patient Payment and Financial
Allowance; HP08-10, Management of Pain

INFORMATION The purpose of this policy is to outline the steps needed to enable
patients or their surrogates who have elected to withdraw life support to be able to
donate organs after death is declared on the basis of cardio-pulmonary criteria. This
policy pertains to patients where the attending physician, patient, or their surrogates
have already decided to withdraw life-sustaining support. Organ donation after cardiac
death (DCD) refers to organ donation from a deceased donor who has been declared
dead on the basis of traditional cardio-pulmonary criteria (permanent cessation of
circulatory and respiratory function), rather than on neurological "brain death" criteria
(permanent cessation of whole brain function).

SUITABLE CANDIDATE SELECTION

A patient who has a non-recoverable and irreversible neurological injury resulting

in ventilator dependency but not fulfilling brain death criteria may be a suitable
candidate for DCD.

Other conditions that may lead to consideration of DCD eligibility include end
stage musculoskeletal disease, pulmonary disease, and high spinal cord injury.

The decision to withdraw life sustaining measure must be made by the Hospital’s
patient care team and legal next of kin, and documented in the patient chart.

The assessment for DCD candidate suitability should be conducted in

collaboration with KODA and the patient’s primary health care team. KODA
determination of donor suitability may include consultation from a KODA medical
director.

Assessment should be made as to a whether death is likely to occur (after the

withdrawal of life-sustaining measures) within a time frame that allows for organ
donation.

DEFINITIONS
Brain Death: The irreversible cessation of all brain functions, including brain stem
function. Donation from this group of patients is detailed in the Hospital organ donation
policy (HP06-27)

207
Cardiac Death: The complete and irreversible cessation of cardiac and respiratory
function. The diagnosis of death by traditional cardiopulmonary criteria requires
confirmation of correct EKG lead placement and absent pulse via an arterial catheter.
The patient must be pulseless, apneic, and unresponsive with five minutes of ventricular
fibrillation or five minutes of electrical asystole (no complexes, agonal baseline drift only)
or five minutes of electromechanical dissociation.
Irreversibility: It is the persistent cessation of function during a 5 minute period of
observation meeting the definition of cardiac death. DCD donor death occurs when
respiration and circulation have ceased and cardiopulmonary function will not resume
spontaneously.

INSTRUCTIONS
Eligibility for Donation after Cardiac Death

As a patient is being evaluated for withdrawal of life sustaining therapy, the Kentucky
Organ Donor Affiliates (KODA) must be notified at 278-3492 or 1-800-525-3456.

After withdrawal of life sustaining therapy has been approved and documented in the
chart by nursing, an assessment will be made by KODA to determine suitability for organ
donation before addressing donation with the patient’s next of kin. If the patient’s family
raises the subject of donation, they should be informed that KODA will be contacted
immediately and the family’s interest expressed to the KODA representative, or if
already on site, guided to the KODA representative. Only a designated requestor can
approach the family regarding consent for organ donation in DCD cases.

If the patient is not already a DNR, the patient should be made so by their attending
physician, as per UK Hospital policy HP07-03, Patient Payment and Financial
Allowance.

Consultation of another critical care attending physician to assist with ICU support
through the DCD process is appropriate. Transfer of the patient to another
attending/service specifically for the DCD process is acceptable but not essential.

KODA Suitability Approval

A request for the withdrawal of life sustaining therapy is made in accordance with the
patient’s previously expressed wishes or upon initiation by next of kin. The guideline set
forth in UK Hospital policy HP06-17, Withholding/Withdrawing Potentially Life-Saving
Treatment, should be followed. A decision to withdraw treatment must be made entirely
independent of any consideration of organ donation. However, KODA should be
contacted on all withdrawal of care cases.

If the patient is initially found suitable for organ donation after cardiac death, and likely to
die soon after removal of life sustaining therapy, a KODA coordinator, in collaboration
with medical staff, will approach the family to discuss the possibility of organ donation.

If the next of kin or authorized party wishes to pursue DCD, the KODA coordinator will, if
clinically indicated, request permission from the patient's physician for the physician to
evaluate the patient for likelihood of cardiac arrest within an hour after extubation.

If the physician consents to this evaluation, the patient is disconnected from the
ventilator by a physician for a period of up to ten minutes to record vital signs and

208
respiratory parameters. If, during the evaluation, the patient becomes unstable, the
patient will be replaced on the ventilator. This suggests a likelihood of expiration shortly
after extubation and DCD should be pursued.

If the patient does not meet criteria for probable cardio-pulmonary death within one hour,
no further evaluation will take place, and the coordinator will explain to the family the
reason why organ donation cannot take place. As these criteria are not absolute,
however, it may be reasonable to proceed at the family's request and with the
physician's consent.

Consent
Permission for organ donation is granted in the State of Kentucky according to the
following order:
• Authorized Donor Designation. This is listed in Section I, KRS 311.175, which
allows a signed donor card or the first person consent. Section II includes those
that follow:
• Legal spouse
• Mentally competent adult child age 18 or over.
• Parent(s) • Mentally competent adult sibling age 18 or over
• Legal Guardian of the decedent
• Person responsible for disposing of the body

Elements of consent must include an overview of the DCD process with ample
opportunity for the family to ask questions and to demonstrate understanding. The
discussion will include the need for additional testing to determine suitability; the
possibility that donation will not take place if cardiopulmonary death does not occur
within one hour following removal of life support; and that in such a case the patient will
return from the OR to their ICU bed and team or an appropriate floor bed, where comfort
care will continue. The patient’s ICU bed will be held until declaration of death has been
made or an appropriate floor bed has been designated. The family will also be informed
that if they accompany the patient to the OR, they will be asked to leave promptly after
the patient dies.

The legal next to kin may elect to consent to procedures or drug administration for the
purposes of organ donation (e.g., heparin, regitine, femoral line placement, ECMO, and
bronchoscopy). No donor-related medications will be administered or donation-related
procedures performed without specific written consent.

Once all questions have been answered, the person authorized to give consent will sign
the consent form (KODA Authorization for Removal of Anatomical Gifts consent form) for
organ and tissue donation after cardiac death. Documentation of two witnesses of
family/next of kin’s consent is required. A copy of the signed consent form will be added
to the patient’s medical record. At this time, consent will also be obtained for
administration of heparin, et al to maintain organ viability.

The family will be provided appropriate emotional and spiritual support. The KODA
coordinator, social worker and nurse will play important roles at this critical time. Pastoral
Care services will be offered and available for additional services.

Withdrawal of life support shall take place in the operating room only, and organs shall
not be retrieved in the ICU for controlled DCD donation. The family will be given the

209
option of saying goodbye to their loved one in the ICU. If they wish, however, members
of the immediate family may accompany the patient to the OR and be present until the
patient expires or until an hour has passed without cardio-pulmonary arrest. (A space
must be defined in the OR for families accompanying these patients.) Families must be
informed that they must leave the OR immediately after death is declared. The KODA
family support liaison or pastoral care will accompany the family to the Hospital chapel.

The Kentucky Organ Donor Affiliates will be responsible and billed for all costs related to
the evaluation of medical suitability and recovery of organs and tissue for
transplantation. No donation-related charges will be passed to the donor family. Should
the patient not reach a determination of death in one hour, the patient will be returned to
the patient care area for further comfort measures and family support. Upon return to
ICU or floor responsibility for care reverts back to the patient’s physician of record (if
care had been transferred as part of DCD) and financial charges revert back to the
Hospital and responsible pre-DCD payors.

Transfer to the OR and Withdrawal of Life-Sustaining Therapy

The critical care attending has sole responsibility for determining whether and when the
patient will be extubated, sedated, and/or given any ancillary procedures in the life
support withdrawal process. The comfort and dignity of the patient will be maximized
during the withdrawal process as it is in every patient death. All members of the DCD
care team must ensure that the highest level of palliative care is provided to the patient
at all times during this process. No member of the transplant team shall be present for
the withdrawal of life sustaining measures. No member of the organ recovery team or
OPO staff may participate in the guidance or administration of palliative care, or
declaration of death.

The KODA coordinator will arrange the time of the organ recovery based on the family's
wishes, and the availability of the OR and donor surgery team. The OR nursing
director/coordinator will be notified as soon as the decision to carry out DCD is made.
The anesthesia attending on call will be notified by the patient's critical care attending
physician or designee prior to transfer of the patient to the OR and, will be fully briefed
concerning the details of the case and the plans for DCD.

The patient will be transferred to the OR and may be accompanied by the ICU nurse
who has been managing the patient. A floor bed should be pre-arranged and held or the
patient’s ICU bed should be held during this time period in case the need arises to return
the patient to a bed because death does not occur within the hour window. If the patient
has a cardiac arrest prior to transfer to the OR, no resuscitation will be carried out in
deference to the patient's DNR status. Organ recovery may still be possible if
circumstances allow.

The patient will be prepped and draped prior to extubation in order to keep warm organ
ischemic time to a minimum, however, the donor surgery team will not be present in the
OR during the terminal wean and until the patient has been declared dead. This will
have been explained to the family at the time consent was obtained. If the patient's
family chooses to be in the OR, they will be accompanied by the KODA coordinator. In
pediatric cases, exceptions can be made, with agreement between the surgeon and
family, as some families may wish to hold their child during this time. The patient should
be accompanied to the OR by a staff member from the primary care team (ICU nurse) or
OR support personnel but without involvement of any anesthesia provider.

210
Appropriate orders must be documented prior to transfer to the OR, as follows:
● Heparin to be administered in the OR as per organ donation protocol
● Authorization for transport on monitor and, if necessary, opiate titration for comfort.
● A DNR order must be in place.

Whether and how much to sedate the patient pre-extubation is a decision that will be
made by the patient’s treating physicians following accepted hospital practice. It is a
decision that should not be influenced by the possibility of organ donation. The usual
measures to ensure patient comfort will be followed. If opioids or sedatives are to be
used, they may be administered in the ICU prior to transfer to the OR, or they may be
begun in the OR. Further dose titration will be left to the discretion of the physician who
will be managing the patient in the OR.

Extubation and removal of life-sustaining therapy will be carried out in the OR or

designated room near the OR by the patient's attending critical care physician or by a
physician designated by the attending physician. This may be another critical care
attending.

The comfort and dignity of the patient will be maximized during the withdrawal process
as it is in every patient death. All members of care team must ensure that the highest
level of palliative care is provided to the patient at all times during this process.

No member of the transplant team shall be present for the withdrawal of life sustaining
measures.

No member of the organ recovery team or OPO staff may participate in the guidance or
administration of palliative care, or declaration of death.

Pronouncement of Death
If, within one hour following life support withdrawal, the patient develops apnea,
asystole, or pulseless electrical activity that is sustained for a period of five minutes (as
defined in the Definitions section of this policy), the patient then will be pronounced dead
by the attending critical care physician or designee (licensed fellow/resident).

The physician will record the date and time of death in the medical record and will fill out
the death certificate.

The physician declaring death may not participate in the procedure to retrieve or
transplant the organ(s) or be associated with the transplant team or with the care of any
potential recipient. After pronouncement of death, the patient's family will be escorted
from the OR. If not present in the OR, the family will be notified promptly by the declaring
physician or designee that death has occurred and that organ recovery will proceed.

The donor surgery team will proceed with organ retrieval immediately after the patient is
pronounced dead.

Hospital Ethics Committee Review

A subcommittee composed of the Ethics Committee chair, director of the OR, and the
chief of Anesthesiology or their designees will review all DCD cases and report findings
to the Hospital Ethics Committee quarterly. Representatives from KODA as well as other

211
external reviewers are invited to observe the case reviews as well. Quality
documentation throughout the process is critical for these reviews to be able to ensure
compliance with the procedures, identify potential or actual problems as well as to
protect the interests of the organ donors, recipients, and health care workers.

Approved by Richard Lofgren, M.D., Chief Medical Officer

Authorized by Murray B. Clark, Jr., Associate VP for MC Operations

212
UNIVERSITY OF KENTUCKY HOSPITAL POLICY NUMBER: HP06-27
CHANDLER MEDICAL CENTER FIRST ISSUED: 1/87
HOSPITAL POLICY CURRENT AS OF: 7/07

SUBJECT: Organ and Tissue Procurement for Transplantation

SEE ALSO: KRS 311.241, KRS 311.992; Hospital policies HP06-17, Care of Terminally
Ill Patients; HP06-19, Diagnosis of Death; HP06-21, Donation of Body Parts;
HP06-33, Advance Directives; HP07-03, Patient Payment and Financial Allowances

INFORMATION
Federal and state legislation requires hospitals to consider every death as a potential
organ or tissue donation. These laws also require that families be given the opportunity
to donate. The families should be approached with discretion and sensitivity as
appropriate to the circumstances, beliefs, and desires of the family and potential donor.

As a result, it is the duty of each physician at University of Kentucky Hospital to facilitate

the procurement of organs and tissue for transplantation whenever possible in cases in
which the patient has died or death is imminent. Organ donor maintenance and organ
recovery take place in accordance with Hospital policy and Kentucky Organ Donor
Affiliates (KODA) procedures. KODA is designated as an organ procurement agency by
the Health Care Financing Administration in compliance with section 372 of the Public
Health Service Act.

All Hospital personnel shall make an effort to convey to the attending physician any
known intent of any hospitalized patient to make a donation of all or part of the body.
Note: The attending physician or another physician designated by the attending
physician will make the declaration of death in accordance with recognized
criteria
(see Hospital policy HP06-19, Diagnosis of Death).

INSTRUCTIONS
1. Whenever a patient has died or death is imminent, the attending physician, another
physician designated by the attending physician, or the nurse shall notify Kentucky
Organ Donor Affiliates (KODA) immediately. Imminent deaths should be referred to
KODA after determining the Glasgow coma score is equal to or less than 4 or if for a
severely brain injured patient’s further care is determined to be futile; and prior to
discontinuing ventilation or life-sustaining treatments when the decision is made to
downgrade, withhold, or withdraw care. KODA will evaluate the patient for suitability of
donation. Only a KODA representative or a designated requester trained by KODA, in
collaboration with the health care staff, may speak with the family about the option to
donate or deny organ donation. KODA will participate in approaching the family to
discuss the option to donate or deny organ donation, and will document the family’s
decision. KODA will also assist with family counseling. If the patient is determined to be
suitable for donation the Hospital will work with KODA to maintain the potential donor
while the necessary testing and placement of organs, tissues, and eyes takes place.

The local KODA telephone number is 278-3492; the 24-hour number is (800) 525-3456
or (866) 206-9250.

213
2. The attending physician, physician designee, or the nurse shall document on the
Provisional Report of Death form that KODA has been contacted, including the name of
the KODA coordinator, if the patient is suitable for donation and the name of the family
member 2 -- HP06-27, Organ and Tissue Procurement for Transplantation approached
with their decision. The Provisional Report of Death form shall be filed in the patient's
medical record.

3. All cardiac standstill deaths (i.e., when artificial respiration and circulation are not
maintained and there is an irreversible cessation of spontaneous respiration and
circulation) will be referred to KODA by the attending physician, the physician designee,
or the nurse. KODA will obtain information about the deceased from the caller and
determine if the patient is suitable for tissue donation. If the patient is suitable, as
determined by KODA, KODA may direct the caller to contact a Hospital staff member
who is trained as a designated requester to offer the family tissue donation (corneas,
eyes, skin, bone, veins, and heart valves). If the family desires donation or wants more
information the caller will contact KODA to speak with the family. The trained designated
requester’s name will be documented in the medical record or the provisional report of
death.

4. When a staff member informs KODA of a potential organ/tissue/eye donor they should
report the patient’s name, age, reason for hospitalization, and medical/social history;
they should also have the patient’s medical record available in order to provide any
additional information as appropriate.

5. If the patient is considered an organ/tissue/eye donor, the designated requester or

KODA coordinator will obtain written consent for donation, using the Kentucky Organ
Donor Affiliates/Lion’s Eye Bank Authorization for Removal of Anatomical Gifts form. If
the family is not present at the Hospital, KODA may obtain a recorded consent from the
next-of-kin. KODA will provide the Hospital a copy of the recorded consent transcript or a
written consent for the medical record. Kentucky Revised Statutes recognizes the
following order of consent for authorization of donation of organs for transplantation:
Section I of KRS 311.175
Authorized donor designation, listed in KRS 311.175, which allows a signed
donor card, authorization through the donor registry, or the first person consent.

Section II of KRS 311.175

a. patient
b. spouse
c. adult daughter or son
d. either parent
e. adult brother or sister
f. guardian at the time of the patient's death
g. any other person authorized or under obligation to dispose of the body
If there is actual notice that the patient or a member of a prior class
opposes donation, the donation shall not be accepted.

Two witnesses should confirm the next-of-kin consent by signing the witness
attestation on the Kentucky Organ Donor Affiliates/Lion’s Eye Bank Authorization
for Removal of Anatomical Gifts form.

214
 The original copy of the authorization form should be filed in the medical record.

6. The KODA coordinator can write all medication and patient care orders in accordance
with established guidelines and protocols for the care of the donor patient.
a. The name and title ―KODA coordinator‖ shall be documented in the body of the
order, not in the physician’s signature space.
b. Pharmacy shall dispense medications upon the written order of the KODA
coordinator. c. All orders will be implemented by the nursing staff upon the
written order of the KODA coordinator.
d. The medication orders written by the KODA coordinator shall be countersigned
by the transplant physician at the time of the organ recovery, or within 24 hours
of the time the orders were written.

Approved by Richard Lofgren, M.D., Chief Medical Officer

Authorized by Murray B. Clark, Jr., Associate VP for MC Operations

215
Brain Dead Organ Donor Management
Guidelines and Protocols
University of Kentucky
Lexington KY

E Hessel
Version 1.1 (July 12, 2007; 1400)

[This protocol represents a modification of the Canadian Guidelines of 2006 (Shemie

SD, etal. Canad Med Assoc J March 14, 2006; 176(2): S-13 to S-30; indicated by the
notation (Canad)]

I. Rationale for involvement of intensivist in management of Brain dead organ

donors.

A new paradigm in management of brain dead organ donors has appeared in the last
few years based upon the observation that the pathophysiologic changes associated
with brain death may not result in irreversible organ damage, but in fact that if the donor
is optimally resuscitated, function of potentially transplantable organs may improve
resulting in more and better organs being available for successful transplantation. This
improved outcome (number of organ donors, and number of organs donated and
transplanted per donor) has been found to be associated with initiation of protocols and
involvement of Intensivists in the management of these donors. The recognition that by
improving the care of one brain dead donor, an intensivist may have the ability to
improve the lives of six other patients is a powerful incentive for this effort.

Instead of rushing the donor to the operating room to retrieve the organs as soon as
possible, the new paradigm proposes that it is important to take the necessary time in
the ICU to optimize multi-organ function to improve transplant outcomes. Resuscitation
and re-evaluation can improve reversible organ dysfunction (myocardial and
cardiovascular dysfunction, oxygenation impairment related to potentially reversible lung
injury, invasive bacterial infections, and hypernatremia) and allow time to evaluate
temporal trends in hepatic aspartate aminotransferase (AST), alanine aminotransferase
(ALT) and creatinine or any other potentially treatable situation. This treatment period
can range from 12 to 24 h and should be accompanied by frequent re-evaluation to
demonstrate improvement in organ function toward defined targets. Once organ function
is optimized, surgical procurement procedures should be arranged emergently. (Shemie,
2006)

II. Initial communication:

1. KODA will be notified of potential donor,
2. KODA will be notified when Brain Death has been declared

III. Initial Evaluation

1. Meet with KODA case manager
a. Review potential organs to be transplanted
b. Review time-lines
2. Review mechanism of brain death and patients course since initial event
3. Review current status of patient
a. Vital signs, fluid balance
b. Current medications and ventilation

216
 c. Latest laboratory studies
d. Determine if meeting KODA goals (see Item IV below)
e. Look for common complication
i. Hypothermia or hyperthermia
ii. Hypertension and tachycardia
iii. Hypotension and/ or low cardiac output
iv. Pulmonary dysfunction and/ or edema
v. Lactic acidosis
vi. Hypernatremia
vii. Other electrolyte abnormalities
viii. Diabetes Insipidus
ix. Hypovolemia
x. Coagulopathy
4. Confirm orders regarding routine management (see item V. below) and
laboratory studies (see item VII. below)
5. Initiate any required invasive monitoring (see item VI below)
6. Assure appropriate consultation i.e., with pulmonary medicine and cardiology,
and potential receiving transplant surgeons.
7. Initiate interventions to achieve KODA donor goals.

IV. General Targets and Objectives

(* = at variance with or not mentioned by with KODA guidelines; Canadian = Shemie,
CMAJ, 2006; SSC= Surviving sepsis campaign, Dellinger CCM 2004))
Heart rhythm Sinus*
Heart rate 60-120
MAP ≥70*; <91 (Canadian); *KODA ≥60;
SSC ≥65;
Systolic Pressure >100; < 160* (Canadian)
CVP 10-12
PAOP <12; 6-10 (Canadian)
Mixed venous oxygen sat (PA or CV ≥70% (SSC); ≥60 (Canadian)
Cardiac Index >2.4 (Canadian)
SVR 800-1200 [Link] cm-5 (Canadian)
LVSWI > 15 gm/kg-min (Canadian)
Urine output 1ml/kg/hr; Canadian 0.5-3.0; SSC
0.5)
Sodium 130-150 (Canadian)
K, Ca, Mg, PO4 normal
Glucose 72-144 (Canadian)
Hematocrit
If hemodynamically stable >21
If unstable >27 (Canadian); > 30 (SSC)
Arterial saturation >95% (Canadian)
PaO2 >80* (Canadian); KODA >100
Ph 7.35-7.45(Canadian)
PaCO2 35-45(Canadian)
Temperature 97-99 F; 36.5-37.4 C

217
V. General Management of all potential donors
1. Baseline laboratory studies and evaluation (See item VII below)
2. Insert monitors
a. Arterial line
b. Central venous catheter
If not already in place, insert introducer suitable for placement of a
PAC and volume therapy (e.g., MAC or AVA) via right internal
jugular vein
c. Pulmonary artery catheter (Consider- see item VI.11 below)
d. Urinary catheter (If not already in, place temperature sensing catheter)
e. Core temperature monitor
f. TEE (Consider- see item VI. 12 below)
3. NG tube to low suction
4. Type and cross match 4 units
5. Ventilator
a. PRVC
b. Tidal volume 8-10 ml/kg (IBW) (Canadian)
c. PEEP 5 (Canadian)
d. Peak pressure limit 30 cm H2O (Canadian)
If not possible, consider lowering tidal volume or accepting higher
pressure limit
e. FiO2 as low as possible to maintain SpO2 ≥ 95%
f. Rate initially about 10
Adjust to keep PaCO2 and pH within desired limits
g. Obtain ABG within 30 minutes of initial settings
Recruitment maneuvers periodically (Canadian) or at least if PaO2
<80 on FiO2 >0.4, or P/F < 300:
-PC ventilation with PAP 25 and PEEP 15 for 2 hours
(SALT protocol; Angel 2006), or
-Sustained positive pressure of 30 cm H2O for 30-60 sec

6. Remove cervical collar

7. Elevate head 30 degrees
8. Suction ETT Q 1- 2 hours
9. Turn to full lateral; alternate right and left every 1-2 hours
10. Cefazolin 1 gm Q 4 hours after cultures
11. Irrigate eyes with normal saline hourly
12. Enteral feeding by jejunal tube if possible (10 ml/hour, increase to 0.5 ml/kg/
hr as tolerated)
13. IV fluids
Maintenance: D5-1/2 normal saline 1.5 ml/ kg/hr
14. Consider triple hormone therapy in all donors
a. Vasopressin: Bolus 1 unit followed by infusion 2.4 units/hr
b. Methylprednisolone: 15 mg/kg and Q 24 hours
c. T4: Bolus 20 microgram followed by infusion 10 mcg/hr
15. See special management of potential heart and lung donors, and of common
problems below.

218
VI. Monitoring (At least hourly unless stated otherwise)
1. Arterial pressure (S, D, M)
2. Pulse oximetry
3. ECG: Heart rate and rhythm
4. Respiratory rate,
5. Ventilator settings (Mode, tidal volume, FiO2, PEEP, PAP)
6. Temperature (central: bladder, esophageal, PA, nasopharyngeal)
7. Urine output
8. Fluid balance
9. CVP
10. Central venous oxygen [continuous or intermittent (Q4h)]
11. PAC: Consider in all. Definite if hemodynamically unstable (hypotensive, evidence of
impaired
cardiac output requiring vasopressors or inotropic drugs or fluid boluses) potential lung and
or
heart donors
12. TEE: consider in hemodynamically unstable patients, or if abnormal TTE
13. Repeat laboratory studies (See item VII below)

VII. Baseline and periodic Laboratory studies

1. Height, weight, BMI, BSA
2. CMP
3. Electrolytes Q 4 hrs
4. Osmolality Daily
5. BUN and Creatinine Q 6 hrs
6. Glucose Q 4 hrs.
Finger sticks hourly if elevated or on insulin

7. Calcium Daily
8. Magnesium Daily
9. Phosphorous Daily
10. Liver panel Q 6 hrs
a. AST
b. ALT
c. Bilirubin
11. Viral studies
a. Hepatitis B surface antigen HBsAg) and HCVAb
b. HIV
12. Type and screen
13. Coagulation studies Daily
a. PT, INR
b. PTT
14. CBC (WBC, hematocrit/hemoglobin, platelet count)
15. Urine analysis and microscopic examination
16. Blood culture x 2 Daily
17. Urine culture Daily
18. Sputum gram stain Daily
19. Sputum culture Daily
20. ABG Q 6 hr
21. ECG
22. CXR Q 12 hrs

219
 23. TTE or TEE
24. Troponin; repeat in 6 hours Q 12 hours
25. Lactate Q 2-4 hours
26. Central venous or mixed venous hemoglobin oxygen saturation;
Q 2-4 hours
27. See special evaluation and laboratory studies for potential Lung and Heart
donors (item IX. A. and B below).

VIII. Management of specific Issues

A. Hypertension (Canada)
Definition: Systolic arterial pressure >160, MAP >90
Management: Sodium nitroprusside 0.5-5.0 mcg/kg/min, or
Esmolol 100-150 mcg/kg bolus followed by an infusion of 100-300
mcg/kg/min

B. Tachycardia
-No established guidelines
-Need to differentiate the probable cause of the tachycardia, i.e., whether it is
compensatory for a low stroke volume (depressed LV function) or is secondary
to the hyperdynamic state due to CNS injury.
- If due to latter, and not needed to maintain cardiac output, consider
administering esmolol bolus followed by an infusion (see item VIII.A. above.)

C. Hypotension and low cardiac output

If MAP low (<60-70) but cardiac output deemed to be adequate (i.e., good
peripheral perfusion, urine output, CI > 2.5, SvO2 > 70)

-If hematocrit < 30, correct with PRBC

-If hematocrit > 30, give vasopressor
-First choice: vasopressin up to 2.4 units /hr
-Second choice: norepinephrine up to 0.2 mcg/kg/min
-If no PAC insert one and consider TEE

If MAP low and Cardiac output low

If CVP <16 and PAOP < 21
-If hematocrit < 30
-Give 1-2 units PRBC
-If hematocrit >30
-Give fluid bolus over 20-30 minutes
-500 ml hetastarch, or
-500 ml 5% albumen, or
- 15 ml/kg crystalloid (e.g., NS, LR)
-If cardiac output and MAP still low
-Start dopamine (5-20mcg/kg/min)
If no PAC insert one and consider TEE

If MAP adequate (>60-70) but cardiac output is low

If CVP <16 and PAOP < 21
-If hematocrit < 30
-Give 1-2 units PRBC

220
 -If hematocrit >30
-Give fluid bolus over 20-30 minutes
-500 ml hetastarch, or
-500 ml 5% albumen, or
- 15 ml/kg crystalloid (e.g., NS, LR)
-If cardiac output is still low
-Start dobutamine (5-20mcg/kg/min) or milrinone (load 50
mcg/kg over 20 minutes; infuse 0.5 mcg/kg/min)

D. Diabetes Insipidus (Canad)

Definition: Urine output > 4 ml/kg/hour plus rising serum sodium >145,
rising serum osmolality >300, and Urine osmolality >200
Treatment: vasopressin l unit followed by infusion of <2.4 units/hour.

E. Hyperglycemia
If > 500 mg/dl administer 20 units insulin and begin infusion (below)
If > 400 mg/dl administer 15 units insulin and begin infusion (below)
If > 300 mg/dl administer 10 units insulin and begin infusion (below)
If > 200 mg/dl administer 5 units insulin and begin infusion (below)
If > 100 mg/dl administer 3 units insulin and begin infusion (below)

Plus infusion
Start at 0.1 unit/kg/hour and adjust to keep glucose 80-120
F. Hypocalcemia
If Ionized <4.6mg/dl or total <8.5 mg/dl give calcium gluconate 1 gm over 10 mins
If ionized <3.6mg/ml or total<7.0mg/dl give calcium gluconate 2 gms over 30
mins

G. Hypernatremia
If > 155 administer D5/water at 100 ml per hour (expected to decrease serum
sodium about 0.4 mEq/ hour in 70 kg patient)
If > 150 administer D5/water at 50 ml per hour (expected to decrease serum
sodium about 0.2 mEq/ hour in 70 kg patient)

H. Hypomagnesemia
If <1.8 gm/dl give 1 gm Magnesium sulfate over 30 minutes
If <1.2 gm/dl give 1 gm magnesium sulfate over 60 minutes

I. Hypohosphatemia
If < 2.7 mg/ml give potassium phosphate 9 mMol/150 ml over 4 hours
If < 1.0 give potassium phosphate 15 mMol/150 ml over 4 hours

J. Hyperthermia (Core temperature > 37.4 C (99F)

Use cooling blanket, Tylenol etc.

K. Hypothermia (core temperature <36.5 C (97F)

Use warming blanket

221
 L. Prevention of Contrast Induced Nephropathy (CIN) (REMEDIAL protocol, Briguori et
al, Circ 2007; 115; 1211-7)
If plan to perform contrast arteriogram (coronaries, hepatic or renal)
-Assure normovolemia
-Administer1200 mg of N-acetylcysteine (NAC) enterally immediately and
repeat in 24 hours
-Infuse 154mEq/L sodium bicarbonate in D5/W at 3ml/kg/hr for one hour
immediately before contrast injection and at a rate of one ml/kg/hour for 6
hours afterwards.

IX. Management of potential donors of specific organs

A. Heart
Special evaluation
1. PAC
2. CK, CK-MB, troponin Q12hrs
3. TEE; Consider repeating Q6-12 hours
4. Cardiology consultation
5. Consider coronary angiography. Canadian guidelines:
i. History of cocaine abuse or males >55, females >60 y/o
ii. Males > 40 or Females > 45 if ≥ 2 risk factors (see below)
iii. Any age if ≥3 risk factors
Risk Factors for considering coronary angiography
-Smoking
-Hypertension
-Elevated lipids
-BMI > 32
-Positive family history of CAD
-Ischemia on ECG
-Anterior-lateral RWMA on ECHO
-EF < 41%
6. Consider dobutamine stimulation test (low level DSE) if have RWMA on
ECHO
Graduated dosing of dobutamine every 3 minutes (5, 10, 15, and
20 mcg/kg/min) looking for improvement in wall motion (which was
found to be associated with improved ventricular function over
time, i.e., reversible cardiac dysfunction.)
(Kono T, etal. Am J Cardiol 1999; 84 (5): 578-2)

Management
T4 protocol ((KODA)
1. 50 ml of 50% dextrose plus 20 units of insulin
2. Solumedrol 2 gm
3. Levothyroxine (T4) 20 mcg bolus followed by 10mcg/hour
4. Vasopressin 1 unit/hour
5. Replace potassium as needed.

222
B. Lung
Special evaluation
1. PAC
2. Measure P/F ratio after being on 100% oxygen and 5 cm PEEP for 10
minutes. Repeat Q 4 hours
3. CXR. Repeat Q 4 hours
4. Bronchoscopy and BAL
5. If Louisville KY Jewish Hospital recipient
Obtain sputum culture for AFB and toxoplasmosis
6. Pulmonary medicine consult for evaluation as possible lung donor

Management
1. Narcan 10 mg
2. LINK vest treatment 10 min per hour
3. If Louisville KY Jewish Hospital recipient
a. Administer gentamicin 80 mg as aerosol
b. Vancomycin 1 gm, ceftazidime, 1 gm, cleocin 900 mg.
4. If P/F < 300 repeat bronchoscopy and performs recruitment
maneuvers:
a. PC ventilation with PAP 25 and PEEP 15 for 2 hours (SALT
protocol per Angel 2006)), or
b. Sustained positive pressure of 30 cm H2O for 30-60 sec
5. Rotate full lateral Q 2 hours
6. Diurese to normovolemia (ARDS-Net Conservative fluid management
protocol, NEJM 2006; 354; 2562-75):

If perfusion is adequate, and MAP > 60 without vasopressors, and

urine output > 0.5 ml/hour: lower CVP to <4 or PAOP to <
8
If perfusion is adequate, and MAP > 60 without vasopressors, but
urine output < 0.5 ml/hour: lower CVP to <9 or PAOP to
<13
If perfusion is inadequate but MAP > 60 without vasopressors:
lower CVP to < 13 or PAOP to < 18

C. Liver
Nothing special other than treating hypernatremia (see item [Link])

D. Kidney
Nothing special other than CIN prophylaxis (see item VIII. L above)

223
X. A. References
1. KODA Routine Adult Organ Donor Maintenance Orders, Revised June 2007

2. Shemie SD, Ross H, Pagliarello J, et al. Organ donor management in Canada:

recommendations of the forum on Medical Management to Optimize Donor Organ
Potential. CMAJ. 2006;174(6):S13-32.

3. Angel LF, Levine DJ, Restrepo MI, et al. Impact of a lung transplantation donor-
management protocol on lung donation and recipient outcomes. Am J Respir Crit Care
Med. 2006;174(6):710-6.

4. National heart. Lung and blood institute acute respiratory distress syndrome (ARDS)
clinical trials network. Comparison to two fluid-management strategies in acute lung
injury. NEJM 2006; 354(24): 2564-75

5. Kono T, Nishina T, Morita H, etal. Usefulness of low-dose dobutamine stress

echocardiography for evaluating reversibility of brain death-induced myocardial
dysfunction. Am J Cardiol 1999; 84: 578-82

6. Briguori C, Airoldi F, D’Andrea D, etal. Renal insufficiency following contrast media

administration trial (REMEDIAL). A randomized comparison of 3 preventive strategies.
Circ 2007; 115: 1211-7

7. Dellinger PR, Carlet JM, Masur H, etal. Surviving sepsis campaign guidelines for
management of severe sepsis and septic shock. Crit Care Med 2004; 32(3): 858-73

8. Osman D, Ridel C, Ray P, Monnet X, Anguel N, Richard C, Teboul JL. Cardiac filling
pressures are not appropriate to predict hemodynamic response to volume challenge.
Crit Care Med. 2007 Jan;35(1):64-8.

X. B. Selected supplemental bibliography

1. Ullah S, Zabala L, Watkins B, Schmitz ML. Cardiac organ donor management.

Perfusion. 2006;21(2):93-8.

2. Demetriou JL, Foale RD, Ladlow J, et al. Canine and feline pyothorax: a retrospective
study of 50 cases in the UK and Ireland. J Small Anim Pract. 2002;43(9):388-94.

3. Hevesi ZG, Lopukhin SY, Angelini G, Coursin DB. Supportive care after brain death
for the donor candidate. Int Anesthesiol Clin. 2006;44(3):21-34.

4. Wood KE, Becker BN, McCartney JG, et al. Care of the potential organ donor. N Engl
J Med. 2004;351(26):2730-9.

224
UNIVERSITY OF KENTUCKY HOSPITAL POLICY NUMBER:
HP06-17
CHANDLER MEDICAL CENTER FIRST ISSUED: 11/85
HOSPITAL POLICY CURRENT AS OF: 12/07

SUBJECT: Withholding/Withdrawing Potentially Life-Sustaining Treatment

SEE ALSO: Hospital policies HP06-09, Consent to Treatment; HP06-27, Organ and
Tissue Procurement for Transplantation; HP06-33, Advance Directives; HP08-03,
Patient Rights; HP08-10, Relief of Pain; Medical Staff Rules and Regulations

INFORMATION
The University of Kentucky Hospital recognizes that the dignity of human life and the
right of all persons to a dignified and peaceful death requires that a medical procedure or
treatment should be used only if it furthers one or both of the following goals:
• the relief of suffering, or
• the prolongation of a life satisfactory to the patient.

Definition of Terms
Do-Not-Resuscitate (DNR) is an order to withhold cardiopulmonary resuscitation
measures (as designated by the American Heart Association standards) that could
restore blood circulation and breathing in a person who has experienced cardiac and/or
respiratory arrest.

Medically Inappropriate Interventions (formerly Futile Treatment) is a form of

therapeutic intervention is appropriately considered medically inappropriate for a patient
when an attending physician, in consultation with a patient’s care team and family or
proxy, and consistent with available medical literature, concludes that such intervention
holds no reasonable possibility of providing: a cure, improvement, or amelioration of the
patient’s condition; restoration of a quality of life satisfactory to the patient; or such
intervention would only increase or prolong the patient’s suffering.

Artificial Nutrition and Hydration is a medical treatment whereby nutrition and/or

hydration are delivered by a feeding tube or parenteral means.

Patient with Decision-Making Capacity is an adult (18 years of age or older) or an

emancipated minor who is able to understand the information that is relevant to making
a decision about the treatment or admission, able to appreciate the reasonably
foreseeable consequences of a decision or lack of decision, and able to communicate a
decision. A person is presumed to be capable with respect to treatment or admission. A
person is entitled to rely on the presumption of capacity with respect to another person
unless he or she has reasonable grounds to believe that the other person is incapable
with respect to the treatment or admission.

Patient without Decision-Making Capacity is a person who has been declared legally
incompetent by a court of law; or a minor (under 18 years of age, unless the minor is
emancipated); or an adult, or an emancipated minor, who is unable to appreciate the
reasonably foreseeable consequences of a decision or lack of decision, and unable to
communicate a decision. A person may be incapable with respect to some treatments
and capable with respect to others. A person may be incapable with respect to a
treatment at one time and capable at another.

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Family or Proxy
• the adult child of the patient, or if the patient has more than one child the
majority of the adult children who are reasonably available for consultation; or
• the parents of the patient; or
• the nearest living relative of the patient, or if more than one relative of the same
relation is reasonably available for consultation; or
• the majority of the nearest living relatives. (KRS 311.631); or
• any other person designated by the patient orally or in writing when the patient
had capacity.

Kentucky Emergency Medical Services (EMS) DNR is the form designed and supplied
by the state for use by EMS personnel that allows DNR status for a transported patient.

Advance Directives
• Living Will is a written declaration instructing the maker’s (patient’s) physician to
withhold or withdraw life prolonging treatment if the patient has a terminal condition or is
permanently unconscious. (KRS 311.625)
• Substitute or Proxy Decision Maker is a person(s), including a health care surrogate,
who has the responsibility (subject to certain limitations) to make decisions on behalf of
a patient without decisional capacity. (KRS 311.625)

INSTRUCTIONS
Autonomy
The decision to withhold or withdraw any potentially life-sustaining treatment should be
based on the principle that a patient with decision-making capacity has the right to reject
potentially life-sustaining treatment even when such treatment is medically
recommended.

Medically Inappropriate Interventions

There is no ethical or legal obligation to provide a treatment which, in the opinion of the
physician, is medically inappropriate.

Withholding versus Withdrawing Life-Sustaining Treatment

There is no ethical, moral, or legal difference between stopping a life-support measure
and not starting it. In the event of uncertainty, it may be preferable to provide a life
support measure for a limited time trial before concluding that it lacks benefit.
Decisions to withhold/withdraw more than one treatment should be made explicitly and
separately. The fact that an order has been written to withhold/withdraw a particular
medical treatment has no bearing on the provision of other medical treatments.

Artificial Nutrition and Hydration

The decision to institute artificial nutrition and hydration requires the same process of
informed consent as any other treatment. Its use is associated with inherent risks as well
as benefits. Institution of artificial nutrition and hydration requires expertise in calculating
the nutritional needs of the patient in the context of the goals of therapy, in placing and
managing the delivery devices and in recognizing and treating complications. The
provision of artificial nutrition and hydration may be associated with more risks and
discomfort for individual patients than withholding or withdrawing this form of therapy. It
is expected that the clinician attending to the patient will address these issues when
discussing end of life decisions. Nutrition and hydration cannot be withheld or withdrawn
if they are needed for comfort or the relief of pain. (KRS 311.629.13-ck) This should

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rarely be the case if the patient is provided access to appropriate palliative care.

Double Effect
Relief of pain and suffering is central to exemplary patient care. Commitment to the relief
of pain and suffering of the dying patient is essential, even if death may be hastened as
a result of effectively relieving the patient’s pain.

Integrity of Medical Profession

A physician has no obligation to render or offer any treatment that violates applicable
standards of medical practice, nor may a physician abandon the patient without referral
to available and competent medical resources.

Patient’s Right of Choice

A patient has the right to change physicians if the patient (or proxy) and physician
disagree over the necessity or appropriateness of treatment. A patient with decision-
making capacity has the right to accept or refuse treatment after being appropriately
informed of treatment choices.

Categories of Inpatient Status

The Hospital recognizes three major levels of support with regard to resuscitation:

Category 1
Full support, including all CPR modalities. The patient receives full resuscitative care.
Unless an attending physician writes an order to the contrary, the patient will be provided
full support, including CPR.

Category 2
DNR. This order only addresses cardiopulmonary resuscitation and does not specifically
limit other appropriate treatments. Active DNR orders will not automatically be rescinded
when patients leave their hospital units for invasive or non-invasive testing.
Note: It is inappropriate to divide resuscitation into components that could be initiated
(e.g. defibrillation, pharmacologic agents) without providing others (e.g. airway
management, mechanical ventilation.

Category 3
Withholding/withdrawing other measures. The patient (or proxy) may, in consultation
with the attending provider decline these treatments. When an order to discontinue
treatment is written but the physical means for providing the treatment remains in place
(e.g., mechanical ventilator or feeding tube) the physician or other willing member of the
health care team should remove or disconnect the treatment device with the assistance
of auxiliary staff, as appropriate. If upon removal of said device, death is expected
imminently, then a physician member of the health care team should be present.

Making End of Life Decisions

Adult Patients (or emancipated minors) with Decision-Making Capacity
Decisions to withhold or withdraw potentially life-sustaining treatment are to be made by
the patient with decisional capacity after consultation with the attending physician.
Adult Patients (or emancipated minors) without Decision-Making Capacity
• Determining Capacity: It is the responsibility of the attending physician to determine if
the patient has decision-making capacity for any proposed medical treatment using the
criteria set out in the definitions.

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• Determining the appropriate surrogate decision-maker: If an adult patient does not
have decision-making capacity, then healthcare decisions on behalf of the patient may
be made by any of the following responsible parties in the following order of priority:
1. The judicially appointed guardian to the patient, if medical decisions are within
the scope of the guardianship;
2. Person named in a properly executed written advance directive;
3. The spouse of the patient;
4. An adult child of the patient, or if the patient has more than one child, the
majority of the adult children who are reasonably available for consultation;
5. The parents of the patient;
6. The nearest living relative of the patient, or if more than one relative of the
same relation is reasonably available for consultation, the majority of the nearest
living relatives. (KRS 311.631);
7. Any other person designated by the patient orally or in writing when the patient
had capacity.

Minors
If a patient is a minor child under the age of eighteen years and not emancipated under
the laws of the Commonwealth of Kentucky, treatment may be withheld or withdrawn
when:
1. the parent(s) or legal guardian of the minor patient expresses to the physician
an understanding of the purpose of treatment and the risks of forgoing the
treatment and declines life-sustaining treatment or indicates that such treatment
be withdrawn.
2. and advance directive has been issued on behalf of the patient declining
treatment and any conditions contained in the directive are met. (Kentucky law)
3. Treatment is medically inappropriate.

An individual authorized to consent for another shall act in good faith, in accordance with
any advance directive executed by the individual who lacks decisional capacity, and in
the best interest of the patient who does not have decisional capacity. (KRS 311.631)

According to Kentucky law (KRS 311.629.13) if the patient is pregnant, life-sustaining

treatment, including nutrition and hydration, cannot be withheld or withdrawn, regardless
of the patient’s (or proxy’s) directions, unless the attending physician and another
licensed physician who has examined the woman determine within reasonable medical
certainty that such procedures:
1. will not maintain the woman in a way to permit the continued development and
live birth of the unborn child, and
2. will be physically harmful to the woman, or
3. will prolong severe pain that cannot be alleviated by medication

The physician is responsible for providing the patient or surrogate decision maker with
all pertinent information concerning the possible benefits and risks of treatment (see
Hospital policy HP06-09, Consent to Treatment). If support services (e.g., palliative care,
pastoral care, social services) have not been involved with the patient’s case, the
attending physician is encouraged to engage these services when a decision to forgo
life-sustaining treatment is made.

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Wards of the State
1. When the attending physician believes that potentially life-sustaining treatment should
be withdrawn/withheld from a patient who is a ward of the state, the family social worker
should be contacted to obtain the necessary state documents to request
withdrawing/withholding treatment.
Note: State regulations specify that withdrawing or withholding potentially life-sustaining
treatment can only be considered for patients who are terminally ill and permanently
unconscious.

2. The attending physician will complete the state-provided form requesting permission
to withhold/withdraw treatment. The attending physician will also request a second
physician to complete a consultative opinion form, also provided by the state, concurring
in the request.

3. The attending physician may or may not seek a consultation from the Clinical Ethics
Consult Service prior to making such a request.

4. The completed documents will be submitted to the patient’s state guardian, who, in
turn, will submit them to the state health decision committee for review. This review is
usually completed in 24 to 48 hours.

5. After receiving written notice from the guardian of the state health decision
committee’s approval, the physician may write orders for the withdrawing/withholding of
potentially life-sustaining treatment (see Documentation section below). The written
notice and physician orders will be added to the patient’s chart.

Documentation

1. In any case in which a health care decision is made, the decision shall be noted
in writing in the patient’s medical record. (KRS 311.631) The note should include the
parties involved, key elements of the discussion and the agreed upon conclusions or
plans. If the level of support designated for a patient excludes CPR, the attending
physician should initiate a conversation with the patient (or proxy). Documentation in the
chart of this discussion should include:
• patient decisional capacity when the order was given, and
• patient consent to the level of support, and
• if the patient did not have decisional capacity:
• whether the patient had a living will that authorized the level of support,
and
• the name and relationship of the proxy who, on the behalf of the patient
consented to the level of support.
• a written order by the attending physician to reflect the decision made.
2. An order must be entered to institute DNR status or withdraw life-sustaining
measures.

3. Telephone Orders: Verbal orders for DNR may be given by an attending physician to
a senior resident in exceptional situations. In such situations, the resident may write the
order, but the attending physician must personally cosign the order and document the
related information within 24 hours.

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4. Review and Revocation of DNR Orders: The patient with decision-making capacity (or
proxy) who initially requested a DNR order has the right to change his/her mind and
retract the agreement, requesting a different level of support by informing the physician.
DNR orders should be reviewed at least every 30 days.

Conflicts
The attending physician is responsible for taking the lead in resolving conflicts between
or among interested parties including the patient, surrogate, family members and health
care team members.

If the disagreement or confusion is not resolved, the patient (or proxy), the patient’s
family, or any member of the health care team can request a clinical ethics consult
through the Clinical Ethics Consult Service.

If the attending physician, because of personal beliefs or conscience, is unable to

comply with the decision of a patient (or proxy) concerning the withholding/withdrawing
of treatment, the attending physician should attempt to transfer care of the patient (as
well as the patient’s medical records) to another physician who is willing to comply. The
new physician must be acceptable to the patient (or proxy). In the event that a transfer is
not possible, the case should be referred to the Clinical Ethics Consult Service.

If the attending physician, in consultation with a patient’s care team, decides that certain
therapeutic interventions are medically inappropriate for the patient, the physician should
discuss carefully with the patient (or proxy) the nature of the ailment; the care options
available and useful for the patient, including palliative and hospice care; the prognosis;
and the reasons why certain interventions are considered inappropriate. If the patient (or
proxy) and the attending physician agree, treatment may be discontinued.

If the patient (or proxy) and the attending physician do not agree with reference to the
futility of a proposed course, the attending physician will discuss with the patient (or
proxy) obtaining an additional medical opinion on the patient’s case from another
physician. The physician who will provide the second opinion will be selected by the
chief medical officer.

If a physician offering a second opinion on inappropriate treatment concurs with the

attending physician, the patient (or proxy) and the patient’s family and/or significant
others should be given adequate time to consider this additional opinion.

If, after considering the opinion of the attending physician and a concurring opinion of
the consulting physician, the patient (or proxy) desires interventions that have been
judged to be inappropriate, and if the attending physician does not want to proceed with
such interventions, the attending physician should:

• request a clinical ethics consult through the Clinical Ethics Consult Service;
• inform the patient (or proxy) that the request has been made; and
• inform the patient (or proxy) that the patient is at full liberty to effect the patient’s
transfer to another hospital or to another physician.

If the consulting physician disagrees with the attending physician about the treatment of
the patient, and if the patient (or proxy) desires, the chief medical officer will facilitate the
patient’s (or proxy’s) request for transfer to another physician.

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If the patient (or proxy) initiates a clinical ethics consult, a clinical ethics consultant
(CEC) will be contacted and will review the case and make recommendations in a timely
fashion. The CEC may call in additional ethics consultants, or other expert consultants
as needed, or bring the case before the entire Hospital Ethics Committee for review. A
CEC letter will document the issues in the case and be inserted into the patient’s chart.

If the CEC agrees with the attending physician that such treatment is inappropriate for
this patient, such treatment will not be initiated or will be discontinued and document the
decision in the patient’s record.

If the CEC disagrees with the attending physician and if the attending physician wishes
to withdraw from the case, the CEC will contact the chief medical officer, to either secure
an attending physician to carry out the patient’s wishes or, failing this, will attempt to
effect the patient’s transfer to another hospital.

Clinical Ethics Consultations

The CEC service pager number is 330-0365; 24 hours a day, seven days a week, to all
clinical enterprise faculty and Hospital staff. A request by email can be sent to
bioethics@[Link]. The Program for Bioethics and Patients’ Rights website is
[Link]/bioethics

Special Situations
EMS Transport of Patients with or Without DNR Designations
Kentucky law requires that patients with DNR designations have a complete, signed
original EMS DNR form, which is given to EMS personnel before transport.

DNR orders without EMS DNR forms cannot be honored by EMS transport personnel.

The EMS DNR form must be notarized, or it may be witnessed by two persons who are
not:
• blood relatives of the patient
• beneficiaries under the descent and distribution laws, or
• directly financially responsible for the patient’s health care.
Note: An EMS DNR can be witnessed by Hospital staff as long as those staff members
are not related to the patient or responsible for the patient’s health care.

Initiating Kentucky EMS DNR in the Hospital

Patients with DNR designations, who want to continue this status, leaving UK Hospital in
emergency medical transport must have a completed and signed Kentucky EMS DNR
form.
1. The patient must have a physician’s order for DNR status.
2. The physician and/or nurse may consult with Social Services, a patient
representative, or the hospice nurse to initiate an EMS DNR.
3. If the patient or family wants an EMS DNR and no DNR order exists, the
health care professional must contact the attending physician for initiation of
DNR specifications to be documented in the medical record.
If the attending physician refuses to grant DNR orders the physician should
request a clinical ethics consult (see pages 5 and 6 of this policy).
4. The completed, original Kentucky EMS DNR should be given to the transport
personnel.
5. The bottom of the Kentucky EMS DNR should be torn off the form and

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 attached to the patient.

6. The transport staff will give the original Kentucky EMS DNR form to the patient
or responsible family member upon arrival at their destination.

7. If the patient has a medical emergency during transport, EMS personnel will
retain the original EMS DNR form.

Patients Arriving with Kentucky EMS DNR Form

1. When a patient arrives with an original, completed Kentucky EMS DNR form, the
receiving medical staff member will notify the physician that DNR issues need to be
addressed immediately.
2. The original Kentucky EMS DNR form will be given to the patient or responsible family
member. If the patient has died in transit the Kentucky EMS DNR form will be retained
by the transport personnel.

Patients Arriving with DNR Designations

Do Not Resuscitate designations (DNR) will be honored upon a patient’s initial arrival to
our emergency department and upon Hospital admission. However, the attending
physician must review treatment options with the patient (or proxy) shortly within 24
hours after admission to determine the level of treatment support desired.

Surgical, anesthesia, and invasive diagnostic procedures for patient with DNR
order or other orders limiting life-saving measures.
A patient with a DNR order may require anesthesia and surgery for palliative care or
other medical reasons. In such circumstances, discussion and clarification of the support
status between the patient (or proxy) and attending surgeon and anesthesiologist will
occur prior to admission to the operating room or procedure area. Consent to anesthesia
and surgery requires delineating the usual treatments necessary to prevent foreseeable
and unanticipated life-threatening events during surgery (e.g., endotracheal intubation,
intravenous fluids, CPR, blood products and inotropic drugs, etc.). Written consent for
surgery and anesthesia will be required by both surgeon and anesthesiologist. Following
that discussion, a note will be written in the chart delineating which forms of life support
will be utilized in the event of need during the perioperative or periprocedural period.
After completion of the post-anesthesia or post-procedure recovery period, a new DNR
order should be written. It seems reasonable to apply these principles to all procedures
requiring informed consent. A review of the risks and benefits of the procedure and its
alternatives should include a review of the DNR decision. DNR orders should not be
automatically rescinded without discussion with patient or proxy.

When intraoperative or periprocedural arrest results in the death of a patient who has a
DNR order in force, the death will be classified ―expected‖ rather than ―unexpected.‖

Approved by Richard Lofgren, M.D., Chief Medical Officer

Authorized by Murray B. Clark, Jr., Associate VP for MC Operations

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SECTION 8: DISASTER MANAGEMENT

UNIVERSITY OF KENTUCKY HOSPITAL POLICY NUMBER: HP12-11

CHANDLER MEDICAL CENTER FIRST ISSUED: 5/85
HOSPITAL POLICY CURRENT AS OF: 3/06

SUBJECT: Mass Casualty Response Plan

SEE ALSO: Emergency Department Trauma Disaster Plan; Departmental
Response Plans

Alert 1
UK Hospital utilizes the Hospital Emergency Incident Command System (HEICS) as its
command and control structure to facilitate response to emergency situations.
In addition, the Hospital has developed a contingency plan to guide Hospital personnel
in the early stages of response to a mass casualty disaster, until a command center can
be established.

Through community planning, UK Hospital has been designated a primary receiving

hospital for acute and critical disaster victims.

This plan assumes that the Hospital and its operations have not been affected by the
disaster. If the Hospital has been damaged or operations have been interrupted, the
incident commander or liaison will notify DEEM to channel patients to alternate health
care facilities until necessary operations can be restored.

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The Hospital uses the code Alert 1 to notify staff that the community has experienced a
mass casualty disaster and that the Hospital is preparing to receive an influx of patients.
The Alert 1 announcement is made over the paging system and preceded by chimes.

1. The external agency of jurisdiction will notify Aeromedical Dispatch that a

disaster has occurred and that casualties will be transported to the Hospital.
2. The dispatcher will connect the caller to the ED charge nurse, 323-5901.
3. Dispatch will call the Fire Department, 252-1124, or Metro Police, 258-3600, to
verify.
4. ED Charge will notify the ED attending and Hospital operations administrator
(HOA).
5. HOA will notify
• administrator-on-call
• Hospital safety officer
• chief of staff
6. The Hospital administrator-on-call will:
• determine whether to issue an Alert 1(in consultation with the ED attending and
ED charge.)
• notify paging operator, 323-5200, to issue an Alert 1 page over the public
address system and to activate the Alert 1 call list.

Notification of Incident Command Staff and Off-Duty Personnel

UK Communications maintains a list of incident command staff who must be notified if
an Alert 1 is issued. The list is update twice a year.
1. After making the Alert 1 page, the paging operator will activate the Alert 1 call
list.
2. When key personnel are notified by announcement or call that a disaster has
occurred, they will consult with their section chief or unit leader to determine what
additional steps must be taken immediately.
3. If off-duty employees are needed, the departmental representatives will
activate their call-in lists.

Triage and Patient Care

During a disaster, certain standing rules and regulations of the medical staff may be
selectively waived by the chief of staff, Hospital administrator, or chiefs of clinical
services to facilitate essential patient care.

For the purposes of this plan, triage is defined as the sorting and classifying of incoming
patients so that they can be channeled to appropriate treatment areas. Although medical
care may be available, treatment at the triage point will be kept to a minimum to facilitate
prompt attention to all disaster victims.

To facilitate triage, patients will be classified as:

• Dead (black)
• Critical (red)
• Acute (yellow)
• Minor (green)

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Treatment Areas
• Triage—ED parking lot
• Critical and Acute Treatment—ED trauma bays
• Acute Overflow Treatment—Pre-operative holding area
• Minor Treatment, General Adult—Cardiac Cath recovery area
• Minor Treatment, Adult Psychiatric—3 West
• Minor Treatment, Obstetric—Labor and Delivery
• Minor Treatment, Pediatric—Children’s Hospital
• Morgue—Morgue

Medical Center PPD will hold both CCC patient transport elevators w on the ground
floor. One will be used to transport victims from the Emergency Department to other
treatment areas. The second patient transport elevator will be used to transport patients
from OR and ICU to inpatient units.

Other Established Alert 1 Areas

• Command Center (EOC)--N102
• Family Center—H116
• Media Center—HSC 307
• Inpatient Discharge Point--Kentucky Clinic lobby, Limestone entrance
• General Personnel Pool—Hospital Cafeteria
• Physician Pool—H133
• Nursing Resources Allocation Center--H178

The Kentucky Clinic will close all clinics when an Alert 1 has been confirmed and issued.
Kentucky Clinic personnel who do not have specific disaster response assignments will
report to the personnel pool. Clinic areas may be used as back-up treatment areas as
needed during disaster response.

Personnel Assignments and Direction

Personnel essential to command and control in a mass casualty incident have been
given assigned specific roles under the Hospital Emergency Incident Command System
(HEICS). Alternates also have been named to facilitate response. Staff will assume
those roles as they are activated by the section chief.

To facilitate immediate response while the command center is being established, the
Alert 1 responsibilities of certain staff are outlined in this plan and in departmental plans.
Staff who has specific assignments will report to designated locations to assume their
roles.

Nurses who do not have specific assignments will report to the Nursing Resources
Allocation Center. Other employees who do not have specific assignments will report to
the personnel pool.

Off duty employees who are reporting for emergency response duties will enter the
Hospital grounds from University Drive and park in the Hospital or KY Clinic parking
structure. Staff will be required to present their Medical Center ID badges to enter
hospital grounds.

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Work Shifts
During emergency response all Hospital employees are considered essential personnel.
• If an employee is on duty at the time the Alert 1 is announced, they are
expected to remain on duty until notified that disaster response efforts are
complete or until they are officially relieved of duty.
• If an employee is notified to report to the Hospital for disaster response duty,
they are expected to report as soon as possible and to remain on duty until the
disaster response effort is complete or until they are officially relieved of duty.

If a supervisor needs replacement or back-up personnel, they should telephone, page,

or send a runner to the appropriate personnel pool to request assistance.

Departmental Planning Responsibilities

Each director will develop a service area response plan that outlines roles and
responsibilities of designated employees under the HEICS, in general, and Alert 1
contingency plan, in particular. Each plan must include a procedure for notifying off-duty
staff.

Before finalizing the plan, the service director will submit the plan to the Hospital safety
officer and Emergency Management Subcommittee for approval. Once the plan has
been finalized, the director will provide comprehensive training for their employees. New
employees will be trained as a part of departmental orientation.

The director will review the plan at least annually and will revise the plan whenever
personnel, location, or structural changes occur.

Employee Education and Training

All hospital employees are introduced to the Hospital’s emergency management plan
and the HEICS during Hospital orientation.

Each employee learns about their role in emergency management and specific
contingency plans during departmental orientation and completes the emergency
management CBL. Continuing education is provided annually and whenever the plan
changes.

Approved by Richard Lofgren, M.D., Chief Medical Officer

Approved by Sandra E. Chambers, Assistant Hospital Administrator
Authorized by Murray B. Clark, Jr., Associate VP for MC Operations

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Appendix 1
Initial Roles and Responsibilities under Plan

Triage Unit Leader

• Report to ED parking lot
• Oversee triage area set up
• Organize and direct staff
• As casualties arrive, assess casualties and direct appropriately

Incident Commander
• When notified of community disaster (Alert 1)
• Gather information about disaster from ED Attending
• Type and nature of incident
• Number of casualties
• Number of patients coming to UK
• Nature of injuries
• ETA
In consultation with ED Attending, determine whether to initiate Alert 1. If decision is
made to initiate Alert 1:
• Notify paging operator, 3-5200.
• Report to N102, establish Command Center
• Assign HEICS roles as appropriate to disaster

Hospital Operations Administrator (Medical Care Director)

If Alert 1 occurs when an administrator is not on site, the HOA may assume the role of
incident commander until the administrator-on-call arrives.

Under normal circumstances, the HOA will serve as the medical care director, reporting
directly to the operations chief.
• Establish auxiliary command center (H-178).
• Activate HEICS section positions.
• Assess bed and staffing availability.
• Organize information and send to operations administrator.

Environmental Services Staff

• Initially, report to H16.
• If assigned to triage, report to triage unit leader: (2 employees)
• Deliver triage supply box to triage area.
• Bring stretchers and wheelchairs from ED to parking lot or area where triage is
established.
• Gather stretchers and wheelchairs from throughout Hospital. Bring to vendor
area for staging.
• As needed, transport stretchers and wheelchairs from vender area to ED
ambulatory entrance. Note: One ES staff member should be stationed in triage to
provide stretchers and wheelchairs as needed.
• If assigned to stretcher/wheelchair clean up, report to materials supply unit
leader: (one To two employees).
• Set up cleaning area in HA063.
• Clean stretchers/wheelchairs.
• Deliver clean stretchers/wheelchairs to vendor area.
• If assigned to transport, report to triage unit leader: (two to three employees)

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 • Report to ED parking lot or area where triage is established.
• After casualties are triaged, transport to designated treatment area.
• After transport, if stretcher/wheelchair is soiled, take to HA063 for cleaning.
• Return to ED entrance to continue transport.
• If assigned to clean patient rooms: (All remaining staff)
• Stand by in H16 for assignment.

Medical Center PPD

• Report to facility unit leader, H43.
• If assigned to CCC patient transport elevators, secure on elevator on ground
floor for transport of casualties to OR.

Appendix 2
Patient Tracking

Initial patient information will be transmitted from triage to the Command Center by fax or
runner. The planning chief will assure that the patient tracking officer receives the
information.
• The patient tracking officer will share information with the patient information officer so
that family notification can begin.
• The patient tracking officer will maintain a log of patient locations. Patient location and
condition updates will be transmitted to the Command Center using a logging system
kept on each treatment unit.
• The patient information officer, working with the Red Cross and other agencies, will
attempt to notify the victim's family, using information on the tag. When the family is
reached, the patient information officer will document notification and send information to
public information officer in Command Center.

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UNIVERSITY OF KENTUCKY HOSPITAL POLICY NUMBER: HP12-15
CHANDLER MEDICAL CENTER FIRST ISSUED: 2/00

HOSPITAL POLICY CURRENT AS OF: 4/06

SUBJECT: Mutual Aid Plan

SEE ALSO: Hospital policy HP12-11, Mass Casualty Response Plan

INFORMATION
University of Kentucky Hospital recognizes the potential for a chemical, biological agent,
or radiation exposure posed by Hospital operations, University and community
research, local industry, terrorism, or interstate transport. In an effort to respond more
effectively to such an event, the Hospital has adopted an all-hazard approach to all
disasters, using the Emergency Incident Command System (HEICS). HEICS provides for
a simplified chain of command or management structure for communications decision-
making during disasters.

University of Kentucky Hospital has a mutual aid agreement with other hospitals in the
Lexington-Fayette county area and with several community hospitals throughout the
state.

This agreement acknowledges the Hospital’s commitment to accept patients evacuated

from those hospitals due to emergency situations, based on the Hospital’s bed
availability and operating capabilities at the time of the event. This mutual aid
agreement also acknowledges the other hospitals’ commitment to accept patients
evacuated from the University of Kentucky Hospital in the event of a disaster.
Procedural aspects of that part of the mutual aid agreement are outlined in the
Hospital’s evacuation contingency plan.

The Hospital may allow the evacuating facility to transfer staff to care for patients.

Departments that have specific responsibilities for implementation will document

procedures for their areas to comply with this policy.

Notification and Plan Activation

When a hospital within the region has an emergency situation that necessitates facility
evacuation, the evacuating hospital or the Lexington-Fayette County Emergency
Operations Center will notify the Capacity Command Center in Admitting and request
that UK Hospital assess its ability to accept evacuated patients.

The Capacity Command Center may provide preliminary bed availability information,
but plan activation is the decision of the Hospital administrator-on-call.

Assessing Current Inpatient Status

1. When a unit is notified that the Hospital is expecting patients evacuated from
another facility, the Hospital operations administrators (HOA) and Capacity Command
Center will consult with the physicians and staff nurses to determine whether any
patient is eligible for immediate discharge.
2. The division charge nurse/HOA will complete the nursing disaster report.
3. If patients on the unit are eligible for discharge, the physician will write orders for
discharge, follow-up, and prescriptions.

The bed assignment clerk will:

• notify the administrator-on-call
• notify the Hospital operations administrator

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• gather appropriate information, including a contact name and telephone number
• notify the Admitting supervisor-on-call
2 -- HP12-15, Mutual Aid Plan

The administrator-on-call will confer with appropriate parties and determine the
Hospital’s ability to accept evacuated patients. (Plan activation assumes that patients
will remain at UK Hospital for at least 24 hours.)

If a decision is made to activate the mutual aid plan, the administrator-on-call will
notify:
• Evacuating hospital or LFUCG EOC (258-3847 or 258-3870)
• Admitting supervisor-on-call
• Emergency Department charge nurse
• Chief of staff
• Hospital safety officer
• Security director
• Emergency Transport communications officer
• Pharmacy director

These representatives will notify other appropriate staff, as outlined in their

departmental or area plans, and will form a command center to oversee response
operations and resource allocation.

Command Center
The Hospital recognizes that success of emergency response activities is due to an
integrated effort by all functional areas of the Hospital. In order to ensure coordination
of all Hospital resources allocated to the disaster response effort, the Hospital will
establish a command center in N102 or other suitable location.

Like most disaster response efforts, mutual aid response requires significant real-time
planning and implementation, based on the specific situation. The primary purpose of
the command center is to identify and allocate resources appropriately and to provide
administrative coordination and support for all Hospital resources allocated to the
response effort.

Command Center Personnel

The Hospital administrator-on-call initially assumes the role of response coordinator.
After consultation with other command center staff, the administrator-on-call may
relinquish responsibility to another administrator, if appropriate.

In most cases, Hospital administrators, the chief of staff, and other key staff will
assume disaster response responsibilities consistent with their primary responsibilities.

To ensure appropriate coordination and documentation of disaster response activities,

the response coordinator may assign the following functions to members of the
administrative or support staffs and other functions as needed.
Operations: The operations officer will work with key personnel to ensure that
the goals and assignments of the command center are carried out and that all
necessary patient care and support functions are appropriately staffed. In some
cases, a personnel pool may be formed from which essential functions are
staffed. Representatives from the chief of staff’s office will work to ensure
appropriate physician resources.

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 Logistics: The logistics officer will work with key personnel to ensure that patient
care and support services have the supplies, equipment, and utilities necessary
to perform essential functions.

Finance Officer: The finance officer will work with key personnel to track
expenditures for cost recovery and to ensure that funds can be allocated for
special purchases essential to disaster response.

Liaison: The liaison will establish contact and work with external agencies
responding to the disaster.
HP12-15, Mutual Aid Plan -- 3

Public Relations Officer: The public relations officer will establish a media center
and provide official information to the media. The public relations officer will
coordinate release of patient information with the command center and the
family center.

Security Officer: The security officer will work with Security and other assigned
staff to limit building and grounds access.

Administrative assistants will work with assigned administrators to:

• answer command center telephone lines
• document actions taken during disaster response
• act as runners
• assume other duties as assigned.

Communicating with External Agencies and Patients’ Families

The liaison will communicate with external agencies to obtain necessary resources and
to help ensure a successful transfer of patients.

The liaison will notify the Red Cross that the mutual aid plan has been activated and
that the Hospital is accepting patients evacuated from another facility. The Red Cross
will assist in notifying families.

If necessary, Patient & Family Services staff may establish a family center to assist in
communicating with patients’ families.

Transportation Resources
The administrator-on-call, in consultation with Emergency Transport, will determine
whether UK Hospital-based transportation resources can be allocated to assist in
moving patients from the evacuating facility to the UK Hospital.

Triage and Room Assignment

Since patients being evacuated from another hospital are assumed to be stable, unless
otherwise indicated, a triage and holding area will be established in the north lobby of
the Hospital or other designated area. The Emergency Department nurse or designee
will oversee the set-up of the triage area. Housekeeping staff will be dispatched to
transport necessary tables, beds, and stretchers to the north lobby and to assist with
the set-up. Respiratory Care will be notified to provide oxygen cylinders and respiratory
services to the area. Materials Management will be notified to provide supplies for the
triage area.

Triage will be coordinated by an Emergency Department nurse and a medical/surgical

divisional charge nurse or manager-on-call.

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If the incident has resulted in casualties or the evacuating hospital is transferring
seriously ill patients, arrangements will be made for these patients to be transported
directly to and triaged in the Emergency Department.

Triage personnel will assess arriving patients and work with the Capacity Command
Center to provide expeditious bed assignment. In some cases, a boarding ward may be
established in the holding area only until beds become available. Once a room is
assigned, transport aids will transport patients and all available patient records from
the holding area to the unit.

If the Hospital segregates patients evacuated from the other hospital by opening a
vacant patient care unit, the Hospital may request clinicians from the evacuating
hospital to care for transferred patients. This decision will be based on the identified
staffing needs of UK Hospital, as the receiving facility.
4 -- HP12-15, Mutual Aid Plan

Triage personnel will include:

• registration counselors
• two nurses
• physician
• transport team (transports or Rehabilitation Services staff)
• respiratory therapist
• security (a secure area and two tables for registration)

Assessing Additional Bed Availability

Although the UK Hospital has agreed to accept patients evacuated from another facility
based on bed availability, in some cases the Hospital may assess its ability to fill
additional beds for incoming patients.

Plan Termination
The Hospital command center will oversee a phased-approach to plan termination.
Primary response will cease when all evacuated patients, designated to be transferred to
University of Kentucky Hospital, have been received, triaged, and appropriately placed.

Additional response efforts, primarily involving the continuing care of patients

transferred from the evacuated hospital, may continue over an indefinite period of time.

Approved by Anna L. Smith, Assistant Hospital Administrator

Approved by Richard Lofgren, M.D., Chief Medical Officer
Authorized by Murray B. Clark, Jr., Associate VP for MC Operations

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UNIVERSITY OF KENTUCKY HOSPITAL POLICY NUMBER: HP12-13
CHANDLER MEDICAL CENTER FIRST ISSUED: 3/92

HOSPITAL POLICY CURRENT AS OF: 8/07

SUBJECT: Decontamination Plans for Chemical, Biological Agent, and Radiation

Exposures
SEE ALSO: Hospital policies HP06-01, Medico-Legal Specimens; HP10-29, Handling of
Chemical Waste; HP12-11, External Disaster Response; Bioterrorism Plan

INFORMATION
University of Kentucky Hospital recognizes the potential for a chemical, biological agent,
or radiation exposure posed by Hospital operations, University and community
research, local industry, terrorism, or interstate transport. In an effort to respond more
effectively to such an event, the Hospital has adopted an all-hazard approach to all
disasters, using the Emergency Incident Command System (HEICS). HEICS provides for
a simplified chain of command or management structure for communications decision-
making during disasters.

This plan has been developed to establish guidelines for treating patients who present
to the Emergency Department and are thought to be contaminated with chemicals,
biological agents, or radioactive materials. The plan has been developed in consultation
with the Lexington-Fayette County Division of Environmental and Emergency
Management (DEEM), which assumes responsibility for community emergency response
planning.

The Emergency Department maintains medical management information regarding

exposure to chemicals or biological agents known to be used or stored within our
geographical region or recognized as potential terrorist agents.

Each Hospital area and department that uses hazardous or radioactive materials or
handles biological agents will, in collaboration with the Hospital Environment of Care
Committee, have written procedures specific to their areas for dealing with exposures.

Note: If exposures seem crime-related, all personnel will treat personal belongings and
clothing as medico-legal specimens.

Internal Exposure Incident (Hospital, Medical Center, or University Exposures)

1. If a hazardous chemical, radiation, or biological agent exposure occurs within the
Hospital, the Medical Center, or University campus, call 911 (UK Police) immediately.
2. Before transporting any exposure victim to the Emergency Department, call 3-5901
for instructions. To reduce the risk of further contamination and/or additional
exposures, the initial decontamination should proceed according to the area’s
procedures or under the direction of the Lexington Fire Department’s Hazardous
Materials team before the victim is transported to the Emergency Department.

External Exposure Incident

1. If the Emergency Department or Air Medical Communications receives a call that a
chemical, radiation, or biological agent exposure incident has occurred, the person receiving
the call should notify the Emergency Department charge nurse and the Emergency
Department attending physician. The UK Air Medical dispatcher or ED charge nurse
receiving the call should obtain the following information:
• type and nature of incident.
• telephone number of caller so that call can be verified, if information is received by

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 other than normal emergency channels.
• number of victims.
• signs/symptoms of exposure.
• nature of injuries.
• name of chemicals, radioactive materials, or biological agents involved.
• extent of decontamination (MSDS, if available).
• if radiation victim, whether patient is contaminated or irradiated, and the
physical identity of the contaminant.
• estimated time of arrival of victims.

2. The Emergency Department charge nurse/dispatch will request that clothing be

removed and left at the scene, if possible. Remind Emergency Medical Services to bring
patients to ambulance entrance.

3. Request assistance from Lexington Fire Department by calling the Lexington Fire
Department dispatch if assistance is needed for unknown chemicals or biological
agents, primary contamination, or for specific information. The Lexington Fire
Department Hazardous Materials team may fax information on identified chemicals or
biological agents.

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Additional information may be obtained or requested as necessary from:
ATSDR Hotline at 1-404-639-6360,
CHEMTREC at 1-800-424-9300 and/or Poison Control,
CDC 24-hour emergency response at 1-770-488-7100
Micromedex

4. The ED charge nurse, attending physician, and Hospital operations administrator

will determine if the Hospital Incident Command Center should be established for
• communication with the ED, DEEM, CSEPP, media, CDC, and other agencies; and
• allocation of resources to care for existing ED patients as well as contaminated
patients.
2 -- 12-13, Decontamination Plan

Emergency Department charge nurse will notify:

• nursing decontamination team.
• attending physician, who will contact the chair of Emergency Medicine at 259-8326.
• financial counselors.
• Hazardous Materials Management, if chemical or biological agent exposure, at on-call
pager 323-5728 during the day or 222-4805 during evenings.
• paging operator.
• ED attending physician.
• UK Hospital Security

Emergency Department financial counseling staff will notify:

• Pharmacist on duty to assist with preparation of antidotes or selected medications, as
appropriate.
• Infection Control at 3-6337 Monday through Friday from 8:00 a.m. to 5:00 p.m., or
259-7009 for evenings, weekends, and holidays (if biological agent suspected).
• PPD at 323-6285.
• Materials Management, if trauma involved.
• OR, if trauma involved.
• additional nursing staff, as directed by the ED charge nurse.

Paging operator will notify:

• Hospital operations administrator.
• Hospital safety officer.
• UK Public Relations.
• Hospital administrator on-call.

ED attending physician will notify:

• chair of Emergency Medicine

Departmental Response
Emergency Department staff will:
• Establish and prepare decontamination area, at the direction of the charge nurse or
decontamination leader.
• Before patient decontamination begins, the charge nurse or decontamination leader
will assign decontamination responsibilities, inspect the set-up, and brief the
decontamination team to ensure that all protocols for decontamination appropriate to
the situation and all other safety precautions are being followed.
PPD personnel will:
• Turn off air handlers in affected areas (internal exposures).
• Turn on air line valves.

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Medical Center Security will:
• Station guard at ambulatory and ambulance entrances of Emergency Department to
ensure that no contaminated patients enter the Emergency Department.
• Block off ambulance entrance area with hazardous material tape.
• Direct all other ambulances to alternative entrance.
• Block the entrance to the Children’s Hospital.
• Block off entrance to decontamination zone.
• Direct pedestrian traffic on the Hospital walkway.
• Secure the contaminated area until the waste is removed.
• Station guard at all other public entrances to the Hospital.

Air Medical Communications will:

• Instruct incoming ambulances that establish radio contact to use alternative
entrance.
12-13, Decontamination Plan -- 3 4 -- 12-13, Decontamination Plan

Materials Management will:

• Bring necessary supplies to the area as requested by Emergency Department.
• Obtain additional supplies, if needed.

Radiation safety officer (in the event of a radiation incident) will:

• Check equipment and take background test.
• Survey victims as they enter area; ambulance crew may be included.
• Remain in area to monitor all victims, personnel, equipment, and samples leaving
area.
• Check dosimeters every 15 minutes. Personnel who experience 75 or higher rems
exposure will be replaced.

Note: Attendants will stay with ambulance until they and the ambulance have been
monitored for contamination.
• If attendants are not contaminated, they will be released for duty.
• If attendants are contaminated, they will proceed to decontamination area.

Cleaning and Disposal

Hazardous Materials Management will oversee and coordinate cleanup of
decontamination area and disposal of rinsate, clothing, protective equipment,
and supplies, as appropriate.

If the incident involves radiation Hazardous Materials Management will

coordinate clean up and disposal with the radiation safety officer.

Hazardous Materials Management will maintain contracts with outside agencies

to assist in clean up and disposal if necessary. In some cases, Physical Plant,
under the direction of Hazardous Materials Management, may assist in clean up
and disposal. No rinsate resulting from decontamination activities will be
disposed of without authorization from Hazardous Materials Management.
In some cases, Hazardous Materials Management may assist in identifying
contaminants or otherwise act as a consultant in the decontamination process
or plan.

When the Hazardous Materials Management is notified that the Hospital has
implemented the decontamination plan, designated personnel will stand by for
notification to begin clean up and disposal activities. In cases in which mass

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 casualties are transported to the Hospital for decontamination, Hazardous
Materials Management may be asked to assist in set-up of decontamination
equipment and to pump rinsate into a reservoir during decontamination
activities.

Staff Education and Training

Emergency Department nursing staff involved in decontamination procedures
will be trained, including a two-day haz-mat operations level course and two
annual refresher courses.

The Hospital will conduct decontamination or other disaster response drills in

compliance with the standards established by JCAHO and in accordance with
recognized facility and community needs.
Approved by Anna L. Smith, Assistant Hospital Administrator
Approved by Byron Young, M.D., Chief of Staff
Authorized by Joseph O. Claypool, FACHE, Hospital Director

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