Trauma Guidelines

Level I Trauma Center

March 2018
 ADULT
Glasgow Coma Scale
Eye Opening
Spontaneous 4
To Voice 3
To Pain 2
None 1
Verbal Response
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible words 2
None 1
Motor Response
Obeys commands 6
Localizes to pain 5
Withdraws to pain 4
Abnormal flexion 3
Abnormal extension 2
None 1

Qualifiers:
•Patient Chemically Sedated
•Patient Intubated
•Obstruction to the Patients Eye
 Trauma Guidelines
Stanford Hospital and Clinics
Lucile Packard Children’s Hospital Stanford
Training Programs

The protocols in this book are guidelines

only. Individual cases may vary and
clinical judgment should always be used.
When in doubt, consult with the trauma
attending on-call.

This manual reflects an abridged version

of the Stanford/LPCHS Trauma Program
documents.

A-1
 TABLE OF CONTENTS

TRAUMA GUIDELINE PAGE

Phone Numbers 1-4

Trauma/ACS Rotation Goals & Expectations 5-6

Trauma APP Roles/Responsibilities 7

Trauma Admission Policy 8

Trauma Team Notification & Response 9

Trauma Team Activation – Code 99, 97 10-11

Trauma Team Notification – Code 95 12

Trauma Resuscitation Roles 13-20

Trauma Order Sets 21

Clinical Trials & Prevention Programs 22

Intervention (CAGE) Programs 23

IV Access 24

Massive Transfusion Guidelines 25-26

Antibiotics in Trauma 27-28

Airway Management 29-30

Rapid Sequence Induction: Adult 31-32

Head Injury 33-37

Blunt Cerebrovascular Injury (BCVI) 38-39

C-Spine Evaluation – Adult 40-41

 TABLE OF CONTENTS

TRAUMA GUIDELINE PAGE

TLS Spine Evaluation 42

Rib Fracture 43-45

Penetrating Neck Trauma 46-47

Blunt Aortic Injury 48-49

Blunt Cardiac Injury 50-51

Penetrating Chest Trauma to the “BOX” 52-53

ED Thoracotomy (EDT) 54-55

Hemothorax 56-57

Truncal Stab Wounds (Back, Flank, Abdomen) 58-59

Blunt Abdominal Trauma 60

Blunt Splenic Trauma 61-62

Blunt Bowel and Mesenteric Injury 63-64

Rectal Injury 65

Pelvic Fracture 66-67

Peripheral Vascular Injury 68-69

Compartment Syndrome - Extremity 70-71

Compartment Syndrome - Fasciotomy 72

Trauma In Pregnancy 73-74

OB Trauma Response 75
 TABLE OF CONTENTS

SICU GUIDELINE PAGE

Surgical Critical Care Policies 76-80

Surgical Critical Care Call Triggers 81

SICU Call Tree 82

Commonly Used ICU Order Sets 83

Emergency Warfarin Reversal Protocol 84

Management Severe TBI 85

ICP Management 86

Richmond Agitation Scale (RASS) 87

ARDS Ventilator Management 88

Empiric Antibiotics in the SICU – Pneumonia 89

Empiric Antibiotics in the SICU – Abdominal INFX 90

Empiric Antibiotics in the SICU – Line Infections 91

Empiric Antibiotics in the SICU – UTI/Urosepsis 92

Empiric Antibiotics in the SICU – Sepsis 93

DVT/PE Prophylaxis 94-95

Critical Care – Nutrition 96-99

Brain Death 100-101

ECMO 102-103

Death Exam and Pronouncing a Patient 104

 TABLE OF CONTENTS

PEDIATRIC TRAUMA GUIDELINES PAGE

Table of Contents 106-108

Pediatric Surgery & Trauma Contacts 109

LPCHS Contacts 110

Pediatric Trauma Inter-facility ED Transfers 111

Pediatric Admissions to SHC & OR Determination 112

LPCHS-OR Response to Stanford-OR 113

Pediatric Massive Transfusion 114

Pediatric Modified RSI for ED 115-118

Pediatric Surgery Response to Trauma 119-120

NS and Ortho Emergent Response to ED 121

Roles & Response to Pediatric Trauma 99 122-124

ED to LPCHS-OR Notification Phone Call 125

ED to LPCHS-OR Emergent Transfer Hand-off 126

Trauma Doe Name & Blood Availability 127

ED to LPCHS Trauma Admission Guide 128

PICU Trauma Admission & Management 129

Trauma Hand-off for T99 & T97 130

Pediatric Neurosurgery Consult 131

 TABLE OF CONTENTS

PEDIATRIC TRAUMA GUIDELINES PAGE

Pediatric Head Trauma CT Decision 132

Cervical Spine Clearance in Children After Trauma 133-134

Pediatric Blunt Cerebral Vascular Injury 135-136

Urgent Pediatric MRI for Trauma (After-Hours) 137

Pediatric Blunt Spleen/Liver Trauma Management 138-139

Pediatric Blunt Renal Trauma Management 140-141

Pediatric Extremity Fracture 142-143

Pediatric Pelvic Fracture 144-145

Pediatric VTE 146-147

Upper Extremity and Digit Replantation 148-149

Social Work Consults Screening 150

Suspected Child Abuse and Neglect 151

Pediatric Trauma Pearls 152

Trauma Tips for Patient Placement 153

 TABLE OF CONTENTS

APPENDIX PAGE
Lund-Browder Burn Percentages 154

Pediatric Trauma – Normal Vital Signs 155

Pediatric Trauma - Weight in Kilograms 156

Pediatric Trauma – Estimated Blood Volume 157

Pediatric Trauma – G-Tubes, Chest Tubes, Foley 158

Pediatric Trauma – Laryngoscope, ETT, Suction 159-160

Solid Organ Grading – Spleen 161

Solid Organ Grading – Liver 162

Solid Organ Grading – Kidney 163

Solid Organ Grading – Pancreas 164

Pediatric Modified Glasgow Coma Scale 165

108
 PHONE NUMBERS – Trauma/ICU

Trauma Clinic Main Line 650-723-6961

Trauma/ICU Attendings Cell Pager

James Badger, MD 650-740-0708 10850
Tim Browder, MD 702-757-8276 23728
Lisa Knowlton, MD 650-272-1649
Javier Lorenzo, MD pager only 24043
Paul Maggio, MD 650-521-7453 13299
Paul Mohabir, MD 650-804-4811 14318
Aussama Nassar, MD 650-304-9548
David Spain, MD 650-776-3912 23990
Kristan Staudenmayer, MD 650-704-0631 23359
Tom Weiser, MD 617-794-5887 23439
Sherry Wren, MD 650-380-4058 13893

Trauma/ICU Contacts Office/Pager Spectra

SICU Fellow 12989 (pager)
SICU Senior Resident 43085
SICU Junior Resident 53234
Trauma Senior 49040
Trauma Floor Intern 12163 53245
Trauma Advanced Practice Providers:
- Jesse Alfaro, NP 650-384-9507 (cell)
- Jessica Behrend, NP 650-850-2446 (cell)
- Ya-Chen Lee, NP 650-847-7154 (cell)
- Gabe Araujo, NP 650-847-9971 (cell)

Trauma Services Office: 650-723-7570 (main)

Trauma Program Manager: Denise Greci Robinson 925-784-3259 (cell)
Trauma Nurse Coordinator: Jo Ann Schumaker-Watt 650-656-7979 (cell)
Trauma Program Director: Michelle Woodfall 650-521-7613 (cell)
Trauma Case Manager: Michelle Paw 650-561-5501 (cell)
Trauma Social Worker: Whitney Gaines 650-475-6908 (cell)

Other Contacts Spectra

Blue MICU 33688
Green MICU 68069
Emergency Anesthesia 67814
1
 PHONE NUMBERS – Units
ED 3-7337
E2/SICU 5-7122
E29 (North ICU) 3-6081
OR 8-4318
PACU 5-4834
B1 4-0690
B2 3-7101
B3 8-7442
C1 5-8106
CDU 4-1710
C2 (Trauma Floor Patients) 3-5236
C3 (Medicine) 3-7266
D-ground (Pharmacy) 5-4954
D1 (CCU) 5-7111
D1 5-7114
D1 (Pharmacy) 5-5159
D2 5-7112
D3 5-7113
DGR (Ortho-trauma) 5-7110
Dialysis 3-7585
E1 5-7121
E3 5-7123
EGR 5-7120
F1 5-7131
F2 5-7132
F3 5-7133
FGR 3-7231
G1 (Nsurg/NCOR) 3-7136
G2 3-6935
G2S 4-3131
H1 7-5800
H2 3-5001
LPCH- OR 1-2820
LPCH- PICU 7-8850
Outpatient 3-5274
Outpatient (Staff) 3-3312
2
 PHONE NUMBERS –Departments

Labs
ABG 6-2127
Blood Bank 3-6445
Core Lab 2-5530
Echo 3-7406
Microbiology 4-4588
Surgical Pathology 3-7211

Central Supply 3-5272

Radiology
Main SHC 3-6717
Bronchoscopy 5-4654
Cath/Angio 3-6738
Cath/Angio (Cancer Center) 5-3325
Colonoscopy/Endoscopy 3-5919
CT/GI 3-6855
CT Day Tech 3-7573
CT Night Tech 1-9659
ED Radiology Resident 6-2107
GI/Fluoroscopy 3-6762
IR 5-3615
Mammogram 5-1323
MRI 3-6335
MRI (after hrs tech) 3-6335
Nuclear Med 3-6884
Xray Day Tech 1-5541
Xray Eve Tech 3-6717
Xray Night Tech 1-9658
Ultrasound 3-3498

3
 PHONE NUMBERS – Hospital

Main Operator 3-4000

Page Operator 3-6661
SHC Admitting 3-6221
Crisis Nurse 1-6542
ED Registration 3-2248
ED Resource RN 4-2243
ED Room 5 5-5096
Medical Records 3-5721
Nursing Supervisor Pager 1-6918
Nursing Supervisor Spectralink 6-1767
Peds Radiology Hotline
07:00 – 17:00 days M-F 7-8757
After-hours/Weekends 7-8758
PT/OT 8-7026
Speech 1-5087
Transfer Center 3-4696 or 800-800-1551

Surgical Clinics:
Trauma Clinic 3-6961
Orthopedic Clinic 3-5643
ENT Clinic 3-5281
Plastic Surgery Clinic 3-7001
Neurosurgery Clinic 3-6469
Vascular Surgery Clinic 5-5227

4
TRAUMA/ACS ROTATION GOALS & EXPECTATIONS
Trauma Chief Resident (PGY-4):
Goals:
• Primary responsibility for the management of all
patients admitted to or evaluated by the team in
conjunction with the attending surgeon
• Function as the team leader, assuming direct
responsibility for day-to-day care of patients on the
service and coordinating care with consulting services
• Gain knowledge of surgical care through discussion on
rounds with the attending and by independent reading
• Gain operative skills through pre-operative reading and
preparation and by direct intra-operative teaching from
attendings

Expectations:
• Function as a team leader for daily patient care
• Attends all Trauma 97 and 99 activations
• Function effectively as trauma captain or trauma
resident (if ED resident is captain) for trauma
resuscitations
• Ensures trauma resident documentation is complete
and timely for trauma H&P’s, daily notes, & discharges
• Notify trauma attending of all Trauma 97 patients within
1 hour of evaluation and prior to any patient discharge
from the ED
• Notify trauma attending if any acute change in patient
condition including ICU admissions, patient deaths,
admissions, or discharges
• Attends trauma clinic on Wednesday
• Attends General Surgery Clinic on Tuesday
• Prepare weekly case presentation for Monday trauma
conference.

5
Rev. 6/16
TRAUMA/ACS ROTATION GOALS & EXPECTATIONS
Trauma Junior Resident (PGY-1):
Goals:
• Develop knowledge & experience in the evaluation and
management of critically injured and ill surgical patients
• Gain knowledge of surgical care through discussion on
rounds with the team and by independent reading
• Refine procedural skills commonly required for these
patients
• Experience and understand the day-to-day function of
a busy surgical service.

Expectations:
• Interact with all members of team including ancillary
and support staff in a productive, professional manner
• Execute the daily plans for the floor patients in a timely
and efficient manner
• Assist in trauma resuscitations
• Maintain appropriate documentation
• Notify trauma chief resident of any significant change in
patient condition immediately. If they are not available,
notify the trauma attending
• Help coordinate discharge plans especially for patients
without insurance with case management/social work
• Attends general surgery clinic on Tuesdays
• Attends trauma clinic on Wednesdays

Medical students - Medical students are an integral member of

the team. They should assist in all aspects of patient care as
dictated by the senior resident. This includes rounding daily on 2-
3 floor patients, responding to all traumas in the ED, & attending
the weekly Friday SICU conference. They may write patient
notes, but these do not suffice for medical documentation, and
thus cannot serve as the progress note in lieu of a resident note.

6
Rev. 6/16
TRAUMA Advanced Practice Provider Roles/Responsibilities

Trauma APP Schedule:

Monday through Saturday (12-hour shifts) 05:30-18:00
for Floor Coverage

Trauma APP Roles & Responsibilities:

• AM/Afternoon rounds with team, no pre-rounding
• Takes 1st call for all trauma patients on the floor
• Writes daily progress notes with or without TTS on
those patients
• Updates and manages problem list for trauma patients
• Review all trauma patients for labs, orders, protocols
• Follows up throughout the day on labs, consults,
additional studies
• Collaborates, communicates with and updates the
Trauma senior resident, fellow and/or Trauma
attending
• Communicates daily plan of care to patients, family
members and consulting providers as able
• Responds to all Trauma 99 and 97 activations
• Communicates daily with social work and case
management for disposition planning
• Assists with complex patient discharges and transfers
• Acts as contact person for communication to accepting
MDs in other facilities
• Performs bedside procedures as needed
• Mentors residents during activations/procedures
• Independently rounds on Trauma patients in SICU to
evaluate readiness for transfer out of ICU
• Writes transfers orders for SICU trauma patients
• Signs out pertinent patient issues to Trauma senior
before leaving
• Attends monthly TMAC and PIPS/PPEC

7
Rev. 6/16
 TRAUMA ADMISSION POLICY

In order to facilitate patient care and to eliminate potential

misunderstandings between various services caring for trauma
patients, the Trauma Committee has established the following
guidelines regarding admission to and transfer of trauma patients
between services:

• Patients with a mechanism for potential multiple system

injuries should be evaluated by the Trauma Service.

• Patients with multiple system injuries, hemodynamic

instability, or spinal cord injuries will be admitted to the
Trauma Service.

• Patients with isolated orthopedic or neurosurgical

injuries requiring ICU care will be admitted to the
Surgical ICU/Trauma Service.

• Admission to the Trauma Service is appropriate if an on-

going evaluation for occult injuries is in progress.

• Patients with single system injuries, without a mechanism for

multiple system injury shall be directly admitted to the
appropriate service.

• Pre-existing medical conditions such as congestive heart

failure, seizures, arrhythmias, diabetes, or COPD do not
necessarily constitute reasons to remain on the Trauma
Service with a single system injury.

• Once suspected occult injuries have been ruled out and the
patient with single system injuries is stable, the patient may
be transferred from the Trauma Service to the appropriate
service.

• Trauma Service will complete a tertiary survey within 24

hours of admission.
8
 TRAUMA TEAM NOTIFICATION & RESPONSE
EMERGENCY DEPARTMENT:
• When alerted of an incoming trauma, the ED RN confers with ED
attending to determine trauma alert status, calls the direct line
(211) to request appropriate trauma team activation, specifies
adult or pediatric activation (99), alert (97), or notification (95),
number of patients, & ETA.

TRAUMA TEAM RESPONSE:

• Trauma 99 activations are seen by the trauma attending, chief,
and junior resident.
• Trauma 97 activations are seen by the trauma chief and junior
resident.
• Trauma 95 notifications are initially seen by ED only. If the
patient is stable and an injury is identified, the ED will request a
Trauma Consult as needed.
• Any patient that meets criteria for a higher level of activation can
be upgraded at any time by any member of the trauma team.
• All residents should sign in with the recording nurse.

ACTIVATING BACK-UP PERSONNEL:

Decision for activating additional personnel is at the discretion of
the Trauma Attending & Trauma Chief Resident. The Back-up
team is expected to arrive within 30 minutes.

NOTIFICATION OF SPECIALITY CONSULTS:

When a specialty related injury is identified, timely consultation should
be obtained especially in the event of a life-threatening, or extensive
injury. The Trauma Chief Resident is responsible for notifying the
consult service, but may be delegated to appropriate trauma/ED
resident personnel. If the consultant does not arrive within 20 minutes,
the chief resident of that service will be notified. If no response within
20 minutes, the attending will be contacted by the ED or trauma
attending.

9
Rev. 6/16
 TRAUMA TEAM ACTIVATION – Trauma 99

Full Trauma Team activation (Trauma 99) should

occur with the following:
• Adults: Confirmed SBP <90 at any time.
• Child less than 6 years: SBP <60.
• Child greater than 6 years: SBP less than 90.
• Airway compromise/obstruction or pre-hospital
intubation.
• Respiratory distress with a rate <10 or >29.
• Significant hypoxia at scene.
• - Pediatric: Nasal flaring, retraction, stridor, cyanosis
• Glasgow Coma Scale score (GCS) <9 with trauma
mechanism.
• Gunshot wound/penetrating trauma
- Head or neck
- Chest, abdomen or pelvis
- Extremities proximal to the knee or elbow
• Traumatic paraplegia or quadriplegia.
• Transfer-in patients receiving blood or vasopressors to
maintain vital signs.
• Emergency Medicine discretion

10
Rev. 6/16
 TRAUMA TEAM ACTIVATION – Trauma 97

Trauma Team Activation (Trauma 97) should

occur with the following:
• High speed auto crash greater than 35 mph.
• Ejection.
• Cycle crash greater than 20 mph (e.g., bike,
motorcycle, ATV) or rider thrown.
• Pedestrian vs. auto greater than 5 mph impact
(e.g., thrown, run over).
• Adult fall greater than 15 feet or children greater
than 10 feet.
• GCS 9 to 13 with trauma mechanism.
• Significant blunt injury to head, including pre-
hospital witnessed neurological change.
• Major facial injuries (w/o airway compromise).
• Flail or crushed chest.
• Suspected pelvic fracture.
• Two or more long bone fractures (femur or
humerus).
• Amputation proximal to wrist or ankle.
• Penetrating extremity injuries proximal to wrists
or ankle.
• Burns <20% with significant trauma: then admit to
Trauma Service/SICU
• Burns >20% with trauma: stabilize for Burn
Center transfer.
• Pregnant woman >=20 weeks with a traumatic
mechanism of injury
• Emergency Medicine discretion

11
Rev. 6/16
 TRAUMA TEAM NOTIFICATION – Trauma 95

Trauma 95 should be initiated when there is no

significant anatomic injury other than
extremity fractures distal to the knee or
elbow, or abrasions, lacerations or
contusions.

These will be initially seen by ED only.

No significant anatomic injury and with the

following mechanisms:

• Rollover.
• Death of occupant of car.
• Prolonged extrication.
• Auto deformity greater than 20 inches or intrusion
to space occupied by passenger.
• Consider risk based on age greater than or less
than 5, or known cardiac, respiratory, metabolic
disease or drug/alcohol influence.
• Adult fall less than 15 feet or children less than
10 feet.
• Emergency Medicine discretion.

12
Rev. 6/16
 TRAUMA RESUSCITATION ROLES

TRAUMA TEAM MEMBERS

Trauma Attending:
• Oversees the trauma resuscitation and acts as a
resource person for the Team Captain.
• Is the deciding voice.
• Has primary responsibility for overseeing all care
rendered.

Emergency Medicine Attending:

• Interfaces with pre-hospital system.
• Initiates trauma activation/alert/consult.
• If no Trauma Attending present, assumes Trauma
Attending duties until their arrival.
• Allocates Emergency Department (ED) resources.
• Is responsible for overseeing airway management.

13
 TRAUMA RESUSCITATION ROLES
Team Captain:
The Team Captain role is rotated between the Trauma Chief
Resident, and the Emergency Medicine (EM) Resident PGY III
based on published schedules.
• Assigns roles to team members.
• NO HANDS ON PATIENT CARE
– ED thoracotomy if necessary will be performed by General Surgery
Trauma Chief Resident
• Directs the trauma resuscitation and assigns residents roles
– Directs fluid resuscitation.
– Decides which tests to obtain.
– Orders medications.
– Requests consults.
• Discusses case and care plan with the ED and Trauma
Attending.
• Team captain role will be assigned by calendar schedule
with alternative ED and Surgery service performing this
role. Monthly calendar is posted in ED Resuscitation
Room.
• In the event that the Trauma Chief is not available (unable to
leave the operating room), there must be clear assignment to
the SICU surgical fellow or chief resident to oversee Trauma
99/97 activations.

Trauma Survey and Procedure Residents:

• Survey Resident performs primary/secondary survey
– FAST if Procedure Resident is performing procedures
• Procedure Resident–lines, chest tubes
• Procedure Resident is either ED R2/3, R3 SICU or Surgery
R2 resident
• Survey and procedure resident should include at least one
resident from the service not functioning in the Team Captain
role. During Tuesday (Surgery conference) and Wednesday
(ED conference) mornings during each departments
educational activities, survey and procedure residents will all
be from the available respective service.
• ED thoracotomy will be performed by surgery trauma chief
resident
14
Rev. 6/16, 12/17
 TRAUMA RESUSCITATION ROLES
Trauma Advanced Practice Provider:
• When possible responds to trauma activations and alerts
• Can function in the survey resident role, if necessary, to
perform primary & secondary surveys and/or supervise
junior resident performing secondary survey
• Able to perform procedures under the supervision of the
trauma chief resident
• May accompany patient to procedures/transfers under
direction of trauma captain
• Collaborate with trauma captain to determine plan of care

Trauma Nurse Coordinator/Trauma Program Manager:

• When possible, responds to trauma activations/alerts to
collaborate with team members to ensure the quality and
timeliness of care
• Assists with RN documentation as needed
• Assists with procedures as needed
• Serves to educate ED RN staff regarding trauma patient
care principles and practices
• Assists with Rapid Infusion device set-up, if necessary

15
Rev. 6/16, 12/17
 TRAUMA RESUSCITATION ROLES

Emergency Department Resource Nurse:

• Consults with the ED Attending to determine the level of
the trauma activation. Directs the Unit Secretary to
activate the trauma beepers via emergency page operator
when a trauma patient is en route.
• Ensures announcement of overhead intercom that a
trauma is arriving with ETA and type of trauma.
• Assures adequate nursing, ancillary staffing.
• Maintains constant communication and awareness of
resuscitation team efforts.
• Follows the procedure for telecommunication backup
staffing PRN.
• Informs the Trauma Resuscitation Nurse when the patient’s
family/friends have arrived in department, and directs
visitation.
• Utilizes all support services to assist patient, family and
friends (i.e. Social Worker, Chaplaincy, etc.).
• Arranges bed access and placement via the nursing
supervisor if patient is to be admitted.
• Reports victims of violent crime to security services.

16
Rev. 6/16, 12/17
 TRAUMA RESUSCITATION ROLES
ED – RN A:
• Located on patient right side
• Prior to patient arrival, prepares resuscitation room (age
specific equipment, IV line prep, special procedure trays,
room temp, etc..)
• Functions as primary patient care RN during initial
resuscitation and stabilization
• Establishes PIV access and draws labs
• Administers medications under direction of team captain
• Remains at patient bedside wearing a lead X-ray apron
• Guarantees compliance with RN guidelines for
documentation (full vital signs with GCS)
• Communicates pertinent information to the Trauma RN
Recorder (ED – RN D).

ED – RN B:
• Located on patient left side
• Places patient on monitors
• Establishes second PIV, if needed
• Initiates IVFs once IV established
• Assists with procedures

ED- RN C: (Only for Trauma 99’s)

• Located on patient right side
• Sets up and runs Rapid Infusion device

17
Rev. 6/16, 12/17
 TRAUMA RESUSCITATION ROLES
ED – RN D: (RECORDER)
• Located off to the left of the foot of the bed
• Receives patient status report from Resource RN
• Ensures lab tubes labeled correctly
• Records initial team patient assessment
• Documents all pertinent patient data and care rendered by
trauma team in the EPIC TRAUMA NARRATOR
• Ensures full set of initial vital signs recorded (temp, BP,
Pulse, Respirations, Oxygen sat & GCS) upon arrival
• Documents repeat VS (BP, HR, RR, sat) every 3-5 mins
during initial assessment and continue if patient is receiving
interventions for hemodynamic instability. Then every 15
min. x4, 30 min x2, then per admit orders.
• Orders initial trauma labs/studies using the Trauma order
sets in the EPIC NARRATOR
• Directs other RNs and ED technician in patient care activities
• Accompanies patient to other services/procedure areas
• Functions as bedside RN once initial survey and
interventions completed
• Keeps ED Resource RN informed of potential transfer of
patient to other patient service areas
• Inventories trauma room at least every 8 hours

ED Technician:
• Located on patient right side
• Assists the ED – RN A with moving patients and reading the
trauma resuscitation area prior to patient arrival
• Performs cardiac compressions if CPR needed
• Connects oxygen tubing to the flow meter
• Removes all patient’s clothing
• Connects to automated BP cuff to patient’s arm & sets for
interval of every 5 minutes, until deemed stable.
• Measures and reports temperature, pulse, respiratory rate,
O2 saturation and blood pressure
• Assists with setting up procedure supplies

18
Rev. 6/16, 12/17
 TRAUMA RESUSCITATION ROLES
ED Technician: (continued)
• Makes clothing list and removes, records and collects
valuables in plastic zip-lock bag. Turns valuables over to
Resource RN to be placed in locked storage.
• Assists with wound care as directed by primary RN
• Assists with preparing patient for transport (obtains oxygen
tanks, consolidates IVs)
• Assists with actual patient transport
• Assists with immediate cleaning and restocking of trauma
resuscitation room
• Prepares and sends trauma procedure trays to Central
Reprocessing as soon as possible

Respiratory Care Technician:

• Carries the trauma beeper 24 hrs/day
• Pediatric RTs respond to pediatric major trauma alerts (less
than 14 years of age)
• Institutes and maintains ventilation with a manual
resuscitator per the instructions of the Trauma Captain
• Participates with other members of the Trauma Team in
establishing an airway, CPR, intubation, airway clearance
techniques, bronchial hygiene, administration of
pharmacological agents, diagnostic and therapeutic
respiratory care procedures, administration of medical
gases, aerosols and humidity.
• At the time deemed appropriate by the physician team
leader, connects the patient to a mechanical ventilator and
adjusts the ventilator in accordance with the verbal or
written physician’s orders.

X-ray Technician:
• Reports to the Trauma Resuscitation Room when trauma
beeper is activated and waits for specific instructions.
• Performs Chest X-ray and Pelvic films promptly for all 99
Activations.

19
Rev. 6/16, 12/17
 TRAUMA RESUSCITATION ROLES
Computed Tomography (CT) Technologist:
• CT Scanner availability is coordinated by the Radiology
Department with the commitment being 5-10 minutes for
a “99” activation and 15-20 minutes for “97” alerts.
• Ensures that the Radiologist is available to immediately
check images to determine type of exams needed (e.g.,
reconstruction views, additional imaging).

Transfusion Services:
• When a Trauma Team Activation (99) occurs and blood
order placed in Epic, the Transfusion Services Charge
Technician dispenses 2 units of uncross-matched
universal donor blood O-negative or O-positive
depending on the gender/age recipient) Packed Red
Blood Cells (PRBCs) and 2 units of AB+ liquid plasma
into a cooler that is labeled with the patient’s trauma
number.
• A Transfusion Services Technician delivers the cooler
containing the blood products to the Trauma
Resuscitation Room in the ED
• Technician collects verification specimen from ED-RN.

Operating Room Charge Nurse:

• The OR has an in-house Trauma OR Team ready 24 hours
a day.
• OR Charge Nurse can be reached via pager
(19502) or SpectraLink (4-4590).
• Anesthesia can be reached via pager (19650) or
SpectraLink (6-0249).
• Upon receiving a trauma page, calls the Trauma
Resuscitation Room at extension 5-5096 for a status report,
and periodically for updates, or responds to the ED to
collaborate with the Trauma Surgeon to determine if an OR
suite is needed.
• The Trauma Resuscitation Room is warmed, has the Level
1 Infuser ready and Trauma Cart in place.

Social Worker:
• Assists in ensuring family notification and contacting the
20
Rev. 6/16, 12/17 primary medical doctor (PMD)/insurer for the past
medical history (PMH).
 TRAUMA ORDER SETS

Trauma ED Order Sets

• There are standard orders for traumas based upon activation

level. The Recording RN should order these through the
trauma narrator in EPIC. They are also available under order
sets by the following names:

• “Trauma 97”: Initial ED Trauma 97 Automatic Orders

• Istat Cr, CBC, type and screen, CMP, Istat INR
• CXR, Peripheral IV

• “Trauma 99”: Initial ED Trauma 99 Automatic Orders

• Istat Cr, Istat INR, Istat VBG/Lactate, CBC, type
and screen, CMP, urine tox screen, serum volatile
screen, UA
• CXR, Pelvis Xray, Peripheral IV, Foley

• “Trauma Radiology” – NO automatic orders. Order

set contains options for initial common CT scans.
Please use these as the CTs are already protocoled.

• “ED Trauma Medication”: NO automatic orders.

Order set contains options for analgesics, anti-emetics,
antibiotics and tetanus.

Note: For Female patients - please ask RN to check

pregnancy test in the order sets.
21
 CLINICAL TRIALS & PREVENTION PROGRAMS
Clinical Trials:
• START Trial – randomized control trial of human mesenchymal stem cells (MSCs)
for the treatment of moderate to severe ARDS (defined by P/F < 200 on at least 8 of
PEEP). Phase II study with 2:1 randomization, primary inclusion is being within 96
hours of meeting criteria for ARDS.
• EPVent 2 – phase II RCT comparing strategy of PEEP titration to end-expiratory
transpulmonary pressure (measured by an esophageal balloon) vs. a high PEEP
LPV strategy. Major inclusion criterion is moderate to severe ARDS (P/F < 200 on at
least 5 of PEEP).
• ROSE – RCT of cisatracurium started within 72 hours of severe ARDS (p/f<150 on
PEEP 8cm H2O) vs. standards care.
• clinical coordinator for above studies Rosemary Vojnik (408) 772-3001
• STOP-AKI – Phase II Study: Safety, efficacy and tolerability of Human Recombinant
Alkaline Phosphatase in patients with sepsis-associated Acute Kidney Injury.
Inclusions: 2/4 SIRS criteria & sustained AKI by elevated Cr (>0.3) or Low Urine
output. Treatment must start by 24hrs of AKI diagnosis. Major exclusions: CKD,
immunocompromised, urosepsis
• Euphrates – Hemoperfusion using Polymyxin B cartridge vs. sham in adults with
severe septic shock. Inclusions: pts on qualifying pressors for minimum 2hrs,
multiple organ failure and high endotoxin levels-tested by research-must begin
treatment within 30hrs of pressor
• clinical coordinator for above studies Valerie Ojha (650) 518-9716
• Stanford ICU Biobank – blood, urine, and available respiratory secretions/left-over
BAL specimens for genomic studies in critically ill patients with risk factors for
ARDS, including trauma, sepsis, and aspiration. Email Angela Rogers
[email protected]

Prevention Programs:
• FAREWELL TO FALLS – ideally for elderly patients who have fallen and are being
discharged from the ED. Some inpatients also qualify if going home without any
home services (i.e. PT/OT Home safety evaluations)
• Contact Ellen Corman via email : [email protected]

22
Rev. 6/16
 INTERVENTION (CAGE) PROGRAMS

• Screening, Brief Intervention & Referral to Treatment

(SBIRT) – is a comprehensive approach to the delivery of early
intervention and treatment services for persons with substance
use disorders, as well as those who are at risk of developing
these disorders.

Screening is to be performed on all trauma patients:

1. Ask the patient:

“When you drink alcohol, how many drinks do you drink?”
2.Patient’s blood alcohol level drawn in the ED?: Y N
Level:_____
• If BAL 0.08 or greater or patient drinks more than 2
drinks at a sitting, ask the CAGE questions.

Check One:
Alcohol CAGE Score:
<2
 2 or more (refer to Social Work)

C = Have you ever felt you should cut down on your drinking?
A = Have people annoyed you by criticizing your drinking?
G = Have you ever felt bad or guilty about your drinking?
E = Do you ever take a drink in the AM to steady your nerves or relieve a
hangover?

Scoring: If 2 or more “Yes” answers, patient is at risk of problem drinking or

alcoholism.

Plan: If BAL 0.08 or if suspected of intoxication or if cage 2 or more, refer to

Social Work

23
 IV ACCESS

Guidelines:
• All lines placed in the field or ED are considered suspect and
should be replaced as soon as feasible after admission.
Exceptions include central lines placed utilizing full barrier
precautions.

• Preferred site of central access during trauma resuscitation is

the femoral vein
• Femoral access should be utilized with caution in an
unstable patient with severe pelvic fractures or likely vena
caval injuries. Subclavian vein should then be considered
• Femoral vein catheters should be removed as soon as
possible to decrease the risk of DVT (if central access is
still required, the femoral line should be replaced by a
subclavian or internal jugular catheter).

• Patients with suspected cardiogenic shock or in need of central

venous pressure monitoring should have a subclavian or internal
jugular venous central line.

• ALL central lines should be placed under “full barrier

precautions” defined as sterile gown and gloves, cap and mask,
and FULL draping (3/4 sheet, lap drape, etc.). Chlorhexidine is
the preferred prep agent. Cap and masks are recommended for
those nearby, while full barrier precautions should be observed
by those assisting.

• Central lines should be covered with chlorhexidine-impregnated

dressings, which have been shown to reduce line infections
threefold.
References:
• Mermel LA, et al. Am J Med 1991, 91:197S-205S
•https://www.cdc.gov/hai/pdfs/bsi-guidelines-2011.pdf 24
 MASSIVE TRANSFUSION GUIDELINE
What are the criteria for activating the MTG?

Adult patients
• requiring > 4 units of PRBCs in the first hour of
resuscitation OR
• high likelihood of > 10 units of PRBCs within 12 hours
of resuscitation

Pediatric patients
• requiring > 20 ml/Kg of PRBCs in the 1st hour of
resuscitation OR
• high likelihood of > 0.1 units/Kg of PBRCs within 12
hours of resuscitation

When the MTG is activated, the following blood products are

delivered:

Adult MTG Pack (> 50 Kg)

• 6 Units of PRBCs
• 4 Units of thawed plasma
• 1 Unit of apheresis platelets

Pediatric MTG Pack (≤ 50 Kg)

• 4 Units of PRBCs
• 2 Units of thawed plasma
• 1 Unit of apheresis platelets

25
 MASSIVE TRANSFUSION GUIDELINE
HOW TO ACTIVATE THE MTG PROCESS:
General Steps:
1. Determine need for MTG
2. Place order for MTG
• Use the appropriate mechanism for ordering based on
patient location
• EPIC MTG order set (ED or ICU patients)
• Downtime paper form (OR patients)
3. Call Blood Bank to notify them of MTG order via phone (3-
6445)
4. All products should be delivered through IV warming device
except platelets
5. If additional blood is anticipated beyond the delivered MTG
pack, the MTG must be re-ordered via same procedure

For patients in the ED:

• 10 units of uncrossed matched type O blood will be available in a
refrigerator in the ED (universal donor liquid plasma will
eventually be stocked as well).
• Use of pRBC in the refrigerator will prompt automatic delivery of
AB plasma a refrigerator in the ED.
• If the patient is experiencing life threatening hemorrhage,
additional blood (over 2-4U) can be ordered by activating MTG
• Use EPIC order set for MTG which will be found in the Trauma
Narrator
• MTG blood will be delivered directly to trauma bay by blood bank
personnel

For patients in the OR:

• Use the Downtime MTG paper order form. The form must have
patient information via a patient label or addressograph to be a
valid order
• Runner from OR takes copy of order form to transfusion services
to obtain MTG pack that was ordered

For patients in the ICU:

• Order in EPIC using “MTG” Order set
• Runner from unit takes label with patient name and either MRN or
DOB to obtain MTG pack from blood bank 26
Rev. 6/16, 12/17
 ANTIBIOTICS in TRAUMA

BACKGROUND:
• Prophylactic antibiotics are frequently recommended by
consulting services, but the data to support many of these
recommendations is weak or nonexistent.
• Drug resistant infections attributable to antibiotic overuse are
becoming more common and far more virulent.
• Antibiotics cannot overcome poor wound management
OPEN FRACTURES:
• Grade I: wound < 1cm long and clean
• Grade II: wound > 1cm without extensive soft tissue
damage, flaps, or avulsions
• Grade III: either an open segmental fracture, open fracture
with extensive soft tissue damage, or traumatic amputation

• Bacterial contamination can lead to cellulitis, osteomyelitis, and

bony nonunion
• Best managed by debridement of devitalized tissue with
concomitant antibiotic therapy
• Infection rate for Grade III open fracture is 24%
• Most difficult fracture to care for is Grade III tibial fracture
• Class I and II data for prophylactic antibiotics as soon as
possible after injury for coverage of gram positive
organisms.
• Grade III fractures- add coverage for gram negatives
• High dose penicillin added if concern for fecal/Clostridial
contamination.
• Class I and II data for discontinuation of antibiotics 24hrs
after wound closure for Grade I and II fractures. For Grade
III wounds, antibiotics should be continued for only 72 hours
after the time of injury or not more than 24 hrs after soft tissue
coverage of the wound is achieved, whichever comes first.
27
Rev. 12/17
 ANTIBIOTICS in TRAUMA
OPEN FRACTURES
• Grade I: cefazolin (perioperative)
• Grade II and III: ceftriaxone 1g IV daily until wound is closed
• CHEST TUBE PLACEMENT
• 1-2% incidence of empyema
• Insufficient Level I data to support prophylactic abx for duration of CT
• Level II data suggests a single dose of prophylactic antibiotics at time of
placement may reduce risks of empyema
FACIAL FRACTURES
• No prospective study demonstrating a decreased incidence of infections
after routine closed facial fractures in patients receiving empiric antibiotics
• Recommend empiric antibiotics for significant midface trauma including
open wounds, or those with orbital, nasal bone, zygomatic and mandibular
involvement
• Augmentin 875 mg IV q8h preop, continue for 24 hrs post-op
• If no surgical intervention planned, 2 days of above abx
recommended
SKULL BASED FRACTURES
• No evidence to support routine prophylactic or empiric antibiotics in cases
without meningitis, irrespective of CSF leak
VASCULAR INJURY
• Single dose of 1st generation cephalosporin for 24hrs if synthetic graft used.
PENETRATING ABDOMINAL TRAUMA
• Should be given as soon as technically possible
• Single preoperative dose of prophylactic antibiotics with cefazolin or
ampicillin/sulbactam is sufficient
• In the absence of contamination or spillage, no further antibiotics are
indicated and should be discontinued within 24hrs.
References:
• Hauser CJ, et al. Surgical Infections, 2006
•Luchette FA, et al. J Trauma. 2000
•Rodriguez et al. JTACS 2014.
•Schaller et al. Br J Oral Maxillofacial Surgery 2013 28
Rev. 12/17 • Alleyne CH, et al. Neurosurgery, 2000
 AIRWAY MANAGEMENT

BACKGROUND: 1% of traumas requiring intubation need a

surgical airway
RISKS: DIFFICULT BAG VALVE MASK (BVM)
• BMI > 26kg/m2
• Absent teeth
• Presence of a beard, facial disruption, or crusted blood on face
• Age > 55 years
RISKS: DIFFICULT INTUBATION
• Massive facial or neck trauma
• Receding mandible (<3 finger breadths from mandibular
symphysis to hyoid bone)
• Short, thick neck (<3 finger breadths from sternal notch to
thyroid cartilage)
• Narrow mouth opening
• Large or immobile tongue
• Immobilized cervical spine
• Inspiratory Stridor (upper airway compromise)
LMA
• Size 4 for patients < 70kg. Size 5 for patients >70kg
• Rests in hypopharynx over the laryngeal opening
• Risk of aspiration, particularly pregnant or obese patients
CRICOTHYROIDOTOMY:
• Does not mandate conversion to tracheostomy
• Use 6mm cuffed ETT or 4-6 tracheostomy tube
• Contraindicated in pediatric patients (<12 years, risk damage to
cricoid and subsequent stenosis) or patients with laryngeal
fracture. These patients should undergo tracheostomy

29
 AIRWAY MANAGEMENT

Need for Intubation#

• Manual in-line cervical immobilization
• Pre-oxygenation
• Rapid sequence intubation*

Successful Intubation
NO YES

BVM
• Adequate ventilation
• SpO2 > 90%
NO

Repeat Intubation Success Confirm Placement

• Perform by senior staff • Auscultation
(ED, surgical, anesthesia) •CO2 detector
• Optimize conditions •CXR
(suction, different blade)

LMA/Rescue airway or Cricothyroidotomy

Decision for cricothyroidotomy
should be made rapidly after
failed airway (1-2mins)

Cricothyroidotomy

NOTES:
# If multiple risk factors for difficult airway, airway management
should be performed by senior staff (ED, surgical, anesthesia)
If the patient has a high risk airway (laryngeal trauma, facial
fractures, etc…) or is already going to the OR, discuss delaying
intubation until the OR with the Trauma Attending.
* RSI should be avoided in patients difficult to ventilate via BVM

Rev. 6/16
30
 RAPID SEQUENCE INDUCTION: ADULT

(1) POSSIBILITY OF SUCCESS (Anticipate Difficulty Airway)

• Examine airway, check anatomy
(2) PREPARATION
• Assemble staff (i.e. ED attending, nurse, respiratory therapist)
• Continuous monitoring of BP, ECG, SaO2
• Consult Anesthesiology if airway problems anticipated
• Prepare equipment
(3) PRE-OXYGENATION
• 100% O2. Bag mask ventilation PRN
(4) PRE-MEDICATION
• See Table 1
(5) INDUCTION
• See Table 2
(6) PARALYSIS
• See Table 3
(7) CRICOID PRESSURE (optional)
(8) INTUBATION
• Inline cervical immobilization
• Intubate orally
• Confirm ETT position with end-tidal CO2
• Release cricoid pressure after balloon is inflated
(9) CONFIRMATION
(10) POST-INTUBATION MANAGEMENT
• Secure Tube
• Re-secure cervical collar
• Sedation: Lorazepam (0.05-0.1 mg/kg) or Midazolam (0.2
mg/kg), or Propofol gtt (initial dose 0.3 mg/kg/hour)
• Paralysis: Rocuronium (0.4-1 mg/kg) or Vecuronium (0.1 mg/kg)
• Pain Management: Morphine (0.2 mg/kg) or Fentanyl (50mcg)
• Chest x-ray 31
Rev. 6/16
 RAPID SEQUENCE INDUCTION: ADULT

Table 1: Pre-medication Agents

Drug Indication Dose

Lidocaine ↑ ICP, RAD 1.5mg/kg

Opioid (fentanyl) ↑ ICP, ischemic heart disease, aortic 3-6mcg/kg

dissection

Atropine (optional) Mitigates bradycardia from 2mg (adults)

succinylcholine

Table 2: Induction Agents

Drug Benefit Precautions Dose

Midazolam Reversible, Apnea, no analgesia, 0.2-0.3 mg/kg

amnestic, variable dosing
anticonvulsant

Etomidate ↓ICP, rarely ↓ BP Myoclonic jerks, 0.3 mg/kg

vomiting, no analgesia

Ketamine ↑BP, bronchodilator, ↑ secretions, ↑ ICP, 1-2 mg/kg

dissociative Emergence phenomenon
amnesia

Propofol No dose adjustment Profound hypotension 1-2 mg/kg

for liver/renal
disease

Table 3: Paralytic Agents

Drug Dose

Succinylcholine 1.5-2 mg/kg

Rocuronium 1 mg/kg

Vecuronium 0.1 mg/kg

32
Rev. 6/16
 HEAD INJURY- INDICATIONS FOR CT

Head CT should be
done within 30 mins

References:
•Stiel IG, et al. Lancet 2001; 357:1391-96
•Mower, et al. J Trauma 2005;59:954-959
Rev. 6/10, 12/17 33
HEAD INJURY- CLINICAL MANAGEMENT GUIDELINES
Repeat head CTs:
• All patients with radiographic-proven traumatic brain injury (TBI) require
repeat imaging within 6 hours.
• Coagulopathic patients without radiographic evidence of TBI but with
mechanism of injury:
• Should be observed for at least 6 hours prior to discharge
• Consider repeat interval CT on a case-by-case basis
Monitoring of patients with head injuries:
• All patients will be admitted to the SICU or H1 (if they meet H1 admission
criteria—see criteria) for 12 hrs, regardless of TBI severity.
• Patients with GCS<14: Practice should be consistent with Brain Trauma
Foundation Guidelines and the ACS TQIP Best Practices in the
Management of TBI guidelines.
Management of chemoprophylaxis for DVT:
• In general, chemoprophylaxis for DVTs may be initiated 72 hours after a
repeat head CT is stable, unless the SICU attending states otherwise.
• If patient is deemed to be at high risk for bleeding from chemoprophylaxis
and chemoprophylaxis is deferred, SICU documentation will reflect the
reasoning for the deviation and the plans for timing institution of
chemoprophylaxis.
• Chemoprophylaxis can be administered while an EVD is in place, but should
be held for 12 hours prior to EVD placement or removal
Therapeutic systemic anticoagulation with heparin:
• Must be determined by Neurosurgical, NCC, and SICU attendings.
• Requires baseline CT prior to initiation of anticoagulation.
• Should be implemented using the high-risk protocol.
• Requires repeat head CT once therapeutic anticoagulation achieved
Reversal of medically-induced anticoagulation in TBI patients:
• Aggressive reversal of anticoagulation to be undertaken using protocols
specific to the medication (i.e. warfarin and direct thrombin inhibitors).
All TBI patients with initial GCS<14 should receive a PM&R consult (Kara
Flavin)

34
Rev. 12/17
 HEAD INJURY- SERVICE COVERAGE
Admitting service:
• ICU: all TBI patients will be on the SICU service
• University Neurosurgery (NSG) will be consulted for all TBI cases,
including patients who have PAMF coverage
• Neurocritical care (NCC) will be involved in all complicated and/or
moderate to severe TBI cases as defined by:
• GCS<14 with any type TBI injury
• Mild TBI (GCS 14-15) if complicated by any other factor such as
large size, high risk for worsening, unexplained coagulopathy,
vascular injury, seizures, or unexplained neurologic findings
• TBI patients that undergo craniotomy:
• Will be on the SICU unless there is an attending-level discussion
between SICU and NSG that determines the patient would be
better served as a primary NSG patient.
• In patients who have undergone craniotomy, NCC will defer to
NSG regarding peri-operative management decisions.
Floor-level care:
• Multisystem TBI patients: Trauma Service or Neurology Stroke Service
• *Isolated TBI:
• S/P craniotomy: Neurosurgery service
• No craniotomy: Trauma service or Neurology Stroke Service
• The Neurology Stroke Service will follow all TBI patients admitted to the
floor for whom Neurocritical Care was actively managing in the ICU.

35

Rev. 12/17
 HEAD INJURY- H1 NEURO UNIT ADMISSION

Patients with blunt head trauma who have an acute abnormality on

head CT require close neurologic monitoring. Certain patients
qualify for neurologic monitoring in a non-critical care setting.

Inclusion Criteria:
1. GCS 15, with normal neurologic exam to include normal
sensorium (i.e. not intoxicated or delirious), not demented or
developmentally delayed, and with no focal neurologic signs.
2. No other physiologic signs that would confound diagnosis of
worsening head injury to include: nausea, vomiting, headache
3. Age <80
4. Normal coagulation status and normal platelets and not on any
anti-coagulants or anti-platelet agents
5. Pattern of injury consistent with a small contusion(s) (<1mm) or
SAH, skull fractures without intracranial injury, and with absence of
extra-axial hemorrhage (SDH or EDH)
6. Hemodynamically normal, defined as being at baseline for both
HR and blood pressure and , not requiring any IV infusions for blood
pressure management (for either hypo- or hyper- tension)
7. Not requiring frequent IV medication for agitation (e.g.
benzodiazepines) or pain control.
8. No acute alcohol or drug intoxication.
9. Not at known risk for drug or alcohol withdrawal.
10. Agreement and documentation by trauma and neurosurgical
teams that patient is at low risk for progression and safe for
admission to the floor TBI unit.

36
 HEAD INJURY- H1 NEURO UNIT ADMISSION

Physician Teams and Expectations:

• All patients will be admitted to the trauma service. The
trauma attending will be primary attending of record and
ultimately responsible for patient care.
• Neurosurgery consult team will co-follow all patients for at
least the initial 12 hours of the hospitalization.
• A follow-up head CT will be obtained 4-6 hours from the
original scan in all patients, regardless of exam.

Nursing Expectations:
• All patients will be admitted to H1 ward with
neurosciences nursing expertise for at least the first 12
hours after injury.
• Patients will be a 2:1 patient-to-RN ratio.
• Neuro checks will be performed q1 hour for the initial 24
hours of hospitalization.
• Neuro checks will include: Glasgow Coma Scale,
pupillary assessment (including size and reactivity), and
an abbreviated NIHSS (level of consciousness, language,
facial strength, motor and sensory exam in all four
extremities, finger-to-nose/cerebellar function).
• Changes in neurologic function will prompt immediate call
to trauma team. If the resident does not respond to page
within 15”, trauma attending should be contacted. If
trauma attending does not respond, then SICU attending
should be contacted.
• RNs will accompany patient for follow-up head CT.

37
 BLUNT CEREBROVASCULAR INJURY (BCVI)

SIGNS & SYMPTOMS OF BCVI:

• Hemorrhage from mouth, nose, ears of potential arterial origin
• Large or expanding cervical hematoma (consider surgery)
• Cervical bruit in patient < 50
• Evidence of cerebral infarction on CT
• Unexplained or CT incongruous neurologic deficit
• Focal or lateralizing neurologic deficit
• Transient ischemic attack, or Horner’s syndrome
• Stroke on CT or MRI
• Major thoracic trauma
RISKS OF BCVI:
• Mechanism compatible with severe cervical hyperextension/
rotation or hyperflexion, particularly if associated with complex
facial fractures
• Near-hanging, seat belt abrasion, or other soft tissue injury of
the anterior neck with significant cervical swelling
• High Risk associated injuries
• Severe traumatic brain injury with GCS ≤ 8
• Petrous bone fracture
• Displaced mid-face (Lefort II/III) fractures
• Mandibular fracture
• Cervical spine fracture, particularly C1-C3
• Cervical vertebral fracture, subluxation or ligamentous
injury
• Diffuse axonal brain injury
• Occipital condyle fracture or basilar skull fracture involving
the carotid canal
• Scalp degloving
• Upper rib fractures
East Guidelines 2010
Rev. 11/17, 12/17 Biffl. J Trauma 2009 38
Burlew. J TACS 2012
 BLUNT CEREBROVASCULAR INJURY (BCVI)

BCVI Signs & Symptoms OR Risk Factor(s)

Yes No

TREAT
CT Angio OTHER
INJURIES
TREAT
OTHER Normal
INJURIES
Abnormal

• Grade I: Intimal irregularity; Dissection/Hematoma with < 25% stenosis.

• Tx: Anti-platelet most commonly used, alternatively IV heparin
• Grade II: Intraluminal thrombus; raised intimal flap; Dissection/Hematoma
with >= 25% stenosis.
• Tx: Anti-platelet or IV heparin
• Grade III: Pseudoaneurysms
• Tx: Anti-platelet or IV heparin
• Grade IV: Occlusions
• Tx: Anti-platelet most commonly used, IV heparin used if
presents with acute stroke
• Grade V: Transection
• Tx: Controversial. Consider operative repair if survivable injury

• Heparin: no bolus; 15units/kg/hr; target PTT 1.5-2x normal

• Antiplatelet: ASA 325mg qday

CTA should be done as References:

early as possible
•Biffl WL et al. J. Trauma 2009; 67:1150
•Cothren CC, et al. J Trauma 2003; 55:811
•Biffl WL, et al. Ann Surg 2002;235:699
• Miller PR, et al. Ann Surg 2002:236:386

Rev. 11/17, 12/17 39

 C-SPINE EVALUATION - ADULT

BACKGROUND:
• Rate of missed cervical spine injuries with plain films alone is
unacceptably high (33%); therefore, the imaging study of choice
in blunt trauma patients should be a cervical CT scan.
SCREENING CT SCAN:
• For all patients, the NEXUS screening criteria are used to
determine who requires a CT scan for clearance of the C-spine.
ROLE OF MRI :
• If an awake patient complains of midline tenderness and has a
normal CT of the c-spine, a MRI or flexion-extension films should
be obtained to rule out ligamentous injury. These patients should
be left in cervical collars until the MRI/Flex-ex report is available.
• For comatose patients, keeping patients in collars awaiting MRI
has been associated with increased morbidity. Therefore, at
Stanford MRI is NO LONGER routinely obtained in order to
clear the C-spine of comatose patients. In general, if the CT is
negative for injury and the patient can move all extremities, the
spine can be cleared at the discretion of the attending.

• In the obtunded adult patient, suggest that flexion-extension

imaging NOT be used to assess for a possible isolated
ligamentous injury or SCIWORA of the cervical spine. While MRI
remains the preferred test to rule out isolated ligamentous injury
or SCIWORA of the cervical spine in the unconscious,
unevaluable patient, there is increasing evidence supporting the
use of advanced CT imaging with appropriate technique in this
setting.

40
Rev. 12/17
 C-SPINE EVALUATION - ADULT

Any NEXUS Criteria?

• Midline neck tenderness
• Neurological deficit
• Distracting Injury*
• Intoxication with drugs or EtOH
• Altered Mental Status

Yes No

CT C-spine Clinical Exam

Normal & Normal & Abnormal

Non-tender Tender

Remove C- MRI , or Spine Spine consult

collar consult

*Distracting injury defined as injury to the head, neck, chest or upper

extremity, or an injury that is so painful that it requires such doses of
analgesics that the patient is unable to co-operate with a clinical
examination

• SCVMC PROTOCOL VARIATIONS:

• If normal CT C-spine, but have tenderness, obtain either MRI
(within 48hrs) or flexion/extension plain films
• If normal CT C-spine, but patient cannot be clinically evaluated,
obtain MRI or flexion/extension plain films
References:
• Mathen et al. J of Trauma 2007; 62(6):1427-31
• Hoffman J, et al. NEJM 2000; 343:94-9
• Heffernan D, et al. J of Trauma 2005;59(6):1396-9
• Muchow R, et al. J of Trauma 2008; 64(1):179-89
• Como J, et al. J of Trauma 2007; 63(3):544-9
Rev. 5/14, 12/17
• Stelfox H, et al. J of Trauma 2007; 63(3):630-6. 41
 TLS SPINE EVALUATION

BACKGROUND:
• Thoracic/Lumbar/Sacral (TLS) spine fractures occur at about the
same rate as cervical spine fractures (2-5% of blunt trauma)
• Although most patients present with pain and tenderness, up to
20% do not have associated pain and tenderness at
presentation.
ANY OF THE
FOLLOWING?
• Back pain
• Tenderness
• Neurologic Deficit
• GCS < 15
• Major Injury1
No Yes

Observe TLS X-ray 2

TLS films adequate 3

Observe CT poorly
visualized or
abnormal areas
1 Hemothorax, flail chest, liver/spleen laceration, long bone fracture
pelvic fracture
2 CT scan may substitute TLS X-ray in patient already undergoing chest/abdomen
scanning
3 Adequate TLS films:

● T1-T5 – anterior images of vertebral bodies are well seen and are normally
aligned and without compression.
● T6 – sacrum – The full vertebral body is well seen, normally aligned and without
compression. Additionally, posterior elements allowing for some overlap from rib
and shoulder girdle structures appear intact 42
Rev. 5/14
 RIB FRACTURE - GENERAL
BACKGROUND:
• Multiple rib fractures (more than 4 ribs) in patients >45 yrs have
been associated with increased morbidity
• The cornerstone of rib fracture management is early and
adequate pain control to avoid complications from splinting
(atelectasis, retained secretions, pneumonia)
Multiple Rib Fractures
• Patients > 45yrs with 4 or more fractures
• Patients > 65yrs with 2 or more rib fractures

Within 2 hrs

• Admit for pain control

• Recommend ICU admission for any patient with
4+ rib fractures
• Recommend ICU admission for age>65 yo & >2
ribs fx. for first 24 hours

• Aggressive early and adequate pain control

• Epidural preferable, PCA as alternative
• Coach patient on coughing and breathing
• Aggressive deep breathing exercises, flutter
• Encourage patient ambulation
• Suctioning when necessary
• Consider rib fixation for flail chest, inability to
wean from ventilator, unremitting pain

Rib fracture patients requiring admission to the SICU should be on

a stable pain regimen for 24 hours that can be reproduced on the
ward for 24 hours prior to transfer out of the SICU.
43
Rev. 12/17
 RIB FRACTURE - GERIATRIC
BACKGROUND:
• Geriatric (>65yrs) patients are especially susceptible to rib fractures due to
ground level falls, and have twice the mortality of younger patients

MANAGEMENT:

*Epidural Placement or Alternatives*:

Paravertebral blockade
Intercostal nerve blockade

Contraindications to Epidural Catheter

Placement:
• Coagulopathy, or anticoagulated with
warfarin, apixaban or rivaroxiban
• Systemic infection
• Spinal cord injury or spinal fracture
near area of catheter placement
• Delirious, dementia with active
behavioral disturbances or non-
cooperative patient
• Body habitus (BMI>40) or unable to
position the patient
44
Rev. 12/17
 RIB FRACTURE - GERIATRIC
MANAGEMENT (PHARMACOLOGIC):
• Special consideration must be given to modulation of pain in elderly (dosing, side
effects, risk of polypharmacy)

45
Rev. 12/17
 PENETRATING NECK TRAUMA

ZONES:
• Zone 1: clavicle to inferior border of cricoid cartilage
• Zone 2: cricoid to angle of mandible
• Zone 3: above angle of mandible to base of skull

EXAM FINDINGS:
• Active bleeding; Hypotension; Large or expanding hematoma;
pulse deficits (carotid, brachial/radial), bruit
• Hemoptysis/hematemesis; SQ Emphysema; Hoarseness;
Dysphagia
• Localizing Signs: Pupils, Limbs, CN’s
• CN’s: Facial, Glossopharyngeal (midline position of soft
palate); Recurrent Laryngeal (hoarseness, ineffective
cough); Accessory (shoulder lift); Hypoglossal (midline
position of tongue)
• Horner’s: Myosis, Ptosis
• Brachial Plexus: Median (fist); Radial (wrist extension); Ulnar
(abduction/adduction of fingers); Musculocutaneous (forearm
flexion); Axillary (arm abduction) 46
 PENETRATING NECK TRAUMA
Penetrating Neck Injury

• Airway Compromise
• Profuse Bleeding
• Persistent Shock
• Evolving Stroke
• Expanding Hematoma
Yes
No

• Bronchoscopy GSW, transcervical, OR

• Esophagoscopy
• Esophagography High risk trajectory?

Zone I or II Zone III

CT Angio CT Angio
Neg Positive
No Yes
OPTIONS:
• OR
• IR, or
OBSERVE • Further diagnostic OBSERVE
evaluation depending
on hemodynamics Angio ±
and injury pattern
Embolization

Obtain CT within 30
mins References:
• Biffl WL, et al. Am J. Surg 1997; 174:678-682
• Demetriades D, et al. World J Surg 1997; 21:41-48 47
• Gracias VH, et al. Arch Surg 2001;136:1231-1235
• Sekharan J, et al J Vasc Surg 2000;32:483-489
 BLUNT AORTIC INJURY (BAI)
BACKGROUND:
• BAI is the second most common cause of death in blunt trauma, following
head injury.
• Deceleration forces cause aortic tearing at points of fixation: ligamentum
arteriosum (80-85%), diaphragmatic hiatus (10-15%), and ascending aorta
(5-10%).
• 85% of fatalities occur at the accident scene. Of the remainder, 25% occur
within 24hrs and another 25% within one week
• CT Angio is the diagnostic test of choice (specificity 100%)
• CAUTION: A normal CXR does NOT exclude BAI
CLASSIC CXR FINDINGS:
• Widened mediastinum
• Indistinct aortic knob
• Depression of left main stem bronchus
• Deviation of NG tube
• Opacification of aortopulmonary window
• Widening of paratracheal/paraspinous stripes
• Apical capping
• Scapular fracture or 1st/2nd rib fracture
MANAGEMENT:
• Consult immediately either:
• Vascular Surgery in even months or
• Cardiac Surgery in odd months
• Guidelines:
• MAP 60-80 SBP<110
• SBP<120 mandatory, <100 desired
• HR 70-80
• Medication options once patient has been stabilized (other sources of
bleeding assessed):
• Esmolol (0.5 μg/kg - 300 μg/kg) - **1st line therapy
• Nitroprusside (2-5 μg/kg/min) or Nitroglycerin (5 -10ug/min)
• Nicardipine (5-15mg/hr)

*Polytrauma patients with head injury will require MAPs.

48
Rev. 6/16
 BLUNT AORTIC INJURY (BAI)

CXR

Findings Associated
with BAI

No Yes

Consider CT Angio Chest

Mechanism

Low-Risk High-Risk
Mechanism Mechanism

No further CT Angio Chest

workup

CXR during primary

survey (5-10 min)
References:
CTA in ED after • Dyer DS, et al. J Trauma 2000; 48:673-683
secondary survey • Razzouk AJ, et al. Arch Surg 2000;135:913-919
(30-45min) • Hochheiser GM, et al. Arch Surg 2002;137:434-438
• Miller PR, et al. Ann Surg 2003;237:877-884
•Symbas PN, et al. Ann Surg 2002; 235:796-802
• Santanielo JM, et al. J Trauma 2002;53:442-445

Rev. 6/11 49
 BLUNT CARDIAC INJURY

• Can result from blunt trauma to the thorax

• Significant complications from blunt cardiac injury include:
arrhythmia requiring management, cardiogenic shock, and
anatomic defects (valve, septum, or free wall rupture)
• Symptomatic blunt cardiac injury can be as high as 13% in
blunt chest trauma; at risk patients should be recognized and
monitored closely
• Manifestations occur within 24h of injury
• Most common presenting symptoms is arrhythmias with
sinus tachycardia being the most frequent
• Patients at risk for BCI should have ECG and troponin I level
checked. If both are normal, BCI is ruled out.
• If either test is positive, the patient should be monitored for
24-48 hours in case the patient develops symptomatic blunt
cardiac injury.
• ECHO should be performed in any patient with a new
arrhythmia or hemodynamic instability.

References:
• Salim et al. J Trauma. 2001;50:237-43.
• Velmahos et al. J Trauma. 2003;54:45-51.
• EAST guidelines. www.east.org 50
 BLUNT CARDIAC INJURY

RISK FACTORS
FOR BCI:
•Multiple rib fractures
•Sternal fracture
•Scapula fracture
•Intrathoracic vascular injury
•> 20% lung contusion
•Chest seatbelt ecchymosis
•HTX/PTX requiring chest tube

Yes

•12-lead ECG ABNL ECG:

•Abnormal
•Serum troponnin I conduction
•ST elev/dep
Either test abnormal? •T-wave
inversion
No Yes •Arrhythmia

Telemetry
abnormalities
during workup?

No
Yes TELE (or ICU) x 24h
•Manage arrhythmia
Discharge if •Manage pump failure
no other •TTE for suspected
injuries anatomic lesion, shock,
severe arrhythmia, or other
hemodynamic instability

Rev. 5/14 51
 PENETRATING CHEST TRAUMA to the “BOX”

BACKGROUND:
• The “Box” = Borders of suprasternal notch, nipples, and costal
margin
• Pericardiocentesis is unreliable in the acute trauma setting: 20%
false positive and 20% false negative
• Most sensitive test for post-traumatic tamponade is (subxiphoid)
pericardial window, but this requires general anesthesia in the
OR.
• For patients who do not require general anesthesia for surgery
following penetrating trauma, the best non-invasive test for
cardiac or pericardial injury is 2D echocardiography. Sensitivity
and specificity is 100% and 89%, respectively, for patients
without hemothorax. Less accurate in the setting of hemothorax
(56%, 93%)
• Penetrating cardiac injuries can occur without entrance or exit
wounds in the “box.”

X = wounds that produce cardiac injuries

52
 PENETRATING CHEST TRAUMA to the “BOX”

Penetrating Chest Trauma

HD Unstable OR decision within 5min

No Yes

Operating room or
Injury within
ED thoracotomy
the “Box”
Yes No

Patient Requires Surgery

for associated trauma
Yes No

Hemopericardium
Subxiphoid
on US?
Window No
Yes
Blood
Yes
No
• Admit & Observe
Median • Treat hemo-pneumothorax
Sternotomy • Consider repeat US or CT

• Admit & Observe

• Treat hemo-pneumothorax
• Consider repeat US or CT
References:
• Asenio JA, et al. Surg Clin N Am 1996; 76:685
• Moreno C, et al. J Trauma 1994; 36:229
•Meyer D, et al. J Trauma 1995; 39:902 53
• Nagy KK, et al. J Trauma 1995; 38:859
 ED THORACOTOMY (EDT)

BACKGROUND:
• Variables to consider: mechanisms of injury (blunt, gunshot,
stab); vitals; signs of life
• Vitals (VS) = palpable pulse or BP
• Signs of Life (SOL) = pupillary activity, respiratory effort, or
narrow complex QRS
• Best outcomes occur in penetrating cardiac wounds
• Worse outcomes occur in blunt abdominal trauma.

GOALS OF EDT:
• Release pericardial tamponade
• Control cardiac and/or great vessel bleeding
• Control broncho-venous air embolism
• Perform open cardiac massage
• Limit intra-abdominal hemorrhage via aortic cross-clamping

TECHNIQUE:
• Ensure proper equipment and assigned roles within the team; exercise
fluids and sharps precautions and communicate clearly
• Incise at 4 or 5th IC space from sternum to posterior axillary line (below
nipple line in men, below inframammary crease in women)
• Initial incision through all subcutaneous tissue and down to chest wall.
• Intercostal muscles are incised with scissors
• Insert rib spreader. HANDLE toward the axilla.
• Sweep lung away
• Bluntly dissect mid-descending thoracic aorta circumferentially. NGT in
the esophagus will help differentiate esophagus from aorta
• Place aortic cross clamp
• Make longitudinal pericardiotomy MEDIAL to phrenic nerve to deliver heart
from pericardial cradle
• Temporize wounds with suture or foley
• Cardiac massage if necessary
• Cardioversion with 10-20J if necessary
54
 ED THORACOTOMY (EDT)

SBP < 60
ED arrival to thoracotomy
within 5 min
Mechanism

Blunt Penetrating

Vital signs in ED Signs of Life in ED

(palpable pulse or BP) (pupillary activity; respiratory effort;
narrow complex QRS)

No Yes Yes No

ED THORACOTOMY

No further action No further action

OUTCOMES
ED: No ED: SOL, No
ED: VS
SOL VS
BLUNT 1% 1% 3%
GSW 1% 3-5% 10-15%

STAB 3-5% 10-15% 30-40%

55
 HEMOTHORAX

BACKGROUND:
• Thoracic injuries are very common occurring in up to 60% of
poly-trauma patients and represent 25% of all trauma
deaths.
• Hemothorax is found in approximately 300,000 trauma
patients per year.
• Most hemothoraces can be treated with simple chest tube
drainage with a larger bore CT (32 French or larger).
• Complications from hemothoraces include empyema and
retained hemothorax (rHTX). Patients with rHTX have a
higher likelihood of empyema.
• If a hemothorax is not drained well by a single chest tube
placement, early VATS is now preferred over placement of a
second chest tube.
• For high risk operative candidates or if the volume of
retained hemothorax is small, alternative treatment with
intrapleural thrombolytics (see TPA protocol below) is
an alternative to try to avoid VATS.
• The ideal timing for VATs is between first 3-7 days which
reduces the likelihood of conversion to thoracotomy.

TPA Protocol:

 TPA 6 mg mixed in 50 mL NS infused under sterile

conditions into the CT. Clamp CT for 30 minutes and
drain.
 If necessary, can be repeated Q8 hours x 3 doses.

Rev. 6/12 56
 HEMOTHORAX

Hemothorax on initial
CT or CXR > 300 mL
Yes
•Place 32 French or larger CT
•Single dose of Kefzol at time of CT placement
•Follow up CXR after placement

Hemothorax fully
evacuated?

Yes No

• 20cm Suction No • Consider

•CXR after 24hrs on suction VATS

No • Water seal
•Any residual PTX or Hemothorax?
•CXR after 24 hrs
Yes
•Any residual PTX or
< 48 hrs Hemothorax?
> 48 hrs

Yes No
Non-contrast Chest CT
• Remove
CT
•Consider VATS if HTX >200-300 mL

Alternative No
TPA Chest Tube Any residual Hemothorax?

Yes
Rev. 6/12 57
TRUNCAL STAB WOUNDS (Back, Flank, Abdomen)

BACK/FLANK:
• Defined: between the tips of the scapulae and posterior iliac
crests, posterior to the mid-axillary line
• Physical exam alone is unreliable, and DPL is unable to evaluate
the retroperitoneum
• Triple contrast (oral, rectal, and IV) CT has sensitivity of 89-
100% and a specificity of 98-100% in diagnosing intra-abdominal
and retroperitoneal injuries

THORACOABDOMINAL:
• Defined: between a circumferential line connecting the nipples
and tips of the scapulae superiorly, and the costal margins
inferiorly
• Occult diaphragmatic injury is problematic in this patient group.

ANTERIOR ABDOMEN:
• Defined: anterior to the mid-axillary line, from the xiphoid
process to the pubic symphysis
• Although controversial, serial abdominal exams in a patient with
HD stability and non-peritoneal signs may be employed.

58
 TRUNK STAB WOUNDS (Back, Flank, Abdomen)

Truncal Stab
Wound
Yes • Shock
OR • Peritonitis
OR decision No • Evisceration
within 5-10min

Left Anterior
Back/Flank
Thoracoabdominal Abdomen
• Triple-Contrast CT • Admit
• OR if positive • Risk of missed injury to
bowel and diaphragm. • Serial Physical Exam
(Right side less likely • CBC q8hrs
since liver).
• Laparoscopy

• Peritonitis
• Hemodynamic Instability
• Drop Hg > 3 gms
• Leukocytosis
•Persistant abdominal pain

Yes No

• Observe ≥
OR 12hrs
• Discharge

References:

•Kirton OC, et al. Am J Surg 1997;173:189-93

• Albrecht RM, et al. Am Surg 1999;65:683-7
• Murray JA, et al. J Trauma 1997; 43:624-626
• Tsikitis V, et al. Am J Surg 2004;188:807
• Biffl WL, et al. J Trauma 2011;71: 1494-1502

Rev. 6/12 59
 BLUNT ABDOMINAL TRAUMA
BACKGROUND:
• Only 5-10% of patients admitted to trauma centers with
suspected abdominal injury will have abdominal injury
• Abdominal injury requiring operative intervention occurs in 5-
10% of all trauma patients.
• Physical exam alone is an unreliable mode of detecting intra-
abdominal injury.
• Delay in diagnosis results in marked morbidity and mortality.
• Negative FAST does NOT exclude intra-abdominal injury.

INDICATIONS for
Abdominal/Pelvis CT
• Spinal cord injury, altered consciousness,
intoxication, distracting injury, or unreliable
exam
• Significant abdominal pain or tenderness
• Gross hematuria
• Pelvic fracture
• Unexplained tachycardia and/or transient
hypotension (even with normal FAST)
• Significant chest trauma
• pulmonary contusion
• greater than 2 unilateral rib fractures
• scapular fracture
• mediastinal hematoma
References:
• Grieshop NA, et al. J Trauma 1995;38:727-731
• Fernandez L, et al. J Trauma 1998;45:841-848 60
• Healey MA, et al. J Trauma 1996;40:875-885
• Livingston DH, et al. J Trauma 1998;44:273-282
 BLUNT SPLENIC TRAUMA
• Non-operative management (NOM) has become the standard of
care for hemodynamically stable patients with low to moderate
grade injuries (Grade I – III) lacking a contrast blush on initial CT
scan.
• NOM includes bedrest, telemetry monitoring, Hg/Hct check
q6hrs, documented serial abdominal exams x 24 hours
• Predictors of NOM failure are associated with:
• Hypotension in ED
• Grade III injuries with contrast blush
• Grade IV/V injuries
• 95% of NOM failures happen within 72 hrs of injury.
• All patients undergoing splenectomy or at high risk for
splenectomy (including those who undergo main splenic
artery embolization) should have pneumococcal,
meningococcal, and Hib vaccines prior to leaving the
hospital.
• A decrease in Hg of <2g or significant change in abdominal
exam should prompt a repeat CT, unless the patient is HD
unstable
• The grade of injury should be documented in the H&P and the
grading scale can be found in the trauma manual appendix.

61
 BLUNT SPLENIC TRAUMA

No
HD Stable? Laparotomy

Yes

Abdominal CT
Yes

Splenic Injury

Grade I – III Grade I – II Grade IV/V or Grade

with No blush with blush III with blush

Observe Consider IR if >2g Consider OR

Hgb drop

• If continued bleeding and • IR embolization is reasonable

stable, consider repeat CT. alternative especially if poor
• If continued bleeding and operative candidate
unstable, then OR

References:
• Crawford RS, et al. Surgery 2007;142:337-41
• Haan J, et al. J Trauma. 2004;56:542-7
• Haan J, et al. Am Surg. 2007;73:13-18
•Smith J, et al. J Trauma. 2008;64:656-665
• Smith HE, et al. J Trauma. 2006; 61:541-5
• Watson GA, et al. J Trauma. 2006;61:1113-1119

Rev. 6/10 62
 BLUNT BOWEL and MESENTERIC INJURY

BACKGROUND:
• CT scan is the best noninvasive test for diagnosing blunt bowel
and mesenteric injury (BBMI), aka hollow viscus trauma.
• Oral contrast does not need to be routinely administered as it
does not add to the specificity of the test at time of initial
evaluation.
• High index of suspicion if “seatbelt sign” or lumbar spine anterior
compression fracture (potential injury to duodenum, jejunum, or
pancreas)
• A single CT finding suggestive of BBMI had 35% chance of
having BBMI. Two CT findings were associated with BBMI in
80%.
• If patient has more than minimal free fluid without solid organ
injury seen on CT scan, hollow viscus injury must be considered.
• In some instances of minimal to trace free fluid and suspicious
mechanism, serial abdominal exams over 24 hours can be
performed.
• Additionally, if repeat CT scan is performed following initial CT
scan for concern of delayed presentation of hollow viscus injury,
oral contrast should be administered.

63
 BLUNT BOWEL and MESENTERIC INJURY

CT Scan Findings

• Pneumoperitoneum Yes
• Extravasation of contrast OR

No

• Free fluid in the absence of solid

organ injury NO
• Bowel wall thickening Observe
• Mesenteric fat streaking
• Mesenteric hematoma

1 finding 2+ findings

• Serial exams OR
• CBC q6hrs
• Consider repeat CT in 6hrs
with oral contrast

• Worsening exam
• Increased WBC Secondary OR decision within
• Decreased Hg/Hct 12-18 hrs
• Fever
• Failure to clear acidosis
• Worsened CT findings

References:
OR • Fakhry SM, et al. J Trauma 2000;48:408-415
• Malhotra AK, et al. J Trauma 2000;48:991-1000
• Killeen KL, et al. J Trauma 2001;51:26-36
• Allen TL, et al. J Trauma 2004;56:314-322
• Rodriguez C, et al. J Trauma 2002; 53:79-85

Rev. 6/10 64
 RECTAL INJURY
BACKGROUND:
• Important to classify as intraperitoneal or extraperitoneal.
• Need to rule-out rectal injury in all transpelvic gunshot wounds
and other penetrating pelvic injuries: digital rectal exam,
proctosigmoidoscopy.
• Genitourinary tract injuries are often associated with rectal
trauma. Hematuria should raise the level of suspicion for further
workup.

ANATOMY:
INTRAPERITONEAL:
• Anterior and lateral surfaces of the upper 2/3 of the rectum
(serosalized):

EXTRAPERITONEAL:
• Posterior surface and lower 1/3 of the rectum (no serosa)

MANAGEMENT:
INTRAPERITONEAL

• Management similar to colon injuries

• Primarily repaired with or without fecal
diversion
• Broad spectrum antibiotics covering gram
negative and anaerobes.

EXTRAPERITONEAL

• Leave untouched, diverting colostomy.

• If injury is easily visualized with minimal
dissection, then primary repair
• Broad spectrum antibiotics covering gram
negative and anaerobes. 65
• Navsaria PH, et al. World J Surg 2007 Jun;31(6):1345-51
• McGrath V, et al. Am Surg. 1998 Dec; 64(12):1136-41
• Gonzalez RP, et al. J Trauma. 1998 Oct; 45(4):656-61
 PELVIC FRACTURE
BACKGROUND:
• Force required to fracture pelvis is substantial
• Can be a source of significant blood a loss
• Suspect lower GU trauma in all patients with displacement of pubic
bone/pelvic ring

PRINCIPLES OF MANAGEMENT:
• Reduce pelvic volume: wrap pelvis (binder or sheet)
• Level III recommendation – Recommended to do but no
evidence to support this decreases blood loss or improves
survival
• Control hemorrhage via IR techniques
• Level I recommendations:
• Hemodynamically unstable (ongoing transfusion and/or
BD > 4) with pelvis fracture and other causes excluded
by CXR, FAST and/or DPL
• HD stable patients with arterial blush on CT scan (> 2 cm
and pelvic hematoma)
• Level II recommendations:
• Pts > 60 yo with major pelvic fractures (open book,
butterfly segment, or vertical shear) irrespective of HD
status
• If repeat HD instability or continued hemoglobin drop
following angiography with or without embolization,
repeat angiography should be considered after other
causes have been excluded
• FAST is good for ruling in bleeding in the presence of pelvic fracture
but it is NOT good enough for ruling out bleeding with pelvis
fractures in HD stable patients (Level I recommendation).
• CT abdomen/pelvis is mandatory in HD stable patients with
major pelvis or acetabular fractures (Level II recommendation).

References:
Rev. 6/12, 3/18
• Biffl WL, et al. Ann Surg 2001;233:843-850
• Cullinane DC, et al. J Trauma 2011; 71:1850-1868
66
•Pereira SJ, et al. Surgery 2000;128:678-685
 PELVIC FRACTURE
Unstable Pelvic Fracture

HD Stable? Bind pelvis and start

transfusion (5-10min)
Yes No
• Resuscitate with 1L crystalloid & 2u PRBC
CT scan
and 2u Liquid Plasma
• Bind pelvis
• Place central line and a-line (if possible)
• Urgent Orthopedic consult

Evaluate Alternative FAST or DPA within 15min

Sites of Bleeding
• CXR
• FAST
• Consider DPL (if FAST equivocal)

Positive Negative HD Stable?

Activate MTG No Yes

Address
Injuries
• CT scan abd/pelvis
Consult IR • Consider operative
pelvic fixation

• Become unstable
• > 60 with major fx
• HD stable with
blush > 2cm
Rev. 6/12, 3/18
Blush < 2cm Blush > 2cm 67
HD stable Observe Consult IR
HD unstable Consult IR Angio/Embo
 PERIPHERAL VASCULAR INJURY
BACKGROUND:
• Limb salvage requires prompt diagnosis and timely reperfusion.

• Factors associated with high rates of limb loss include:

• Treatment delay >6 hours
• Blunt mechanisms (more transfer of kinetic injury)
• Popliteal artery injuries
• Associated injuries especially those with significant soft tissue loss,
nerve injury, and/or bony fractures
• High velocity gunshot (hunting/military weapons) or close-range
shotgun wounds
• Pre-existing vascular disease
• Failure or delay in Fasciotomy
• Presenting with frank ischemia
• In profound shock on arrival to trauma bay

• Fasciotomy should be considered in all patients in whom time to

reperfusion approaches 4-6 hours

• For any injury with potential for peripheral vascular injury, you must
document a detailed vascular exam, neurologic exam (motor and
sensory), and a soft-tissue exam.
• Vascular exam includes documenting pulses proximal and distal to area
of suspected injury.

• Vascular injuries associated with particular orthopedic injuries:

• Knee dislocation/Tibial plateau fracture – Popliteal artery
• Femur fracture – Superficial femoral artery
• Supracondylar humerus fracture – Brachial artery
• Clavicle fracture – Subclavian artery
• Shoulder dislocation – Axillary artery

References:

• Callcut RC, et al. J Trauma 2009; 67(2):252-257.

Rev. 6/12
• Levy RM et al. The Trauma Manual. 2008. 255. 68
 PERIPHERAL VASCULAR INJURY
Suspected Injury – Perform Detailed Vascular, Neurologic, & Soft-Tissue Exam

Hard Sign of Injury:

• Absent pulse
•Active hemorrhage over vessel
•Expanding or pulsatile mass
•Thrill or bruit
•Distal ischemia (pain, pallor, paralysis,
paresthesias, poikilothermia [cool])

Yes No

Immediate OR & Perform ABI

Vascular Consult
How to perform Ankle-Brachial Index (ABI):
•Use a doppler to identify the proximal and distal
arterial signal around the area of suspected injury
• Measure the systolic blood pressure in the arm
and ankle by doppler
If ABI normal - •Compare the ankle SBP/brachial SBP in the
observe affected limb to the unaffected limb

Abnormal ABI (ABI <0.9) or wax/waning pulse:

Consult Vascular Surgery

No immediate OR needed for Immediate OR needed for other

other injuries injuries

CT-Angio of affected limb with Place on Angio table in OR and

run-off start with on-table angiogram

Injury identified & Vessel Repaired

Time to revascularization <4hrs Time to revascularization >4hrs

ICU for Q1hr x 24 hrs for

Consider Fasciotomy
Vascular Checks

Rev. 6/12 69
 COMPARTMENT SYNDROME – EXTREMITY

BACKGROUND:
• Condition in which the perfusion pressure falls below the tissue
pressure in a closed anatomic space, with subsequent
compromise of tissue circulation and function
• As many as 45% of all cases are caused by tibial fractures
• Other causes include long-bone fracture, vascular injury, crush
injury, drug overdose, and a tight cast or dressing.
• The earliest and most important symptom is pain greater than
expected due to injury alone
• The 5 Ps (pain, pallor, paresthesias, paralysis, pulselessness)
are usually late signs
ANATOMY COMPARTMENTS:
• Anterior: Deep peroneal nerve (dorsiflexion, sensation 1st and 2nd toes)
• Lateral: Superficial peroneal nerves (eversion, lateral foot sensation)
• Deep Posterior: Tibial nerve (planterflexions); posterior tibial artery,
peroneal artery
• Superficial Posterior: Sural nerve
TECHNIQUE – MEASURE (STRYKER SYSTEM):
• Intercompartmental pressures greater than 30mmHg warrant
decompression.
• “Normal” compartment pressures should not preclude fasciotomy
in patients with obvious findings of compartment syndrome
• For Stanford Hospital, the Stryker can be found in the ortho
cast room.
• Prep and drape extremity, knee 30° flexion, ankle 90° flexion
• Setup the transducer and follow instructions with the kit.

70
 COMPARTMENT SYNDROME – EXTREMITY

STRONG CLINICAL SUSPICION

No Yes
4 compartment
Risk Factors fasciotomy
Tibial shaft fracture Crush or Vascular injury
Reperfusion injury Shock resuscitation
Abdominal Compartment Syndrome
Yes No

Measure Compartment Observe

Pressure

< 20mmHg 20-30mmHg > 30mmHg

Observe Assess
Perfusion *Perfusion pressure = MAP – compartment
Pressure* pressure
• If < 40mmHg, then 4 compartment fasciotomy
• If > 40mmHg, then serial measurements
q2hrs until stable

71
Rev. 6/10
 COMPARTMENT SYNDROME – FASCIOTOMY

TECHNIQUE – Fasciotomy:
• Longitudinal lateral incision midway between the tibia and fibula overlying the
intermuscular septum separating the anterior and lateral compartments. Incision
extends from 1cm below the fibula head (to avoid injury to the common peroneal
nerve) to above the ankle
• Using Mayo scissors, open the fascia of both the anterior and lateral
compartments
• Longitudinal medial incision is made 2cm posterior to the tibia edge to
decompress the superficial posterior compartment. Open the fascia overlying
the superficial compartment. Avoid injury to the greater saphenous vein.
• Detach the soleus from the posterior surface of the tibia to decompress the deep
posterior compartment. Avoid injury to the posterior tibia vessels.
• Early closure (5-7 days) reduces wound infection.
• Monitor for rhabdomyolysis. IV hydration to maintain adequate urinary output (at
least 1-2 ml/kg/h), follow serial creatinine kinase (CK) levels.

72
 TRAUMA in PREGNANCY

BACKGROUND:
• Trauma is the leading cause of non-obstetrical maternal death
• Life threatening maternal trauma associated with 50% fetal loss
• Less severe injuries still have fetal loss rates of up to 5%
BLUNT TRAUMA:
• Placental Abruption: Over 50% of fetal losses are due to
placental abruption (usually occurs within 6 hours of the event).
Classic triad of frequent contractions, bleeding and abdominal
pain occurs in fewer than half of cases. Ultrasound will identify
placental clot only 50% of the time. If mother is hypotensive
without a source, consider abruption.
• Uterine Rupture: Not common. Classic presentation is searing
pain, and transabdominal palpation of fetal parts
• Fetal-Maternal Hemorrhage: Defined by fetal blood cells in the
maternal circulation. All pregnant trauma patients with Rh (-)
blood type should be considered for RhoGam within 72hrs.
PENETRATING TRAUMA:
• Associated with high fetal loss rates
• Cesarean section is frequently necessary
DETERMINING FETAL AGE:
• Evaluate fundal height
• Below umbilicus – less than 20 EGA– NON-VIABLE
• Above umbilicus – cm from pubis to fundus = weeks
gestational age +/- 2 weeks
PERIMORTEM C-SECTION:
• Once there is maternal loss of vital signs, there should be an
immediate consideration for the performance of a Cesarean
section if the fetus is viable.
• Survival is optimized if performed within 4 minutes. If fetus is
delivered >15 min after maternal death, fetal survival is only 5%.

73
 TRAUMA in PREGNANCY

INITIAL MANAGEMENT:
• Highest priority in a pregnant trauma victim is to evaluate and
stabilize the mother
• Special considerations (ABC): Airway: mother increased risk for
aspiration; Breathing: left shift fetal O2 Hg dissociation curve, so
minimal decreases in maternal SAO2 can compromise fetal
oxygenation; and Circulation: a) mother can exhibit delayed
manifestations of shock; b) supine positioning can compress
IVC, thus position mother’s right hip on a pillow or IV bag to
displace the uterus to the left
DETERMINING FETAL VIABILITY:
• Survival neonate delivered at 21 weeks is 0%; 25 weeks =75%.
• 50% of surviving newborns delivered < 25weeks have severe
disabilities
RADIATION EXPOSURE:
• Rate of childhood leukemia increases from 1/3000 (background)
to 1/2000 among children exposed to in-utero radiation
• Greatest potential risk is in the first trimester
• The concern for radiation, however, should not prevent medically
indicated diagnostic x-rays from being performed on the mother.

74
 OB Trauma Patient Response

• For any severe trauma (trauma 99) in a pregnant

woman > 20 weeks the OB team should be called
via the OB stat pager (call 211 and ask for an OB
stat* to come to the ED)
– The Stanford OB attending will cover all OB
patients for code 99 until their primary OB can be
contacted and present.
– If the OB Stanford attending is not available the
MFM (maternal fetal medicine physician) on call
will be asked by the OB team to cover until the
OB Stanford attending is available
– Consider calling Neonatal Code Blue if emergent
delivery will take place (call 211)
• For less severe trauma (codes 97,95) or in a
patient < 20 weeks
– The patient’s primary OB attending should be
consulted via phone on the patient's arrival.
– If the patient is a Stanford patient, the ED should
call L&D, identify that the ED is calling for an OB
trauma in a Stanford patient and ask to be
connected to the OB attending on call
immediately.
• If the OB Stanford attending is busy (in a c/s etc)
they will delegate someone to respond.
– An L&D nurse can be sent to the ED for fetal
monitoring if indicated.
* OB stat will provide the following personnel: OB Stanford
attending, OB chief resident, OB anesthesia attending, OB
anesthesia resident, L&D Charge nurse, nursing supervisor
75
Rev. 6/16
 SURGICAL CRITICAL CARE POLICIES

To ensure optimal patient care as well as a

productive educational experience, the Trauma
Critical Care staff have formulated the following
guidelines. These policies cover the roles and
responsibilities of each member of the Surgical
Critical Care Team, specific policies regarding patient
care, and other issues essential to the efficient
running of the Surgical Critical Care Service.

The SICU is a closed ICU model and patients are

transferred to the care of the critical care team on
a full-time basis. Care is expected to be
coordinated with the primary surgical and
consulting care services, but patient
management in the ICU, including order writing,
formally resides exclusively within the domain of
the ICU team.

Attendings are to be notified of all new

admissions to the ICU.

76
Rev. 12/17
 SURGICAL CRITICAL CARE POLICIES

Fellow/Resident/Medical Student Roles

SICU fellow: is the “team leader”, expected to function at the level
of junior attending. As the most responsible physician on the team
after the attending.
• SICU fellow is responsible for direct oversight of resident
staff in the care of patients and in the performance of all
procedures.
• The fellow is to perform an independent assessment of each
patient admitted to the SICU, and develop a plan of care for
each individual patient. In addition.
• SICU fellows are responsible for organizing monthly Surgical
Critical Care journal clubs
• Attendance at M&M, TMAC, PPEC and PIPS is also
required.
• They are encouraged to be involved in at least one
research/quality improvement project.
• Each fellow will be provided a faculty mentor with whom they
will meet on a quarterly basis.

The PGY-3 is the Senior Resident on the service.

• Responsible for coordinating and leading rounds at the
discretion of the attending or fellow
• Supervising and educating both residents and medical
students.
• Equitably divide workload among other residents and
medical students.
• This includes running daily work rounds, review of the
previous night’s work-ups including radiology studies and
coordinating the care plan with the primary surgical and
consulting services.

77
Rev. 12/17
 SURGICAL CRITICAL CARE POLICIES

All residents are expected to participate in daily patient care,

including independent assessment and documentation. ICU
progress notes must be documented using the Epic smart
text, “IP ICU PROGRESS NOTE,” and all notes must be
selected for attending co-signature. Under no circumstances is
it acceptable to copy a medical student’s note in place of a
resident’s progress note.

Fellow/Resident/Medical Student Roles

Medical students will assist in all aspects of patient care as

dictated by the senior resident. This includes patient assessment,
documentation, and presentation during attending rounds.
Students are also expected to deliver a Friday noon conference
presentation on a critical care topic.

Daily Rounds Structure

• SICU and MICU fellows to divide the week and take turns to
act as a “team leader” of the day
• Team leader to act as the junior attending, reviewing rounds
with residents
• Fellows to give a bedside teaching point for each patient
• R3 resident is expected to review patient care plan with the
fellows or attending after each patient encounter
• After conclusion of rounds, ideal to debrief and have the
other fellow/s give feedback to the “team leader” fellow
• On-call night-shift resident to round and see each patient
between 8-10pm and again at 4-6am to preemptively
address any issues

78
Rev. 12/17
 SURGICAL CRITICAL CARE POLICIES
Weekly Evaluation:
• Weekly evaluation in-person for both Fellows and residents to be
performed by the SICU attending on Friday of each week.

Residents morning teaching sessions:

All residents are expected to attend mandatory MICU teaching sessions
on Wednesday, Thursday and Friday from 8-830 am

General Policies
1. All residents will follow ACGME requirement for resident work hours
2. Attending rounds begin in the SICU at 10 am on Mondays and
Tuesdays, and at 8 am Wednesdays through Fridays. Weekend times
may vary, but must occur before 10 am
3. All admissions to and discharges from the ICU require approval of the
ICU attending
4. Admission orders, except for patients admitted directly to the SICU,
should be written by the primary surgical service and reviewed by a
member of the SICU team
5. All transfer orders should be written by the accepting service and
reviewed by a member of the SICU team prior to the patient leaving the
ICU
6. Rounds must be conducted in the patient room at bedside.
7. Introductions must be done by team members on rounds, including
identification and pager number of resident assigned to given patient.
8.The Daily Goal Sheet must be completed during rounds, preferably by
the fellow. This document is meant to be used by all providers
(physicians, nurses, respiratory therapists, and pharmacist), and is
designed to improve communication and patient care
9. Available members from the SICU are expected to respond to all
Trauma 99 activations
10. All trauma patients should have the tertiary survey form completed
within the first 24 hours of patient admission
11. Unanticipated changes in patient condition must be communicated to
the ICU attending and primary surgical services
12. All procedures performed in the ICU require documentation in Epic
Rev. 12/17
79
 SURGICAL CRITICAL CARE POLICIES

11. For procedures in the ICU the hospital promotes the

Universal Protocol to Prevent Wrong Site, Wrong Procedure
and Wrong Person Surgery. It is expected, to the extent
possible and appropriate, that the patient and team
members will be involved in site marking and a “time-out”
immediately before a procedure to verify the correct patient,
procedure and site. For procedures requiring moderate
sedation or anesthesia and a boarding pass must be
completed by participating nursing staff. Invasive procedures
not requiring sedation or anesthesia require only
documentation of a time-out by the physician. Any
exceptions, circumstances, etc. precluding the Universal
Protocol MUST be documented in the medical record
12. The Trauma Chief Resident is available at night for
additional support in the ICU. If the Chief Resident is
unavailable or more help is needed the fellow or ICU
attending should be contacted
13. All Trauma deaths must be referred to the coroner. Refer to
the Epic “IP Death Certificate Worksheet,” for a complete
list of indications
14. A SICU representative is expected to attend the weekly
multidisciplinary meeting to discuss patient needs. Meetings
are held each Monday at 2 pm in the E2 conference room
15. Conferences:
• ICU Multidisciplinary Conference 2pm Mondays,
weekly
• Emergency Medicine/Trauma Conference, second
Wednesday of the month, LKSC
• Emergency Medicine/Critical Care Medicine
Conference, third Wednesday of the month. LKSC
• SICU RN/resident Journal Club, every other month

80
Rev. 12/17
 SURGICAL CRITICAL CARE CALL TRIGGERS

The following are a list of absolute indications for alerting the

SICU attending1
• New admission or transfer to the ICU
• Unplanned intubation or respiratory failure requiring ventilator
support
• Inability to oxygenate (pO2<60) or ventilate (acute increase
in pCO2>10 mmHg)
• Unanticipated changes to a patient’s hemodynamic condition
including persistent hypotension, new arrhythmia with
hemodynamic instability, cardiac arrest, or CODE BLUE
• Development of a significant neurologic change (CVA,
seizure, new onset paralysis)
• Medication or treatment errors requiring clinical intervention
(invasive procedures, increased monitoring, new medications
excepting Narcan)
• Unexpected blood product transfusions not previously
discussed with attending, or activation of the Massive
Transfusion Guidelines (MTG)
• Ongoing fluid resuscitation of greater than 4L crystalloid to
maintain hemodynamic stability
• Initiation of new pressors, or continued escalation of pressor
requirements (addition of an additional pressor, maximization
of a single agent with ongoing hypotension)
• Any patient requiring an urgent operation (or return to OR)
with any service

ElBardissi et al. Ann Surg 2009

81
 SICU CALL TREE

SICU Resident ICU Rounds

5-3234 Morning
10am Mon/Tue
8am Wed-Sun
Afternoon
4-6pm
Fellow check-in
Senior Resident 9-10pm

Night check-in
Day Page SICU Senior Resident
rounds w/ bedside
nurses (resident)
Night Page Trauma Chief 8-10pm
Morning check-in
rounds w/ bedside
nurses (resident)
4-6am

Phone Numbers:
SICU fellow - pager
Page SICU Fellow SICU attendings:
Spain 650-776-3912
Maggio 650-521-7453
Staud. 650-704-0631
Weiser 617-794-5887
Lorenzo 650-704-2825
Mohabir 650-804-4811
SICU Attending* Browder 702-757-8276
*Attendings can be called at any time Nassar 650-304-9548
82
Rev. 6/16
 COMMONLY USED ICU ORDER SETS

A number of order sets exist in EPIC for ICU patient care and
these order sets should be utilized. They can be found under the
following headings:

Use the following for admission orders:

• IP ICU Sur/Trauma ICU Admit

Use the following for ordering blood products:

• Massive Transfusion Adult (>50kg)
– For massively hemorrhaging patients in the ED, OR, or ICU
• IP Emergency Release Blood Products
– For hemorrhaging patients who can not wait for cross matched blood but
do not require massive transfusion
• IP Lab Transfusion Service
– For routine transfusion orders

Common additional routine order sets needed:

• IP ICU Electrolyte Replacement Scales (aka ICU)
• IP Insulin Continuous IV Infusion
• IP Insulin Transition Off IV Infusion
• IP Subcutaneous Insulin
• IP Gen Tube Feeding

Use the following for intubated patients:

• IP ICU Intubation
• IP ICU Sedation Vacation and Spontaneous Breathing Trial

Condition specific order sets:

• IP Neu Hypothermia After Cardiac Arrest
• IP ICU Sepsis Management
• IP ICU Pneumonia
• IP ICU COPD
• IP ICU Acute pancreatitis
• IP ICU GI Bleed
• IP ICU Rib Fracture (available soon)
83
 EMERGENCY WARFARIN REVERSAL
Patient known or suspected to be on Warfarin
with Life Threatening Hemorrhage1

INR 1.4-1.6 INR 1.7-1.9 INR ≥ 2.0

option 1 option 2

Vit K 5 mg IV
+ Vit K 10 mg IV
Vit K 10 mg IV
Liquid plasma + Vit K 10 mg IV
+
1-2 units Kcentra 15-25
Liquid Plasma
1-2 units units/kg
(max 1500U.)

Kcentra:
INR 2-4: 25 u/kg IV
Re-check INR in 15-30 mins INR 4-6: 35 u/kg IV
INR >6: 50 u/kg IV

INR ≤1.4 INR >1.4

INR q6hr until 2 FFP if

consecutive clinically
readings ≤1.4 indicated

INR>1.4 @ 24 hrs, 1. Intracranial, intraocular, deep muscle

repeat Vit K 5 mg IV with compartment syndrome, pericardial,
active bleeding & shock

NB: repeat dosing with KCentra not

recommended. Kcentra is contraindicated
in patients with HIT.
84
Rev. 6/16
 MANAGEMENT SEVERE TBI
General Care of Severe Head Injury (GCS 3-8):
1. Endotracheal Intubation/Mechanical Ventilation
•Target :
•PaO2 > 100 mm Hg@
•PaCO2 35-45 mm Hg*
•pH 7.35-7.45
2. Euvolemic Resuscitation – with NS.
•Goal:
•CVP 5-7 mm Hg
•Na 135-145
3. Avoid hypotension (SBP<100 mm Hg)
•Goal:
•MAP ≥ 80 or SBP > 120 mm Hg
4. ICP Monitoring –ventriculostomy is preferred #
•Goal:
•CPP>= 60 mm Hg
5. Seizure Prophylaxis (Phenytoin 1000 mg loading dose and
300 mg/day for 7 days in divided doses)
6. Normothermia (36.0-38.3°C)
7. Euglycemia (80-180 mg/dL)
8. Prophylaxis:
•Stress ulcer prophylaxis
•DVT Chemoprophylaxis by 72 hours with SQ heparin in
the absence of contraindications
9. Short-acting sedatives/analgesics
10.Head of bed 30 °
11. Avoid INR> 1.4, platelet count <75K and Hemoglobin <8
mg/dL

@ABG trumps O2 sat except when weaning. Goal SpO2>=90%

*There is no role for prophylactic or prolonged hyperventilation to
decrease ICP and it should be especially avoid in the first 24-28
hours. .
# The guidelines recommend “ICP should be monitored with an EVD in
all salvageable patients with GCS 3-8 after resuscitation with signs
and symptoms of raised ICP, and considered in patients with severe
head injury, normal CT scan, and two or more of the following on
admission: age over 40 years, unilateral or bilateral motor posturing,
or SBP < 100 mg Hg.”

The above interventions may be initiated in any

appropriate order or simultaneously based on the
clinical situation.

85
 ICP MANAGEMENT
ICP Monitor CSF Drainage (EVD)

Target ICP ≤ 20,

CPP ≥ 60

ICP ≥ 20 ICP < 20

CPP < 60 CPP < 60

Hypertonic Saline ± a. 3% Saline per hospital

Mannitola Norepinephrine or protocol.
Norepinephrine or Phenylephrine
Mannitol 0.5-1.0 gm/kg over
Phenylephrine
10-20 mins. Check serum
Osm and Na q 6 °

Yes ICP/CPP b. Sedation: propofol

Controlled (maximum dose = 80
mcg/kg/min). Alternatives
include midazolam and
No
dexmedetomidine
Further Sedation / Consider Paralysis b
Paralytics: cisatracurium or
vecuronium
Yes
ICP/CPP
Controlled c. Hypothermia: mild = 35-37°
C; moderate 33-35° C.
No
Barbiturate Coma should be
considered a temporizing
Hypothermia and/or Barbiturate Coma with
measure, or in those who are
Continuous EEG c
poor surgical candidates.
EEG for burst suppression
monitoring
Yes
ICP/CPP
Controlled d. Decompressive
Craniectomy All decisions
regarding surgical
intervention should be
No
discussed with the attending
neurosurgeon. In general,
early surgical interventions
Consider Decompressive
may improve clinical outcome
Craniectomy d

References
1. Brain Trauma Foundation Guidelines for
Management of Severe Traumatic Brain Injury.
New York: 2016. Link: www.braintrauma.org

Rev. 5/14
86
 RICHMOND AGITATION SCALE

Richmond Agitation Scale

Score Term Description

+4 Combative Overly combative or violent. Immediate

danger to staff.

+3 Very Agitated Agitated Pulls/Removes tubes or

catheters. Has aggressive behavior
towards staff.

+2 Agitated Frequent non-purposeful movement.

Patient ventilator dyssynchrony.

+1 Restless Anxious or apprehensive but movements

Not aggressive or vigorous.

0 Alert & Calm

-1 Drowsy Not fully alert, but has sustained (>10 sec)

awakening with eye contact, to voice

-2 Light Sedation Briefly (<10 sec) awakens with eye

contact to voice.

-3 Moderate Any movement (but no eye contact) to

Sedation voice.

-4 Deep Sedation No response to voice, but any movement

to physical stimulation

-5 Unarousable No response to voice or physical

stimulation

87
 ARDS Ventilator Management 1. Basic LPVS
ARDSNet ventilation strategy:
Patients with ALI/ARDS - Assist Control
- Vt 5-7 ml/kg PBW
- PIP <30-35 cm H2O
Basic Lung Protective
Strategies (1)
2. Criteria for failing LPVS
On LPVS 24-72 hrs and PaO2 <55
Failing? (2) torr on ≥ 70% oxygen & PEEP
>15
No Yes On LPVS < 24 hrs and PaO2 <55
torr on 100% oxygen & PEEP >
Consider: 20
Recruitment Maneuvers
Recruitment Maneuvers
Use 30-40 cm H2O x 30-40 sec.
Failing?
(2)
No
Yes 3. General Failure Criteria
• PaO2 < 55 torr
Spontaneously Breathing? • SpO2 < 88%

APRV
Yes No Refer to RT Care policy
Consider PCIRV
Consider APRV Flolan
See Epic Flolan Order Set
Failing?
(3) No *Inhaled Nitric Oxide
iNO is no longer used
Yes
routinely for severe
Failing? hypoxia, but may be
Consider paralysis
(3) consider if due to intra-
No cardiac shunt and
Yes bleeding risk with Flolan
Failing? is too high.
(3) iNO Test
No
-15 min test on 20 ppm
Consider Flolan* -Requires at least 10%
increase in PaO2

Failing?
No Rescue Strategies:
Yes HFOV
Refer to RT Care policy
Proning
Recent evidence points to improvements in oxygenation;
Rescue Strategies: hospital does not yet have a protocol for this
HFOV ECMO
Proning Absolute contraindication: on vent >10 days pre-ECMO
ECMO Evaluate, but low survival (<10%) on vent 7-10 days pre-
ECMO
Refer to ECMO protocol

Rev. 5/14 88
 EMPIRIC ANTIBIOTICS IN THE SICU - PNEUMONIA

Rev. 5/13
89
 EMPIRIC ANTIBIOTICS IN THE SICU – ABDOMINAL INFX

Rev. 5/13
90
 EMPIRIC ANTIBIOTICS IN THE SICU – LINE INFECTIONS

Rev. 5/13 91
EMPIRIC ANTIBIOTICS IN THE SICU – UTI AND UROSEPSIS

Rev. 5/13 92
 EMPIRIC ANTIBIOTICS IN THE SICU – SEPSIS

Rev. 5/13 93
 DVT/PE PROPHYLAXIS

DVT/PE Prophylaxis in Adults Following Multiple Trauma

Multiply injured trauma patients are at high risk for development of
thromboembolic complications and should receive chemoprophylaxis as
soon as it is safe. Without prophylaxis, the rate of VTE (venous
thromboembolism) is as high as 58% in high risk trauma patients.
Accurate assessment of VTE risk is critical for proper prophylaxis. High
risk patients who receive early chemoprophylaxis have only a 5% risk of
VTE, whereas delays in initiating prophylaxis result in a marked risk
elevation that exceeds a threefold higher risk if delayed beyond 4 days.
When indicated, anti-coagulation should be immediate and continuous.
Duration of therapy is dictated by the period of immobilization and therapy
should continue through rehabilitation until ambulation is achieved.

Although chemoprophylaxis is associated with a low risk of bleeding (1-

3% depending upon agent utilized), the benefit outweighs the risk for
most trauma patients. However, for select patient populations the risk
exceeds the immediate benefit and therefore, absolute contra-indications
to chemoprophylaxis exist. These include intracranial bleeding (<=24hrs.
post injury), incomplete spinal cord injury associated with hematoma,
uncorrected coagulopathy, and active hemorrhage. There currently is no
universally accepted timeframe in which initiating prophylaxis for
neurosurgical/spinal cord injuries is absolutely safe and therefore, our
local standard mandates spine service or neurosurgery consultation
to determine initiation timeframe. However, most experts agree that
in this select group, DVT prophylaxis may commence as early as 48-
72 hours post injury.

For major trauma patients, low molecular weight heparin (LMWH) is the
most effective means of protecting against DVT. Use of prophylactic IVC
filters should be reserved for high risk patients that have a
contraindication to chemoprophylaxis. In minor trauma patients requiring
hospitalization, sequential compression devices (SCDs) and early
ambulation alone are recommended as the risk of VTE is extremely low.
Routine screening duplex ultrasound is not recommended and should
only be performed in patients who are at high risk of VTE who have
94
received suboptimal chemoprophylaxis.
Rev. 12/17
 DVT/PE PROPHYLAXIS FOR HIGH-RISK PATIENTS

Note it is not necessary to hold dosing

of chemo prophylaxis for Ortho or
General Surgery procedure unless
spinal anesthesia is being used

Refer to TBI
Guidelines

95
Rev. 12/17
 CRITICAL CARE - NUTRITION
The role of adequate and timely nutritional therapy in the ICU
cannot be overstated. Early nutritional support has been
associated with reduced disease severity, diminished
complications, decreased ICU LOS, and improved patient
outcomes.

All appropriate patients will have enteral nutrition initiated

by 24-48 hours and caloric goal to be reached by 72 hours
after initiation.

A nutrition consult should be obtained for all candidates of

total enteral (TEN) or parenteral (TPN) nutrition therapy.

For adequately nourished patients who have relative

contraindications to enteral nutrition, do NOT recommend
initiating early parenteral nutrition (reassess clinical status daily).
Do not initiate TPN if low nutritional risk and contraindications
expected to persist for less than one week.

Relative contraindications to enteral feeds include:

•Peritonitis
•Intestinal obstruction/ severe or protracted ileus
•Mesenteric ischemia
•Major GI bleed
•Complicated or high output enteroenteric fisula
•Severe malabsorptive state
•Patients requiring neuromuscular blockade
•Patient requiring ongoing resuscitation with fluids and
vasoactive support to maintain MAP > 60 mmHg (inadequate
tissue perfusion)

Rev. 4/16, 12/17 96

 CRITICAL CARE - NUTRITION
Enteral Access: All feeding tubes will be confirmed
radiographically, not by auscultation alone. Gastric access
(NGT/OGT) is adequate for most patients. Post-pyloric placement
will be determined necessary by one of the following:
• Gastric outlet obstruction
• Gastroparesis despite pro-kinetic agents or recurrent emesis
• Open abdomen patient
• Unable to maintain head of bed at ≥ 30 degrees
• Attending physician preference

Selection of Appropriate Enteral Formulation: Osmolite 1.2 Cal

(no fiber) or Jevity 1.2 Cal (fiber enriched) is adequate therapy for
most. Consider Glutamine (Impact Glutamine) in burn and trauma
patients (avoid severe sepsis). Patients with ARDS/ALI should be
placed on an enteral formulation characterized by an anti-
inflammatory lipid profile and antioxidants (Pivot 1.5).

Metabolic Requirements:
General initial recommendations: 25 kcal/day of calories and 1.5
grams of protein/kg/day
May be calculated using indirect calorimetry or predictive
equations (ie, Harris-Benedict, Ireton Jones, or Penn State
equations).
• Conditions to consider obtaining indirect calorimetry include:
• Extremely obese patients (Class III – BMI > 40 kg/m2)
• Multiple organ dysfunction syndrome (MODS) / ARDS
• Multiple or neurologic trauma / Burns
• Severe sepsis
• HIV patients
• Malnourished patients, amputees, severe thyroid disorders,
failure to respond to medical therapy.
• Postoperative organ transplantation
• Large or multiple open wounds
97
Rev. 12/17
 CRITICAL CARE - NUTRITION

Peri-Procedural Guidelines For Enteral Nutrition

Hold On-Call to OR/Procedure:
Principals: Patients must have a secure airway, no planned
manipulation of the GI tract and no prone positioning
(1) Intubated patients (orotracheal, nasotracheal or tracheostomy)
with a post-pyloric feeding tube or feeding jejunostomy tube
should have nutrition continued until the OR/procedure. Feeding
held during procedure.
(2) Intubated patients (OT, NT, Trach) with a OG or NG (with
sump) should have nutrition continue until the OR/procedure.
OG/NG placed to suction on-call for the procedure. Feeding held
during the procedure.
(3) Intubated patients with a single lumen NG (no sump, keofeed
that is not post pyloric, PEG), nutrition should be stopped on call
to the OR and aspiration of gastric contents should be done with
a syringe.

Hold 6 hours Prior to OR/Procedure

(1) Intubated patients undergoing a procedure that involves
manipulation of the airway or GI tract (exchange of the ETT,
tracheostomy , laryngectomy or any abdominal surgery), feeding
should be discontinued 6 hours prior to the procedure. Feeding
tube should be flushed and residual aspirated on call to OR.
(2) Non-intubated patient on oral diet or receiving pre-pyloric tube
feeding should have their tube feeding held 6 hour prior to the
OR.

References:
1.Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult
Critically Ill Patient. ASPEN. JPEN,2016;40(2);159-211
2. Pousman RM, et al. Feasibility of Implementing a Reduced Fasting Protocol for
Crtically Ill Trauma Patients Undergoing Operative and Nonoperative Procedures.
JPEN, 2009;33;176

98
Rev. 12/17
 CRITICAL CARE - NUTRITION
Standard
(No TPN) Critical Care Patients
with Expected ICU
No
LOS >2-3 Days

Yes Protein
calorie
malnutrition?
(c)

No
Yes No
Contra-
NPO ≥ TEN(b)
indication
7 days?
to EN(a)

Yes -Initiate at 20 ml/hr

and advance by 20 ml/hr
q 6 hr to goal
TPN(b) -Obtain gastric residuals
(GRV) and assess for
signs of intolerance
(SOI)(d) q 4 hr

Yes GRV ≥
-Replace residual
400ml
-Hold TF
or
-Recheck GRV after 2 hr
SOI?(d)

No

Consider Prokinetic:
-E-mycin 200 mg IV or
Yes GRV ≥ -Replace residual
per tube q 6 hr 400ml -Advance TF rate by 20
-Metoclopraminde 10 or ml/hr or goal
mg q 6 hr SOI?(d) -Once at goal, check
GRV q 4 hr x 24 hr
No
(a)Note relative contraindications
(b)Consult Nutrition when initiating

-Replace residual
TEN or TPN support
If GRV persistently ≥ (c) Defined as acute weight loss ≥ 10-

400 and/or SOI -Restart TF at previous 15% or body weight < 90% ideal body

consider: rate weight

-Gastroparesis, then -Recheck GRV after 2 hr (d)Signs of intolerance (SOI) = gastric

tympany, abdominal distension, or
SB access emesis

-Ileus, then TPN

99
Rev. 12/17
 BRAIN DEATH

Definition: “An individual who has sustained irreversible

cessation of all functions of the entire brain, including the
brain stem, is dead.”
The Uniform Determination of Death Act, AMA,1980.

(1) Required criteria prior to diagnosis:

● Known mechanism of injury
● Normothermia (>34°C)
● Normotension (SBP >80mmHg)
● Absence of CNS depressants, paralytics or confounding drugs (ie.,
sedatives)
● Absence of significant metabolic and/or electrolyte abnormalities

(2) Loss of brain stem reflexes:

● pupillary reflex ( check with magnifying glass if necessary)
● corneal reflex
● oculocephalic reflex (doll’s eyes)-no movement of eyes with fast turn
of head
● oculovestibular reflex (cold calorics)-have HOB at 30 degrees, no
movement of eyes after instilling ice water in ear, use 5 min interval
between sides.
● cough reflex (gag not reliable)-test cough with deep ET suctioning
(to carina)
● response to painful stimuli (excluding spinal reflexes)-supraorbital
nerve, TMJ pressure or nail bed pressure
● spontaneous respirations
● If brainstem reflexes negative, proceed with apnea exam- may need
to correct BP with fluid boluses or pressors in SBP < 90
● C-spine fracture above C4 may not have intact diaphragm function
and may preclude a reliable apnea test therefore consider EEG or
other test of cerebral blood flow.

100
 BRAIN DEATH
(3) Apnea exam:
● Adjust ventilator settings to normalize ABG, esp pCO2 (35-45)
● Pre-oxygenate with 100% O2 for 10-15 minutes
● Disconnect ventilator but oxygenate patient with 100% O2 by T-
piece***
● Observe for spontaneous respirations
● After 10 min of apnea, draw ABG
● Hyperventilate for 2 min then reconnect ventilator and return to
previous settings
*** Abort if patient becomes unstable (SaO2 <80%, hypotension,
arrhythmias). Immediately draw an ABG, hyperventilate patient, and
then reconnect to the ventilator.

DOCUMENTATION OF BRAIN DEATH:

● Two different licensed physicians (independent of the
transplant service) should document brain death. Two notes
are needed; however, only one documented apnea exam is
necessary.
-Stanford (attending and/or fellow, one physician must
be from neurology or neurosurgery)
- SCVMC -attending
● Clearly document the following: 1) absence of
aforementioned brain stem reflexes, 2) pCO2 > 60 during
apnea exam, and 3) that “the patient is brain dead”
● The two brain death notes must have a date and time.
Second note is the legal time of death.
● Consider alternative studies (e.g. EEG, CBF, and/or
cerebral angiography) if unable to perform apnea exam (e.g.
patient instability or pentobarbital coma).

101
 ECMO
ECMO can be used for respiratory (V-V) and/or cardiac (V-A)
support.

V-V Indications:
1. Severe Respiratory Failure despite and after optimal
treatment.
• Must meet ALL of the following criteria:
• Mechanical Ventilation <=7 days
• PaO2/FiO2 <80 on 100% FiO2 –or-
PaO2/FiO2 <100 on 100% FiO2 with PaCO2>100
mmHg for >1 hour
• Murray Score >=3
• Common causes of Severe Respiratory Failure
include:
• severe pneumonia, ARDS, acute lung
(graft) failure after transplant, pulmonary
contusion, smoke inhalation, status asthmaticus,
and airway obstructions.
2. Bridge to lung transplant
• Must already be active on transplant list –or-
decompensate during the initial evaluation process
• Absence of other established organ dysfunction
including:
• Renal failure
• Severe liver failure
• Systemic infection

V-A Indications:
1. AMI refractory to convention therapy including IABP
2. Post cardiac surgery – failure to wean from bypass
3. Myocarditis with significant heart failure
4. Early graft failure: post heart/heart-lung transplant
5. Massive PE
6. Bridge to VAD or cardiac transplantation

Rev. 6/12 102

 ECMO
Contraindications to ECMO initiation:
• Absolute Contraindication to ALL forms of ECMO:
1. Age > 65 years
2. Non-recoverable cardiac disease
3. Non-recoverable pulmonary disease
4. Non-recoverable neurologic disease 5.
Active end-stage malignancy
6. BMI>40
7. Advanced liver disease or ESRD
• Relative Contraindications to ALL forms of ECMO:
1. Trauma with multiple bleeding sites
2. Multiple organ failure
• Absolute V-V ECMO Contraindications:
1. Severe pulmonary hypertension
(mPAP > 50mmHg)
2. Severe right or left heart failure (EF<25%)
3. Cardiac arrest
• Absolute V-A ECMO Contraindications:
1. Aortic dissection
2. Severe aortic valve regurgitation

ECMO Inclusion Criteria for Cardiogenic Shock

Major Comorbidities/Contraindications
ESRD (on dialysis or Cr>3)
Cirrhosis (any grade) No No
CPR Candidate for
Previous stroke or new deficit emergent ECMO
Severe PVD
Age > 65 years old Yes

< 30 min of
witnessed CPR Yes Yes
No

Yes
Unwitnessed CPR Awake after CPR with
or > 30 min of negative neurologic
CPR exam

Not Candidate for No

emergent ECMO 103
Adopted from Bermudez et al. Ann Thorac Surg 2011
 Death Exam and Pronouncing a Patient

When a Patient dies, you may be asked to pronounce

the patient.

Death Exam and Pronouncing a patient

1. Check ID bracelet
2. Check pupils for position and response to light
3. Check response to tactile stimuli
4. Examine respectfully: No pinches or nipple twists
5. Check for spontaneous respirations
6. Check for heart sounds and pulses
6. Record time of death

Make sure to call the family and any teams that were
taking care of the patient.

For documentation, go through the “Discharge as

Deceased” tab in Epic. Fill out the “Death Certificate” flow
sheet with all the relevant information. All deaths should
be reported to the Coroner, and all the Traumas are
Coroner’s cases. The phone number to call is (408) 793-
1900. The nurse will call CTDN. Write a Death Summary
and discharge the patient as deceased.

104
 PEDIATRIC
Trauma Guidelines
Level I Pediatric Trauma Center

March 2018
 TABLE OF CONTENTS

PEDIATRIC TRAUMA GUIDELINES PAGE

Table of Contents 106-108

Pediatric Surgery & Trauma Contacts 109

LPCHS Contacts 110

Pediatric Trauma Inter-facility ED Transfers 111

Pediatric Admissions to SHC & OR Determination 112

LPCHS-OR Response to Stanford-OR 113

Pediatric Massive Transfusion 114

Pediatric Modified RSI for ED 115-118

Pediatric Surgery Response to Trauma 119-120

NS and Ortho Emergent Response to ED 121

Roles & Response to Pediatric Trauma 99 122-124

ED to LPCHS-OR Notification Phone Call 125

ED to LPCHS-OR Emergent Transfer Hand-off 126

Trauma Doe Name & Blood Availability 127

ED to LPCHS Trauma Admission Guide 128

PICU Trauma Admission & Management 129

Trauma Hand-off for T99 & T97 130

Pediatric Neurosurgery Consult 131

 TABLE OF CONTENTS

PEDIATRIC TRAUMA GUIDELINES PAGE

Pediatric Head Trauma CT Decision 132

Cervical Spine Clearance in Children After Trauma 133-134

Pediatric Blunt Cerebral Vascular Injury 135-136

Urgent Pediatric MRI for Trauma (After-Hours) 137

Pediatric Blunt Spleen/Liver Trauma Management 138-139

Pediatric Blunt Renal Trauma Management 140-141

Pediatric Extremity Fracture 142-143

Pediatric Pelvic Fracture 144-145

Pediatric VTE 146-147

Upper Extremity and Digit Replantation 148-149

Social Work Consults Screening 150

Suspected Child Abuse and Neglect 151

Pediatric Trauma Pearls 152

Trauma Tips for Patient Placement 153

 TABLE OF CONTENTS

APPENDIX PAGE
Lund-Browder Burn Percentages 154

Pediatric Trauma – Normal Vital Signs 155

Pediatric Trauma - Weight in Kilograms 156

Pediatric Trauma – Estimated Blood Volume 157

Pediatric Trauma – G-Tubes, Chest Tubes, Foley 158

Pediatric Trauma – Laryngoscope, ETT, Suction 159-160

Solid Organ Grading – Spleen 161

Solid Organ Grading – Liver 162

Solid Organ Grading – Kidney 163

Solid Organ Grading – Pancreas 164

Pediatric Modified Glasgow Coma Scale 165

108
Pediatric Surgery & Trauma Contacts

Pediatric Trauma Medical Director

Stephanie Chao MD 650-504-1852

Pediatric General Surgery

24/7 Pediatric Surgery/Trauma 650-723-6439
Matias Bruzoni MD 650-213-6105
Stephanie Chao MD 650-504-1852
Bill Chiu MD starts Jan 2018
James Dunn MD 650-206-0317
Julie Fuchs MD 650-384-9463
Gary Hartman MD 650-353-0720
Claudia Mueller MD 650-319-5037
Stephen Shew MD 310-498-6177
Karl Sylvester MD 650-804-0597
James Wall MD 650-556-5042
Enrico Danzer MD, Fellow 267-301-5722

Nurse Practitioners
Karen Barnaby NP, Pediatric Surgery pgr 18976
May Casazza NP, Neurosurgery pgr 18182
Megan Dombrowski NP, Pediatric Surgery pgr 28107
Raji Koppolu NP, Pediatric Surgery pgr 18426
Karley Mariano NP, Pediatric Critical Care pgr 18746

Pediatric Trauma Program Manager

Melanie Stroud, RN 650-521-2904
Email: [email protected]

Interim Pediatric Trauma Coordinator

Brittney Bunnell, RN 714-330-9765
Email: [email protected]

109
 LPCHS Contacts

Pediatric Radiology Hotline: For CT Scan Reads

• 0700 – 1700 Days, M-F 7-8757
• After-hours/Weekends 7-8758

Lucile Packard Children’s Hospital Stanford

LPCHS Nursing Supervisor 7-8430
LPCHS-OR 24/7 1-2820
LPCHS-OR RSN 1-2820
LPCHS Patient Placement (for beds) 5-7788
LPCHS Radiology Manager On-Call 24/7 18703 pgr
LPCHS Social Worker 7-8303
LPCHS Vascular Access 6-8417 ph 47422 pgr
LPCHS-Wound Care RN 650-815-5891
Pager 3-8222
Pediatric Surgery/Trauma 24/7 3-6439
Pediatric Anesthesia Emergency 24/7 1-9706
Pediatric Anesthesia Resource 24/7 1-9705
Pediatric ED Child Life 6-0896
Pediatric ED - desk 3-4422
Pediatric ED RSN 4-0057
PICU - desk 7-8850
PICU Fellow 1-9748
SCAN Consult 24/7 27226 pgr
Stanford ED - desk 3-7337
Stanford ED RSN 4-2243
Stanford Nursing Supervisor 6-1767
Stanford-OR 3-7251
Transfer Center 3-7342
110
 Pediatric Trauma Inter-facility ED Transfers

PEDIATRIC TRAUMA ADMISSION

REQUEST FROM OUTSIDE HOSPITAL

TRANSFER CENTER

TRANSFER CENTER WILL CONNECT REFERRING MD

TO STANFORD TRAUMA SURGEON ON-CALL

STANFORD TRAUMA SURGEON

TRIAGES CALL

Accepted?
YES NO

PT GOES TO ED FOR TRANSFER

TRAUMA EVALUATION CANCELLED

Early alert and consult to Pediatric

DECISION TO ADMIT Neurosurgery for head/spine trauma
TO LPCHS Trauma Service remains responsible
(PICU bed always available) for pediatric trauma patient throughout
the ED phase of care

Pediatric Surgery assumes care of

Approved: Pediatric Trauma Task Force 12/10; pediatric trauma patient at time of
Revised: 3/11, 3/13, 3/14, 3/16 admission to LPCHS or at time of
Approved: EDTWG and Trauma PIPS, 6/17
Trauma Attending to Pediatric Surgery111
Attending face-to-face handoff
 Pediatric Trauma Admissions to Stanford

and OR Determination

Admission determination:
• For admission to Stanford Health Care, pediatric patients
must be at least 14 years of age and 80 pounds (36.4 kg)
• LPCHS admits pediatric patients <18 years of age and
maternity patients

OR determination:
• Pediatric patients will transfer to LPCHS-OR from the ED for
treatment.

• In the event that surgery is required immediately (less than

30 minutes from arrival in ED), and the Trauma Surgeon
feels that transfer to the Stanford-OR is the most efficient
plan of care for the patient, the Stanford-OR will receive the
patient.

• In this case, the Pediatric Anesthesiologist and LPCHS-OR

Team will come to the Stanford-OR to assist in the care of
the pediatric patient.

• Care will be provided by the Stanford-OR Team until the

LPCHS-OR Team arrives.

• The Stanford-OR Team will remain available to assist with

patient care, as needed.

Rev. 5/15

112
 LPCHS-OR Response to Stanford-OR

Pediatric Equipment available in Stanford-OR

• Broselow Code Cart
• Pediatric Trauma Cart
o Pediatric downtime documentation pack
o Pediatric cardiac pack
o Pediatric neuro trauma pack
o Pediatric general trauma pack
• Pediatric Anesthesia Cart

LPCHS-OR Response Team

• Circulating RN
• Surgical Tech
• Anesthesia Tech
• Pediatric Attending Anesthesiologist
• Pediatric Attending Surgeon

Stanford-OR needs to provide:

• For emergent pediatric Cardiac case
o Slush drape & Slush machine
o Internal defib paddles (Sizes 1.0, 1.6, 2.0, 2.7)
• For emergent pediatric Neurosurgery case
o Craniotomy set
o Midas drill
o Solution warmer drape

113
Approved: LPCHS and Stanford OR Management Teams, 3/16
 Pediatric Massive Transfusion

Pediatric MTG Activation Criteria

• Pediatric patient requiring > 20 ml/kg of PRBCs in first
hour of resuscitation.
• Pediatric patient with the high likelihood of requiring
transfusion of > 0.1 units/kg of PRBCs within the first
12 hours of resuscitation.

Pediatric MTG Pack (<50 kg)

• 4 units of packed red blood cells (Blood group O or
type-specific)
• 2 units of plasma
• 1 apheresis platelet stored at room temperature, NOT
IN BLOOD COOLER

Process
• Have only one authorized provider place orders for
emergency blood at a time, to prevent delays in
releasing blood if duplicate/conflicting orders are
placed.
• Place an Order for Emergency Blood before sending a
courier for pickup
• Additional Information provided to Transfusion Service:
• Type of emergency blood request
• Minimum of two patient identifiers (patient name and medical
record number or date of birth)
• Name of responsible physician/surgeon
• Location of nursing unit
• Contact person and phone number
• Send courier for pick-up
Rev. 9/15
Lucile Packard Children’s Hospital: Patient Care Procedure: Massive Transfusion Guidelines (MTG) and 114
Emergency Release of Blood Products (ERBP)
Pediatric Modified Rapid Sequence Intubation for ED

Assemble equipment
• Utilize Broselow Tape and Cart
• Utilize Difficult Airway Cart for alternative airway supplies
• Call PEDIATRIC ANESTHESIA STAT at 211 for anticipated
difficult airway

Airway/Alertness/Simultaneous C-spine stabilization

• Facial, cervical, laryngeal trauma
• Congenital anomalies and syndromes
• Maintain manual in-line c-spine immobilization
• The C-Collar can be opened during in-line-c-spine
immobilization

Breathing and Ventilation

• Pre-oxygenate patient with 100% O2 by face mask.
• Assess chest rise
• Bag/valve/mask ventilate if no spontaneous breathing
• Use oral airway for unconscious patients to improve
ventilation

Circulation with hemorrhage control

• Obtain intraosseous (IO) access if two peripheral IVs cannot
be rapidly placed

Monitor
• Continuous cardio-pulmonary monitoring, cardiac rhythm and
rate, pulse oximetry, and frequent BPs

Rev. 6/17
Approved: Pediatric ED Medical Director and Trauma Liaison
115
Pediatric Modified Rapid Sequence Intubation for ED

Sedation and muscle relaxation:

Vagolytic
• Atropine 0.02 mg/kg IV
• Consider using atropine as pre-medication when
there is higher risk of bradycardia (eg, when
giving succinylcholine for neuromuscular
blockade during intubation)

Sedative
• Etomidate 0.3 mg/kg IV
• Decreases ICP, minimal CV effects

• Ketamine 1.5 mg/kg IV

• Bronchodilator, increases BP and HR
• Does not increase ICP

Paralytic
• Succinylcholine 2 mg/kg IV
• Contraindications: glaucoma, penetrating eye
injuries, skeletal muscle myopathies, history of
malignant hyperthermia or pseudocholinesterase
deficiency, patients with known hyperkalemia
(recent laboratory results), or severe burns or
crush injuries beyond the acute phase (>1 day
old)

• Rocuronium 1 mg/kg IV
• May have slower onset of action (30-90 vs 30-60
seconds) and is longer acting (28-60 vs 3-12
minutes) than succinylcholine

Rev. 6/17
Approved: Pediatric ED Medical Director and Trauma Liaison
116
Pediatric Modified Rapid Sequence Intubation for ED

Intubation
• Utilize laryngeal manipulation (BURP maneuver) to visualize
cords as needed
• Await full paralysis
• Intubate orally
• Depth of intubation: 3 x ETT size
• Confirm ETT placement with auscultation and end-tidal CO2
device
• If second intubation attempt is required, hand over the
procedure responsibility to a more experienced provider
• For multiple intubation attempts:
• Call PEDIATRIC ANESTHESIA STAT at 211 for difficult
airway
• Consider airway alternatives from the Difficult Airway
Cart (Bougie, Frova, Glide Scope, Endoscope, LMA,
surgical cricothyrotomy,etc.)

Post-intubation
• Continuous end-tidal CO2 capnography
• Confirm proper placement of ET tube by CXR
• Maintain sedation
• Propofol
• Dexmedetomidine
• Benzodiazepines and opioids

References
American College of Surgeons: Advanced Trauma Life Support: Student Course Manual, 2012. 9 th edition.
Bhalla T, Dewhirst E, Sawardekar, A, et al. Perioperative management of the pediatric patient with traumatic brain injury. Pediatric
Anesthesia 2012; 22:627-640.
Bledsoe GH, Schexnayder SM. Pediatric rapid sequence intubation: A review. Ped Emerg Care 2004; 20:339-344.
Chng Y, Sagarin M, Chiang V, et al. Pediatric emergency airway management. Acad Emerg Med 2004;11:438-439.
Sagarin MJ, Chiang V, Sakles JC, et al. Rapid sequence intubation for pediatric emergency airway management. Ped Emerg Care
2002;18:417-423.

Rev. 6/17
Approved: Pediatric ED Medical Director and Trauma Liaison
117
 Pediatric RSI Flow Diagram for ED

Rapid Sequence Intubation for Pediatric Patients

Pre-oxygenate
BVM if no spontaneous respirations

Consider: Atropine Sulfate 0.02 mg/kg IV

Sedation

Etomidate 0.3mg/kg IV or Ketamine 1.5mg/kg IV

Utilize laryngeal manipulation (BURP maneuver)

to visualize cords as needed

Paralysis

Succinylcholine Chloride 2mg/kg IV or Rocuronium 1mg/kg IV

Intubate, inflate cuff, check tube position

Rev. 6/17 118

Approved: Pediatric ED Medical Director and Trauma Liaison
 Pediatric Surgery Response to Trauma

Pediatric Trauma 99
• Stanford Trauma Service is responsible for pediatric trauma patient
throughout the ED phase of care
• Pediatric Surgery assumes care of pediatric trauma patient at time of
admission to LPCHS or at time of Trauma Attending to Pediatric
Surgery Attending face-to-face handoff
• Pediatric Surgery Attending/Fellow will respond to the ED within 30
minutes (for children age <14 years)
• Pediatric Surgery Resident will respond to the ED within 30 minutes
(for children age <14 years)

Pediatric Trauma 97
• Stanford Trauma Service is responsible for pediatric trauma patient
throughout the ED phase of care
• Pediatric Surgery Team will assess Trauma 97 patients within 30
minutes of admission to PICU
• Pediatric Surgery Attending will assess Trauma 97 patients within 16
hours of admission to Acute Care

Documentation
• Trauma Flow Sheet – MD Name and ED arrival time stamp (Stanford-
EPIC)
• Tell the Recording RN your name and role upon arrival to ED
• Stanford Trauma H&P by Trauma Service (Stanford EPIC)
• Pediatric Trauma H&P by Trauma Resident with admission update
(LPCHS-EPIC)

Trauma Tertiary Survey within 24 hours of admission

• All trauma patients admitted to PICU
• All Trauma Activations admitted to Acute Care
• Upon request of Admitting Sub-specialty Service for isolated injury
• All suspected Non-Accidental Trauma patients

Approved: Trauma PIPS, Pediatric Surgery Division,

and Pediatric Trauma Medical Director, 2/16
119
Rev. 6/17
Pediatric Surgery Response to Trauma Continued

To facilitate patient care and to eliminate potential

misunderstandings between various services caring for
trauma patients, the Pediatric Trauma Service established
the following guidelines regarding admission to and
transfer of trauma patients between services.
• Patients with a mechanism for potential
multiple system injures should be evaluated by
the Pediatric Surgical Services
• Patients with multiple system injuries,
hemodynamic instability, or spinal cord injuries
will be admitted to the Pediatric Surgery
Service
• Admission to the pediatric surgical service is
appropriate if an ongoing evaluation for occult
injuries is in progress.
• Patients with single system injuries, without a
mechanism for multiple system injury shall be
directly admitted to the appropriate service.
• Once suspected occult injuries have been ruled
out and the patient may be transferred from the
Trauma Service to the appropriate Service.

120
Neurosurgery & Ortho Emergent Response to ED

Neurosurgery will respond to the ED within 30 minutes for

the following:
• Significant penetrating injury to head
• Acute intracranial hematoma with >4mm midline shift
• Obvious, severe open cranial injury
• Comatose patient with unilateral fixed, dilated pupil
• Patient with traumatic intracranial or spinal injury needing
emergent operative management

Approved: Pediatric Neurosurgery Division, 3/16

Orthopedic Surgery will respond to the ED within 30

minutes for the following injuries:
• Fractured or dislocated extremity without a pulse
• Any dislocation that could not be reduced

Approved: Orthopedic Surgery Division, 3/16

121
Roles & Response to Pediatric Trauma 99

Emergency MD
• Confers with ED RN to determine trauma activation
status
• Initiates trauma survey and care
ED-RSN or designee
• Sends out pediatric trauma page by calling 211
• If Trauma 99, provides notification call with basic ring-
down info to LPCHS-OR RSN (1-2820)
o Age, mechanism, and known injuries
• Contacts Transfer Center (3-7342) to request Pediatric
Critical Care Transport for transfers to LPCHS-OR or
PICU, if needed
Adult Trauma Surgeon
• Responds to ED
• Leads trauma survey and resuscitation
Pediatric Trauma Surgeon/Fellow
• Responds to the ED for Pediatric Trauma 99 (for
children age <14 years)
• Provides resuscitation consultation
• If emergent OR needed, provides notification call to
LPCHS-OR ARC (1-9706 or 1-2820)
PICU Fellow
• Responds to the ED for Pediatric Trauma 99
• Role: Provides airway back-up assistance or
supervision to ED Resident, as needed
• Remains in ED if patient requires active management
o PICU Attending responds within 30 minutes to cover PICU
o If assistance with active patient management is not needed , PICU
Fellow returns to PICU
• Provides concurrent status updates to PICU and OR
• Transports unstable patient to LPCHS-OR
• Provides face-to-face IPASS hand-off to OR Team 122
Approved: 11/14 Pediatric Trauma Task Force, Stanford Trauma Service, Pediatric ED Medical Director,
Pediatric Anesthesia Medical Director, PICU Trauma Liaison, and PICU Surgical Director
 Roles & Response to Pediatric Trauma 99

PICU RSN or designee

• Receives Pediatric Trauma 99 page
• Ensures PICU Fellow and Attending are notified
• Works with PICU Fellow and Attending to plan for
potential trauma admission, including:
o Staffing
o Bed availability
o Pre-admission orders
o Room preparation
• Coordinates PICU admission with ED or OR

Pediatric Anesthesia Attending

• Responds to the ED for Pediatric Trauma 99
o Evaluates airway in conjunction with ED Physician and PICU
Fellow
o Coordinates with OR
• Receives IPASS hand-off from Surgical Team or PICU
Fellow
• After-hours:
o Attending receives page from OR RSN and responds to OR within
30 minutes
o Calls PICU Fellow for update (1-9748)
o Checks with OR RSN for Trauma Notification info

Anesthesia Resource Coordinator (ARC)

• Receives trauma page or call from OR RSN
• Alerts Anesthesia Attending to respond to ED
• Works with OR RSN to book case and designate OR
room
• If no LPCHS-OR availability, calls Stanford ARC
(6-0249)

Approved: 11/14 Pediatric Trauma Task Force, Stanford Trauma Service, Pediatric ED Medical Director,
Pediatric Anesthesia Medical Director, PICU Trauma Liaison, and PICU Surgical Director
123
 Roles & Response to Pediatric Trauma 99

Pediatric Anesthesia Resident or Fellow

• Available 24/7 to respond to ED
• Responsible for emergent OR room set-up
• After-hours: May start an emergent case under
supervision of OB Anesthesia Attending prior to
Pediatric Anesthesia Attending arrival
OB Anesthesia Attending
• After-hours:
o Remains in contact with OR Desk to assist prior to Pediatric
Anesthesia Attending arrival
LPCHS-OR RSN
• Receives Pediatric Trauma 99 page
• Receives Notification Call from ED RSN
• Works with ARC to book case and designate OR room
• After-hours: Pages OR Call Team via 222 system to
document timing and sends text page
LPCHS-OR RN Call Team
• Receives call from LPCHS-OR RSN
• Sets up OR to receive trauma patient
• After-hours:
o Receives page from OR RSN and responds to OR within 30
minutes
o Provides Omnicell access for OB Anesthesiologist prior to
Pediatric Anesthesia Attending arrival
LPCHS-OR Anesthesia Tech
• Receives call from LPCHS-OR RSN
• Sets up OR to receive trauma patient
• After-hours:
o Receives page from OR RSN and responds to OR within 30
minutes

Approved: 11/14 Pediatric Trauma Task Force, Stanford Trauma Service, Pediatric ED Medical Director,
Pediatric Anesthesia Medical Director, PICU Trauma Liaison, and PICU Surgical Director

124
 ED to LPCHS-OR Notification Phone Call

Call: 1-9706, Backup: 1-2820

I-PASS: Notification Phone Call to LPCHS-OR

Trauma/Surgical Attending to LPCHS-OR

ILLNESS SEVERITY
Critical Stable
____________________________________________________
PATIENT SUMMARY
Brief Intro:
Name, age, weight (if available), traumatic mechanism, known major
injuries/emergent medical condition, Operation planned.
A. Airway (Compromised, difficult, intubated)
B. Breathing (PTX, HemoTX, chest tubes, O2 sats)
C. Circulation (most recent vitals, ACCESS, blood products
given/ordered/MTG)
____________________________________________________
ACTION LIST
PREOPERATIVE PREPARATION
• What do you plan to do in ER prior to coming to the OR, including
studies?
• ETA to OR?
• What do you think we will have to do in OR prior to start (Major
lines/tubes)?
____________________________________________________
SITUATION AWARENESS
OPERATIVE PLAN
• Operation, anticipated surgical complications and blood loss
____________________________________________________
SYNTHESIS by receiver
• Does the receiver verbally accept the notification phone call?
125
ED to LPCHS-OR Emergent Transfer Hand-off

I-PASS: Surgical Team or PICU Fellow to Operative Team

Face to Face Hand-off
ILLNESS SEVERITY
Critical Stable
_____________________________________________________________________
PATIENT SUMMARY
Brief Intro: Age, weight, traumatic mechanism, known major injuries/emergent medical
condition

A. Airway - Intubation in ER, difficulty with intubation, C-spine, facial fractures, etc.
B. Breathing - PTX, hemoTX, other chest findings, oxygenation/ventilation
requirements
C. Circulation/hemorrhage control - Most recent vitals, resuscitation given thus far,
blood products available and on order/MTP, IV Access and attempted access
D. Disability - GCS score, spine precautions, intracranial injury if any

Other injuries:
• Head to toe
AMPLE History, if available
• Allergies
• Medications at baseline and administered since arrival
• PMH/PSH
Recent lab values, pertinent pending labs
Lines and tubes:
• What patient has, what is needed
_____________________________________________________________________
ACTION LIST
PREOPERATIVE PREPARATION
• Antibiotics
• Blood products
_____________________________________________________________________
SITUATION AWARENESS
OPERATIVE PLAN
• Operation
• Blood loss
• Anticipated surgical complications
_____________________________________________________________________
SYNTHESIS by receiver
Does the receiving OR team verbally accept and understand the handoff? 126
 Trauma Doe Name & Blood Availability

Pediatric Trauma Admission to LPCHS: Impact of

Name Change on Blood Product Availability

• Pediatric Major Trauma 99 arrives in ED

• Patient is assigned “Doe” name and MRN

• O-neg blood & FFP is brought to bedside in ED prior to

patient arrival

• If unstable patient transfers to LPCHS-OR or PICU:

o O-neg blood & FFP transfers with patient from ED to LPCHS-OR or PICU
o O-neg blood & FFP remains with patient until stabilized
o Keep Doe Name & MRN until patient is stabilized

ALERT:
• For patients new to LPCHS, access to the patient medical
record and ability to place orders may be delayed while the
Doe name and MRN are changed to patient given name
during the admission process

• For least impact to downstream processes such as Lab and

Transfusion Services, change the name after the patient
transfers to the PICU and is stabilized post-op; confirm with
PICU Attending prior to initiating name change

• Current EPIC processes do not allow charts to merge until

after patient discharge.

Approved: Pediatric Trauma Task Force, 11/15

Revised 9/16
127
 ED to LPCHS Trauma Admission Guide

Emergency Department LPCHS Admitting Surgeon

Pediatric Trauma If PICU
with disposition LPCHS • Pediatric Surgery
• Neurosurgery

If Floor
• Pediatric Surgery
• Neurosurgery
• Orthopedic Surgery
• Other surgical service

Approved: Pediatric Trauma Task Force, Pediatric Trauma Medical Director,

Pediatric Emergency Medical Director, Pediatric Trauma Neurosurgery Liaison,
and PICU Trauma Liaison, 4/16

128
PICU Trauma Admission and Management Guidelines

Trauma patients are co-managed by the PICU and Pediatric Surgery or

Neurosurgery.
• Pediatric Surgery admits all injured children requiring PICU level of care and
consults the appropriate subspecialty surgeons, as needed.
• Neurosurgery may admit injured children with confirmed isolated head or spine
trauma.
• Evaluate need for Suspected Child Abuse and Neglect (SCAN) consult.
• The PICU manages the day to day needs and coordinates surgical consults and
recommendations for care of the trauma patient.
• The PICU is the first responder in case of patient deterioration and manages
appropriate resuscitative efforts.
• All major and critical decisions regarding patient clinical management are made
collaboratively involving both the PICU and the admitting surgical specialty
surgeons.

All trauma patients admitted to the PICU must have a Surgical/Trauma H&P as well
as a Medical/PICU H&P authored by the respective team.

All trauma patients admitted to PICU must have a Trauma Tertiary Survey by
Pediatric Surgery.

Outside hospital trauma transfers:

• Outside Hospital ED patients transferring for higher level of care must first transfer
to the Stanford-ED for Primary and Secondary Trauma Surveys before admitting
to the PICU
• Outside Hospital in-patients transferring for higher level of care must admit
directly to PICU
o Direct admits <24 hours post-injury require a full trauma evaluation by an
ATLS certified Pediatric Surgery Attending, Fellow, or Resident within 30
minutes of arrival
o Direct admits >24 hours post-injury require a full trauma evaluation by an
ATLS certified PICU or Pediatric Surgery Attending or Fellow or Resident
within 30 minutes of arrival
• The Transfer Center will direct requests for transfer of injured children to the
Trauma Service in the ED; however, occasionally requests for direct transfer of
injured patients from an Outside Hospital ED to the PICU slip through. Please
refer these calls back to the Trauma Service through the Transfer Center.

C-spines are cleared by Neurosurgery or Pediatric Surgery Attendings or Fellows.

Approved: 5/15 by Pediatric Trauma Medical Director, PICU Surgical Director, and PICU Trauma Liaison
129
Revised: 6/17
 Trauma Hand-off for T99 & T97

Pediatric Trauma 97 Pediatric Trauma 99

Hand-off Hand-off

ED • Stanford Trauma Service • Stanford Trauma Service

discharge responsible for ptatient responsible for patient
Home
• Call Peds Sx Fellow/Sr Res to • Call Peds Sx Fellow/Sr Res to
arrange follow-up arrange follow-up

PICU or OR Trauma Resident Trauma Attending

Admission to to
Peds Sx Fellow/Sr Res Peds Sx Attending
AND
PICU Attending

Acute Care Trauma Resident Trauma Attending

Admission to to
Peds Sx Fellow/Sr Res Peds Sx Attending

Pediatric <16 hours if admitted to Acute Care

Surgery by Attending2
Evaluation1 Seen in ED by Attending
<30 minutes if admitted to PICU by
Trauma team

• Early alert and consult to Pediatric Neurosurgery for head/spine trauma

• Trauma Service remains responsible for pediatric trauma patient throughout the ED
phase of care
• Pediatric Surgery assumes care of pediatric trauma patient at time of admission to
LPCHS or at time of Trauma Attending to Pediatric Surgery Attending face-to-face
handoff
• Utilize Trauma Service hand-off attestation via Stanford-EPIC dot phrase
(.pedstrauma) to document hand-off to Pediatric Surgery AND PICU for any injured
patient requiring PICU admission
• Pediatric Surgery will complete a tertiary survey within 24 hours of admission for all
trauma activations.

1. Applies to patients admitted to Pediatric Surgery trauma service

2. Pediatric Surgery Attending to determine shorter time period for evaluation as dictated by patient clinical condition

130
Approved: Pediatric Trauma Medical Director, Pediatric Emergency Medical Director,
PICU Trauma Liaison, and Trauma Medical Director, 4/16
 Pediatric Neurosurgery Consult

Any Head Injury/Trauma with:

• Loss of Consciousness or seizure
• Abnormal findings on head CT
• Concussive symptoms with or without Loss of Consciousness
• GCS <14
• Agitation
• Somnolence
• Repetitive questioning
• Slow response to verbal communication
• Severe headaches
• Vomiting
• Spine injury
• Consider Pediatric Neurosurgery consult for any patient <3
months of age

Reference:
Pediatric Emergency Care Applied Research Network (PECARN): Pediatric Head
Injury/Trauma Algorithm

Approved: Pediatric Trauma Task Force and Pediatric Neurosurgery Trauma Liaison, 1/15
Revised: 3/16

131
 Pediatric Head Trauma CT Decision Guideline

HIGH RISK
• GCS ≤ 13
Yes
• Palpable skull fracture
• Altered Mental Status • Non-contrast head CT
o Agitation • Consult Neurosurgery
o Somnolence
o Slow response
o Repetitive questioning

No

MODERATE RISK • Non-contrast head CT

• Scalp hematoma (excluding frontal) • Consult Neurosurgery
• LOC or amnestic • Imaging based on clinical
• Change in behavior (subjective) findings:
• Severe mechanism if injury o Multiple vs isolated
Yes factors
o Fall > 3 feet
o MVA with/ejection, o Worsening
rollover, or fatality symptoms
o Bike/ped vs. vehicle w/o o (altered mental
helmet status, headache,
o Struck by high-impact vomiting)
object o < 3 months of age

Relative Radiation Level Designations

Relative Adult Effective Dose Pediatric Effective
No Radiation Level* Estimate Range Dose Estimate Range
O 0 mSv 0 mSv
☢ <0.1 mSv <0.03 mSv
☢☢ 0.1-1 mSv 0.03-0.3 mSv
☢☢☢
LOW RISK 1-10 mSv 0.3-3 mSv
☢☢☢☢ 10-30 mSv 3-10 mSv
• CT not indicated
☢☢☢☢☢ 30-100 mSv 10-30 mSv
• Observation *RRL assignments for some of the examinations cannot be
made, because the actual patient doses in these
procedures vary as a function of a number of factors (eg,
region of the body exposed to ionizing radiation, the
imaging guidance that is used). The RRLs for these
examinations are designated as “V aries”.

References:
Ryan ME, Palasis S, Salgal G, et al. ACR Appropriateness Criteria Head Trauma-Child. J Am Coll Radiol. 2014;11:939-947.
Schonfelf D, Bressan S, Da Dalt L, et al. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable
in practice. Arch Dis Child. 2014;99:427-431.

Adapted from PECARN TBI, age-based clinical prediction rules of outcome

132
Approved: Pediatric Neurosurgery Division, Pediatric Trauma Task Force and Pediatric Radiology Division, 8/15
Cervical Spine Clearance in Children after Trauma

If the child is stable, conscious and communicative and has no high-risk

mechanism or distracting injuries per NEXUS/CCR criteria, the
ED/Trauma/Pediatric Surgery/Neurosurgery Attending or Fellow may
assess for midline posterior c-spine tenderness and ROM.

If no tenderness, range of motion is full, and the child is neurologically

intact, the ED/Trauma/Pediatric Surgery/Neurosurgery Attending or Fellow
may clear the C-spine without X-rays. The child should not be taking any
medications or drugs to alter neuro exam.

If the child is crying, moving all limbs, and moving the neck, they may have
“cleared themselves”, in absence of painful distracting injury.

If the child is < 3 years old, developmentally delayed, or unable to

communicate, consider pediatric neurosurgery consult if unsure
NEXUS/CCR criteria are met.

If the child is unconscious, has distracting injuries, presents with motor or

sensory deficits, or is inconsolable, place the child in rigid c-collar, if not
already done. Proceed with neuroimaging (CT c-spine if stable) and consult
pediatric neurosurgery.
• CT c-spine is more sensitive than plain film x-rays and is preferred if
range of motion is limited.
• C-spine clearance will require CT c-spine and MRI to rule out
ligamentous injury.

If positive for neurological deficit, high suspicion for spinal shock, or

evidence of c-spine injury on imaging, child must be immobilized with a rigid
c-collar and c-spine precautions must be used during transport. Consult
pediatric neurosurgery.

All children with c-spine injury should be managed in PICU. Maintain

normal BP, MAP or CPP goals for spinal cord perfusion.

References
• Anderson RC, Kan P, Hansen KW and Brockmeyer DL. Cervical spine clearance after trauma in children. Neurosurgical
Focus 2006
• Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients
with Trauma. N. England J Med. 2003;349:2510-8. 133
Approved: Pediatric Neurosurgery Division, Pediatric Trauma Task Force and Pediatric Radiology Division, 8/15
 Cervical Spine Clearance in Children after Trauma

Child in Meets ALL of NEXUS/CCR Criteria:

cervical 1. Normal level of alertness
collar 2. No evidence of intoxication, no sedating drugs
3. No posterior midline cervical-spine tenderness
4. No focal neurologic deficit
If patient is non-verbal or 5. No painful distracting injuries
difficult to assess, 6. No dangerous mechanism of injury (a)
consider 7. Moves head in flex/ex and 45 degrees to both
Pediatric Neurosurgery sides without pain
consult

Yes No

CT C-spine with 3D
C-SPINE reconstruction
cleared by OR
ED/Trauma/PSx/NS X-ray 3 views (AP/LAT/OD) (b)
Attending or Fellow
Type of imaging at discretion of
practitioner based on clinical
exam.

NORMAL ABNORMAL

C-SPINE
NORMAL ABNORMAL
cleared by Neurologic NEUROSURGERY
ED/Trauma/PSx/NS Exam CONSULT
Attending or Fellow
Normal
but with
NORMAL persistent Abnormal
neck pain Flex/Ext X-ray
(a) Dangerous Mechanism is considered OR unable to
- Fall from ≥ 3 feet or 5 stairs move neck
- Axial load to the head (i.e. diving) adequately.
Recheck range of motion
- MVC at high speed or rollover or ejection
- Collision involving a recreational vehicle or a bicycle Consider Flex/Ext X-ray

(b) 3 views of c-spine are considered adequate if C1-T1

are visualized and open-mouth odontoid view visualizes
dens and C1 lateral masses. If inadequate or unable to
perform plain films, obtain CT scan of C spine with 3D
reconstructions.
134
Approved: Pediatric Neurosurgery Division, Pediatric Trauma Task Force and Pediatric Radiology Division, 8/15
 Pediatric Blunt Cerebrovascular Injury

SIGNS AND SYMPTOMS OF BCVI

• Seat belt abrasion or soft tissue injury of the anterior neck resulting in significant
swelling or altered mental status
• Cervical bruit
• Expanding cervical hematoma
• Focal neurologic deficit

RISKS OF BCVI
• Mechanism compatible with severe cervical hyperextension/rotation or
hyperflexion, particularly if associated with
• Displaced midface or complex mandibular fracture
• Closed head injury consistent with diffuse axonal injury
• Near hanging resulting in anoxic brain injury
• Cervical spine fracture patterns: subluxation, fractures extending into the
transverse foramen, fractures of C1-C3
• Basilar skull fracture with carotid canal involvement
• Diffuse axonal injury with GCS ≤ 6

IMAGING for BCVI

• Noninvasive imaging with CT angiography or MR angiography is considered the
first-line imaging for arterial injury: Imaging is indicated for patients with any
clinical sign or symptoms of BCVI, unexplained neurologic symptoms and
asymptomatic patients with any of the mechanisms of injury.
• CTA: provides high spatial resolution and rapid assessment but exposes the
patient to ionizing radiation
• MRA: can evaluate intracranial vasculature without radiation and be performed in
conjunction with MRI for evaluation of hemorrhage and ischemia (lengthy study,
may be difficult in emergent situation)

References:
• BBiffle WL, Ray CE, Moore EE, et al. Treatment-Related Outcomes From Blunt Cerebrovascular
Injuries: Importance of Routine Follow-Up Arteriography. Annals of Surgery, 2002; 235: 699-707.
• Bromberg WJ, Collier BC, Diebel LN, et al. Blunt Cerebrovascular Injury Practice Management
Guidelines: The Eastern Association for the Surgery of Trauma. J of Trauma, 2010; 68: 471-477.
• Ryan ME, Palasis S, Saigal G, et al. ACR Appropriateness Criteria head Trauma - Child, J Am Coll
of Radiology, 2014;11:939-947.

Approved: Pediatric Neurosurgery Division, Pediatric Trauma Task Force, and Pediatric Radiology Division, 8/15

135
 Pediatric Blunt Cerebrovascular Injury
Adapted from adult protocol

SIGNS AND RISKS OF BCVI

SYMPTOMS
OF BCVI
Yes
Yes URGENT
No No
EMERGENT

OBSERVE
CT ANGIO* OBSERVE
(NV checks)
(NV checks)
ABNORMAL
CONSULT
PEDIATRIC
NEUROSURGERY

Grading Scale

Grade I – irregularity of vessel wall or a dissection/intramural hematoma with < 25% narrowing
Grade II – intraluminal thrombus, dissection or intramural hematoma >25% narrowing
Grade III- pseudoaneurysm
Grade IV – vessel occlusion
Grade V – Transection or hemodynamically significant arteriovenous fistulae

*For Urgent MRI/MRA refer to Urgent Pediatric MRI for Trauma Guideline

Approved: Pediatric Neurosurgery Division, Pediatric Trauma Task Force and Pediatric Radiology Division, 8/15

136
 Urgent Pediatric MRI for Trauma (After-Hours)

Ensures:
• Adequate resuscitation
ED/Trauma determines
• IV access
need for urgent
• Admission to LPCSH
Pediatric MRI
• Transfer to LPCHS MRI
• Hand-off to MRI staff

NO Admit to LPCHS
Go to Pediatric YES
• Pediatric Surgery – any trauma
Stanford Anesthesia
• Neurosurgery – isolated
MRI needed?
head/spine

LPCHS Admitting MD must request

after-hour inpatient exam by:
1- Place order in LPCHS-EPIC
2- Contact Radiology Resident/
MRI
NO Approved by Fellow On Call via page operator
Radiology for approval
cancelled
Attending 3- Complete NPO instructions
and Consent
4- Radiology Resident/Fellow
must confirm approval with
YES Radiology Attending

Radiology Resident/Fellow LPCHS MRI Tech contacts:

Contacts LPCHS Radiology Tech 1- Pediatric Anesthesiologist
On Call via Page Operator On Call via pager operator
2- LPCHS Radiology Manager
On Call at pager 18703
3- LPCHS OR Front Desk at
Estimated time 2-4 hours 1-2820 to confirm availability
of resources (Anes Tech, PACU)
4- LPCHS Nursing Supervisor at
Questions? 7-8430
• Refer to LPCHS Procedure:
After Hours Imaging Exams with
Anesthesia
• Contact LPCHS Radiology Approved: 7/17

Manager On Call at pager 18703

Pediatric Trauma Medical Director, Pediatric ED Medical Director and
LPCHS Radiology Manager
137
 Pediatric Trauma Blunt Spleen/Liver Management

ABDOMINAL TRAUMA?
Any of the following?
• Abdominal Pain or Kehr’s Sign on Exam Evaluate for
• Hypovolemic Shock eligibility for
• Abd wall ecchymosis or abrasions Lumason study
• History suggestive of abdominal injury within 48 hours
of admission
• Hematuria
• Unable to cooperate with exam
• Unconscious/MS changes

No Yes

Further workup & HCT, Type & Cross

treatment as Abdominal CT
With Grading of Injury
clinically indicated

Liver/Spleen
Liver/Spleen
Grade I – IV
Grade V or VI
Care Per Protocol

Grade I-II Grade III Grade IV Manage based upon

Admit to Floor Admit to PICU/Floor Admit to PICU Clinical Assessment &
Advance care Advance care Advance Care Potential for OR
per protocol per protocol per protocol

Discharge Criteria
•Physiologically stable
Discharge Criteria Met? • Adequate oral intake
• Independent to bathroom
• Pain controlled with oral meds
• Discharge teaching completed
with family participation
D/C Home
• Return clinic appointment

Rev. 7/17
Pediatric Surgery Division and Pediatric Trauma Medical Director
138
 Pediatric Trauma Blunt Spleen/Liver Management

Care Protocol Based Upon Grade

CT GRADE I II III IV

PICU LOS NONE NONE 24 24 HOURS

HOURS*
HOSPITAL LOS 24 – 48 48 – 72 72 – 96 96 – 120
HOURS HOURS HOURS HOURS
PRE- OR POST- NONE NONE NONE NONE
DISCHARGE
IMAGING
NPO x 8hrs, NPO x 24hrs,
DIET clears then ADAT clears then ADAT
(if clinically stable)
RESTRICTED 2 WEEKS/ 3 WEEKS/ 5 WEEKS/ 6-8 WEEKS/
ACTIVITY/ 2 WEEKS 2 WEEKS 2 WEEKS 2 WEEKS
F/U VISIT
BEDREST 8h 24h 24h 48h
HCT Admission and 4 hours post Q6-8h until stable,
ambulation (includes Grade III then q12hx2, then
admitted to floor) q24h

Delayed clinical findings may present > 48h post trauma

*Grade III – PICU/Floor depending on clinical stability

Notrica DM, et al. J Trauma Acute Care Surg. 2015;79(4):683-93

Davies DA, et al. J Pediatric Surgery. 2009; 44:1005-1008.
Jen HC, et al. Annals of Surgery. 2010; 251:1162-1166.
Rev. 6/17
Leinwand MJ, et al. J Pediatric Surgery. 2004; 39:487-490.
Pediatric Surgery Division and
Notrica DM, et.al. J Trauma Acute Care Surgery. 2015; 79:683-693.
Pediatric Trauma Medical Director
139
St. Peter SD, et al. J Pediatric Surgery. 2013; 48: 2437-2441.
Stylanos S, et al. J Pediatric Surgery. 2000; 35:164-169.
 Pediatric Blunt Renal Trauma Management

Suspected Blunt Renal

Trauma?
H&P
Labs (HCT, UA)
CT w/contrast

Determine Grade of Injury

Admit to Pediatric Surgery/Trauma*

Grade I-II (Stable III) Grade III-IV Grade V

Admit to Floor Admit to PICU Bleeding
Hemodynamic instability
OR or IR
and
Admit to PICU

Discharge Criteria
• HCT stable
• Tolerate diet
• PO pain meds
• Ambulate

• Consider Consult to Urology

• Evaluate for eligibility for
Lumason study within 48 hours
Approved Pediatric Trauma Task Force, 4/15; of admission
Revised, 2/16

140
 Pediatric Blunt Renal Trauma Management

CT Grade I II III IV

Floor/PICU for
24 hours
PICU for 24
(depending on
Floor Floor hours then
Admit to clinical
floor if stable
stability) then
floor if stable

Based on discharge criteria: HCT stable, tolerate diet and PO pain

Hospital LOS
meds and ambulate
Pre- RUS for
discharge NONE NONE NONE urinary
imaging extravasation
Post-
RUS as
discharge NONE NONE NONE
needed
imaging
Post-
discharge 3 weeks 3 weeks 4 weeks 5 weeks
activity
Bed rest Ambulate when patient is able

6 hours, 18
12 hours and
12 hours post 12 hours post hours, 40-48
HCT 36 hours post
injury injury hours post
injury
injury

Approved Pediatric Trauma Task Force, 4/15

J Pediatric Surgery 2014; 49: 198-201

J Pediatric Urology 2014; 10: 815-818
J Pediatric Surgery 2010; 45: 1311-1314

141
 Pediatric Extremity Fracture

Admit to LPCHS*
• Admit to Pediatric
Orthopedic Surgery if Concern for Contact
isolated injury Child Abuse? Social Worker

• Admit to Pediatric Surgery

if polytrauma

• Timing and sequence of

long bone fracture repair
for multiply injured patients
Pain Management Treatment
are managed on an A/P & Lateral Xrays proceeds as
individual basis and Consult Pediatric Ortho indicated
require multi-disciplinary
discussion with Pediatric
Surgery, Orthopedic
Surgery, PICU and
Neurosurgery
Neurovascular compromise? If open fracture,
• If Trauma 97 or Trauma 99
Compartment Syndrome? ensure updated
activation or requiring
PICU admission, provide Open or Closed Fracture? tetanus vaccine
hand-off to PICU AND
Pediatric Surgery

Operative
ED Management?
Management?

LPCHS-OR As indicated
or • Reduce
Stanford-OR • Immobilize
• Post-reduction Xrays
• Repeat neurovascular
assessment

Determine Urgency
• Emergent – next case
• Urgent – within 24h
• Add on today Admit to LPCHS*
• Admit & schedule tomorrow vs
DC home with follow-up

Approved: Pediatric Trauma Task Force, Pediatric Trauma Orthopedic Liaison, 11/15
142
 Pediatric Extremity Fracture

May consider Stanford-OR if Documentation Guidelines

>14y and >80 lbs (36.4 kg) • Concern for Non-accidental trauma
AND or Child Abuse
Adult-type fracture with skeletal maturity • Mechanism of injury
• Assessment
• ED procedures
Open Fractures • Plan of care
IV Antibiotic: one dose pre-op • Hand-off
• Cefazolin 30mg/kg q8h x 24h
• If Penicillin allergy: Clindamycin Discharge Criteria
10mg/kg q6h x 24h • Tolerating regular diet
Time to OR: Emergent, next case • Pain controlled with PO meds
• Cleared by PT for safe DC home
Supracondylar fracture, displaced
Discharge Instructions
• Closed reduction and percutaneous
• Pain management
pinning with 2-3 lateral pins; if other,
• Return precautions
document reason
• Cast care
• Open reduction internal fixation
• Durable medical equipment use
• Follow-up Ortho Clinic appointment
Femur fractures
<6 months
• Pavlik harness References:
• Spica cast • The Treatment of Pediatric Supracondylar
>6 months to 5 years Humerus Fractures. 2011. American
Academy of Orthopaedic Surgeons.
• Spica cast • Treatment of Pediatric Diaphyseal Femur
5 to 11 years Fractures. 2015. American Academy of
• Flexible intramedullary nail Orthopaedic Surgeons.
• Rigid intramedullary nail • Tachdjian’s Pediatric Orthopaedics, 4th
• Sub-muscular plate edition, edited by John Anthony Herring,
2008, page 2372.
• If other, document reason

Neurovascular Assessment
• Distal pulses and perfusion
• Sensation
• Supracondylar fractures:
Nerve Motor Sensory
Median (AIN) “OK” sign and Index finger
thumb abduction
Radial (PIN) “Thumb’s up” sign Dorsal web space
Ulnar Scissors” Small finger

Compartment Syndrome Assessment

Increasing agitation or anxiety
Increasing analgesia requirement 143
Palpation or measurement of compartment pressures
 Pediatric Pelvic Fracture

Background Principals
• Due to pediatric anatomy,
pelvic fractures are rare
Pelvic fracture <18y • Assume high energy
mechanism injuries that are
more likely than the pelvic
fracture to be life-
Skeletally *Skeletally threatening
Immature Mature

Avulsion Follow adult pelvic

fracture? fracture guidelines

Yes No

Symptomatic Hemodynamically
treatment stable?

No

Yes • Resuscitate per APLS guidelines

• Place pelvic binder
• R/O alternative source of bleeding

Physical Exam:
• High index of suspicion for open fracture
• AP Pelvis
• CT vs MRI (controversial)
• CONSULT PEDIATRIC ORTHOPEDIC SURGERY

Admit to LPCHS Pediatric Surgery/Trauma

HAND-OFF: Trauma Attending to Pediatric Surgery & PICU Attending

Approved: Pediatric Trauma Task Force, Pediatric Orthopedic Surgery Trauma Liaison and Orthopedic Surgery Division Chief, 2/16
144
Rev. 7/17
 Pediatric Pelvic Fracture

*Admit to Stanford if
• >14y and >80 lbs (36.4 kg)
AND
• Adult-type fracture with skeletal maturity
• Operative pelvic ring fracture
• Lumbopelvic dislocations
• Operative acetabular fracture
• Operative spine fracture with neurological deficits
• Consult Orthopedic Trauma Association Fellow

Documentation Guidelines
• Mechanism of injury
• Assessment
• ED procedures
• Plan of care
• Hand-off

Discharge Criteria
• Tolerating regular diet
• Pain controlled with PO meds
• Cleared by PT for safe DC home

Discharge Instructions
• Pain management
• Return precautions
• Cast care, if applicable
• Durable medical equipment use
• Follow-up Ortho Clinic appointment

References:
High-energy pediatric pelvic and acetabular fracures.
Amorosa LF, Kloben P, Jelfet DI; Orthrop Clin North Am,
2014. 45(4):483-500.

Approved: Pediatric Trauma Task Force, Pediatric Orthopedic Surgery Trauma Liaison and
Orthopedic Surgery Division Chief, 2/16
Rev. 7/17
145
 Pediatric VTE

VTE RISK FACTORS* CONTRAINDICATIONS TO

ANTICOAGULATION**
Trauma:
• >1 lower long bone fracture
• complex pelvic fractures Neurosurgical procedure
• spinal cord injury or TBI requires
• operative intervention > 2 hours Multidisciplinary Discussion
• transfusion > 4 units PRBC
with Neurosurgery Team
Acute infection
Absolute:
Central line (tunneled or temporary) Bleeding disorder
History of venous thrombosis) Hemorrhage (evidence of or at high risk
for)
Inflammatory disease (eg IBD, SLE)
Platelet count unable to sustained
Major lower extremity orthopedic surgery
>50,000/mm3
Medications: asparaginase, estrogen
Relative:
Nephrotic Syndrome Acute stroke
Uncorrected coagulopathy
Obesity (BMI > 95th percentile for age)
Intracranial mass/neurosurgical
Oncologic diagnosis
procedure
Pregnancy
Lumbar puncture or epidural catheter
Thrombophilia (personal or family history) removal in prior 12 hrs

PHARMACOLOGIC PROPHYLAXIS***
Enoxaparin:
• Patients ≤ 18 years old and < 50kg: 0.5mg/kg/dose SQ q12hrs or 1 mg/kg/dose DAILY
• Patients ≤ 18 years old and > 50kg: 40mg SQ daily (for CrCl < 30, 30mg SQ daily)
• Monitoring not necessary unless concerned about clearance with renal dysfunction

Heparin gtt:
• Patients ≤ 18 years old: 10 units/kg/hr
• Do NOT elevate HAL > 0.3 or PTT above 50 seconds

146
 Pediatric VTE

Does not meet criteria

No Hospitalized Altered
for routine prophylaxis.
patient age mobility
If ≥ 18 years eligible for
≥10 years > 48hrs?
adult guidelines

No Yes

Other Other
VTE risk VTE risk
factors*? factors*?

No Yes

No Yes
Contraindications to
anticoagulation**?

No Yes

Early Early ambulation Early ambulation Early ambulation

ambulation AND AND AND
Mechanical Prophylaxis Mechanical Mechanical
Prophylaxis Prophylaxis
AND
LOW Risk MODERATE Pharmacologic
Risk Prophylaxis HIGH Risk
+/-
Hematology Consult

References:
Thompson AJ, et al. J Pediatr Surg. 2013. 48(6):1413-21.
Azu MC, et al. J Trauma 2005. 59(6):1345-9.
Thorson CM, et al. Crit Care Med. 2012. 40(11):2967-73.
Mahajerin A, et al. Haematologica 2015. 100(8):1045-50.

Approved: Pediatric Trauma Task Force, PICU Trauma Liaison and PICU Surgical Director, 3/16 147
 Upper Extremity and Digit Replantation

Prevent peripheral vasoconstriction or vasospasm

• Thrombosis secondary to vasospasm or clot is the most
common cause of early replant failure
• Room temperature >75°F
• Use Bair hugger
• Ensure adequate hydration or fluid resuscitation to avoid
hypotension
• Provide pain control and anxiolytics to prevent fight or flight
response related vasoconstriction
• Avoid caffeine, chocolate, and nicotine

Replant monitoring
• Pulse oximetry
• < 94% and/or loss of a waveform on pulse oximetry
indicates potential vascular compromise
• Check skin for color, capillary refill and turgor

Anticoagulation
• No consensus on appropriate postoperative anticoagulation
• The surgery team will prescribe aspirin, low-molecular weight
dextran, or heparin depending on the case
• Thrombolytics: primarily used for salvage; not indicated for
prophylaxis

Contact the Hand Surgery/Plastics Surgical Team prior to:

• Manipulating or repositioning the extremity
• Changing, loosening or reinforcing the dressing

Approved: 5/17 Dr. James Chang, Chief, Division of Plastic & Reconstructive Surgery, Dr. Amy Ladd, Professor & Chief, Robert A.
Chase Hand Center, and Dr. Stephanie Chao, Pediatric Trauma Medical Director

148
 Upper Extremity and Digit Replantation

Assessment
• Arterial Insufficiency
• Signs/Symptoms:
• Decreased Capillary Refill Time (<2sec)
• Decreased tissue turgor
• Decreased temperature
• Treatments:
• Contact the Hand Surgery/Plastics Surgical Team, who may:
• Release constricting bandages
• Place extremity in dependent position
• Consider heparinization
• Early surgical exploration if previous measures unsuccessful

• Venous Congestion
• Signs/Symptoms:
• Increased Capillary Refill Time (>2sec)
• Increased tissue turgor
• Increased bleeding from wound edges
• Treatments:
• Contact the Hand Surgery/Plastics Surgical Team, who may:
• Elevate extremity
• Consider leech therapy
• Releases hirudin (powerful anticoagulant)
• Aeromonos hydrophila or Serratia marcescens infection
can occur (prophylax with Bactrim or ciprofloxacin)
• Use heparin soaked pledgets if leeches are not available

References
Nanda V, Jacob J, Alsafy T, Punnoose T, Sudhakar VR, and Iyasere G. Replantation of an amputated hand: A rare case report and
acknowledgement of a multidisciplinary team input. Oman Medical Journal. 2011;26(4):287-282.
Watts E. Hand Replantation. Orthobullets.com. Lineage Medical, Inc. 2017.
Wolfe VM and Wang AA. Replantation of the upper extremity: Current concepts. Journal of the American Academy of Orthopaedic
Surgeons. 2015;23(6):373-381.

Approved: 5/17 Dr. James Chang, Chief, Division of Plastic & Reconstructive Surgery, Dr. Amy Ladd, Professor & Chief, Robert A.
Chase Hand Center, and Dr. Stephanie Chao, Pediatric Trauma Medical Director

149
Social Work Consults and CRAFFT Screening for
Pediatric Trauma Patients
All Patients admitted to the Pediatric Trauma Service
should have a Social Work Consult
All Children ages 12 years and older admitted to the
Pediatric Trauma Service should have a CRAFFT
screening completed in the Tertiary phase of care and
Social Work Consulted if Screening is positive.

150
 SUSPECTED CHILD ABUSE & NEGLECT

Be alert to possible abuse when there is a discrepancy in the

reported history and physical findings.

Contact Social Work for CPS report and SCAN Team referral.

Consult a child abuse pediatrician for the following physical

examination findings:
• Bruising in non-mobile children
• Bruising of the torso, neck, or ears in children <4y
• Injury ascribed to household accidents without trauma history
o Head trauma in children <2y
o Long bone fractures in children <2y
• Burns
o Patterned
o Widely separated, especially bilateral
o With different stages of healing
o In unusual areas such as backs of hands, torso, or
buttocks
• Any thin, holohemispheric subdural hemorrhage in children <2y
• Any widespread retinal hemorrhage

Board Certified Child Abuse Pediatrician

o Consult 24/7, pager 2-SCAN (2-7226)

Approved 5/15
Pediatric Trauma Task Force and SCAN Medical Director

151
 PEDIATRIC TRAUMA PEARLS
Basic principles to consider when caring for the injured child:

• Use of a commercial length-based resuscitation tape (Broselow)

expedites care by providing appropriate weight-based equipment sizes
and medication dosages.

• Children have narrow airways which can occlude easily with edema or
foreign bodies. Keep a low threshold for initiating endotracheal intubation
and for requesting support from pediatric anesthesia or PICU.

• Children may not show a change in systolic blood pressure until >45% of
the blood volume is lost.

• Tachycardia in the presence of normothermia and controlled pain,

suggests cardiovascular compensation.

• Children are susceptible to heat loss due to a high ratio of body surface
area to body mass, large head, and small amount of subcutaneous
tissue.

• Eighty percent of pediatric trauma death is associated with head injury.

Involve pediatric neurosurgery early.

• The estimated total blood volume of a child is 75-80ml/kg. Resuscitation

goals for hypovolemic shock:
o Obtain intraosseous (IO) access if two peripheral IVs cannot be
rapidly placed
o Administer warmed crystalloid fluid bolus (20ml/kg); repeat 1-2
times
o If signs of shock persist, administer 10ml/kg warmed PRBCs (type
specific or O-negative).
o Monitor intake and urinary output:
• Newborn and infant 2ml/kg/hour
• Toddler 1.5ml/kg/hour
• Older child through adolescence 1ml/kg/hour

• Acute compartment syndrome indicators include increasing:

o Analgesic requirement American Heart Association. (2011). Pediatric Advanced Life
Support: Provider Manual. Dallas, TX: author.
o Anxiety Bae, DS, Kadiyala, K, Waters, PM, and et al. Acute Compartment
o Agitation Syndrome in Children: Contemporary diagnosis, treatment, and
outcome. J Pediatric Orthopedics 2001; 21:680-688.

Rev. 6/14
Pediatric Trauma Program Manager, Pediatric ED Clinical Nurse Specialist
152
 Trauma Tips for Patient Placement

Trauma Patients
• Any Trauma 95/97/99 ED patient requiring admission to LPCHS
• Any patient with isolated injury requiring admission to LPCHS
• NOTE: The ED may choose not to activate some injured patients as a
Trauma 95/97/99; however, any injured patient requiring admission to
LPCHS is considered a trauma patient

Inter-facility transfers
• Outside Hospital ED patients transferring for higher level of care must first transfer
to the Stanford-ED
• Outside Hospital in-patients transferring for higher level of care must admit
directly to PICU
• Direct admissions to PICU require both an accepting PICU Physician and an
accepting Surgeon

Admitting Service
• Trauma patients must admit to a Surgical Service
• Pediatric General Surgery is the primary admitting service for trauma patients
• Trauma patients admitting to PICU should have both a PICU and Pediatric
Surgery Attending
• Non-Accidental Trauma patients needing ICU care must admit to PICU and
Pediatric Surgery
• Patients with isolated injury needing Acute Care, may admit to any surgical
service, for example:
• Neurosurgery – isolated head injury
• Orthopedic Surgery – isolated extremity injury
• Exception: General Pediatrics may admit:
• Ocular/Eye injuries since Ophthalmology is not an admitting
service
• Non-Accidental Trauma patients only needing Acute Care

Most Appropriate Unit

• All trauma patients needing ICU level of care must admit to PICU regardless of
age; PICU has committed to always make a trauma bed available
• PCU 350 is the preferred Acute Care Unit for trauma patients
• Best choice for head and/or spine injured patients
• Best choice for any poly-trauma patient (multi-system injury)

153
Approved: 6/17 Director of Clinical Access, Pediatric Trauma Program Manager
APPENDIX
Lund-Browder Burn Percentages

Consider Transfer to Burn Center for deep partial

(2nd degree) or full thickness (3rd degree) burns
>10% Body surface Area

Rev. 10/14 Stanford Health Care, Life Flight, Critical Care Transport Policy: 154
Burns Standardized Procedure
 PEDIATRIC NORMAL VITAL SIGNS

Age Weight SBP HR Respiratio

ns

Lbs kg

Newborn 7 3.5 50 – 90-160 30 - 60

70

1-6 mos 7 3.5 70 – 100- 30 – 60

95 160

6 mos 15 7 80 – 90-120 25 – 40
100

1 year 22 10 80 – 90-120 20 – 30
100

3 years 33 15 80 – 80-120 20 – 30
110

6 years 40 18 80 – 70– 18 – 25
110 110

10 years 60 28 90 – 60 – 15 - 20
120 90

155
 PEDIATRIC WEIGHT (Kilograms)

Approximate weight in kg: 50th percentile boys and girls (USA)

AGE BOYS GIRLS

3 MONTHS 5.9 5.4

6 MONTHS 7.8 7.2

1 YEAR 10.1 9.5

2 YEARS 12.3 11.8

3 YEARS 14.6 14.1

4 YEARS 16.6 15.9

5 YEARS 18.6 17.6

8 YEARS 25 24.8

10 YEARS 32 32

14 YEARS 50 50

156
 PEDIATRIC Estimated Blood Volume

Estimated Circulating Blood

Volume

Neonates 85 – 90 ml/kg

Infants 75 – 80 ml/kg

Children 70 – 75ml/kg

Adolescent/Adult 65 – 70 ml/kg

157
 PEDIATRIC G-Tubes, Chest Tubes, Foley

AGE NG TUBE CHEST URINARY

SIZE TUBE CATHETER
SIZE SIZE

Infant 5 – 8 Fr 10 – 12 Fr 6 – 8 Fr
3 – 9 kg

Small Child 8 – 10 Fr 16 – 20 Fr 8 – 10 Fr
10 – 11 kg

Child 10 Fr 20 – 24 Fr 10 Fr
12 – 14 kg

Child 10 Fr 20 – 24 Fr 10 – 12 Fr
15 – 18 kg

Child 12 – 14 Fr 24 – 32 Fr 10 – 12 Fr
19 – 22 kg

Young adult 14 – 18 Fr 28 – 32 Fr 12 Fr
24 – 28 kg

Young adult 16 – 18 Fr 32 – 38 Fr 12 Fr
30 – 36 kg

158
PEDIATRIC Laryngoscope blades, ETT, Suction

Age Of Laryngoscope Endotracheal Distance Suction

Patient Blade Tube Size From Mid Catheter
(Internal Trachea To Size
Diameter In Lips (cm) (French)
mm)

Age (yrs) + 16 3 x ETT 2 x ETT size

4 size

Term Miller 0 – 1 3.5 cuffed, 3.5 9 – 10 6–8

Infant Wis-Hipple 1 uncuffed

6 months 4.0 cuffed & 10.5 – 12 8

uncuffed

1 year Miller 1 4.0 cuffed & 12 – 13.5 8

Wis-Hipple uncuffed
1½

2 years Miller 2 4.5 & 4.0 cuffed 13.5 8

Macintosh 2-3

4 years 5.0 & 4.5 cuffed 15 10

6 years 5.5 & 5.0 cuffed 16.5 10

159
PEDIATRIC Laryngoscope blades, ETT, Suction

Age Of Laryngoscope Endotracheal Distance Suction

Patient Blade Tube Size From Mid Catheter
(Internal Trachea To Size
Diameter In Lips (cm) (French)
mm)

Age (yrs) + 16 3 x ETT size 2 x ETT size

4

8 years Miller 2 6.0 cuffed 18 12

Macintosh 2-3
10 years 6.5 cuffed 19.5 12

12 years Macintosh 3 7.0 cuffed 21 12

Adoles- Macintosh 3 7.0, 8.0 cuffed 21 12

cent Miller 3

160
 SOLID ORGAN GRADING - SPLEEN

Injury Type Description of injury AIS

I Hematoma Subcapsular, <10% surface area 2

Laceration Capsular tear, <1 cm parenchymal 2

depth

II Hematoma Subcapsular, 10% to 50% surface 2

area; intraparenchymal, <5 cm in
diameter; minor; superficial;
nonexpanding

Laceration Capsular tear, 1-3 cm parenchymal 2

depth that does not involve a
trabecular vessel; minor; superficial

III Hematoma Subcapsular, >50% surface area or 3

expanding; ruptured subcapsular or
parenchymal hematoma;
intraparenchymal hematoma > 5 cm or
expanding; major

Laceration No hilar or segmental parenchymal 3

disruption or destruction; parenchymal
depth >3 cm or involving trabecular
vessels; moderate

IV Laceration Laceration involving segmental or hilar 4

vessels producing major
devascularization (>25% of spleen) but
no hilar injury; major

V Laceration Completely shattered spleen; tissue 5

loss; avulsion; stellate; massive

Vascular Hilar vascular injury that 5

devascularizes spleen

*Advance one grade for multiple injuries up to Grade III

161
 SOLID ORGAN GRADING - LIVER

Injury Type Description of injury AIS

I Hematoma Subcapsular, <10% surface area 2

Laceration Capsular tear, <1 cm parenchymal depth 2

II Hematoma Subcapsular, 10% to 50% surface area; 2

intraparenchymal, <10 cm in diameter

Laceration Capsular tear, 1-3 cm parenchymal depth, <10 cm 2

in length

III Hematoma Subcapsular, >50% surface area or 3

expanding; ruptured subcapsular or
parenchymal hematoma;intraparenchymal
hematoma > 10 cm or expanding; blood
loss >20%; major

Laceration Parenchymal depth >3 cm; major duct 3

involvement; blood loss >20%; moderate

IV Laceration Parenchymal disruption involving 25% to 75% 4

hepatic lobe or 1-3 Couinaud’s segments;
multiple lacerations >3 cm deep; “burst”
injury; major

V Laceration Parenchymal disruption involving >75% of hepatic 5

lobe or >3 Couinaud’s segments within a
single lobe

Vascular Juxtahepatic venous injuries (i.e., 5

retrohepatic vena cava/central major
hepatic veins); massive; complex

VI Vascular Hepatic avulsion (total separation of all vascular 6

attachments)

*Advance one grade for multiple injuries up to Grade III

162
 SOLID ORGAN GRADING - KIDNEY

Injury Type Description of injury AIS

I Contusion Microscopic or gross hematuria, urologic 2

studies normal

Hematoma Subcapsular, nonexpanding without 2

parenchymal laceration

II Hematoma Nonexpanding perirenal hematoma confined 2

to renal retroperitoneum; minor;
superficial

Laceration Parenchymal depth of renal cortex (<1.0 cm) 2

without urinary extravasation; minor;
superficial

III Hematoma Subcapsular; >50% surface; major; large 3

Laceration Parenchymal depth of renal cortex (>1.0 cm) 3

without collecting system rupture or
urinary extravasation; moderate

IV Laceration Parenchymal laceration extending through 4

the renal cortex, medulla, and
collecting system

Vascular Main renal artery or vein injury with contained 4

hemorrhage; major

V Laceration Completely shattered kidney 5

Vascular Avulsion of renal hilum which devascularizes 5

kidney (total destruction of organ)

*Advance one grade for bilateral injuries up to Grade III

163
 SOLID ORGAN GRADING - PANCREAS

Injury Description of injury AIS

Type

I Contusion Minor; superficial; no duct involvement 2

Laceration Minor; superficial laceration without duct injury 2

II Hematoma Major contusion without duct injury or tissue loss 2

Laceration Major laceration without duct injury or 3

tissue loss

III Laceration Distal transection or parenchymal injury 3

with duct injury; moderate with major
duct involvement

IV Laceration Proximal transection or parenchymal 4

injury involving ampulla†; moderate if
involving ampulla; major if multiple
lacerations; major if involving ampulla

V Laceration Massive disruption of pancreatic head; 5

avulsion; complex; rupture; stellate;
tissue loss

*Advance one grade for multiple injuries up to Grade III

†Proximalpancreas is to the patient’s right of the superior mesenteric vein

164
 PEDIATRIC
Modified Glasgow Coma Scale

CHILD Eye Opening INFANT

Spontaneous 4 Spontaneous
To speech 3 To speech
To pain only 2 To pain only
No response 1 No response
CHILD Verbal INFANT
Response
Oriented, 5 Coos and babbles
appropriate
Confused 4 Irritable cries
Inappropriate words 3 Cries to pain
Incomprehensible 2 Moans to pain
sounds
No response 1 No response
CHILD Motor INFANT
Response
Obeys commands 6 Spontaneous,
purposeful
Localizes to pain 5 Withdraws to touch
Withdraws to pain 4 Withdraws to pain
Abnormal flexion 3 Abnormal flexion
Abnormal extension 2 Abnormal extension
No response 1 No response

Qualifiers:
Patient Chemically Sedated
Patient Intubated
Patient Eye Obstruction 165