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SEVERE HEAD TRAUMADOCTORNURSERTMEDICATIONSPE: GCS, pupils, neuroVS: temp, MAP, ICP, CPPRad: CXR, CTLabs: CBC, chem, coags, sOSM, uSG, glu, Na trends, TEGDVT prophylaxis?Sz prophylaxisC/T/L cleared / precautionsOsmotic agents given?Suspicion for DI?Other injuries?Lines:TLC ? CVPICP, ventric (drain?)ArterialFoley, UOP trendNGSedation ratesGlucose trends? Insulin?Neuro trendsBlood products3% or mannitol?RestraintsAdditional pumpVent settingABG, PCO2 trendBring iSTAT + cartridgesBackrest3% NS (250 mL bolus, 50 mL/hr), mannitol, D5NSPropofol, fentanyl, midazolam, ketamineKeppra / DilantinAncef 1 g TIDProtonix 40 mg QDInsulinDDAVP 2-4 mcg SQ/IV BIDIV APAPVasopressin, levophed, NeosynephrineLovenoxVecuronium or cisatricuriumPRBC, FFP, PLTNimodipine (if risk of vasospasm)TARGETS: ICP < 20 | CPP > 60 | MAP > 60 | SaO2 > 93% | CVP > 5 | PCO2 35-40 | Na 138-165 | glu 80-150 | Plts >= 100k | INR <= 1.3 |TEG normal | sOSM 280-320CPP < 60 / ICP > 20DOCTORNURSERTPROGRESSIONEvaluate patientDrain 10 mL via ventricPropofol 20-40mg (2-4 mL)Fentanyl 50-100 mcg (2-4 mL)3% NS: 250 mL bolus, then 50 mL/hrIncrease MAP: neosynephrine 100 mcgElevate HOBLoosen collar/trach tiesRun iSTATIncrease MAP further:Vaso 0.04 U/minLevo 2-30 mcg/min? blood productsMannitol: 25-50 mgHyperventilate PCO2 30-35Call neurosurgeonELEVATED PEAK PRESSURESDOCTORNURSERTPROGRESSIONEvaluate patientCheck chest tubePropofol 20-40mg (2-4 mL)Fentanyl 50-100 mcg (2-4 mL)Check ventTrace circuitSuctionAlbuterol nebNeedle decompressionCheck bladder pressureCARDIACSTEMITHROMBOLYTICSASA 325 mgPlavix 75 mgLovenoxLipitor 80 mg? metoprolol 25 mg PO Q6Cath or Lytics TNKase:<60 kg = 30 mg61-69 = 35 mg70-79 = 40 mg80-89 = 45 mg>=90kg = 50 mgAbsolute contraindications:Prior hemorrhagic CVA (ever)CVA in past yearIntracranial neoplasmActive internal bleedingSuspected aortic dissectionSPINAL INJURYGet detailed neuro exam prior to flight (see appendix in CPG for ASIA form)Spinal stability: HOB > 30 / If T12-L5 reverse TrendelenburgKeep MAP 80-90 for 7 days, avoid SBP < 90, keep SPO2 > 92%If penetrating, watch for CSF leakDVT prophylaxis: aim to start within 72 hours; If +VTE and no anticoagulation for 14 days IVC filterBURN (>20% TBSA)DOCTORNURSERTMEDICATIONSPrint CPG with flowsheetCalculate TBSAVS and UOP trendsAdjust IVF +/- 20-25% Q 1 hr to reach target UOPRad: CXR, CTLabs: CBC, chem, coags, glu, TEG, random cortisolGI & DVT prophylaxisC/T/L cleared / precautionsOther injuries?CO? CN?Treat hypocalcemia (iCa < 1.1)Escharotomy, fasciotomy?Lines:TLC ? CVPArterialFoley, UOP trendNGSedation ratesGlucose trends? Insulin?Propofol 20-40mg (2-4 mL)Ketamine 0.5 mg/kg IV Q 1hr prnFentanyl 50-100 mcg (2-4 mL)Keep patient warmSecure all lines (suture or staple)Ensure wire cutters present if ETT wired to teethHeparin/Albuteral nebs Q4 hrs for inhalational injuryVent settingsABG, PCO2 trendBring iSTAT + cartridges (CG8)BackrestExtra burn dressingsExtra LR (D5NS if CNS trauma)5% albumin (start at hour 24)Vasopressin, levophed, NeosynephrinePropofol, ketamine, fentanylCalciumHydrocortisone 100 mg Q8CalciumHeparin 5000 U for nebsInsulinProtonix/LovenoxFirst 48 fluids: LR 10 mL/hr * %TBSA (add 100 mL/hr for each 10 kg over 80 kg)24 hr projected IVF calculated at hour 12: [ IVF given + (current IVF rate * hours remaining) ] / %TBSA * kg If 24 IVF > 6 mL * kg * %TBSA, start albumin prior to the 24 hour mark, check bladder pressure Q 4hr24’ Albumin hourly rate = (Burn Factor * %TBSA * kg) mL / 24 hr [Burn Factor: 0.3 for 30-49% TBSA, 0.4 for 50-69% TBSA, 0.5 for 70+% TBSA]TARGETS: CVP 8-10 | UOP > 30-50 mL/hr or 0.5 mL/kg*hr (for peds) | iCa > 1.1 | ScvO2 60-65HYPOTENSION (MAP < 55)DOCTORNURSERTPROGRESSIONConsider volume depletion, missed injury, ongoing bleeding, abdominal compartment syndrome (ACS)Vasopressin 0.4 U/hr (2.4 mL/hr)Check CVPIf CVP < 8, increase IVF rate by 25%If CVP >= 8, start Levophed 5 mcg/min and titrate (max 20 mcg/min)Report PIPs, Vt, ETCO2, O2 satRun iSTATDobutamine 5 mcg/kg/min (max 20)Catechol-resistant shock:Ensure iCa > 1.1Consider hydrocortisone 100 mg Q8 hrACS: (Sx: hypotension, incr PIP, decr UOP, Dx: bladder pressure > 25 mmHg):ParalyzeCall hospitalACUTE HYPOXIADOCTORNURSERTIf patient is easy to re-ventilate and oxygenate with BVM, problem probably lies with vent/circuitIs patient hemodynamically stable? Resuscitate as required.If little chest wall movement with BVM:Check ETCO2Pass catheter or bougie to ensure ETT patentIf in doubt, take ETT outImmediate ABGPlace patient on defibrillatorPrepare vasopressor infusionCheck of current vent settings and report:PressuresVolumesO2 satETCO2RateDisconnect patient from vent and bag with 100% FiO2Report ability to bag and chest riseCAUSESHIGH AIRWAY PRESSURENORMAL AIRWAY PRESSURELOW AIRWAY PRESSURETension pneumothoraxObstructionDyssynchrony ETT mainstemWorsening alveolar disease (ARDS, pulmonary edema)BronchospasmO2 source problemPulmonary embolismAnemiaWorsening sepsisToxin (CO, CN)Leak ................
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