Trauma Guidelines - Health First

Together, we’re better.TraumaGuidelines2002

TABLE OF CONTENTSPhilosophies and Objectives TR-I 1Treatment Guidelines and AlgorithmsTR-IIPrimary Assessment TR-II-A 1Airway Management of the Trauma Alert Patient TR-II-B 11Standing Orders for Trauma Resuscitation TR-II-C 15Head Injury TR-II-D 16Temperature Control Guideline TR-II-E 19Burns – Electrical and Thermal TR-II-F 21Burn Trauma Alert Management and Transfer Criteria TR-II-G 27Chest Trauma TR-II-H 30Spine Injury TR-II-I 34Abdominal Trauma TR-II-J 39Pelvic Trauma TR-II-K 41Urology TR-II-L 44Orthopaedic TR-II-M 45Hand Trauma TR-II-N 46DVT Trauma Algorithm TR-II-O 47Pediatric Trauma Alert Management and Transfer Criteria TR-II-P 49Pregnant Trauma Patient TR-II-Q 53Medications & Dosages TR-II-R 57Solu-Medrol (methylprednisolone) Administration in Spinal Cord Injury TR-II-S 59AHA Advanced Cardiac Life Support Algorithms TR-II-T 61AHA Advanced Cardiac Life Support Medications TR-II-U 71Guidelines for the Management of Trauma Alert PatientsTR-IIIBlunt Head Trauma Patients on Coumadin TR-III-A 1Cervical Spine Clearance TR-III-B 3Indications for Trauma Psychology Services TR-III-C 5Transportation of Trauma Patients from the Resuscitation Area TR-III-D 7Trauma Team NotificationTR-IVGuidelines for Cross Coverage of Emergency Department by Trauma Center TR-IV-A 1NursesInternal Trauma Alert Notification (Red and Blue) TR-IV-B 3Launching of First Flight for Trauma Alert Patients TR-IV-C 7Neurosurgery Response Time TR-IV-D 9Notification of Backup Trauma Surgeon of Trauma Alert TR-IV-E 11Notification of Subspecialty Physicians TR-IV-F 13Notification of Trauma Surgeon of Trauma Alert TR-IV-G 15PACU Call TR-IV-H 17Radiology Technologist Response to the Trauma Alert TR-IV-I 19Trauma System Paging Checklist TR-IV-J 21Trauma Team Response TR-IV-K 23

Trauma Center Roles and ResponsibilitiesTR-VA Delineation of Roles for Trauma Team Members TR-V-A 1Disaster Event or Emergency Department Overload Plan TR-V-B 15Hurricane Plan TR-V-C 21Multidisciplinary Rounds for a Patient on the Trauma Service TR-V-D 25Multidisciplinary Trauma Conference TR-V-E 27Protective Equipment in the Trauma Room TR-V-F 29Trauma Room Designation TR-V-G 33University of Florida Physicians Office Trauma,TR-V-H 37General Surgery, OrthopaedicLaboratory GuidelinesCollection/Labeling/Acceptance of Blood Bank Sample Policy TR-V-I 39Documentation of Lab Times and Results TR-V-J 47Emergency Blood Bank Supply andTR-V-K 49Maintenance of Trauma Center Blood Bank RefrigeratorLaboratory Protocol for a Trauma Alert TR-V-L 55Radiology GuidelinesRadiology - CAT Scan / Trauma Services TR-V-M 57Radiology - Reading of Studies for Trauma Patients TR-V-N 59Radiology - Scanning Trauma Patients in MRI TR-V-O 61Radiology Technologist Response to the Trauma Alert TR-V-P 63Trauma Center Admission, Patient Flow, and StaffingTR-VIAcceptance and Transfer to Interfacility Trauma Patients TR-VI-A 1Admission, Transfer, and Discharge Policy TR-VI-B 3Alias Registration TR-VI-C 19Case Manager/Social Worker Protocol TR-VI-D 21Direct Admission of Trauma PatientsTR-VI-E 23from the Operating Room to ICUDocumentation on Trauma Flow Sheet TR-VI-F 25Emergency Department Representative Protocol TR-VI-G 31Field Trauma Alert Patients TR-VI-H 33Continuing Education TR-VI-I 37Operating Room Availability TR-VI-J 41Patient Classification System/Urgency Categories TR-VI-K 43Patient Name Change for Security TR-VI-L 45Priority Status of Trauma Alert Patient TR-VI-M 47Rehabilitation Availability on Saturdays & Sundays TR-VI-N 49Rehabilitative Services Outpatient Care TR-VI-O 51Scheduling Procedure for RNs in Trauma Center TR-VI-P 53Staffing Policy TR-VI-Q 55Trauma Center Admission Bed Assignment TR-VI-R 57Trauma Unit Procedure for Acuity Level Shift Staffing TR-VI-S 59Triage of Emergency Room Patients to the Trauma Center TR-VI-T 61

Performance Improvement / Quality OutcomeTR-VIITrauma Patient Follow-up TR-VII-A 1Trauma Quality Management Committee TR-VII-B 3Performance Improvement Trauma Resuscitation Videotaping Policy TR-VII-C 7Reporting of Brain and Spinal Cord Injuries TR-VII-D 9Sentinel Event and Reporting TR-VII-E 13Procedures - TreatmentTR-VIIICentral Line Placement TR-VIII-A 1Cricothyroidotomy TR-VIII-B 3Cutdowns TR-VIII-C 5Pericardiocentesis TR-VIII-D 7Thoracotomy (Open) TR-VIII-E 9Tube Thoracostomy TR-VIII-F 11Standing OrdersTR-IXAbbreviated Trauma Evaluation History & Physical TR-IX-A 1Trauma Service Admission Orders (Floor Orders) TR-IX-B 3Trauma Service Discharge Instructions TR-IX-C 5Trauma Service SICU Admission Orders TR-IX-D 7

Title: Trauma Philosphy and ObjectivesNo. TR-IOrigin: 11/01Reviewed: 8/02Approved By: Emran Imami, MD Page: 1 of 1Trauma Medical DirectorI. PHILOSOPHY:Holmes Regional Trauma Center’s primary focus is to provide optimal care to all acutelyinjured patients. The care provided is rendered by a multidisciplinary trauma team thatincludes prehospital personnel, trauma surgeons, consult physicians, nurses, and ancillarystaff. Specialty areas (e.g. radiology, operating room, critical care units, etc.) of the hospitalprovide specific functions that are integrated into an pre-established organized system of carefor the most severely injured patients.II.OBJECTIVES:A. To provide initial resuscitative care required for critically injuredpatients.B. To provide a complete evaluation of all patients hospitalized fortrauma, to insure that no injuries are missed.C. To provide easy accessibility to the hospital's radiological, blood bank,laboratory services, and operating rooms.D. To provide all necessary team coordination in cases of complex, multisystemtrauma.E. To provide all necessary intensive care - both diagnostic andtherapeutic - for all trauma patients admitted to Holmes RegionalMedical Center.F. To provide an environment that is conducive to the training of futurephysicians and trauma nurses.G. To provide clinical experience and teaching for nursing, emergencymedical technicians, and physician extenders.H. To perform trauma research designed to produce new knowledgeapplicable to the care of injured patients.I. To provide outreach activities on trauma prevention, including publiceducation and continuing education for staff, physicians, nurses, alliedhealth personnel and community physicians.APPROVED:_______________________________ ________________________________ Emran Imami, MD Date Michele K. Ziglar, RN, MSN DateTrauma Medical DirectorTrauma Program ManagerTR-I – 1

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Safe Assumptions About Trauma Patients1.) All trauma patients are bleeding until proven otherwise2.) All trauma patients have a c-spine injury until provenotherwise.3.) All trauma patients have a full stomach until provenotherwise.PRIMARY SURVEY OF THETRAUMA CENTER PATIENTTrauma Team 1History of Mechanism of Injury 2Assess Airway 3TR-II-AOrigin: 1/99Reviewed: 8/02SpontaneousRespirationsRespiratoryPotential RespiratoryPatient ArrivesCompromise/Hypoxia 4 Compromise withHypoxia Present 5 Intubated 8Chin LiftJaw ThrustSuctionImproper PlacementAusculate ChestCheck ETCO 2Proper placementAirway OpenTrauma AirwayAlgorithm 6,7Protect andMaintain AirwayAusculate Both Lung FieldsTR-II – 2Continued on the next page

Airway Maintinence with CervicalSpine Immobilization - ContinuedEvaluate:VentilationOxygen Level 8Assess:Respiratory RateRespiratory RhythmRespiratory Symmetry 9Inspect Chest:PercussPalpateAusculateClear Bilateral Breath Sounds Ventilatory Compromise 10Administer Oxygen to Maintain S aO 2>95% Administer Oxygen to Maintain S aO 2>95%FlailChestTensionPneumothoraxOpenPneumothoraxMassiveHemothoraxContinue to Monitor andRe-evaluate PatientManage Life Threatening Injuries 11Obtain Chest X-rayContinued on the next pageTR-II – 3RupturedDiaphragm

CirculationAssess Circulatory Status: 12Skin ColorLevel of ConciousnessNormotensiveand NOTTachycardicEvaluate for Ongoing Blood Loss 13Hypotensive orTachycardic 14Initiate Two Large Bore IV LinesObtain: Type and Crossmatch, H&H, and monitorEKG StatusInitiate Two Large Bore IV Lines,**Infuse warmed IV fluidsObtain:Type and Crossmatch, H&H,and Monitor EKG StatusContinue to Monitorand Re-evaluatePatientAssess:HeartVolume StatusVascular ResistanceAssess Circulatory Status: 12Skin ColorLevel of ConciousnessIdentify Type of Shockand Manage 15Hypovolemic 16(most common)NeurogenicCardiogenicVasogenicAdminister Blood ifIndicated 15Continued on the next pageTR-II – 4** Administer 2 litersof fluid (or20ml/kg in children). If patientremains hemodynamically unstableconsider blood administration.

NeurologicI. Eyes OpenNever 1To pain 2To verbal stimuli 3Spontaneously 4II. Best Verbal ResponseNo response 1Incomprehensible sounds 2Inappropriate words 3Converses but disoriented 4Converses and oriented 5III. Best motor responseNo response 1Extension (decerebrate) 2Flexion, abnormal (decorticate) 3Flexion withdrawal 4Localizes pain 5Obeys commands 6Evaluate Neurological Status 17 Focal FindingsPresentPotential Subdural / EpiduralHemorrhageGCS 13-15GCS < 12Continue to Monitor andRe-evaluate PatientCT Scan 18Reduce IntracranialPressure 19Hyperventilate Administer Mannitol asIndicatedExpose Patient Evaluate Entire Body Surface. Logroll maintainging C-Spine alignmentRemove the backboardIdentify All InjuriesPlace-Orogastric or Nasogastric Tubeand Urinary Catheter 20Re-evaluate Overall Condition and EstablishPriorities 21DetermineDispositionTR-II – 5

Primary Survey in the Trauma Center1.) Upon arrival in the Trauma Center the injured patient will be met by the Trauma Team. This team includes a qualifiedphysician with the American College of Surgeons Advanced Trauma Life Support (ATLS) training. The Trauma Teamincludes a trauma surgeon, ed. physician, and an experienced trauma nursing team, radiology technicians, social services andpastoral care. Additionally, Anesthesia, Orthopedics and a Neurosurgeon will be readily available. Others that are notifiedinclude the OR, ICU, Lab, Respiratory, CT and Security.2.) A complete history of the mechanism of injury should be obtained. All preceding events should be taken into account to createa high index of suspicion for traumatic injury.3.) Management of airway takes precedence over all other activity. Hypoxia generally occurs because of the patient’s lack ofability to oxygenate the blood properly. This may be caused by mechanical problems or lack of oxygen exchange at thealveolar arterial interface. An uncooperative, anxious, combative, and/or restless patient may clinically manifest hypoxia.These findings should not be confused with the alcoholic or drug abuser. Patients who present to the hospital with spontaneousrespirations should be continuously reassessed. The airway should be protected and maintained.4.) The upper airway should be assessed for patency. Initial attempts to establish a patient’s airway include the chin lift or jawthrust maneuver and suctioning to remove foreign debris. The cervical spine should be stabilized in the neutral position toprevent injury.5.) Patients who have an upper airway obstruction manifested by poor air exchange, slow or rapid respirations, or depressedcentral nervous system should be rapidly intubated. During this procedure spinal stabilization and immobilization must bemaintained until a cervical fracture has been ruled out. Intubation should be preceded by a period by pre-oxygenation with abag mask device to help alleviate hypoxia.6.) Follow RSI protocol.6.) Prior to intubation the patients should be assessed for laryngeal injury, edema of the glottis, or severe oropharyngealhemorrhage associated with facial trauma. Inability to intubate the trachea is the only indication for a surgical airway. Aneedle or surgical cricothyroidotomy is the preferable choice. (Surgical cricothyroidotomy is not recommended for childrenTR-II – 6

Primary Survey in the Trauma Center – Continuedunder 12 years of age) or patients with a laryngeal fracture. Laryngeal fracture is the only indication for an emergenttracheostomy.8.) Patients who arrive at the hospital already intubated must be evaluated for proper tube placement. Placement can be checkedquickly by listening for bilateral equal breath sounds and by listening over the stomach for improper placement. In addition, anETCo 2 detector may be utilized to confirm proper placement.9.) The chest should be exposed to assess adequate ventilatory exchange. The team should note the rate, rhythm, and symmetry ofthe chest wall movement. One should look for distended neck veins, open wounds, lacerations, bruising, and abrasions thatmay indicate underlying injury. Oxygen should be administered to maintain a Pao 2 greater than 60 torr on room air or 100 torron 40 per cent O 2 . (Keep SaO2 > 95%.)10.) Simultaneously the chest must be assessed for mechanical factors that compromise the ventilatory process.11.) All life threatening injuries must be quickly treated. See Chest Injury Protocol.12.) Hemorrhage is one of the early causes of post injury death that is amenable to effective treatment. Rapid assessment of theinjured patient’s hemodynamic status is essential. The key components to circulatory assessment are heart rate, skin color,temperature, and state of consciousness. Compensatory mechanisms will frequently mask the magnitude of bleeding. A bloodloss of 30 to 35 per cent of the total volume can occur before significant changes are noted in blood pressure.13.) The patient must be rapidly assessed for external, exsanguinating hemorrhage during the primary survey. Direct pressure to thewound is applied to control rapid ongoing blood loss. Patients can exsanguinate into or out of 7 places: Chest (pleuralcavities), Mediastinum, Abdomen, retroperitoneum, Pelvis, Extremities and External.TR-II – 7

Primary Survey in the Trauma Center – Continued14.) Three interrelated physiologic functions must be assessed in hypotensive patients, as follows: (1) the heart, (2) the blood andextracellular fluid volume, and (3) the arterial and venous resistance. Pump failure may occur as the result of primary cardiacdisease, myocardial contusion, or mechanical problems such as cardiac tamponade. Volume deficits are most commonlyassociated with hemorrhage but may result from crush injuries, third spacing, or redistribution. Cardiac output may bediminished because of inadequate venous return as seen with tension pneumothorax. Vascular resistance may be altered byinjury to the spinal cord, drugs, and sepsis. Regardless of the mechanism, circulatory collapse results in the low Flow State andinadequately perfused cells. Normal aerobic metabolism is converted to anaerobic metabolism and, if untreated, leads tometabolic acidosis and eventual cell death.15.) Four types of shock are commonly recognized, as follows: (1) hemorrhagic or hypovolemic, (2) neurogenic (3) cardiogenic,and (4) vasogenic. Although hemorrhagic shock is the most common type seen in the trauma patient, it is possible for morethan one source to contribute to the patient’s hypotension. Compensatory mechanisms may preclude a measurable fall insystolic pressure until the patient has lost up to 30 per cent of blood volume: therefore, specific attention should be directed tothe heart rate, respiratory rate, skin perfusion, and pulse pressure. A narrowed pulse pressure is one of the earliest signs ofhypovolemia. The heart rate is a sensitive indicator but may be normally high in children or artificially low in the elderly.Older patients may have a limited cardiac response to catecholamine stimulation or may be taking medication such as betablockers.The other common signs of hypovolemic shock are diaphoresis, cool clammy skin, decreased venous pressures,decreased urine output, thirst and an altered state of consciousness.Neurogenic shock symptoms are much different than those of hypovolemic shock. The patient will have a motor andsensory deficit associated with dry skin, normal or slow heart rate, normal mentation, and normal urine output. Because of itsinfrequency, the diagnosis of neurogenic shock is often missed and patients inappropriately treated with large fluid volumes.(It is emphasized that neurogenic shock refers to spinal cord injury and not to head injury).Cardiogenic shock caused by myocardial infarction or arrhythmias is often determined by history and should beconfirmed by EKG monitoring. Myocardial dysfunction may occur from tension pneumothorax, myocardial contusion, cardiactamponade, or an air embolus from the patients associated injuries.Cardiac contusion is not uncommon in rapid deceleration blunt trauma to the thorax. Patients with blunt thoracictrauma may need constant EKG monitoring to detect dysrhythmias. Any patient suspected of having cardiogenic shock shouldhave careful monitoring of fluid resuscitation.TR-II – 8

Primary Survey in the Trauma Center – Continued16.) Hypovolemic shock is initially treated by the administration of crystalloid solutions given through established large boreperipheral intravenous lines. Central line catheters should be avoided if possible during the initial resuscitation. Complicationsfrom the central venous route are more frequent, especially in the flailing uncooperative trauma patient. If the patient does notrespond to the first 2 liters of fluid (or 20cc/kg in the child) and if other causes can be ruled out, blood administration isindicated. Depending on the blood source loss, autologous replacement offers many advantages. In urgent cases type-specificblood can be given. In the emergent life threatening case it may be necessary to use O-negative blood. Four units of O-negative blood are stored in the Trauma Center and are readily available. Immediately type and cross for 6 units PRBC’s. Inthe trauma patient, one should not be reluctant to give blood if there is any evidence of hemodynamic instability. On the otherhand, if the individual can be managed just as safely without blood administration that should be the goal, provided that thepatient is asymptomatic and no longer bleeding.17.) As part of the primary survey, a brief neurologic examination is performed and baseline observations recorded. The GlasgowComa Scale is used to help quantify the extent of neurologic injury. Patients with a coma score of less than 9 are classified ashaving severe injuries; 9 to 12, moderate injuries; and 13 to 15, minor injuries. Lateralizing neurologic signs generally indicatelocalized pressure phenomena in the brain usually caused by a subdural or epidural bleed.18.) The diagnosis of neurologic injury is best made on clinical evaluation. There are many diagnostic studies available, but theinjured patient may not be stable enough to allow a time consuming work-up. The CT scan is the single most useful study toobtain and, with proper planning, can be performed without causing delay in the initial management of the trauma patient.19.) Increased intracranial pressure is a common sequela of blunt trauma. Evidence points to more favorable outcomes if theintracranial pressure can be quickly reduced and the duration of hypoxia kept to an absolute minimum. Cerebral ischemia orhypoxia results in insufficient substrate delivery to the injured brain. The principal metabolic requirements of the brain areoxygen and glucose; both used at extremely high rates. Elevated intracranial pressure is often accompanied by hypertension,temperature elevation, and bradycardia, but it may be masked in-patients who are hypovolemic. Recognized hypotensioncannot be attributed to bleeding in the head unless the patient is very young and the sutures have not closed or unless there isevidence of an open fracture with measurable external blood loss. Reduction of intracranial pressure can be rapidlyaccomplished by the use of moderate hyperventilation. Patients with a Glasgow Coma Score of less than 11 frequently benefitif the Pco 2 can be lowered to 30 to 35 torr and monitor this with ETCo2 and serial ABG.TR-II – 9

Primary Survey in the Trauma Center – ContinuedHypocarbia will cause vasoconstriction, which contributes to the reduction of brain edema. Diuretics such as mannitol are alsoused, but caution must be exercised and their administration withheld in the hypovolemic patient. The hypovolemichypotensive head injured patient should be resuscitated in the usual manner, with no attempt to withhold fluids.20.) Simultaneously, as the primary survey progresses, other procedures are performed. Oxygen is administered, two large boreperipheral intravenous lines are established, and Ringer’s lactate solution is given. Blood is drawn for an H&H, type andcrossmatch and other studies as indicated. A nasogastric tube should be placed in the stomach, and the contents evacuated.(Since a nasogastric tube placement is contraindicated if the patient has signs of a basilar skull fracture an orogastric tubeshould be placed). A urinary catheter should be inserted unless there is evidence of blood at the meatus or unless there is ascrotal hematoma, perineal hemorrhage, or a high riding prostate on rectal examination.21.) When the primary survey has been completed and the initial resuscitation and stabilization begun, the patient’s overallcondition must be re-evaluated. Priorities must be assessed, and the patient taken immediately to the operating room ifindicted. The trauma surgeon will assume leadership and coordinate the activities of the Trauma Team and consultingservices.REFERENCESMcQuillan, K., Von Rueden, K., Hartsock, R., Flynn, M., & Whalen, E. Trauma nursing: from resuscitation throughrehabilitation. (3 rd Edition). Pennsylvania: W. B. Saunders Company, 2002.American College of Surgeons Committee on Trauma. Advanced trauma life support for doctors: Instructor course manual.(6 th Edition). USA. First Impression. 1997.TR-II – 10

Title: Airway Management of Trauma PatientApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-II-BOrigin: 1/99Reviewed: 8/02Page: 1 of 3I. OBJECTIVE:Airway management for all trauma patients (pediatric and adult) meetingstated criteria will follow pre-established guidelines in an effort to ensureeffective airway control and to promote an optimal level of patient care.II.III.POLICY:Early evaluation and control of the airway are primary maneuvers duringtrauma resuscitation to optimize oxygenation and ventilation. Misjudged,the uncontrolled airway is a downfall of any resuscitative attempt, whichcan lead to temporary, if not permanent, ramifications.PROCEDURE:All trauma patients* are in need of airway management which mayinclude pharmacologic control and intubation. This consideration isespecially applicable in those with hypoventilation, severe injuries,persistent shock, closed head injury, or those that may be combative orenraged secondary to drugs, alcohol, or altered personality.*All trauma patients are considered to have a full stomach and are at riskfor regurgitating and aspirating gastric contents during endotrachealintubation.Trauma patients fall into five (5) broad categories. The categories,followed by the appropriate management (standard of care), are listedbelow.NOTE: All trauma patients must have cervical spine immobilizationmaintained during airway management. The airway status of alltrauma patients should be closely monitored and frequently reevaluated.I. Patients who are stable, who have patent airways with spontaneousrespirations that provide adequate gas exchange, and who have a relativelyclear mental statusA. Supplemental oxygen as necessaryB. Pulse oximetryTR-II – 11

II.Patients who arrive intubated by the prehospital care providersA. Prompt and accurate assessment (to include, auscultation,end tidal CO 2 monitoring, and visualization) that theendotracheal tube (ET) is in proper position* and that goodgas exchange is taking place.*It is recommended that one does not suddenly remove theET tube if discovered within the esophagus. Rapid reintubationshould be accomplished prior to anymanipulation of the esophageal tube to avoid aspiration ofvomitus.B. Pulse oximetryC. End tidal CO 2 monitoring; EtCO 2 should not drop below33-35 in the head-injured patientD. Baseline ABGs; pCO 2 should not drop below 30 in headinjured patientsE. CXRIII.Patients who arrive unconscious and are presumed to have a headinjuryA. Evaluate for intubation and airway protection*B. Supplemental oxygenationC. Pulse oximetryD. End tidal CO 2 monitoring if intubated; EtCO 2 should notdrop below 33-35 in the head-injured patientE. Baseline ABGs; pCO 2 should not drop below 30 in headinjured patientsF. CXR*Any patient with a Glasgow Coma Scale of 8 or less must beintubated.IV.Patients who arrive hemodynamically unstable and persist in ashock state despite adequate volume resuscitationA. Early intubation for airway and patient control to promoteadequate oxygenation and ventilation using rapid sequenceinduction with a pharmacological agent as necessary*.**Succinylcholine, Zemuron, or Vecuronium isrecommended because of its short duration and minimaleffect on blood pressure.TR-II – 12

B. Pulse oximetryC. End tidal CO 2 monitoring; EtCO 2 should not drop below33-35 in the head-injured patientD. Baseline ABGs; pCO 2 should not drop below 30 in headinjured patientsE. CXRV. Patients who are intoxicated or mentally deranged secondary to alcohol ordrug use, combative or enraged and require intubation for definitiveevaluation and treatment.*A. Rapid sequence induction and intubation for airway andpatient control using a pharmacological agent as necessary;B. Pulse oximetryC. End tidal CO 2 monitoring; EtCO 2 should not drop below33-35 in the head-injured patientD. Baseline ABGs; pCO 2 should not drop below 30 in headinjured patientsF. CXR*Many of these patients will eventually be diagnosed withno critical injury, however, sometimes they may have headinjuries which are difficult to distinguish withoutappropriate radiographic studies. There is often difficultyin assessing the patient in the acute situation, and thismethod enables the trauma team to have patient controlthus eliminating the danger to staff and the patient. A smallpercentage of these patients will have critical intracranial,intrathoracic, or intraabdominal injuries, which requireimmediate diagnosis and treatment, and therefore, thismethod is believed to be the most efficient, efficacious, andsafe way to deliver good trauma care.VI.In rare instances, patients may present with a history of MalignantHyperthermia or known sensitivity to anesthetic agents. They mayverbalize this information, have a medic alert bracelet with thisinformation, or have family members who describe a past history ofproblems with previous anesthesia or malignant hyperthermia.A. SUCCINYLCHOLINE SHOULD NOT BEADMINISTERED TO THESE PATENTS.B. Consult anesthesia IMMEDIATELY.C. In the event, a patient is determined to be sufferingfrom Malignant Hyperthermia afteradministration of neuromuscular blockade, pleaseTR-II – 13

efer to the attached treatment protocol which is aduplicate of the wall poster.D. Signs and symptoms to observe for includetachycardia, rigidity, hypercarbia, tachypnea,cardiac arrhythmias, respiratory and metabolicacidosis, fever, unstable/rising blood pressure,cyanosis/mottling and myoglobinuria.E. The hotline number is 800-644-9737.F. Malignant Hyperthermia treatments kit locatedin the Operating Room.TR-II – 14

Title: Standing Orders for Trauma ResuscitationNo: TR-II-COrigin: 8/02Reviewed:Approved By: Emran Imami, MDTrauma Medical DirectorPage: 1 of 11. Adhere to universal blood and body fluid precautions.2. Identify Trauma Team Leader.3. Establish and maintain airway, stabilize cervical spine, administer oxygen andcontrol bleeding.4. Establish two intravenous lines and insert a large bore intravenous cannula andconnect warmed Normal Saline solution to tubing.5. Assess the following hemodynamics: Heart rate and quality, respirations andquality, blood pressure, oxygen saturation, temperature, and Glasgow Coma Scale(GCS). ** NOTE: Monitor q5 minutes if the patient is hemodynamicallyunstable.6. Monitor Temperature per guidelines.7. Perform abdominal and pericardial ultrasound by technician.8. Obtain the following x-rays:• Chest••PelvisLateral C-Spine9. Collect following labs: Hemoglobin & Hematocrit and Type and Screen asindicated.10. Insert Oral/nasogastric tube, assure its position in the stomach, and irrigate withsaline as needed to establish effective function and attach to suction (Caution infacial fractures).11. Insert indwelling urinary catheter (unless evidence of bleeding from the urethra orabnormal rectal exam). Record volume and gross characteristics of urine andattach to urinometer.11. Administer oral contrast material as ordered by physician (adult: 20mlGastrografin/500ml water).12. Administer pain medication and sedation as ordered.TR-II – 15

Head InjuryAirway Breathing CirculationImmobilization of the C-Spine 1Mechanism ofInjuryBlunt Head Trauma Penetrating Head TraumaNeurological Exam 2Neurological Exam 2TR-II-DOrigin: 1/99Reviewed: 8/02NormalAbnormalGCS 14-15No Signs of Basilar Skull Fracture,No external evidence of head trauma,or no focal deficit or seizuresGCS 13 or LessSigns of Basilar Skull FractureLateralizing Neuro Exam 3Present NeurologicalFunctionNo Neurological Function(Brain Death)ObserveCT ScanNeurosurgery ConsultInitiate Therapy 4CT ScanNeurosurgery ConsultSkull Films (AP/Lat)Neurosurgery ConsultOPO 5TR-II – 16

Head Injury1. ABCs as defined by ATLS. Because hypoxia increases brain swelling anything that block the unconscious patient’s airway isdisastrous.The tongue, blood, or gastric contents can cause obstruction. Providing a patent airway and giving oxygen are important in theearly treatment of patients with head injury.Any patient unconscious from a closed head injury is assumed to have a cervical spine injury until proven otherwise. Thepatient should be immobilized with a cervical collar. C spine X-rays C-1 to C-7/T-1 should be obtained. Spine fracture can bepresent in 5%-20% of patients with severe head injury.2. Neurological exam includes evaluation of eye opening, verbal response and motor response. On the Glasgow Coma Scale(GCS) a rating of 8 or less is considered coma. Pupillary size and reactivity, corneal reflex, spontaneous eye movement, rectaltone, plantar reflexes, deep tendon reflexes and signs of a basilar skull fracture should also be evaluated. Never attributeneurologic abnormalities solely to the presence of drugs or alcohol.3. Lateralizing neurological exam reveals unequal pupils or focal weakness.4. Initiate Therapy-Hyperventilation (PCo 2 = 30-35mmHg)Mannitol, 1 g/kg IV push (if B/P stable and after neurosurgical consultation)Immediate CT scan if not already obtained. Prepare for operating room for intracranial operation as directed by neurosurgery Usean orogastric tube, not a nasogastric tube, if an anterior basilar skull fracture or midface fracture is suspectedState law mandates that the organ procurement agency (OPO) be notified of patients with low GCS, those expected to die, those whoare brain dead as well as those who have expiredREFERENCESMcQuillan, K., Von Rueden, K., Hartsock, R., Flynn, M., & Whalen, E. Trauma nursing: from resuscitation throughrehabilitation. (3 rd Edition). Pennsylvania: W. B. Saunders Company, 2002.American College of Surgeons Committee on Trauma. Advanced trauma life support for doctors: Instructor course manual.(6 th Edition). USA. First Impression. 1997.TR-II – 17

The Glasgow Coma ScaleHead Injury - ContinuedI. Eyes OpenNever 1To pain 2To verbal stimuli 3Spontaneously 4II. Best Verbal ResponseNo response 1Incomprehensible sounds 2Inappropriate words 3Converses but disoriented 4Converses and oriented 5III. Best motor responseNo response 1Extension (decerebrate) 2Flexion, abnormal (decorticate) 3Flexion withdrawal 4Localizes pain 5Obeys commands 6Add all three sections' scores for total score. Most comatose patients will have a score of 3 (lowest possible) to 7. A locked-in patient may score only 6, althoughnot in fact comatose. Nevertheless, in the setting of head injury or subarachnoid hemorrhage, the Glasgow Coma Scale is a useful indicator of the severity of thepatient's condition. From G. Teasdale and B. Jennett, Assessment of coma and impared consciousness: a practice scale. Lancet 2:81, 1974TR-II – 18

Title: Temperature Control GuidelineNo.: TR-II-EOrigin: 3/02Reviewed: 8/02Approved By: Emran Imami, MDTrauma Medical DirectorPage: 1 of 2I. OBJECTIVE:To assure monitoring of patient’s temperature upon arrival to the traumacenter, hypothermic conditions recognized and warming methods initiated.IIII.POLICY:Patients with a single or multisystem injury will have core temperaturesmonitored and interventions implemented as indicated.PROCEDURE:A. Assure core temperature is taken during the secondary assessment; mustbe within 15 minutes of trauma center arrival and upon disposition to nextphase of care (i.e. OR, ICU, Floor).B. Monitor the core temperature by one of following methods: oral, rectal ortemp probe indwelling urinary catheter.C. Maintain passive warming for ALL trauma patients regardless of initialtemperature.Passive external:Remove wet clothingKeep room temperature above 80° FChange field IV bags to warm IV bagsApply warm blanketsDecrease any airflow coming into environmentD. Repeat temperatures on all trauma patients with temperatures < 96. 8°Fahrenheit (36° Celsius) every 30 minutes and document on the trauma flowsheet.E. The Level One TM fluid warmer must be used during fluid resuscitation andwhen infusing large volumes of blood and/or blood products. Use the LevelOne TM fluid warmer on all trauma patients with temperatures< 96. 8° Fahrenheit (36° Celsius).F. Use active internal rewarming measures for temperatures < 93° Fahrenheit(34° Celsius). The following measures should be initiated:TR-II – 19

Active internal:• Peritoneal lavage (KCl free) or other body cavity(i.e. bladder) irrigations• Continuos arterio-venous rewarming (CAVR)• Cardiopulmonary bypassG. Continue to reassess the patient’s clinical hemodynamics (vital signs, clinicalsigns, symptoms, and O2 saturation).TR-II – 20

Electrical BurnsMechanism of Injury 1Airway Breathing and Circulation(ABC’s) 2TR-II-FOrigin: 1/99Reviewed:8/02Continous EKG Monitoring12-lead EKGTreat Arrhythmia’s per ACLS ProtocolMonitor for 24 hoursProcessInsert Urinary CatheterUrine Myogobin Present?YESNOEstablish Diuresis:Initiate IV Ringers LactateAdministor Mannitol (25g IV push)Administer NaHCO 3(44mEq)Keep Urine Output at 75-100 ml/hrResuscitate asThermal BurnAssess Neurovascular Status HourlyDebride WoundsApply Topical AgentFasciotomyDetermineDispositionTR-II – 21

Electrical Burns1.) Determine voltage and type of current and whether the patient lost consciousness, had a documented cardiac arrest, or had anabnormal EKG during transport. Also, determine if the patient sustained associated trauma, e.g., a fall. High voltage injuriesare those caused by more than 1,000 volts. At lower voltages deep soft tissue injury is unlikely.2.) ABC’s as defined by ATLS.3.) A urinary catheter with urometer is inserted. Urine is evaluated for gross urinary pigmentation (myoglobin and /orhemoglobin). If the evaluation is negative, re-evaluate after initial bladder emptying.4.) Gross urinary pigmentation (darker than pale red) should be treated to minimize pigment precipitation in the renal tubules.Intravenous access with large bore peripheral catheters should be preformed with administration of 25 g of mannitol (IV push)followed by 44 meq of sodium bicarbonate (NaHCO 3 ) . This is then followed immediately by administration of Ringer’slactate at a rate that will achieve urine output sufficient to clear the urine grossly (75-100 ml per hour). This is done toestablish immediate urinary diuresis and to alkalinize initial urinary output to minimize precipitation. Output is thenmaintained with Ringer’s lactate. Further use of diuretics and bicarbonate is seldom necessary.5.) Neuromuscular status of all extremities should be evaluated hourly. Paresthesia, absent pulses, paralysis, swelling, and deeppain on active or passive motion are indications for immediate decompression.REFERENCESMcQuillan, K., Von Rueden, K., Hartsock, R., Flynn, M., & Whalen, E. Trauma nursing: from resuscitation throughrehabilitation. (3 rd Edition). Pennsylvania: W. B. Saunders Company, 2002.American College of Surgeons Committee on Trauma. Advanced trauma life support for doctors: Instructor course manual.(6 th Edition). USA. First Impression. 1997.TR-II – 22

Thermal BurnsMechanism of Injury 1TR-II-FOrigin: 1/99Reviewed: 8/02Assess Airway to Include Signs of Burns toFace and Neck 2NoAble to Maintain Patent Airway 3IntubateContinual Re-evaluationAssess Breathing andCirculation 4BURN CENTERREFERRAL CRITERIA 91)Second and third-degree burns greater than 10% ofthe body surface area(BSA) in patients under 10or over 50 years of age.2)Second and third-degreeburns greater than 20% BSA inother age groups.3)Second and third-degree burnsthat involve the face, hands, feet,genitalia, and perineum, orwhich involve skin overlyingmajor joints.4)Third-degree burns greaterthan 5% BSA in any agegroup.5)Significant electrical burnsincluding lightning injury.6)Significant chemical burns7)Inhalation injury.8)Burn injury in patientsthat could complicatemanagement prolongrecovery or effectmortality.9)Any burn patient in whomconcomitant trauma poses anincreased risk of morbidity ormortality may be initially treatedin a trauma center until stablebefore transfer to a burn center.10)Children with burns who wereseen initially in hospitals withoutqualified personnel or properequipment for burn care shouldbe transferred to a burn centerwith these capabilities.11)Burn injury in patients whowill require special social andemotional or long-termrehabilitative support includingcases involving suspected childabuse and neglect.TR-II – 23Initiate Therapy 6Obtain IV AccessInsert Nasogastric TubeInsert Urinary CatheterEvaluate forBegin Fluid12)Circumferential burns .8 centertransfer to burnAssess Burn Size and Depth 5>20%TBSA10%if Older than 605% Third DegreeAirway or Inhaltion InjurySignificant Associated Injuryor Pre-existingdiseaseDeep burns of Face, Hands, Feet, Perineum, orMajor JointsYESresuscitation, recordLR @4ml/kg/%burn/24h 7NOMinor Burn:Debride woundApply Topical Agent andDressingDetermine DispositionAdmit Outpatient Care

Thermal Burns1.) Utilize pre-hospital history and assessment. Electrical, chemical burns: burns occurring in closed spaces and those withtraumatic injuries have special significance.2.) Examine airway for the following signs of burn and inhalation injury; Burns about the face, nose and mouth singed nasal hairs,glottic edema, hoarseness and stridor: production of carbonaceous sputum. Burns of the lower face and neck result insupraglottic and pharyngeal swelling. This injury is almost always above the vocal cords and has the risk of acute airwayobstruction. Burn edema is gravity dependent. Thus, facial swelling can be minimized by continuous elevation of the head ofthe bed at greater than 45 degrees for the first 48 hours after injury. Bronchoscopy confirms airway and pulmonary injury.3.) Upper airway evaluation is done hourly. Swelling of the upper airway increases for the first 24 hours. The primarycomplication of this injury is failure to intubate or accidental extubation with catastrophic results. Complaints of breathingdifficulty, hoarseness, or swelling are significant. Evaluation may require direct or indirect laryngoscopy or bronchoscopy toensure patency of the airway. If warning signs or symptoms are not present, the patient is observed closely.4.) Assess breathing and circulation as defined by ATLS protocols. Associated significant injuries should be identified andtreated.5.) Burn size is expressed as a percentage of total body surface area (TBSA). The percentage includes areas of second degree andthird degree but not of first degree. Initial assessment of burn size may be with the “rule of nines” (Fig. 1).6.) • Intravenous access by a percutaneous peripheral route using large bore catheters preferred. This may be through burnedtissue.• Place nasogastric tube and attach to suction if there is nausea, vomiting, or distention, or if burns involve more than 25%TBSA.• Place indwelling urethral catheter attached to a urometer. This is necessary for the hourly evaluation of urinary output.• Give analgesic medication intravenously.• Burns are tetanus prone wounds. Tetanus prophylaxis as dictated by patient’s immunization status.• Dry sterile dressings• Prevent hypothermiaTR-II – 24

Thermal Burns - Continued7.) Estimate fluid needs for first 24 hours post-burn:• Adults: 2-4 ml lactated Ringer’s solution / kg body weight / percent of burn• Children less than 3 years old: 4ml lactated Ringer’s solution kg body weight / percent of burn plus normalmaintenance fluidPlan on administering one-half of volume in first 8 hours post-burn, but adjust infusion rate to obtain:1.) 30-50 ml of urine per hour in patients weighing more than 30 kg2.) 1 ml urine per hour / kg body weight in patient weighing less than 30 kg8.) Patients with circumferential burns should be monitored continuously for maintenance of peripheral circulation:A) Remove rings and braceletsB) Assess for sings of impaired circulation:-Cyanosis-Impaired capillary refill-Progressive neurologic signs(i.e. paresthesias and deep tissue pain)-Doppler determination of pulsesC) Prepare for escharotomy if patient has continued signs of vascular insufficiency:-No anesthesia is needed-Place incision in mid-lateral and/or midmedial line of limb-Must carry incision across involved jointsIncise only to depth that allows cut edges of eschar to separate-Constriction of the chest by eschar can limit respiration and prompt release is criticalD) Fasciotomy is usually indicated only when injury involves subfascial tissue (recommended as an operatingroom procedure)9.) Disposition is determined by burns size, body parts burned, patients age, and ability of the patient and/or the family to care forthe burn. Each case should be individualized.TR-II – 25

Thermal Burns - ContinuedREFERENCESGamelli R, in conjunction with the American Burns Association, Assessment and initial care of the burn patient, AmericanCollege of Surgeons Committee on Trauma, 1995.McQuillan, K., Von Rueden, K., Hartsock, R., Flynn, M., & Whalen, E. Trauma nursing: from resuscitation throughrehabilitation. (3 rd Edition). Pennsylvania: W. B. Saunders Company, 2002.American College of Surgeons Committee on Trauma. Advanced trauma life support for doctors: Instructor course manual.(6 th Edition). USA. First Impression. 1997.TR-II – 26

Title: Burn Trauma Alert Management and TransferCriteriaApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-II-GOrigin: 1/99Reviewed: 8/02Page: 1 of 3POLICY:The needs of the trauma alert patient with thermal injuries will beweighed against the services available at Holmes Regional MedicalCenter (HRMC). Major burns should be transferred to a Burn Unit,however, in certain specific instances patients with major burns may beproperly cared for at HRMC at the discretion of the plastic surgeon incoordination with the Trauma Service. If the hospital environment, lackof personnel or equipment, and lack of ancillary services will hinderoptimal care, transfer to a Burn Unit will be initiated as soon as possiblewhile the patient is being resuscitated and stabilized.PROCEDURE:1. Major burns according to the American Burn Association are:A. Second and Third degree burns > 25% BSBAB. Second and Third degree burns > 20% BSBA in children under10 years, adult over 40 years.C. Full-thickness burns involving more than 10% BSBA.D. All burns involving face, eyes, ears, hands, feet, perineumwhich are likely to result in functional or cosmetic impairmentE. Burns associated with significant fractures or other majorinjury.F. High-voltage electrical burns.G. Inhalation injury and significant facial burns.H. Burns in patients with significant preexisting disease.TRANSFER CRITERIA:A. The plastic surgeon on call is not called torespond if the patient is being transferred withcertainty to a Burn Unit. The patient will bemanaged by the attending trauma surgeon until thepatient leaves the hospital.B. In borderline cases, the plastic surgeon will beconsulted to determine if the type and percentage ofburns can be cared for properly a HRMC.I. Initial Patient Care Guidelines should include:TR-II – 27

A. Nasogastric (orogastric) tube if orderedB. Indwelling urinary catheter if orderedC. IV narcotics for pain relief (Morphine if notallergic)D. Maintain body temperature and preventhypothermiaE. Remove all clothing and jewelryF. Burn wound care1 Cool the burning process with salinesoaked gauze if time of burn to arrival athospital is less than 30 minutes. Otherwisedry, sterile dressings should be applied.Debridement will be done only at thediscretion of the attending physician.2. There will be NO topical agents (ieSilvadene) applied to the burns prior totransport to a Burn Unit.G. IV Fluid ReplacementII. The Transfer of Burn Victims to a Burn UnitA. The appropriate party is contacted andapproval for transfer is elicited from eitherthe receiving attending physician, resident incharge, and/or administrator.B. Transfer agreements (verbal and written)for burn care exist. Attempts will be madeinitially to place the patient in OrlandoRegional Medical Center’s Burn Unit due toclose proximity.TR-II – 28

C. Once the patient is accepted by a BurnUnit, arrangements will be made forappropriate transportation via ambulance orhelicopter by the transferring facility.D. The Burn Unit should be notified whenthe patient leaves the emergency departmentwith a report of burn history, the proceduresthat have been done, an update of thepatient’s condition, and an estimated time ofarrival via which mode of transport.E. Copies of the patient’s chart, laboratorytest results, and xrays should accompany thepatient at the time of transport to the BurnUnit.F. If the transfer process should take longerthan one hour, the patient should be taken tothe ICU for continued resuscitation andstabilization by the Trauma Service.III. Burn victims with coexisting multiple trauma, such asinjuries sustained in MVCS, explosions, etc, who have lifethreateninginjuries, such as intraabdominal hemorrhage,will be treated as any Trauma Alert and have operativeintervention as indicated. If a patient is to be transferred toa Burn Unit, operative intervention will occur at HRMCprior to transport. The patient may be transferred to theBurn Unit after operative intervention if stable.TR-II – 29

Chest TraumaAirway Breathing and Circulation(ABC’s) 1TR-II-HOrigin: 1/99Reviewed: 8/02Hemodynamically Stable Hemodynamically UnstableCXRConsider EKGTracheal Shift PresentBreath Sounds AbsentHeart Tones MuffledNeck Veins DistendedCardiopulmonary Arrest 5with Vital Signs Present inTransportSimple Pneumothorax -> Chest Tube 1Myocardial Contusion -> MonitorPulmonary Contusion -> MonitorconsiderintubationAortic Injury - Angiogram -> ORDiaphragmatic Hernia -> OREsophageal Injury -> Esophagram -> ORFlail Chest -> Monitor-consider intubationTension Pneumothorax 2Massive HemothoraxNeedle Thoracostomy 3Chest TubePericardial Tamponade 4BluntACLS ProtocolPenetrating>1500cc/ml first hour (considerautotransfusion)>500cc per hour (considerautotransfusion)>200cc per hour over 6 hoursUnsuccessfulSuccessfulNOYESTerminate Codeafter 15 minutes ofasystoleImmediateThoracotomyObserveTR-II – 30ORIMMEDIATELY-Cross Clamp Aorta 6-Open Pericardium-Cross ClampPulmonary Hilum if LungBleeding

Chest Trauma1.) • Simple pneumothorax – Chest tubes are inserted for radiographic or physical evidence of hemothorax or pneumothorax. Oneor more size 36 to 40 French chest tubes are placed through the fifth or sixth intercostal space in the midaxillary line afterfinger inspection confirms that the pleural space has been entered and not the abdomen.• Myocardial contusion – Twelve-lead EKG and continuous cardiac rhythm monitoring are a diagnostic priority for the patientwith suspected myocardial contusion. EKG abnormalities that are characteristic of this injury range from non-specific ST-Twave changes and / or inversion associated with myocardial ischemia to rhythm disturbances of paroxysmal atrial tachycardia,right bundle branch block, ventricular tachycardia, and premature ventricular contractions.• Pulmonary contusion – Pulmonary contusion often can be managed with oxygen and fluid restriction. A ventilator is used ifserial blood gas determinations indicate hypoxia or hypocarbia.• Aortic injury – The usual site of aortic rupture is at the aortic isthmus. Other sites are the base of the innominate artery andthe descending aorta. Mediastinal widening, multiple fractures of upper ribs on the left, an apical cap on the left lung, anddeviation of the esophagus to the right are signs of rupture of the isthmus. An aortogram is done if bleeding is not lifethreatening.• Ruptured diaphragm – Clinical diagnosis of a ruptured diaphragm is difficult, especially with associated intrathoracic injury.Chest radiography is the best initial imaging tool but is normal in 20 to 50 percent of patients. Once herniation of abdominalcontents occurs, x-rays should demonstrate the presence of stomach or small bowel in the chest. Delayed presentation of aruptured diaphragm is common. Diagnostic peritoneal lavage is positive in most cases, dictating laparotomy with examinationof the entire diaphragmatic surface.• Esophageal injury – A small esophageal tear detected early may be sutured successfully. Pleural space drainage ismandatory. Tenuous closures in the distal esophagus can be protected with a gastric wrap. Temporary cervical esophagostomyprevents continued soiling from an esophageal leak until healing occurs.• Flail Chest – All patients with flail chest do not require intubation. The patient is placed on 40 per cent oxygen by mask andassessed frequently for hypoxia. This injury does not itself cause hypoxia; rather, it is damage to the underlying lung tissue thatis the concern. The patient with hypoxia is defined as having a PaO 2 less than 60, PaCo 2 greater than 50, and /or respiratoryrate greater than 25, on 40 per cent oxygen concentration.If the patient is intubated, depending on the depths of hypoxia and the decrease in compliance, a positive end-expiratorypressure may be employed. A Swan-Ganz catheter is inserted to assess fluid status. The lungs are sensitive to either overTR-II – 31

Chest Trauma - Continuedhydration or dehydration, and a flail chest injury predispose the patient to ARDS. The underlying goal of treatment isprevention of hypoxia.2.) A tension pneumothorax is a pneumothorax associated with progressive accumulation of air trapped in the pleural space. Thepleural space is converted from a negative to an increasingly high positive pressure system that impairs venous return. Thepressure produces a mediastinal shift that compresses the inferior vena cava as is passes through its diaphragmatic hiatus.Contralateral lung compression along with pulmonary collapse on the affected side results in hypoxia. These physiologicchanges can result in hypoperfusion, hypoxia, and sudden death. The most common causes of tension pneumothorax aremechanical ventilation with positive end-expiratory pressure, spontaneous pneumothorax in which ruptured emphysematousbullae have failed to seal, and blunt chest trauma in which parenchymal lung injury has failed to seal. Tension pneumothorax isa clinical rather than a radiographic diagnosis.A hemothorax can be detected on a finding of decreased breath sounds and dullness to percussion in the involved hemithorax.Confirmatory evidence comes from the chest film: however, the radiograph is not necessary to make the diagnosis, and thosepatients who are unstable should have a chest tube placed immediately without waiting for the film. About 500 ml of blood isrequired to detect a hemothorax on the chest film.3.) The pleural space should be decompressed immediately with a needle thoracostomy. A 14-gauge angiocath is rapidly insertedinto the second intercostal space in the midclavicular line of the affected hemithorax. This converts the tension pneumothoraxinto a simple pneumothorax.4.) Cardiac tamponade is characterized by shock; distended neck veins, and elevated central venous pressure. Bedside ultrasoundcan facilitate diagnosis. Pericardiocentesis is performed by aiming a large bore needle from the left paraxiphoid area towardthe left shoulder. Generally, patients at a trauma center should go immediately to the OR. If fluid is aspirated from thepericardium and the patient improves, operation through a median sternotomy is done promptly to repair a cardiac wound. Ifno improvement occurs, immediate left thoracotomy or subxiphoid pericardiotomy is performed.5.) Emergency thoracotomy for trauma should be attempted only in those patients with signs of life either at the hospital or whenin close proximity to the hospital with rapid transport. It is likely to be more successful in penetrating trauma than in blunttrauma and in those patients who are agonal or have rapidly deteriorating vital signs despite adequate resuscitation.TR-II – 32

Chest Trauma - Continued6.) The initial maneuver is cross clamping of the descending thoracic aorta using a suitable vascular clamp. If there is massivehemorrhage from the lung itself, it may be controlled by cross-clamping the entire hilum of the lung with a vascular clamp. Ifmassive hemorrhage is coming from any of the great vessels inside the chest, manual compression and rapid transport to theOR for repair should be attempted.-If there is penetrating cardiac injury, pericardial tamponade, or cardiac arrest; the pericardial sac should be opened withscissors anterior to the phrenic nerve.-If visualization is inadequate, or if there is a right chest injury, the thoracotomy may be extended across the sternum with asuitable bone-cutting instrument into the right chest.-If there is a penetrating injury to the heart; this should first be occluded manually or with an inflated Foley catheter balloonand then closed using pledgeted sutures. Cardiac massage, fluid resuscitation, and defibrillation should be continued asnecessary.REFERENCESMcQuillan, K., Von Rueden, K., Hartsock, R., Flynn, M., & Whalen, E. Trauma nursing: from resuscitation throughrehabilitation. (3 rd Edition). Pennsylvania: W. B. Saunders Company, 2002.American College of Surgeons Committee on Trauma. Advanced trauma life support for doctors: Instructor course manual.(6 th Edition). USA. First Impression. 1997.TR-II – 33

Spinal Cord InjuryAirway Breathing Circulation 1Immobilization of C-spine with C Collarand Long BackboardTR-II-IOrigin: 1/99Reviewed: 8/02Evaluable 2Neurological Exam 4RadiologicalInvestigation 5No Neurological Deficit Neurological DeficitOblique Views@ 24 Hrs.No Neck / Back PainRemove C-collarNon-Evaluable 3Radiological Investigtion5Neck / Back PainEvaluable Non-evaluableSpine Consult(ortho or neuro)RadiologicalInvestigation 5 CT ScanMRIInitiate Therapy 690 Degree Lateral ViewObliqueViews@ 24 HrsNo Neck / Back PainRemove C-CollarNormal AbnormalNormalD/C Collar 7 AbnormalNeck PainNo YesRemoveCollarFlex/ExtCT ScanSpine consult(ortho or neuro)TR-II – 34CT ScanNSG Consult

Spinal Cord Injury1. •ABCs as defined by ATLS. Be suspicious of spinal cord injury when there is weakness, numbness, spine pain, headinjury, high velocity and multisystem injury.•Careful handling of the patient is essential. Always suspect that a spinal fracture exists until a xray analysis is obtainedand a fracture is ruled out. All injured patients who are comatose are presumed to have cervical spine fracture until it isruled out.•Because 10%-15% of patients with a spinal injury will have a secondary injury of the spine at another level, carefullyimmobilize and assess the entire spine.•Special considerations of ABCs with spinal cord injuryA. Maintain patient in the supine position and immobilize head, neck, and body by using- Semirigid plastic collar- Long spine boardB. Assess respiratory status- Establish airway, if intubation required maintain in line stabilization of the neck- Administer supplemental oxygen- Assess ventilationC. Assess circulation- Monitor blood pressure continuously- If hypotensive, differentiate hypovolemic shock (↓BP;↑HR) from neurogenic shock (↓BP; ↓HR)- Replace fluids if there is hypovolemic shock- If spinal cord injury is present, fluid resuscitation should be guided by central venous pressure monitoring;some patients may need inotropic support2. Evaluable - GCS ≥ 13, no distracting injuries or drugs that confuse or cloud physical exam.3. Unevaluable – GCS < 13, distracting injury or drugs that confuse or cloud physical exam.TR-II – 35

Spinal Cord Injury - Continued4. Assess neurological statusA. Establish level of consciousness (Glasgow Coma Scale).B. Palpate the entire spine posteriorly, keeping in-line stabilization when log rolledC. Document neuro-examination-Test sensation to pinprick in all dermatomes (see sensory chart); record the most caudal dermatome thatfeels pinprick.-Check motor function (see motor function examination chart).-Test deep tendon reflexes (DTRs); (see reflex chart).-Perform a rectal examination to assess sphincter tone and sensation.-Insert Foley catheter; note sensation to insertion-Check for cremasteric reflexxCervical SpineA. Order cross table lateral cervical spine x-ray study first; all seven cervical vertebraeB. and C-7 –T-1 junction should be seen; to do so may require:-Firmly pulling down patient’s shoulders, without movement of the neck: or-Lateral swimmer’sB. Order anterior / posterior cervical x-ray and an open mouth Odontoid x-ray.C. Specifically look at:-All seven vertebrae-Shape, size and alignment of vertebral bodies-Prevertebral swelling-Position and integrity of the Odontoid processTR-II – 36

Spinal Cord Injury - Continued•Thoracic spine-Orientation and clarity of facet joints-All seven spinous processes-Alignment of the spinolaminal lines-Relationship of occiput to C-1-Order lateral and anterior /posterior x-rays-View all thoracic vertebraexLumbar spine-Order lateral and anterior/posterior view-View all lumbar vertebrae•Standard CXR and abdominal films5. Initiate TherapyA. Immobilization. Cervical collar must not be removed until x-rays have been reviewed and spinal injury has been ruledout. Consider removing from spine board to prevent decubitus ulcers. Log roll patient until entire spine has been cleared.B. Corticosteroids to be given to patients with neurological deficit within 8 hours of injury: methylprednisolone IV, bolusdose of 30 mg/kg of body weight over 15 minutes, followed by maintenance dose of 5.4 mg/kg per hour for 23 hours.C. Intravenous fluids. Limit to appropriate levels.D. Bladder catheterization.TR-II – 37

Spinal Cord Injury - ContinuedE. Insert nasogastric tube in patients with para- or quadriplegia.6. Removal of C-collar based on surgical judgment Warning: Even with this conscientious x-ray survey, some spine fracturesmay go undiagnosed. Continue index of suspension in high-risk groups.REFERENCESMcQuillan, K., Von Rueden, K., Hartsock, R., Flynn, M., & Whalen, E. Trauma nursing: from resuscitation throughrehabilitation. (3 rd Edition). Pennsylvania: W. B. Saunders Company, 2002.American College of Surgeons Committee on Trauma. Advanced trauma life support for doctors: Instructor course manual.(6 th Edition). USA. First Impression. 1997.Saul T, in conjunction with the Joint Section on Neurotrauma and Critical Care of the American Association of NeurologicalSurgeons and Congress of Neurological Surgeons. Management of spinal cord injury, 1995.TR-II – 38

Non Evaluble Patients-Altered Mental Status-Equivocal (non-diagnostic) exam-High risk due to mechanism- Prolonged Anesthesia-Ongoing blood lossAbdominal TraumaAirway, Breathing, Cirdulation(ABCs) 1TR-II-JOrigin: 1/99Reviewed: 8/02Blunt (Mechanism of Injury) 2 PenetratingVS Stable VS UnstableStab Wound GSW 8NonEvaluable EvaluableNonEvaluableNo Surgical Abdomen Surgical Abdomen 7No evidencefor penetrationNormalExamObservation 3SurgicalAbdomenLocal ExplorationORObserveUltrasound (or DPL)Positive NegativeUltrasound,DPL, or CT 4NormalObserveObserveAbnormal/QuestionableVital Signsremain stableDeteriorationOR based onsurgical judgement 5 ORContinue 6workupNo-PenetrationConsiderDischargeObserveDeteriorateAnterior DPL 10 PosteriorFlank and Back(controversial)DPL 10 and/or Abd.CTand/or ObservePositive Negative Positive NegativeOR ObserveOR ObservePenetration 9TR-II – 39

Abdominal Trauma1. ABCs as defined by ATLS.2. Utilize prehospital EMS history and assessment.3. No other injuries or drugs that confuse or cloud exam.4. CT with GI and IV contrast preferred to IVP to evaluate hematuria.5. Intra-abdominal fluid (not blood), bowel wall thickening, peripancreatic fluid, or blood without solid organ injury.6. Emergent angiography, particularly with pelvic fractures.7. Peritonitis, hypotension, evisceration, and so on.8. Low-velocity superficial tangential wounds without fascial penetration may be observed.9. Penetration includes peritoneum and/or fascia: decision controversial.10. Debate over level of positive RBC count (>1,000 to >100,000). Ultrasound may be used in selected cases.REFERENCESFerrera, P., Coluccielo, S., Marx, J., Verdile, V., & Gibbs, M., Trauma management an emergency medicine approach. St. Louis,Missouri: Mosby, Inc. 2001Sing, R. & Reilly, P. Initial management of injuries: An evidence based approach. London: BMJ books. 2001.TR-II – 40

UrologicalPelvic TraumaAirway, Breathing and Circulation 1(ABC’S)TR-II-KOrigin: 1/99Reviewed: 8/02stable unstableX-ray Pelvis 2 X-ray Pelvis 2Blood at theAbdominalmeatus? 3 UltrasoundYes NoRetrogradeInsert UrinaryUrethrogram 4 CatheterOrthoConsultationOR 11OrthoStabilizeConsultation 8Fracture 9Negative PositviveGross HematuriaPresent? 6YesNoAngiogram withCystogramEmbolization 10Consultation 5CT ScanInlet and OutletViews CT Scan 7SICUOrthopedicConsult 8TR-II – 41

Pelvic Trauma1.) ABCs as defined by ATLS.2.) A simple anteroposterior view of the pelvis provides enough information to detect most fractures.3.) The determination of a potential injury is vital. Ecchymosis or hematoma around the penis or scrotum or blood at the penilemeatus is highly suggestive of an injury. A urinary catheter cannot be placed until urethral integrity is assured.4.) Fifteen to twenty ml of water-soluble contrast is injected into the meatus in a sterile manner. Voiding is prevented by urethralcompression until a plain film is obtained. Any evidence of extravasation indicates the need for further studies (i.e.,intravenous pyelogram, cystogram) to exclude other urologic injuries.5.) Urologic input is valuable in planning the patient’s potential operative sequence. Suprapubic catheter placement is mandatoryfor urethral injuries.6.) Hematuria is the best indicator of renal trauma. A count of greater than 40 red blood cells per high power field suggests theneed for an IVP and a cystogram to exclude other injuries.7.) Computed tomography scanning may be of value, especially if an acetabular fracture is suspected. Careful hemodynamicmonitoring is needed while the patient is in the radiology suite.8.) Orthopedic input is essential in determining fracture type and further therapy.9.) Stabilize fracture. Stabilization can include traction, an external fixator, mast trousers or wrapping the patients pelvis with asheet.10.) Angiography may be useful for continued blood loss. Delineation of a single vessel allows embolization: however, singlevessel injury as the source of ongoing blood loss occurs in only 1 percent of these patients, approximately.TR-II – 42

Pelvic Trauma - Continued11.) After repair of abdominal injuries, if there is no single vessel injury, packing the pelvis and closing may tamponade furtherlosses. Packing removal must occur in the next 48 to 72 hours.REFERENCESMcQuillan, K., Von Rueden, K., Hartsock, R., Flynn, M., & Whalen, E. Trauma nursing: from resuscitation throughrehabilitation. (3 rd Edition). Pennsylvania: W. B. Saunders Company, 2002.American College of Surgeons Committee on Trauma. Advanced trauma life support for doctors: Instructor course manual.(6 th Edition). USA. First Impression. 1997.TR-II – 43

Urology ProtocolBlunt TraumaTR-II-LOrigin: 8/02Reviewed:Blood at the ureathral meatus, scrotal hematoma,high-riding prostateYESNORetrogradeUreathrogramnegativePlace FoleyHematuriapositiveGross Hematuria(red or pink tinged)Microscopichematuria (dippositive)Urology ConsultpositiveAbdominal CTShockSBP

Orthopaedic InjuryExamine: check neurovascular statusC-spine, T-spine, and L-S spineTR-II-MOrigin: 8/02Reviewed:Positive xray or exam findingsSee Neurological injury protocolPelvisFemurNOStable fractureYESPositivefractureexternalfixatorPT, OT asorderedHaretractionsplintMay needarteriography andembolizationOpen FractureORIF ASAPExtremity FractureImmobilizedSaline CleansingTractionSplintObtain AppropriateX-RaysSterile DressingORIF as indicatedAntibotics / TetanusOperative debridement andstabilization are usuallyneccessarySpecial Note:Fractures that result in vascular compromisemay require angiography.* Ortho should be notified after the initialassessment or for any patient with orthoinjuries, within 30 minutes.*Involve Orthopaedics early in evaluation.TR-II – 45

Hand Injuries and RevascularizationNotify Orthopaedics IMMEDIATELYDevascularization or Circulatory CompromiseTR-II-NOrigin: 8/02Reviewed:YESNOOngoing continous resuscitation,stabilization, and supportive careWarm / well hydratedAnalgesicsTetanus and AntibioticsOpenSalineClensingDressingTetanusProphylaxis /AntibioticsClosedCare for theStumpCare for theAmputated PartImmobilize with splintSaline RinseCover withmoist gauseWrapOcclusively andElevateSaline RinseWrap in SALINEmoistened gausePlaced inLABELED plasticbag or specimen cupElevateObtain appropriate X-RayOperative intervention asneededX-Ray both stump and amputated partOperative intervention ASAPTR-II – 46

DVT ProphylaxisTrauma patient admittedTR-II-OOrigin: 8/02Revised:Anticipated LOS 48 q! 48 qSCDs and TEDs Low risk High riskHeparin5000 u SQ q12qSCDsNo’ ContraindicationTo HeparinYesInitial Duplex oflower extremitieswithin 72 hrs ofadmission (thenserial exams 5-7days) ifanticoagulation ispossible** Evaluate for Fragmin SCDsGreenfield5000 U SQ q 24qGreenfieldFilter• Spinal cord injury• Spinal column fractures• All SICU patients• Significant Closed-Head InjuryPatients• GCS < 9• ISS > 15• Pelvic fracture• Femur / tibia fracture• Immobility >3 Days• Lower extremity long boneinjury• Major venous injury• Hypercoagulable• Femoral central line in trauma’• Active Hemorrhage• Solid Organ Injury• Intracranial Injury• Major Pelvic Fracture• Pre-operative Orthopedic’’• 36 Hours forOrthopedic Procedures• 7 days for Closed HeadInjuries’’ ContraindicationResolvedPlacement Greenfield• Significant Closed-headinjury• Spinal Cord Injury• Pelvic Fracture• Multiple Long boneFractures• Immobility >3 monthsApproved by P&TCommittee 08/06/02TR-II – 47

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Title: Pediatric Trauma Alert Management and TransferCriteriaApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-II-POrigin: 1/99Reviewed: 8/02Page: 1 of 3I. OBJECTIVE:To ensure optimal care of the patient meeting Pediatric Trauma Alert Criteria whenevaluated by the Pediatric Trauma Alert Scorecard Methodology.II.III.POLICY:1. Holmes Regional Medical Center is not a State Approved Pediatric Trauma Center.There are occasions, however, when a Pediatric Trauma Alert will present to theTrauma Center. These instances include:1. Mistriage by EMS2. Patient presents to HRMC on own.3. Patient in need of stabilization prior to transport.4. Weather conditions that do not permit First Flight totransport safely.PROCEDURE:1. These patients will be initially evaluated, stabilized, and then transported to aState Approved Pediatric Trauma Center as soon as appropriate for optimal patient care.The Trauma Surgeon will make the determination of when it is safe to do so.2. The following are considered automatic Pediatric Trauma Alerts or “Red” criteria.Only one red criteria needs to be met for a Trauma Alert to be initiated:Pediatric Trauma Alert patients PEDIATRIC (Age 15 or less)*A. Airway: Patient is intubated or breathing is assisted through manualjaw thrust, suctioning or through the use of other adjuncts to assistventilatory efforts.B. Consciousness: Altered mental status including drowsiness, lethargy,the inability to follow commands, unresponsiveness to voice, totallyunresponsive, or in a coma; presence of paralysis, suspicion of spinalcord injury, or loss of sensation.C. Circulation: Faint or nonpalpable radial or femoral pulse; systolic bloodpressure less than 50mmHg.D. Fracture: Evidence of open long bone (humerus, radius, ulna,femur, tibia, or fibula) fracture or multiple fracture sites or multipledislocations (except isolated wrist or ankle fractures or dislocations).E. Cutaneous: Major soft tissue disruption, including degloving injuryor major flap avulsion; 2nd or 3rd degreeburn to 10 percent or more of total body surface area; amputationproximal to the wrist or ankle; penetrating injury to the head, neck, orTR-II – 49

torso (excluding superficial wounds where the depth can bedetermined).The following are considered Pediatric Trauma Alerts when two criteria listedbelow are met. Also known as “Blue” criteria.A. Consciousness: Symptoms of amnesia or loss of consciousnessB. Circulation: Carotid or femoral pulse is palpable, but radial or pedalpulses are not palpable; systolic blood pressure is less than 90mmHg.C. Fracture: The patient has signs or symptoms of a single closed longbone fracture (not including isolated wrist or ankle)D. Size: Weight less than or equal to 11 kgs or body length equal to thisweight on the pediatric measurement tape (33 inches or less)In the event that none of the criteria above are met, a paramedic maycall a “Trauma Alert” if in his or her judgment, the conditionwarrants such an action.2. The following equipment will be available for the immediate care of the PediatricTrauma Alert Patient:A. Fully stocked Pediatric Broselow CartB. Pediatric Intubation EquipmentC. Broselow tape in PlexiglasD. Pediatric IV suppliesE. Equipment for the stabilization of the following conditions will beavailable in the Trauma Room for the Pediatric patient:1. Unstable airway or respiratory distress2. Unstable cardiovascular system3. Head injuries4. Skeletal injuries or fractures5. Spinal cord or column injuries6. Facial injuries7. Visceral injuries8. Amputations9. Burns3. Upon Trauma Surgeon’s evaluation that the patient is stabilized for transport, andphysician acceptance at SAPTC, appropriate paperwork will be completed according toPatient transfer policy, patient will be transferred without delay to a SAPTC. TheTransfer of Pediatric Trauma Alert Patients to SAPTC occurs when:A. The appropriate party is contacted and approval for transfer is elicited fromeither the receiving attending physician, resident in charge, and/oradministrator.B. Transfer agreements (verbal and written) for Pediatric Trauma Alerts exist.Attempts will be made initially to place the patient in Orlando RegionalMedical Center’s Trauma Center due to close proximity.C. Once the patient is accepted by a SAPTC, arrangements will be made forappropriate transportation via ambulance or helicopter by the transferringfacility.TR-II – 50

1. The SAPTC should be notified when the patient leaves theemergency department with a report of history, the proceduresthat have been done, an update of the patient’s condition, and anestimated time of arrival via which mode of transport.2. Copies of the patient’s chart, laboratory test labs, and x-raysshould accompany the patient at the time of transport to theSAPTC.D. If the transfer process should take longer than one hour; the Trauma Serviceshould take the patient to the ICU for continued resuscitation andstabilization.*Pediatric Trauma Alert patients who have life-threateninginjuries, such as intraabdominal hemorrhage, will be treatedas any Trauma alert and have operative intervention asindicated. If a patient is to be transferred to a SAPTC,operative intervention will occur at HRMC prior to transport.The patient may be transferred to the SAPTC after operativeintervention if stable.4. If the Trauma Surgeon on call determines that the patient will be managed at HRTCinstead of being transferred to the nearest SAPTC, he/she will call the on call PediatricTrauma Surgeon via the recorded line. The Trauma Surgeon on call will call theTransfer Center at that facility to discuss the case and his plans to admit at HRMC andthe pediatrician on-call at HRMC will be consulted.TR-II – 51

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Title: Pregnant Trauma PatientNo.: TR-II-QOrigin: 1/99Reviewed: 8/02Approved By: Emran Imami, MD Page: 1 of 2Trauma Medical DirectorI. OBJECTIVE:To provide guidelines for the management of a pregnant trauma patient presenting tothe Emergency Department/Trauma CenterTo outline the collaborative process of the Trauma, Obstetric and NeonatologyServices in providing care to the pregnant trauma patient in order to achieveoptimum outcome for her and her fetus.II.DEFINITION:• Pregnant Trauma Alert: pregnant patient with injuries meeting the State of FloridaTrauma Alert Criteria• Pregnant Non-Trauma Alert: pregnant patient with injuries not meeting the State ofFlorida Trauma Alert Criteria• Obstetric Support Services: includes Labor and Delivery staff, OB-GYN medicalstaff, Neonatology/NICU staff, and Respiratory Therapist.III.POLICY:A. Treatment priorities for the injured pregnant patient remain the same as for the nonpregnantpatient. Optimal treatment of the mother provides the best care for thefetus.B. Pregnant trauma patients are classified according to the State of Florida TraumaAlert Criteria.C. Pregnant Non-Trauma Alert patient should be evaluated in the ED by the EDphysician. Appropriate obstetric support services should be called to provideOB/fetal assessment as indicated by maternal condition and gestational age. Thepregnant patient > 16 weeks should be sent to L&D after evaluation and treatment ofinjuries.D. Pregnant Non-Trauma Alert patients < 16 weeks who are cleared by the EDphysician (ultrasound if obvious vaginal bleeding) can be discharged to follow-upwith primary MD and /or OB-GYN physician.E. The Transfer Center will notify L&D for Pregnant Trauma Alert Patient > 16 weeks.L&D will send a nurse to assist with assessment and initiate fetal monitoring asappropriate. L&D will also notify OB-GYN of record or on call, Neonatology andTR-II – 53

Respiratory Therapist. Pregnant Trauma Alert patient will be evaluated in theTrauma Room by the Trauma Physician.F. L&D nurse will continue to provide OB/Fetal Assessment while pregnant traumaalert patient is being evaluated and stabilized. Unstable pregnant trauma patients willnot be transferred to L&D.G. Any pregnant trauma patient admitted as an inpatient must have an OB-GYN consultand a pregnancy ultrasound performed. L&D staff will provide OB/Fetalassessments as determined by the OB-GYN.H. Pregnant patients sustaining trauma at 24 weeks gestation or more should have fetalmonitoring initiated as soon as condition has stabilized.I. Fetal monitoring should be continued as long as there are uterine contractions, nonreassuringfetal heart pattern, vaginal bleeding, significant uterine tenderness orirritability, serious maternal injury or ruptured membranes.J. Consideration should be given to administering D immunoglobulin (RhoGAM) toun-sensitized, D-negative pregnant patient who is evaluated for abdominal trauma.Use of the Kleihauer-Betke (fetal Hb/blood) assay may be helpful.K. Neonatal resuscitation equipment and supplies will be maintained in the ED/TraumaCenter.L. Both the Trauma physician and OB-GYN must discharge pregnant trauma patientsadmitted to the Trauma Service.IV.PROCEDURESee attached Algorithm.V. REFERENCESGuidelines for Perinatal Care. American Academy of Pediatrics and American College ofObstetricians and Gynecologists. 4 th Edition. 1997.Ferrera, P., Coluccielo, S., Marx, J., Verdile, V., & Gibbs, M., Trauma management anemergency medicine approach. St. Louis, Missouri: Mosby, Inc. 2001.Sing, R. & Reilly, P. Initial management of injuries: An evidence based approach. London:BMJ books. 2001.TR-II – 54

Pregnant Trauma Patient AlgorhithmTR-II-QOrigin: 1/99Revised: 8/02PregnantNon-Trauma AlertPatientPregnant Trauma Alert PatientEvaluate in TraumaRoomEvaluate in ED byEDMD 20 weeks< 16 weeks > 16 weeksCleared?(to include Neg. USNeg. HematuriaNeg. Vag Bleed)Notify L & DOB-GYNConsultOB-GYNAdmit?Transfer Centerto call L &DL & D RN torespond t oTrauma RoomYes?D/C to f/uwith PMD andOB-GynNo?1. Trauma Consult2. OB-GynConsultYes?To L &DCleared byEDMD?No?1. TraumaConsult2. OB-GynConsultNo?D/C to f/uwith primaryMD and/orOB-GYNYes?Notify L & DL & D to call OB-Gyn, Neonatalogist, &RTDiagnostic Work-upas indicated byTrauma Surgeonand OB-GYnTR-II – 55

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Title: Medications & DosagesApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-II-ROrigin: 8/02Reviewed:Page: 1 of 4Dilution / ConcentrationFormulation mg ml ConcentrationPan/Vecuronium 10 10 1mg/mlAtropine 1 10 0.1mg/mlLidocaine 2% 100 5 20mg/mlEtomidate 20 10 2mg/mlSuccinylcholine 200 10 20mg/mlPan/VecuroniumAtropineLidocaine 2%EtomidateSuccinylcholinePediatric Dosages0.02mg/kg0.02mg/kg1.5mg/kg0.3mg/kg2mg/kgAdult DosagesPremedicationsPan/Vecuronium1mg1ml(defasiculation)Lidocaine 100mg 5mlInduction AgentEtomidate 20mg 10mlParalytic AgentsSuccinylcholine 100-150mg 5-7.5mlPan/Vecuronium(maintenance)10mg10mlTR-II – 57

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Title: Solu-Medrol“ (methylprednisolone)administration in Spinal Cord InjuryApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-II-SOrigin: 1/99Reviewed: 8/02Page: 1 of 2I. OBJECTIVETo establish a procedure for the safe, effective administration of the Solu-Medrol® Protocolfor Cervical Spine Injured Patients.II.III.POLICYThe Solu-Medrol® Dosing Protocol for Acute Spinal Injury is attached.Copies of the protocol orders are also available in the Trauma Center and in Pharmacy. Thishigh-dose steroid protocol should begin immediately upon receiving physician’s order.PROCEDUREUpon receiving the physician’s order for Solu-Medrol® Protocol, prepare and administerthe bolus dose. The dose is 30mg/kg mixed in 50ml D5W and given over 15 minutes via anIV pump.Contact Pharmacy at 4-7115 and ask for the maintenance drip to be prepared. Must beready to provide the pharmacist with a patient name and weight.(STAT fax a copy of the orders to Pharmacy)Start the maintenance infusion exactly 45 minutes after the 15-minute bolus is infused.Clear the “volume administered” function in the IV pump before initiating the 23-hour drip.This infusion must be completed 23 hours after starting maintenance therapy.If the maintenance drip is discontinued for any period of time during this 23-hour period,The infusion rate must be recalculated to ensure administration of all drug within 23 hours.Recalculate the patient’s drip rate by using the remaining amount of volume and theremaining time (ml/hr). This will ensure that the proper amount is administered within the23-hour time frame.*Administer IV Pepcid® as described on the protocol orders.TR-II – 59

Holmes Regional Medical Center, Inc.Palm Bay Community HospitalPHYSICIANORDERSAppendix 1Solu-Medrol“ Dosing Protocol for Acute Spinal Cord Injury(addressograph)1. Obtain and document the patient’s admission weight: kg2. Contact Pharmacy (x37398 or x37396) with the patient’s weight.3. Pharmacy will use the dosing information and table below to calculate and prepare the Bolus dose and Bag #1initially.4. Since some patients may have their 23-hour infusion discontinued prematurely based on their clinical status,Pharmacy will prepare two separate IV bags to provide this dose. Nursing Staff MUST notify Pharmacy whenBag #2 is needed.5. Solumedrol“ (methylprednisolone) dosing and administration:Bolus Dose:Infusion Dose:30 mg/kg IVPB over 15 minutes (in 50ml D5W)5.4 mg/kg/hr by continuous IV infusion x 23 hoursbegin infusion 45minutes after completion of bolus dose above6. Bolus and infusion doses will be rounded to the nearest 250mg.7. Infusion dosing and bag preparation … mixed in D5W and infused at 10ml/hr (23-hour infusion total)Bag #1 will be prepared as an 11-hour infusion (110ml total volume)Bag #2 will be prepared as 12-hour infusions (120ml total volume each)• If the maintenance drip is discontinued for any period of time during this 23-hour period, the infusion rate must beecalculated to ensure administration of all drug within 23 hours. (refer to Policy and Procedure if necessary)• Recalculate the patient’s drip rate by using the remaining amount of volume and the remaining time (ml/hr).8. Refer to dosing chart below to determine appropriate doses for a given patient weight.Patient Weight(kg)BOLUS DOSE(g)23-hour INFUSIONDOSE (g)11-hr Infusion(Bag #1)40 1.25 5 2g 3g45 1.5 5.5 2.5g 3g50 1.5 6.25 3g 3.25g55 1.75 7 3.5g 3.5g60 1.75 7.5 3.5g 4g65 2 8 4g 4g70 2 8.75 4g 4.75g75 2.25 9.25 4.5g 4.75g80 2.5 10 5g 5g85 2.5 10.5 5g 5.5g90 2.75 11.25 5.5g 5.75g95 2.75 11.75 5.5g 6.25g100 3 12.5 6g 6.5g105 3.25 13 6g 7g110 3.25 13.75 6.5g 7.25g115 3.5 14.25 7g 7.25g120 3.5 15 7g 8g9. Pepcid® 20mg IV q12h. (start Pepcid after “bolus” Solumedrol® dose given)10. Additional Orders::12-hr Infusion(Bag #2)TR-II – 60

Title: American Heart AssociationAdvanced Cardiac Life Support AlgorithmsApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-II-TOrigin: 1/99Reviewed: 8/02Page: 1 of 9TR-II – 61

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Title: American Heart AssociationAdvanced Cardiac Life Support MedicationsApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-II-UOrigin: 1/99Reviewed: 8/02Page: 1 of 20ADENOSINEDOSAGE:6 mg, rapid IV push (1-3 seconds).If, after 1-2 minutes cardioversion does not occur, administer 12 mg, rapid IV push (1-3seconds).INDICATIONS:Paroxysmal supraventricular tachycardia (PSVT), (Class I).Wide-complex tachycardia of uncertain type, (Class IIA).USED TO: Suppress supraventricular tachycardia.ACTIONS: Depresses AV and sinus node activity.SIDE EFFECTS:CVS: Transient bradycardia & ventricular ectopy are common after termination of PSVTwith adenosine.CNS: Dizziness, headache.Others: Facial flushing, shortness of breath, chest pain and nausea.PRECAUTIONS - Should not be used in:Second or third degree heart block.Sick sinus syndrome.Known hypersensitivity to the drug.Use with caution in: Asthma patients.ADDITIONAL INFORMATION:Because adenosine produces a short-lived response of less than 5 seconds, PSVT mayreoccur. Sideeffects usually resolve spontaneously within 1-2 minutes. Administer adenosine directlyinto a vein oradministration port closest to the patient. Flush the line with IV solution afteradministering the drug.TR-II – 71

AMIODARONE HYDROCHLORIDEDOSAGE:Cardiac Arrest: 300mg IV push. Consider repeating 150 mg IV push in 3-5 min. Maxcumulative dose: 2.2 gIV/24 hours.Wide-Complex Tachycardia (stable):Rapid infusion: 150 mg IV over 1st 10 min (15 mg/min). May repeat rapid infusion (150mg IV) q 10 min asneeded.Slow infusion: 360 mg IV over 6 hours (1 mg/min).Maintenance infusion: 540 mg IV over 18 hours (0.5 mg/min).INDICATIONS:Recurrent ventricular fibrillation or recurrent hemodynamically unstable ventriculartachycardianonresponsive to adequate doses of other antiarrhythimics or when alternative agentscan’t be tolerated.USED TO: Suppress ventricular dysrhythmias and raise the fibrillation threshold.ACTIONS: Unknown. Thought to prolong the refractory period and action potentialduration.SIDE EFFECTS:CVS: arrhythmias, heart failure, heart block, sinus arrest, and edema.CNS: tremors, malaise, fatigue, sleep disturbances, insomnia.Other: Nausea and vomiting elevated liver enzymes, hepatic failure, adult respiratorydistress syndrome,severe pulmonary toxicity, photosensitivity, hypothyroidism, coagulation abnormalities.PRECAUTIONS - Should not be used in:Don’t give with procainamide.Second or third degree heart block.Sick sinus syndrome.Known hypersensitivity to the drug.TR-II – 72

ATROPINE SULFATEDOSAGE:In Bradycardia: 0.5-1.0 mg (repeated q 3-5 minutes, to a total of 3 mg or 0.04 mg/kg).In Asystole/PEA: 1 mg (may be repeated in 3-5 minutes, to a total of 0.04 mg/kg).INDICATIONS:Symptomatic bradycardia (Class I).Bradycardia with PVCs.Asystole (Class IIA).PEA (with rate

If intubated and continued long arrest interval (Class IIb).Upon return of spontaneous circulation following long arrest interval (Class IIb).USED TO: Reverse metabolic acidosis.ACTIONS: Buffers metabolic acids.SIDE EFFECTS:CVS: Increased vascular volume.Others: Lowers serum potassium, build up of CO2.PRECAUTIONS (should not be used in):Hypokalemia.CHF.Hypoxic lactic acidosis such as that which occurs in non-intubated patients withprolonged CPR.CALCIUM CHLORIDEDOSAGE: 2-4 mg/kg (10% solution) slow IV push. May be repeated at ten minuteintervals as considerednecessary.INDICATIONS:Acute hyperkalemia.Acute hypocalcemia.Overdose of calcium channel blocker (nifedipine, verapamil, et cetera.)USED TO: Replace electrolytes.ACTIONS: Increase myocardial contractility.SIDE EFFECTS:CVS: Arrhythmias, bradycardia, asystole, hypotension, may cause coronary and cerebralvasospasm.Others: Chalky or metallic taste.PRECAUTIONS (should not be used in): Patients receiving digitalis.ADDITIONAL INFORMATION:IV line should be flushed between calcium chloride and sodium bicarbonateadministration.Calcium Chloride is the antidote of choice for Magnesium Sulfate overdose.Extravasation may cause tissue necrosis.TR-II – 74

DIAZEPAMDOSAGE: 5-10 mg, slow IV push (every 5 minutes, up to a maximum of 20 mg).INDICATIONS:Premedication prior to cardioversion.Acute anxiety states.USED TO: Sedate patients.ACTIONS: Depresses the central nervous system, produces a transient amnesia.SIDE EFFECTS:CVS: Hypotension, reflex tachycardia.CNS: Respiratory depression, apnea, drowsiness, ataxia, and transient amnesia.Others: Warmth, pain, burning or phlebitis extending from IV site; may causethrombosis, nausea and vomiting.PRECAUTIONS (should not be used in):Patients with a history of hypersensitivity.Respiratory depression.Hypotension.ADDITIONAL INFORMATION:Has short duration of effect.Some recommend including an analgesic along with the administration of the sedativethat precedescardioversion.Antidote: Romazicon (0.2 mg over 15 seconds), may repeat four times (total dose not toexceed 1 mg), observefor re-sedation related to Romazicon having shorter half-life than diazepam. May repeat q20 minutes, not toexceed 3 mg/hour.DILTIAZEMDOSAGE:0.25 mg/kg, IV push, followed by a second dose of 0.35 mg/kg.May also be used as a maintenance infusion of 5 to 15 mg/hour to control the ventricularrate in atrialfibrillation.INDICATIONS:Atrial fibrillation/flutter.Refractory atrial tachycardia with normal or elevated B/P.TR-II – 75

USED TO: Suppress supraventricular tachycardia.ACTIONS:Blocks entry of calcium into cells slowing conduction and increasing refractoriness in theAV node. Diltiazemmay terminate reentrant arrhythmias that require AV conduction for their continuation.SIDE EFFECTS:CVS: Conduction disturbances, arrhythmia, hypotension, and bradycardia, CHF,peripheral edema.CNS: Headache, fatigue, drowsiness, dizziness, nervousness, CNS depression, confusion,and insomnia.Others: Nausea, flushing, rash.PRECAUTIONS:May decrease myocardial contractility and exacerbate congestive heart failure in-patientswith severe leftventricular dysfunction.DOBUTAMINEDOSAGE: 2-20 mcg/kg/min, IV infusion.INDICATIONS:Depressed myocardial function(when the systolic B/P is > 100 mmHg and diastolic B/P is normotensive).Cardiogenic shock, CHF.USED TO: Increased cardiac output by increasing myocardial contractility.ACTIONS:Strong B1 stimulant (increased contractility) that has effect on the heart rate.Also has a slight B2 stimulatory effect (some vasodilation).SIDE EFFECTS:CVS: Palpitations, PVCs, tachycardia, and angina increased B/P.CNS: Headache, tremor.Others: Nausea, vomiting.PRECAUTIONS (should not be used in):Hypovolemia.Uncorrected tachycardia.Signs of myocardial ischemia.TR-II – 76

ADDITIONAL INFORMATION:Beta-blockers may inhibit effects.Alkaline solutions may inactivate.Sometimes used with Dopamine or Nitroprusside.Less adverse cardiac effects than Dopamine.Dobutamine should not be used alone in the seriously ill patient withsystolic B/P about 100 mmHg.DOPAMINEDOSAGE: 2-20 mcg/kg/min, IV infusion, titrated to effect (add Norepinephrine ifDopamineis >20 mcg/kg/min).INDICATIONS:Cardiogenic shock (when the systolic B/P is 70-100 mmHg).Other shock (hemodynamically significant hypotension).Refractory bradycardia.USED TO: Increase cardiac output and B/P.ACTIONS:Dopaminergic stimulant (dilates renal and mesenteric blod vessels) at doses of 1-2mcg/kg/min,B1 stimulant (increases cardiac output) at 2-10 mcg/kg/min, a adrenergic stimulant(peripheralvasoconstriction and increased pulmonary occlusive pressure) at > 10 mcg/kg/min.SIDE EFFECTS:CVS: Tachycardia, ectopy, palpitations, and angina.CNS: Headache, tremor.Others: Nausea, vomiting.PRECAUTIONS (should not be used in):Hypotension caused by hypovolemia.Uncorrected tachyarrhythmias.Ventricular fibrillation.Pheochromocytoma.ADDITIONAL INFORMATION:If norepinephrine is used to increase the B/P, move to Dopamine and stopNorepinephrine whenthe B/P improves. Monoamine oxidase inhibitors potentiate the effects of dopamine.TR-II – 77

EPINEPHRINEDOSAGE:In cardiac arrest: 1.0 mg, IV push (may be repeated every 3-5 minutes).In refractory bradycardia: 2-20 mcg/minute, IV infusion.INDICATIONS:Ventricular fibrillation/pulseless ventricular tachycardia.Asystole.Pulseless Electrical Activity.Refractory bradycardia.USED TO: Increase cardiac output.ACTIONS:Strong alpha and beta stimulant (increased heart rate & B/P). It’s alpha adrenergiceffects increase myocardial and cerebral blood flow during CPR.SIDE EFFECTS:CVS: Palpitations, tachycardia, angina, ectopic beats, increased B/P.CNS: Nervousness, anxiety, headache, tremors, and pupil dilation.ADDITIONAL INFORMATION:May be administered via ET route at 2 to 2½ times the IV dose.The doses of intermediate, escalating and high doses as to be considered is thoughtto possibly be associated with a worse neurologic outcome. If 1 mg doses fail,higher doses of epinephrine (up to 0.2 mg/kg) may be considered (Class IIb), butthese higher doses are not recommended and may be harmful.Follow each dose of epinephrine (given by peripheral injection) with a 20-ml normalsaline solution flush or IV fluid to ensure effective distribution of the drug into thecentral compartment.FUROSEMIDEDOSAGE: 0.5-1.0 mg/kg, IV push (typically 20-80 mg).INDICATIONS (circulatory overload):Acute pulmonary edema.Congestive heart failure.Hypertensive crisis.Cerebral edema after cardiac arrest.USED TO: Increased urine output and dilate blood vessels.TR-II – 78

ACTIONS:Inhibits reabsorption of sodium in the proximal and distal renaltubule and loop of Henle. This action results in the excretion ofmore sodium and water. Also has a direct venodilating effect.SIDE EFFECTS:CVS: Potassium depletion with attendant dysrhythmias.CNS: Vertigo, visual/auditory disturbances.Others: Nausea, vomiting, dehydration.PRECAUTIONS (should not be used in):Pregnant women.Hypokalemia.Patients who are allergic to sulfas or thiazides.ISOPROTERENOLDOSAGE: 2-10 mcg/minute, IV infusion (titrated to a heart rate of sixty per minute).INDICATIONS:Hemodynamically compromising bradycardia refractory to atropine.Hemodynamically significant bradycardia in denervated hearts of heart transplants (IIa).Refractory torsades de pointes (IIa).USED TO: Increase the heart rate.ACTIONS:B1 and B2 stimulant with potent inotropic and chronotropic properties that increasecardiac output and myocardial work.SIDE EFFECTS:CVS: Hypotension, palpitations, angina, may lead to worsening of ischemia/infarction.CNS: Dizziness, anxiety, nervousness, headache, tremors.Others: Flushing, sweating, dyspnea, nausea, vomitting.PRECAUTIONS (should not be used in):Patients with cardiac arrest or hypotension.Preexistent tachyarrhythmias.Digitalis toxicity or hypokalemia.Hepatic or renal insufficiency.ADDITIONAL INFORMATION:Isoproterenol should be used with extreme caution, if used at all. At low doses it isClass IIb (possibly helpful); at higher doses it is Class III (harmful).TR-II – 79

LIDOCAINEDOSAGE:If hemodynamically stable: 1-1.5 mg/kg, IV push (repeated q. 5-10 minutes, at0.5-1.5 mg/kg, if necessary, to a total of 3 mg/kg).In ventricular fibrillation/tachycardia: 1.5 mg/kg, IV push (repeat q. 3-5 minutesto a loading dose of 3-5 mg/kg).INDICATIONS (>ventricular ectopy):PVCs.Ventricular tachycardia.Wide-complex tachycardia.Refractory ventricular fibrillation.USED TO: Suppress ventricular arrhythmias, raise fibrillation threshold.ACTIONS:Reduces velocity of electrical impulses through conduction system and disparityin action potential duration between ischemic and normal myocardial zones.SIDE EFFECTS:CVS: Hypotension, bradycardia, conduction disturbances.CNS: CNS depression, drowsiness, dizziness, respiratory depression, numbness /tingling, slurred speech, confusion, tremor, seizures.PRECAUTIONS (should not be used in):3° AV block (with ventricular escape).Bradycardia related PVCs.Idioventricular rhythm.ADDITIONAL INFORMATION:May be administered via ET route at 2 to 2½ times IV dose.In stable conditions, the IV bolus of lidocaine is followed by a 2-4 mg/min, IV infusion.Give lidocaine at half the initial dose in decreased cardiac output (e.g., acute MI,CHF, shock), patients older than 70 years, and those with hepatic dysfunction.MAGNESIUM SULFATE (MgSO4)DOSAGE:In recurrent or refractory VF/VT: 1-2 gm, diluted in 100 ml of D5W, administeredIV push over 1-2 minutes.In documented hypomagnesium: 1-2 gm, diluted in 50-100 ml of D5W, adminsiteredover 50-60 min. An infusion of 0.5-1.0 grams/hour, should follow for up to 24 hours.TR-II – 80

INDICATIONS:Torsades de pointes.Suspected hypomagnesium state.Severe recurent or refractory ventricular fibrillation.Digoxin Toxicity.USED TO: Reverse refractory ventricular fibrillation, hypomagnesium.ACTIONS: Stabilizes muscle cell membranes by interacting with thesodium/potassium exchange.SIDE EFFECTS:CVS: Cardiac arrest.CNS: Drowsiness, respiratory depression.PRECAUTIONS (should not be used in):Renal disease.Heart block.NOTE: Caution should be used when magnesium is administered to safeguardagainst clinically significant hypotensionor asystole.MORPHINE SULFATE (MSO4)DOSAGE: 1-3 mg, slow IV push (as often as q. 5 min).INDICATIONS:Pulmonary edema due to CHF (Class IIb).Pain associated with AMI.USED TO: Relieve pain and dilate blood vessels.ACTIONS: Analgesia, vasodilation (which reduces myocardialoxygen consumption), and sedation.SIDE EFFECTS:CVS: Hypotension, bradycardia.CNS: Respiratory depression/apnea, CNS depression, euphoria,drowsiness, dizziness, weakness, paradoxicaL CNS stimulation,nervousness, anxiety, headache, seizure, coma.Other: Flushing, nausea, vomitting, pupil constriction.PRECAUTIONS (should not be used in):Head Injury.Volume depletion.Undiagnosed abdominal pain.TR-II – 81

Patients with hypersensitivity to the drug.NOTE: Naloxone (narcan) should be available to reverse significantside effects such as respiratory depression or hypotension.NITROGLYCERINDOSAGE:With chest pain: 0.3 to 0.5 mg tablet SL----- (may be repeated q. 3-5 minutes up to a total of 1.2 mg).In congestive heart failure: 10-20 mcg/min, IV infusion.INDICATIONS:Ischemic chest pain.AMI.Selected cases of pulmonary edema due to CHF.USED TO: Improve coronary circulation and reduce myocardial workload.ACTIONS: Smooth muscle relaxant, reduces cardiac workload, dilatescoronary arteries, dilates systemic arteries.SIDE EFFECTS:CVS: Hypotension, bradycardia, paradoxical angina, reflex tachycardia, palpitations.CNS: Throbbing headache, dizziness, weakness.OTHERS: Flushing, feelings of warmth, nausea, vomitting, hypoxemia caused byincreased pulmonary ventilation-perfusion mismatch, methemoglobinemia.PRECAUTIONS (should not be used in):Increased intracranial pressure.Hypotension.Glaucoma.Hypovolemia.Suspected tamponade or pericarditis.NITROPRUSSIDEDOSAGE: 0.1-5.0 mcg/kg/min, IV infusion.INDICATIONS:Acute hypertensive crisis.CHF, cardiogenic shock.USED TO: Improve cardiac output.TR-II – 82

ACTIONS:Potent, rapid-acting direct peripheral vasodilator used to treat heart failure andhypertension. Nitroprusside reduces peripheral arterial resistance (afterload).SIDE EFFECTS:CVS: Hypotension, reflex tachycardia, palpitations, angina.CNS: CNS depression.Others: Thiocyanate toxicity, may cause warmth, pain, burning or phlebitisextending from IVsite.PRECAUTIONS (Should not be used in):Compensatory hypertension.Dissecting aneurysm.ADDITIONAL INFORMATION:Reduce the BP slowly.Extravasation cause tissue necrosis.NOREPINEPHRINEDOSAGE: 16-20 mcg/min, IV infusion.INDICATIONS: Severe inappropriate systemic vascularresistance (when the systolic B/P is

INDICATIONS:Prevention or treatment of hypoxemia (global or local) from any cause.Myocardial ischemia/infarction.Respiratory difficulty.Cardiac arrest.USED TO: Relieve hypoxemia.ACTIONS: Increases PaO2 and hemoglobin oxygen saturation.SIDE EFFECTS: None with short-term use.PRECAUTIONS:A concentration of 24-35% oxygen should be used when the stablepatient has a history of COPD.PROCAINAMIDEDOSAGE:Ventricular tachycardia: 20-30 mg/minute, IV push. (Loading Dose)Refractory ventricular fibrillation: 30 mg/minute, IV push.INDICATIONS:Frequent PVCs.Wide-complex tachycardia.Ventricular fibrillation/tachycardia.USED TO: Suppress ventricular ectopy and raise the fibrillation threshold.ACTIONS:Slows conduction through myocardium by increasing electrical thresholdof ventricle, HIS Purkinje system.SIDE EFFECTS:CVS: Hypotension, eflex tachycardia, ventricular fibrilation, AV block,widened QRS, bradycardia, asystole.CNS: CNS depression, hallucination, confusion, dizziness, seizures.Others: Nausea, vomitting, fever.PRECAUTIONS (should not be used in):Complete AV block.Digitalis toxicity.Preexisting QT prolongation.Torsades de pointes.ADDITIONAL INFORMATION:TR-II – 84

End points of procainamide administration are:suppression of the dysrhythmia.total of 17 mg/kg given.more than 50% widening of QRS complex.hypotension ensues.If procainamide suppresses VT, start continuous infusion at 1-4 mg/minute.The maintenance dose should be reduced in renal failure.VASOPRESSINDOSAGE:40 U IV, single dose, 1 time only.INDICATIONS:Ventricular Fibrillation/Pulseless Ventricular Tachycardia (VF/VT).USED TO: Increases blood flow to the brain and heart during CPR.ACTIONS: Naturally occurring antidiuretic hormone, becomes a powerfulvasoconstrictor when used at much higher doses than those normally observedin the body without having the negative, adverse effects of epinephrine on theheart, such as increased ischemia and irritability and paradoxically, thepropensity for VF.SIDE EFFECTS:CVS: Vasoconstriction, arrhythmias, cardiac arrest, myocardial ischemia,circumoral pallor, decreased cardiac output, angina in patients with vasculardisease.CNS: Tremor, headache, vertigo.GI: Abdominal cramps, nausea, vomiting, flatulence.Skin: Diaphoresis, cutaneous gangrene.Others: Water intoxication, hypersensitivity reactions including urticaria,angioedema, bronchoconstriction, anaphylaxis.PRECAUTIONS (should not be used in):Patients with chronic nephritis and nitrogen retention.VERAPAMILDOSAGE:2.5 to 5 mg, slow IV push (over two minutes).If tachycardia is not resolved in 15-30 min: 5-10 mg, slow IV push(repeated q 15-30 minutes to a maximum of 20 mg).TR-II – 85

INDICATIONS (refractory supraventricular tachycardia):Narrow complex PSVT refractory to vagal and adenosine withnormal/elevated BP.Rate control in atrial fibrillation.Ventricular rate control in atrial flutter, multifocal atrial tachycardia.USED TO: Suppress supraventricular tachyarrhythmias.ACTIONS: Calcium channel blocker, antiarrhythmic.SIDE EFFECTS:CVS: Hypotension, AV or sinus blocks, bradycardia, asystole,tachycardia, may exacerbate CHF/pulmonary edema.CNS: Dizziness, headache, seizures.Others: Nausea, abdominal discomfort, sweatyness, flushing.PRECAUTIONS (should not be used in):Severe hypotension.Cardiogenic shock.Severe CHF.2° and 3° AV block.Sick sinus syndrome.Patients receiving intravenous beta adrenergic blocking drugs.ADDITIONAL INFORMATION:Give only in dysrhythmias known with certainty to be supraventricular.May decrease myocardial contractility and exacerbate congestive heartfailure in patients with left ventricular dysfunction.TR-II – 86

Title: Blunt Head Trauma Patients on CoumadinApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-III-AOrigin: 1/99Reviewed: 8/02Page: 1 of 1POLICY:The evaluation of a blunt head trauma victim who is on Coumadin presents achallenge to health care providers. Specifically, this is true of the elderlytrauma patient in whom cerebral vessels are much more friable and result in agreater potential for vascular damage and subsequent neurological injury. Itmust be remembered that a normal neurological exam does not preclude adeveloping process. This group of patents can initially present intact andtherefore, one must maintain a high index of suspicion.PROCEDURE:In consideration of the above, any patient with a history of blunt head traumawho is on Coumadin should not be released without consideration of theguidelines listed below:1. Stat CT scan2. PT/PTT3. Consideration of anticoagulation reversal4. Possible inpatient observationTR-III – 1

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Title: Cervical Spine ClearanceApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-III-BOrigin: 1/99Reviewed: 8/02Page: 1 of 2I. OBJECTIVE:To ensure timely, efficient and accurate clearance of the cervicalspine for Trauma Patients for patient comfort and to prevent skinbreakdown.II.POLICY:Trauma Alert patients and any trauma patient who is admitted tothe Trauma Service will have their cervical immobilization devicesremoved as soon as possible. Cervical collars should not beremoved until it has been determined that abnormalities of thecervical spine that would make such removal dangerous are notpresent.This policy applies for all trauma patients admitted to theTrauma Service.III. PROCEDURE:The following procedure will be followed when clearing thecervical spine:1. All cervical spine the radiologist or the trauma surgeonbefore the cervical collar will review x-rays is removed.2. The radiologist will review the cervical spine x-rays pertrauma protocol and the official radiology report will beavailable by phone, fax, and dictation in a timely fashion.All trauma radiographs will be treated as “wet readings”necessitating immediate reporting to the trauma physicianor trauma center nursing staff.3. If the radiologist's reading suggests the need for repeatfilms, these films will be repeated in the x-ray departmentwhere the patient will remain pending results of the “wetreadings”. If repeat or additional studies are necessary, theywill be automatically obtained through this protocol.TR-III – 3

4. The trauma surgeon or the physician assistant will completethe removal of the collar or nurse practitioner only whenthe official radiology reading is available by any of theabove three methods and that reading is negative; and onlyafter clinical examination reveals no pain or neurologicdeficits. This, of course, presumes adequate visualizationof the cervical spine.5. If clinical exam reveals pain or deficits and the cervical x-rays have been read as negative, the cervical collar will notbe removed and the trauma surgeon will determine the needfor additional radiographs.6. All seven cervical vertebrae must be visualized beforeclearance can be given to remove the immobilizationdevices and move the patient. The standard method forvisualization will be:a. A cross-table lateral cervical spine with someonepulling down on the patients shoulders if necessary.*Note: a swimmers view is sometimes needed tovisualize C7.b. AP and Oblique views with open mouth Odontoid.If the technologist is unable to obtain satisfactory viewsof all seven cervical vertebrae to include the superiorend plate of the first thoracic vertebrae, they willinitiate the standing order protocol for a CT of thecervical spine and notify the trauma physician of this.This will be an approved order protocol for patientsmeeting the criteria. (See below).Standing order for Cervical Spine trauma:If unable to satisfactorily visualize the seven cervical vertebraethrough the traditional x-ray methods, then do a CT of the cervicalspine; Order #12050 CT Cervical Spine without contrast.This is the standard of practice that has been agreed upon bythe trauma physicians and the radiologists to ensure timelydiagnosis and disposition of trauma patients.7. Cervical spine clearance will occur as promptly as possiblewhile considering risks from potentially unrecognized spineinjuries.8. All patients will be monitored for skin breakdown whilecervical immobilization devices are in place.TR-III – 4

Title: Indications for Trauma Psychology ServicesApproved By: Emran Imami, MDTrauma Medical DirectorNo. TR-III-COrigin: 6/01Reviewed: 8/02Page 1 of 2I. OBJECTIVE:A. Provide prompt psychological assessment and treatment of all patients in acutepsychological distress, referred to the Florida Brain and Spinal Cord InjuryProgram, with comorbid psychiatric conditions, or substance abuse problemsregardless of ability to pay.B. Provide emotional support to family members of patients during the acute phaseof a medical crisis and assist the families to mobilize their own availableresources.C. Participate in hospital and UF committees to ensure the psychological aspects ofpatient care are recognized and given consideration through formal policies.D. Provide education and support to staff through CEU presentations, stressdebriefings, and informal consultations.E. Engage in trauma related social research to advance the field of psychologythrough professional presentations, publication in peer reviewed journals, andsupervision of psychology students.F. Provide courtesy consultation/liaison service to surgical sub-specialties.II. DEFINITIONS:A. Acute Psychological Distress-emotional distress sufficient to impede patient’sability to participate in medical treatment decisions.B. Comorbid Psychiatric Conditions-prior history of Major Depression, BipolarDisorder, Schizophrenia that interfere with the patient’s physical recovery.C. Substance Abuse-continued substance use despite impairment in judgment, social,occupational, and other important areas of functioning.D. Acute Stress Reaction-patient exposed to a traumatic event experiences numbing,nightmares, flashbacks, heightened startle response, hypervigilance, recurrentthoughts, or avoidance of reminders of the traumatic event.III. POLICYHolmes Regional Trauma Center provides timely psychological services by theTrauma Psychologist or a student under the direct supervision of the Psychologistto patients and family members who require emotional support during the acutephase of a medical crisis. The Psychological Assessment shall consist of a socialhistory, psychiatric history, mental status examination, diagnosis, treatment plan,and recommendations. Patients will be seen regardless of ability to pay.TR-III – 5

IV. PROCEDURE:A. Psychological services shall be initiated by the attending physician or physicianextender requesting a consultation when evident psychological issues interferewith the patient’s plan of care or when premorbid family dynamics create adisturbance sufficient enough to impact the patient’s well-being. Appropriatereferrals include but are not limited to: TBI, SCI, trauma related deaths, acutestress reactions, comorbid psychiatric disorders, traumatic amputation, suicideattempts, mental status changes, substance abuse, and domestic violence. Socialwork or case manager should direct recommendations to the attending orphysician extender so they may request a psychology consultation.B. A psychological evaluation shall be performed by the Trauma Psychologist andtreatment recommendations provided upon completion of the evaluation. ThePsychologist shall follow the patient while in the hospital to providepsychological support and ongoing assessment for such mental disorders asdepression, anxiety, or difficult adjustment. Patients with a premorbid psychiatriccondition shall be monitored while in the hospital for signs of decompensation.Patients who arrive under the influence of any licit or illicit substance will beproperly counseled on their increased risk of subsequent traumas.C. In cases where pharmacotherapy may be required, a psychiatry consultation willbe recommended to the attending physician.D. Patients who verbalize suicidal or homicidal ideations, plan, or intent shall beevaluated for dangerousness to determine need for continuous observation whilehospitalized and prior to discharge in order to determine if the patient meetsBaker Act criteria for transfer to a receiving facility for a psychiatric evaluation.E. Emotional support shall be provided to family members exhibiting acute distressthrough a consultation for the patient to direct family members’ emotionalresponse to more acceptable forms of expression. Assistance is also availablewhen withdrawal of life support is indicated to address end of life issues forfamily members.F. Patients, who are medically cleared for discharge, however, require continuedpsychological care shall be referred to a provider covered by the patient’sinsurance carrier.G. Indigent patients that are to return to the community and have limited access tomental health resources shall be referred to appropriate resources in thecommunity designated to assist unfunded patients.H. The Trauma Psychologist shall also interview all patients seen by a student toproduce a separate evaluation and to ensure all student reports are acceptable priorto being co-signed by the Psychologist.TR-III – 6

Title: Transportation of Trauma Patients From theResuscitation AreaApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-III-DOrigin: 1/99Reviewed: 8/02Page: 1 of 1POLICY:Trauma patients requiring procedures for which they must leave the TraumaResuscitation Room and/or the Emergency Department (ED), will have theappropriate personnel in attendance and any equipment necessary in order to ensurethe safety of the patient and the continuity of care.PROCEDURE:1. Trauma patients requiring procedures within the ED (e.g. CT scan, etc.),will be accompanied by appropriate personnel*, equipment**, etc.2. Trauma patients being transported to another department for a diagnostic procedureor examination (e.g. special procedures, etc.) will be accompanied by appropriatepersonnel*, equipment**, etc.3. Documentation of the patient’s status throughout any procedure/examination willcontinue on the trauma flow sheet.*Appropriate personnel may include nursing staff, respiratory therapist, etc. and isdependent on the patent’s condition. Any patient who is admitted to the ICU will have, ata minimum, one RN and a paramedic in attendance. If the patient is being admitted tothe ICU and is transported to another department for an examination or procedure, theED nurse may relinquish care to the ICU nurse if deemed appropriate by the attendingphysician/charge nurse.**Equipment may include but will not be limited to portable oxygen, ventilator, pulseoximetry, end tidal C02, suction capabilities, cardiac monitor/defibrillator, blood pressuremonitoring, resuscitative devices such as the Level 1, etc.TR-III – 7

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Title: Guideline for Cross Coverage of EmergencyDepartment by Trauma Center NursesApproved By: Emran Imami, MDTrauma Medical DirectorMichele Ziglav, RNTrauma Program ManagerNo.: TR-IV-AOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. OBJECTIVE:To assist in cross covering the Emergency Department by Trauma CenterNurses.II.III.POLICY:The policy is a guideline designed to assist the Emergency Department tosupplement nursing care.PROCEDURE:A. Trauma nurses shall contact the ED Clinical Charge Nurse (CCN) to seeif assistance in patient care is needed after performing the room check,trauma patient follow-ups and other daily routine responsibilities. Thisshould be within the first one to two hours of arrival on duty.B. Exceptions to the aforementioned statement would be if the TraumaNurses have a trauma patient or a trauma alert response has beenactivated. Other exceptions may arise that are not stated in this guideline.C. Assignments to the Trauma Center Nurses shall be patients in minor careand/or patients that will have a quick turn around time.D. The ED CCN shall have a back-up plan in case the Trauma Nurse has torespond to a trauma alert activation and will communicate back-up planto the Trauma Center Nurse.E. There shall always be another ED Staff Nurse or Charge Nurseimmediately available to take over the nursing care of a patient in traumaactivation situations. If the CCN has identified whom the ED Nurse isthat will assume care, this should be shared with the Trauma CenterNurse.F. When the Trauma Center Nurse transitions the care to the ED Nurse, theTrauma Center Nurse shall document the following in the nursing notes:1. Name of the ED Nurse in which the nursing care was transferred to2. Date and time3. Trauma Center Nurse’s signatureG. Following are examples of situations that may compromise the TraumaCenter Nurses availability to respond to a trauma alert activation andshould be avoided.1. Transporting patients2. Caring for critical care patients3. Assisting with conscious sedationTR-IV – 1

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Title: Internal Trauma Alert Activation (Red and Blue)No.: TR-IV-BApproved By: Emran Imami, MDTrauma Medical DirectorOrigin: 5/02Reviewed: 8/02Page: 1 of 5I. DESCRIPTION:The Internal Trauma Alert Activation guideline shall be initiated when injuredpatients meet the Internal Trauma Alert Criteria.II.III.IV.OBJECTIVE:To improve utilization of appropriate resources and to contain costsPOLICY:The trauma team will respond to the Trauma Center without delay when notifiedof the impending arrival of the trauma patient. Resources and personnel aremobilized to ensure immediate and appropriate care of the trauma patient. SeeInternal Trauma Alert Activation Criteria Table for Red/Blue categories.PROCEDURE:1. Upon notification by the flight team that a Trauma Alert patient isto be delivered to the Trauma Center, First Flight dispatch centerwill notify the Trauma Team by paging a TRAUMA ALERT.2. The First Flight team member will report:a. Patient assessmentb. Mechanism of injuryc. Interventionsd. Patient Trauma Alert Activation Category (Red/Blue)3. The Dispatch Center will page out:a. TRAUMA ALERTb. 10 MINUTE ETAc. RED or BLUE4. First Flight Dispatch will call the Trauma Center and provideverbal notification of the arriving Trauma Alert patient and reportof condition.5. If a Trauma Alert is activated and the patient is transported to theTrauma Center by one of the following methods: 1) groundambulance, 2) aeromedical program not oriented to the InternalTrauma Alter Activation Criteria, or 3) private vehicle, the FirstFlight Dispatcher will notify the Trauma Team by calling aTrauma Alert RED and will give a 10 minute notice whenpossible. If there is less than a 10 minute ETA, the dispatcher willcall an IMMEDIATE RESPONSE RED.TR-IV – 3

6. To ensure that injured patients receive appropriate medical care,the following criteria shall guide health care professionals inrendering trauma care.TR-IV – 4

Internal Trauma Alert Activation CriteriaComponent Trauma Red Activation Criteria Resources for Trauma Trauma Blue Activation Criteria Resources for Trauma BlueRedAirway R Active airway assistance (allintubated patients)R Respiratory distressR Unstable airwayCirculation R Hemodynamic instabilityLevel ofConsciousnessPenetratingInjuries(B/P < 90 mm Hg, or HR < 50 orHR > 120/min)R Unresponsive (GCS < 12), orBMR < 4R Penetrating head, neck or torsoinjury (i.e. GSW)Team MembersResponding to AlertTrauma AttendingED AttendingPhysician ExtenderTrauma Center Nurses (2)EMT-ParamedicOR RNRadiology TechnologistRespiratory TherapistUltrasound TechnologistSecurity OfficerR RR > 30R Sustained HR > 120R Altered LOC (GCS > 12)R BMR = 5R Penetrating wound to extremityTeam Members Responding toAlertTrauma AttendingED AttendingPhysician ExtenderTrauma Center Nurses (2)Radiology TechnologistUltrasound TechnologistSecurity OfficerBurns R Significant inhalation injury R 2 nd or 3 rd burns > 15% TBSAR High-voltage electrical injurySoft Tissue R Traumatic amputationR Major degloving injury or flapavulsionAbdominal R Suspected intra-abdominal injuryMS/Neurovascular Open or unstable pelvic fx R Femur, pelvic fxMechanism ofinjuryTeam Members on NoticeBlood BankCT ScanSocial ServicesPastoral CareSICU Charge Nurse6 West Charge NurseCRNA/AnesthesiaFirst FlightAdministrative SupervisorTrauma Program ManagerCase ManagerRegistrationR Spinal cord injuryR Extremity with neurovascularcompromiseR Ejected from high speed MVCR Rollover MVCR High-speed MVCR Steering wheel deformity (driver)R Automobile pedestrian- bicycleinjuryR MCC > 20 mphR Fall > 10 feetTeam Members on NoticeBlood BankCT ScanSocial ServicesPastoral CareSICU Charge Nurse6 West Charge NurseCRNA/AnesthesiaFirst FlightAdministrative SupervisorTrauma Program ManagerRespiratory TherapistOR RNEMT-ParamedicCase ManagerRegistrationAge R Lower threshold for patient’s > 55Judgment R EMT-Paramedic or RN R EMT-Paramedic or RNTR-IV – 5

INTERNAL TRAUMA ALERT RED/BLUE PAGING ALGORITHMTrauma Alert ActivatedGround/other aeromedical teamFirst FlightPage “Trauma Alert” Page “Trauma Alert”Page “Trauma Alert 10 min. ETARED”(at 10 min. ETA)Page “Trauma Alert 10 min.ETA RED” or “Trauma Alert10 min. ETA BLUE” asinstructed by flight crew.TR-IV – 6

Title: Launching of First Flight for Trauma Alert PatientsApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-IV-COrigin: 12/98Reviewed: 8/02Page: 1 of 2I. OBJECTIVE:To establish specific guidelines for the launching of First Flight for Trauma Alertpatients.II.III.DEFINITION:Trauma alert patients are identified as those patients who have sustained seriousinjuries and meet the Trauma Alert Criteria (attached), that require a Level II facility.POLICY:A. Communications dispatcher will launch First Flight immediately at the request of anyEMS agency, Fire Department, and Police Department, for prehospital.B. If communications dispatcher receives an initial call from a referring emergencydepartment (within Brevard and Indian River Counties) that have a trauma alertpatient in their ED and is less than one (1) hour from initial time of injury, First Flightwill be launched immediately and the Trauma teams will be notified as per protocol.C. If communications dispatcher receives an initial call from a referring emergencydepartment (within Brevard and Indian River Counties) that have a trauma patient inthe ED and is more than one (1) hour from time of initial injury, the dispatcher willcontact the Trauma Surgeon on call and refer the request to him.D. If the communication dispatcher receives an initial call from a referring emergencydepartment that is not within Brevard and Indian River County, who has a traumapatient, the communication specialist will request the following:l. Medical records2. EMS run sheet3. History and physical4. Nurses notes5. Physician notes6. Face SheetAfter receiving the above information the communication specialist will then notify Dr.Imami for approval.IV.PROCEDURE:A. Upon receiving a request for prehospital the First Flight team will be toned out bynormal procedure.TR-IV – 7

B. If the communications dispatcher receives a call from a referring emergencydepartment (within Brevard and Indian River Counties) who has a trauma patient thatmeets the one (1) hour criteria specified in B above, the First Flight team will betoned out by normal procedure. Once the team is toned out, the communicationsdispatcher will page T1 and T2 using the paging key F2 (interfacility). When theFlight Team is inbound with the patient, and ten (10) minutes out, thecommunications dispatcher will activate group pages T1 and T2 and paging key F3(10 minute ETA).C. If the referring facility has a trauma patient that has been in the facility for greaterthan one hour and the facility is within Brevard and Indian River Counties), thecommunications dispatcher will notify the Trauma Surgeon, who will call thereferring agency and talk with the ED physician. He will then make the decision if hewants the patient transferred by First Flight or ground.D. If the decision is made to accept the patient the Trauma Surgeon will then notify theCommunication Center and advise if the patient needs air transport or will be comingby ground. The Communication Specialist will then proceed with the appropriateprocedure for transport and the appropriate Trauma System paging.TR-IV – 8

Title: Neurosurgeon Response TimeApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-IV-DOrigin: 1/00Reviewed: 8/02Page: 1 of 2I. OBJECTIVETo provide triage criteria in order to identify those patients who require that aneurosurgeon by available in house immediately.II.III.DEFINITION:Upon arrival to the State Approved Trauma Center the patient is evaluated by theTrauma Surgeon who will classify the patient as: Emergent, the Neurosurgeon on callmust respond within 30 minutes of the initial phone call from the Trauma Surgeon;Urgent, the Neurosurgeon on call will be immediately available to respond to theTrauma Room upon notification by the Trauma Surgeon; or Stable, the Neurosurgeonon call and the Trauma Surgeon on call determine the appropriate responsiveness ofthe Neurosurgeon.POLICYThe Trauma Surgeon on call will assess the trauma alert patient upon his/her arrival tothe Trauma Room. If the patient is determined to have a significant head injury theTrauma Surgeon on call will determine the need for an in-hospital neurosurgeon byclassifying the patient as Emergent, Urgent, or Stable using the following criteria:Emergent1. Brain or dura exposed2. CSF leak3. Impalement injuries4. Missile wounds5. Seizure6. Pupillary changes without direct injury to the eye.7. Obvious neurologic deficit.a. Hemiparesisb. Aphasiac. Cranial nerve palsy8. Glasgow Coma Scale 9 or below.9. Evidence of diffuse injury resulting in small ventricle10. Upon the Discretion of the Trauma SurgeonTR-IV – 9

Urgent1. Increasingly severe headache2. Spine fracture3. Clinical evidence of a basilar skull fracture.a. Raccoon eyesb. Battle sign (Neither of these may be present immediately)c. Hemotympanum4. Palpable evidence of a depressed skull fracture confirmed by CT or x-ray.5. Changes on CT scan.a. Skull fracture.b. Extra-axial hemorrhages1. Extradural2. Subdural3. Subarachnoidc. Intra-axial hemorrhages1. Hemorrhage2. ContusionStable1. Definite loss of consciousness which lasted under 5 minutes.Completely negative neurological examination.2. Head Injury with no loss of consciousness and negative neurologicalexamination.**If there is an agreement between the attending physician and the neurosurgeon thata delay in neurosurgical consultation is in order this should be documented on themedical record. This should include the name of the attending physician and theneurosurgeon, the time of the telephone discussion, and the agreement reached.TR-IV – 10

Title: Notification of Backup TraumaSurgeon of Trauma AlertApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-IV-EOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. OBJECTIVE:To summon the backup trauma surgeon on call to respond emergently to the traumacenter to care for the Trauma Alert patient.II.POLICY:In the event that the Trauma Surgeon on call is in the operating room with a traumapatient, or unavailable for other trauma/surgical emergencies, the surgeon on SECONDcall (BACKUP) will be called according to pre-established guidelines. This process willensure appropriate care of the trauma patient.III.PROCEDURE:Adult backup coverage will be determined as follows:1. If the Trauma Surgeon on primary trauma call has taken a patientto the OR from the ED, the trauma staff has the responsibility ofnotifying Dispatch to call the backup Trauma Surgeon.2. If the patient goes from another area in the hospital to the OR, it isthe responsibility of the Trauma Surgeon to notify Dispatch to callthe backup Trauma Surgeon.3. In the event that the Trauma Surgeon and the backup TraumaSurgeon are both in the operating room, the Director of the TraumaService will be notified within ten minutes.4. If one of the Trauma Surgeons in the operating room is theDirector of the Trauma Service, he will determine the next traumasurgeon to be called.5. In the event the Director of the Trauma Service is out of town, adesignated backup Director for the Trauma Service will beassigned.TR-IV – 11

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Title: Notification of Subspecialty PhysiciansApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-IV-FOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. OBJECTIVE:To summon appropriate subspecialty physicians to respond to the trauma center to assistin the management of the Trauma Alert patient.II.POLICY:Patients with multiple system injuries are under the care of the Trauma Surgeon who willconsult with subspecialty physicians as indicated.III.PROCEDURE:1. The on-call schedule for all subspecialty physicians is provided tothe Trauma Room on a daily basis by the HRMC operators and isimmediately accessible.2. Subspecialty consults can be the physician of the patient’s choiceor the physician on call for that service.3. The Attending Trauma Surgeon in charge of the case will directnotification of subspecialty consults.4. The subspecialty physician must respond within 30 minutes of theinitial phone call by the Trauma Surgeon. If the Trauma Surgeonrequests the subspecialty physician to come in, the physician mustarrive within 1 hour of the request.5. All Trauma Alert patients will be admitted to the Trauma Service.6. All trauma consults will be admitted to a surgical service.7. It is preferred that the Trauma Service admit all trauma consultsfor a minimum period of observation prior to transferring toanother service unless prior discussion among the attendingsurgeon and other involved physician negates this pre-establishedguideline.TR-IV – 13

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Title: Notification of Trauma Surgeon of Trauma AlertNo.: TR-IV-GOrigin: 1/99Reviewed: 8/02Approved By: Emran Imami, MD Page: 1 of 1Trauma Medical DirectorI. OBJECTIVE:To summon the trauma surgeon on call to respond emergently to the trauma center tocare for the Trauma Alert patient.II.III.POLICY:All Surgeons taking Trauma Call will be paged via their trauma group page beeper toensure prompt notification and response to the Trauma Resuscitation Room (TRR).PROCEDURE:The following procedure will be followed when notifying the Trauma Surgeon of theimpending arrival of a Trauma Alert Patient.1. First Flight Dispatch will notify the Trauma Surgeon by traumagroup page beeper.2. The Trauma Surgeon will respond by calling the numberimmediately to notify Dispatch that he/she received the page and toreport his/her ETA to the TRR.3. Dispatch will keep a log of the above notification and responsetimes.4. Dispatch will expect a return call to the dispatch office from theTrauma Surgeon within 10 minutes. In the event the TraumaSurgeon does not respond within 5 minutes, the page will berepeated once, and dispatch will also attempt to contact the TraumaSurgeon through other means, (office, home, cellular, or regularbeeper), for an additional 10 minutes.5. If the Trauma Surgeon does not respond within the 15 minutes, thebackup Trauma Surgeon will be notified as per policy.6. For greater than two trauma alerts presenting to the EDsimultaneously, the Director of the Trauma Service will benotified.TR-IV – 15

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Title: PACU CallApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-IV-HOrigin: 1/99Reviewed: 8/02Page: 1 of 1HEALTH FIRST, INC.DEPARTMENT OF SURGICAL SERVICESTITLE: PACU CALLNO:EFFECTIVE DATE:REVISION DATE: 10/96,12/98, 02/00I. OBJECTIVE:To provide post anesthesia call on a 24-hour basis.II. POLICY:Personnel will cover call as schedule by their department. Call may consist of:• Primary (1 st call)• Back –up (2 nd call) – as indicated by ICU, children 9 and under, multiple patients, or at thediscretion of the primary nurse• Ancillary staff on call ( when second person needed in PACU)The call team covers the unit after regular working hours, weekend and holidays. Two personnelmust be present at all times when taking care of PACU patient.III. PROCEDURE1. Associates on call must be present within 30 minutes of notification.2. Call personnel will be accessible for the duration of their call obligation (telephone orbeeper).3. SICU charge nurse is available in house to cover PACU during traumas until the PACUnurse on call arrives.4. During a Disaster by the primary call RN will evaluate PACU readiness and take thenecessary actions as defined by the Disaster Manual to secure adequate PACU staffing.TR-IV – 17

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Title: Radiologic Technologist Response to aTrauma AlertApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-IV-IOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. OBJECTIVETo provide a consistent and expeditious response to the radiographic needs of the traumapatient from the Department of Radiology.II.III.POLICYThe response of the radiologic technologist to a trauma alert patient will follow preestablishedguidelines.PROCEDURE1. Immediately and without delay upon notification via traumabeeper, the designated radiologic technologist reports to the traumaresuscitation room (TRR).2. After obtaining pertinent information such as age, type of injury,and estimated time of arrival, the technologist takes appropriatefilm to the TRR.3. X-rays that have been ordered by the trauma team leader areperformed. Technologist should be prepared for x-rays of thecervical spine, chest, and pelvis.4. Films are processed and provided to the Trauma surgeon and thenreturned to the radiologist for interpretation. During times whenthe radiologist is not in-house, films may be reviewed byteleradiography.5. The radiologist will respond to the trauma center when requestedby the trauma surgeon.6. The technologist remains available for the trauma patient untildismissed by the trauma surgeon or his/her designee.TR-IV – 19

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Title: Trauma System Paging ChecklistApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR –IV-JOrigin: 1/99Reviewed: 8/02Page: 1 of 2I. OBJECTIVE:To establish a system for daily checks for the trauma pagers.II.III.DEFINITION:Trauma pagers are those pagers that are assigned to the responding in-house andout-of-house trauma teams.POLICY:A. It will be the responsibility of the First Flight Transfer CenterCommunication Specialist to do daily pager checks for all trauma pagers.B. It will be the responsibility of the First Flight Transfer Center CommunicationSpecialist to log all responses to the trauma pager test daily.IV.PROCEDURE:A. The communication specialist will do a group page daily between 7 am and 8 amon in-house.B. The communication specialist will do a group page daily between 7 am and 8 amfor all out of house pagers.C. The communication specialist will do a group page daily at 1700 on the out-ofhousetrauma pager (T1) for the Trauma surgeon that assumes primary call at 5pm.D. The communication specialist, using the Quik-Tel paging system, will use T1- foroutside group pagers, and T2 for in-house group pagers.E. The communication specialist, using the Quik-Tel paging system, will use F6 (testpage call 47296.)F. Upon each response of the trauma team (in-house and outside pagers) thecommunication specialist will place a check in the daily log sheet beside thatresponding team member.TR-IV – 21

G. If the primary pm trauma physician fails to respond to the pager test within 15minutes at the 1700 test time, the communication specialist will:l. call his office2. call his personal pager3. call his home4. individually page assigned trauma numberIf all above fails, contact the backup Trauma surgeon and contact the TraumaMedical Director.H. If any member fails to respond to the group page the communication specialistwill:l. Call that members extension for their department (provided on thedaily log sheet), or2. Do individual pager test for those that do not respond.3. After attempting the above steps in procedure E, with no response,the communication specialist will document that no response wasreceived, and notify the Chief Flight Nurse.I. It will then be the Chief Flight Nurses responsibility to correct the problem, andnotify the transfer center.J. The communication specialist will keep a daily log sheet by the monthin a notebook that will remain in the transfer center. This log will bereviewed with the Emergency Services Director monthly.TR-IV – 22

Title: Trauma Team ResponseApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR –IV-KOrigin: 1/99Reviewed: 8/02Page: 1 of 2I. OBJECTIVE:To rapidly mobilize the necessary trauma team members and resources necessary toensure immediate evaluation and treatment of the TRAUMA ALERT patient.II.III.POLICY:The trauma team will respond to the designated trauma room in the Trauma Centerwithout delay when notified of the impending arrival of the trauma patient. All necessaryresources and personnel are mobilized to ensure immediate and appropriate care of thetrauma patient and to provide the trauma patient with the best possible chance for afunctional outcome.PROCEDURE:1. Upon notification by the prehospital care provider that a Trauma Alert patient isto be delivered to the Trauma Center, First Flight Dispatch will notify the TraumaTeam by calling a TRAUMA ALERT. First Flight Dispatch will call the TraumaCenter and provide verbal notification of incoming Trauma Alert patient andreport of condition. If a patient presents to the Trauma Center by means otherthan a prehospital care provider (e.g. private vehicle or "walk-in"), and the patientmeets the Trauma Alert criteria; the First Flight Dispatch will notify the TraumaTeam by calling a TRAUMA ALERT.2. The following members of the Trauma Team are in the ED and will immediatelyrespond to the trauma resuscitation area without delay when notified:A. Emergency Department PhysicianB. Trauma Nurses - 2 Trauma nurses (one nurse to function as thescribe and one to function as a bedside nurse.3. When a TRAUMA ALERT has been identified, First Flight Dispatch will initiatethe in-house and out-of-house Trauma Group Page. The following in-housepersonnel will be group paged on the beeper system* and will immediatelyrespond to the Trauma Resuscitation Area, within a minimum 10 minute responsetime:A. Trauma SurgeonB. Two Trauma NursesC. Respiratory TherapistD. Radiology TechnologistE. Ultrasound TechnologistF. EMT-ParamedicG. SecurityTR-IV – 23

*In the event the beeper system is not available, dispatch will notify the traumateam in the following manner:A. Trauma nurses will be notified by telephoneB. Trauma nurses or charge nurse will locate and notify EDMDC. The remainder of the team will be notified by overheadpage.D. During the “off hours” for social work and pastoral care, atelephone call will only be initiated if these individuals areneeded to respond to the trauma center. They are available24 hours a day, 7 days a week, 365 days a year.4. The following members of the Trauma Team are in-house and are put on notice ofthe impending arrival of a Trauma Alert patient by group page. They do not needto respond to the Trauma Room, however, they will be called if needed torespond.A. Operating Room Nurse (responds to all RED alerts)B. Laboratory PersonnelC. Blood Bank PersonnelD. Social ServicesE. Pastoral CareF. SICUG. CRNA/AnesthesiaH. CT Technologist5. The following members of the Trauma Team will report immediately to thetrauma resuscitation room upon request of the Attending Trauma Surgeon.A. Surgical Sub-specialist on callB. Non-Surgical Sub-specialist on-call6. The scribe RN will be responsible for recording the time that each Trauma Teammember is notified and the time that each individual arrives to the TraumaResuscitation Room on the Trauma Flow Sheet.TR-IV – 24

Title: Delineation of Roles for Trauma Team MembersApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-V-AOrigin: 1/99Reviewed: 8/02Page: 1 of 14I. POLICY:In an effort to provide the best care for trauma patients, a team approach has beeninstituted. The role of each individual member of the trauma team will bedefined. The key elements of the trauma team are focused around the leadershiproles of the Trauma Service, which includes the Trauma Director and the TraumaProgram Manager. Other responding personnel who are considered teammembers include Emergency physicians, Trauma Nurses, Patient Care technicians(PCT), Health Unit Coordinators (HUC), Operating Room (OR) personnel,CT/radiology technologists, laboratory technicians, blood bank personnel,respiratory therapists, patient relations representative, registration clerks, andsecurity.II. PROCEDURE:1. Each member of the team should report to the Trauma Resuscitation Room.2. Trauma team members will be divided into an ’inside team" and an ’outside team’.The inside team will be inside the treatment room at the bedside. The inside teamwill consist of the physicians and nurses on the trauma team. The outside teamwill consist of ancillary staff on the trauma team. The outside team will remainoutside the treatment room doors. The members of the outside team will enter thetreatment room to provide their respective service, on a priority basis, when calledin by the team leader.3. The Emergency Department physician is responsible for the patient caremanagement until the arrival of the trauma surgeon.4. The trauma team leader (ED physician or trauma surgeon) is responsible fordefinitive airway management and may receive assistance from anesthesia.5. The Trauma nurses will monitor vital signs, ECG, neuro status, initiate andmaintain peripheral venous access, and obtain/assist with obtaining appropriateblood6. The Trauma Surgeon or ED MD is responsible for central venous access,fluid/blood resuscitation, and arterial punctures.7. Emergency procedures such as surgical airway management open thoracotomy,tube thoracotomy, peritoneal lavage, and wound management is performed by thetrauma surgeon and/or emergency physician.TR-V – 1

8. The trauma team leader examines the patient and performs both the primary andsecondary patient survey in conjunction with the physician assistants.9. A Trauma nurse, or designee, will accompany the patient when he/she istransported to another department, i.e., x-ray, CT scan, when the patient is atrauma alert or other injured patient which is to be admitted to the ICU or OR.10. A definitive patient management plan is decided upon through a consultativeprocess including the trauma surgeon, surgical residents, ED physician, andspecialty on-call physicians.TRAUMA SURGEONROLE:Ultimate responsibility for the conduct and all activities within the traumaroom. The trauma surgeon will assess the patient, coordinate, anddelegate all diagnostic and invasive procedures.HOW NOTIFIED:Trauma pager, and/or telephone. During the hours of 7 a.m. - 5 p.m. the trauma surgeonon call will be notified through his beeper. After 5 p.m., pager will notify the traumasurgeon on call then by telephone, unless otherwise instructed. The First FlightCommunication Center will be responsible for placing the page/or call.WHO RESPONDS:Trauma SurgeonRESPONDS TO:Trauma resuscitation room.RESPONSIBLE FUNCTIONS:1. Immediately available on arrival of the trauma victim to coordinatethe total care of the patient.2. Performs the primary and secondary patient survey as medical teamleader.3. Performs or delegates invasive procedures as deemed necessary orclinically indicated. (See item #7 above).4. Defines priorities and orders laboratory, radiology, andcardiopulmonary studies.5. Requests additional consultants as clinically necessary.6. Reassesses the patient as clinically indicated after review ofconsulting opinions, diagnostic information, and physical findings.7. Responsible for ongoing trauma ICU care, intraoperative care, andpost operative care of the trauma patient.TR-V – 2

EMERGENCY PHYSICIANROLE:Coordinates and directs prehospital care as necessary. Assesses patient in the emergencydepartment coordinating and directing all diagnostic procedures until the trauma surgeonor neurosurgeon arrives.HOW NOTIFIED:Trauma PagerWHO RESPONDS:Emergency physician.RESPONDS TO:The trauma resuscitation room.RESPONSIBLE FUNCTIONS:1. Responds to and directs patient care in the field via the Medcom radio system.2. Immediately available on arrival of the trauma patient to coordinate the total care ofthe patient until the trauma surgeon arrives. Continues to assist with coordination andtreatment of patient care as necessary.3. Assesses the condition of the patient and performs the primary and secondary patientsurvey when in the role of team leader.4. Responsible for definitive airway management.5. Manages cardiac dysrhythrrias.6. Provides backup for trauma surgeon or neurosurgeon in case of multiple victims or asneeds arise.NEUROSURGEON AND OTHER SPECIALISTSROLE:Assesses and coordinates the care of the trauma patient as requested by the emergencyphysician and/or trauma surgeon.HOW NOTIFIED:Overhead page, trauma pager, and/or telephoneWHO RESPONDS:Specialists on trauma call.RESPONDS TO:The trauma resuscitation room, operating room, CT scan, ICU, or other area as requested.TR-V – 3

RESPONSIBLE FUNCTIONS:1. Promptly available, responding without delay (within a 30 minute time frame forneurosurgery) and dedicated to the trauma service when on-call.2. If the services of the specialist are requested, the PCT/HUC contact the physicianon-call. When feasible direct communication should occur between the specialistand the trauma team leader (ED physician or trauma surgeon).3. Assesses patient and coordinates care with the trauma team leader.4. Other diagnostic procedures as deem necessary.5. Performs and delegates invasive procedures as he/she deems clinically necessary6. Responsible for ongoing care of the patient according to his/her specialty service.PHYSICIAN ASSISTANTROLE:Performs the primary and secondary assessment and treatment proceduresat the direction of the Trauma Surgeon.HOW NOTIFIED:Trauma PagerWHO RESPONDS:Physician assistant assigned to trauma service.RESPONDS TO:Trauma resuscitation room.RESPONSIBLE FUNCTIONS:1. Sands at the right side of the Trauma surgeon2. Performs the primary and secondary assessment.TRAUMA PROGRAM MANAGERThis individual has responsibility for the day to day operations of the Trauma Program.She will respond when available to facilitate care of the patient among all the disciplines.Any problems or concerns with specific cases should be directed to the Trauma ProgramManager who works closely with the Trauma Services Medical Director in promotingquality care and solving system issues.TRAUMA NURSE(Primary Trauma Nurse)ROLE:Performs nursing assessment of trauma patient. Attaches monitors, which may include:blood pressure, pulse oximetry, ECG electrodes, end tidal CO 2 - Monitors and reportsphysiologic parameters. Assists with emergency procedures as appropriate.TR-V – 4

HOW NOTIFIED:Trauma PagerWHO RESPONDS:Trauma NurseRESPONDS TO:Trauma resuscitation room.RESPONSIBLE FUNCTIONS:1. Prepares trauma room according to Trauma Room Checklist2. Performs initial nursing assessment, reports findings to Scribe.a. Assesses airway, breathing, and circulation.b. Ensures C-spine protection as necessary. c. Trauma score evaluation.d. Evaluates Glasgow Coma Scoree. Performs respiratory assessmentf. Performs cardiovascular assessment• Places ECG electrodes and monitors rhythm• Peripheral pulses• Skin color, cap refill, temperature g. Performs abdominal assessmenth. Performs musculoskeletal assessment3. Exposes patient completely - removing all clothing with minimal manipulation.4. Establishes two large bore IVs if not already in place.5. Ensure patient is turned to inspect back.6. Insert Foley catheter, as ordered7. Insert naso/orogastric tube, as ordered.8. Assist with setup and performance of emergency procedures as indicated.9. Assists with splinting of orthopedic injuries.10. Assists with wound care management.11. Accompanies the patient to ancillary areas (i.e. CT, MRI, and Special Procedures).12. Monitor and report to the scribe nursea. Vital signsb. Trauma scorec. GCS1) On admission2) Patients with skull fracture(s), intracranial injury, or cord injury.d. ECG rhythm, as indicatede. End tidal C02 as applicablef. Pulse oximetryg. I&Oh. Neurovascular extremity checks, as indicatedi. Ongoing assessment and evaluation.13. Completes all nursing orders and assists with emergency procedures as appropriate.14. Prepares patient for transport with portable monitors, 02, et cetera.15. Notifies Patient Relations when patient leaves the ED.TR-V – 5

TRAUMA NURSE(Scribe Nurse)ROLE:Coordinates nursing, ancillary and clinical activities in the trauma room.Initiates documentation on the ED flow sheet. Records patientinformation as reported by trauma team members. Performs nursing taskoriented procedures as ordered.HOW NOTIFIED:Trauma PagerWHO RESPONDS:Trauma Nurse.RESPONDS TO:Trauma resuscitation roomRESPONSIBLE FUNCTIONS:1. Ensures the overall coordination of trauma room activates. Recordstime of arrival of trauma team members.2. Initiates documentation on the ED flow sheet. Records informationregarding the patient’s condition as evaluated by the medical teamleader and nurses.3. Applies bracelet with account number and alias registration name onthe trauma victim. (Designee may be assigned to this task)4. Obtains prepared tab slips and specimen slips. Prepares emergencyblood for bedside nurse and ensures accuracy of blood slips.5. Obtains patients FIO2, and site of blood gas drawn by RT.6. Scribe or designee is available to obtain equipment, supplies, ormedications as needed. Responsible for obtaining drugs from thecrash cart or other location (Pyxis).7. Completes ED documentation.8. Completes Alias Registration log.9. Places all telephone call requests from the Trauma Center treatment room.10. Orders all requests and diagnostic studies.11. Empowered to control traffic in and out of trauma room.NOTE: If a paramedic is used as one of the team members, he/she will function withinthe scope of practice as defined by Holmes Regional Trauma Center.EMERGENCY DEPARTMENT CLINICAL NURSE COORDINATOR (CNC)ROLE:Maintains control and coordination of total emergency department operations. Controlsthe flow of traffic in and out of trauma treatment room. Utilized as a resource person forall members of the trauma team as needed.TR-V – 6

HOW NOTIFIED:Trauma PagerWHO RESPONDS:On Duty CNCRESPONDS TO:Trauma resuscitation room when needed.RESPONSIBLE FUNCTION:1. Controls the flow of all traffic in to the trauma room (in conjunction with patientrepresentative and security).a. Prevents onlookers standing outside trauma treatment room.b. When appropriate, dismisses prehospital providers, fire, and police personnelfrom trauma area.c. Prevents excessive family members from congregating in trauma room.2. Available to answer questions and problem solve situations that may arise for traumateam members.PARAMEDICROLE:Identifies self and obtains appropriate direction from SCRIBE.HOW NOTIFIED:Trauma PagerWHO RESPONDS:Assigned to trauma team by CNC.RESPONDS TO:Trauma resuscitation room.RESPONSIBLE FUNCTION:1. Reports to Trauma Resuscitation Room for direction.2. Completes tasks as requested.3. Released to return to job duties at discretion of the Scribe Nurse.SECURITYROLE:Ensures the preparation of helicopter pad and safety of all personnel when patient isarriving via helicopter. Controls media and traffic in and about the ED and securespatient belongings with Scribe.TR-V – 7

HOW NOTIFIED:Trauma PagerWHO RESPONDS:Designated Security personnelRESPONDS TO:Trauma resuscitation roomRESPONSIBLE FUNCTIONS:1. The PCT/HUC will specify the arrival mode and estimated time of arrival.2. The Security Officer will take charge of the helipad area ensuring personnel safetyand preparing area for impending helicopter landing by ensuring elevators doors areopen for Trauma Team.3. Security Officer escorts the Trauma Team to helipad (Trauma Team waits in elevatoruntil ‘OK’ from pilot is received).4. Security Officer remains at elevator, Trauma Team goes to patient in the helicopter.5. Flight Team escorts patient to Trauma Center.6. In the Emergency Department, security will be responsible for media and trafficcontrol as well as securing, properly bagging and assisting scribe with completion ofappropriate gunshot wound or unnatural death paperwork.ROLE:Patient advocatePATIENT REPRESENTATIVEHOW NOTIFIED:Trauma PagerWHO RESPONDS:Patient representative / social worker assigned to the Trauma CenterRESPONDS TO:Trauma resuscitation room, outside team.RESPONSIBLE FUNCTIONS:Identifies patient: obtains name. address, and other demographicinformation.1. Notifies patients family, obtains medical history allergies, medications,et cetera, from the family when patient is unable to provide thisinformation.a. IF GSW or IF UNNATURAL DEATH clothes to police in paper bag and allarticles to be held for detectives.2. Shares information with registration, police, and charge nurse, bedside nurse,security, nursing supervisor.TR-V – 8

4. Provides privacy for family and visitors. Keeps family informed and providesemotional support.a. Special needs: clergy, locating support persons, nourishment.3. Provides emotional support and assistance where needed during patient expiration.4. Contact next of kin.5. TRANSFERS: Assist with phone calls, paperwork, (copying of chart, et cetera) inevent of an Interhospital transfer.REGISTRATIONROLE:Immediately available to trauma patient to assist with identification and also to producethe medical record.HOW NOTIFIED:Trauma PagerWHO RESPONDS:Designated Registration ClerkRESPONDS TO:Trauma resuscitation room, outside team.RESPONSIBLE FUNCTIONS:1. Identifies patient: obtains name, address, and other necessary demographicinformation if obtainable.2. If no information is available, will initiate an alias registry chart according to the aliasregistry policy.4. Provides staff with a copy of the face sheet when completed.5. When cleared by the Trauma Surgeon, enters trauma room to obtain information andnecessary signatures.ADMINISTRATIVE SUPERVISORROLE:Participates as resolve person to ED staff as needed to best promote trauma care.HOW NOTIFIED:The Trauma RN notifies the Administrative Supervisor via telephone when necessary.WHO RESPONDS:Nursing Supervisor on duty.RESPONDS TO:Trauma treatment room, outside team.TR-V – 9

RESPONSIBLE FUNCTIONS:1. After hours, media will be referred to Nursing Supervisor/Marketing for details.2. Will assist, as appropriate, in obtaining bed assignments.3. Assists in any other way deemed necessary to facilitate the care of the trauma patient.RESPIRATORY THERAPYROLE:Performs respiratory assessment of trauma patient. Assists with monitors, which mayinclude: BP monitors, pulse oximeter, ECG monitor, end tidal C02. Reports physiologicchanges. Assists with procedures as appropriate.HOW NOTIFIED:Trauma PagerWHO RESPONDS:Respiratory Therapist assigned to TraumaRESPONDS TO:Trauma resuscitation room, inside team.RESPONSIBLE FUNCTIONS:1. Prepares trauma room:a. Ambu set upb. Oxygen delivery devices (masks, cannula, etc.)c. ET tubed. End Tidal CO 2e. Suction apparatusf. Ventilatorg. Warm humidified O 22. Stabilize airwaya. Secures tubeb. Verifies tube placement after patient movement (i.e. transport to CT scan, otherdepartments, etc.)3. Manual ventilation4. Set up life support systems5. SAO, and End tidal CO, monitor application6. Performs CPR7. Assists with transport of patient8. The respiratory therapist if not utilized for airway management and isreleased from the Trauma Room by the Trauma Surgeon.TR-V – 10

ULTRASOUND TECHNOLOGISTROLE:Performs the pericardial and abdominal ultrasound on trauma patients.HOW NOTIFIED:Trauma pagerWHO RESPONDS:Ultrasound Technologist assigned to Trauma.RESPONDS TO:Trauma resuscitation roomRESPONSIBLE FUNCTIONS:1. Responds to the trauma room.2. Checks ultrasound machine and positions machine.3. Performs pericardial and abdominal ultrasound during primaryassessment.4. Reports results to Trauma Team Leader.RADIOLOGY TECHNOLOGISTROLE:Immediately available to trauma room. Performs stat portable, trauma X-ray series. Ensures immediate development of films and delivery tophysicians.HOW NOTIFIED:Trauma PagerWHO RESPONDS:Designated Radiology TechnologistRESPONDS TO:Trauma resuscitation room, outside team.RESPONSIBLE FUNCTIONS:1. Respond to the trauma room with appropriate equipment.2. The film plates are placed on stretcher in trauma room prior to the patient arrival:chest and pelvis.3. When called into the trauma room the tech will take x-rays ordered by the TraumaSurgeon / or ED M.D.4. The films will immediately be developed and taken to the trauma room. (See PolicyVI-G.)TR-V – 11

CT SCAN TECHNOLOGISTROLE:Immediately available to the trauma room. Ensures prompt availability ofScanner. Performs CT Scan studies as ordered.HOW NOTIFIED:Trauma Group PagerWHO RESPONDS:Designated TechnologistRESPONDS TO:Radiology Department, CT scannerRESPONSIBLE FUNCTIONS:1. The Tech will inquire/assess potential need for CT Scan and thenumber of trauma patients.2. When CT is required, the Tech. will:• Verify orders• Check labs: BUN and CR, if IV contrast is required• Verify consent signed by patient or physician• Notify radiologist during CT scan3. Films will be developed and sent STAT to radiologist for reading4. Scribe Nurse will notify CT Technologist/designee when multiple exams arerequired.5. Ensure that the results of the CT scan are faxed or delivered to the Trauma Surgeonor Trauma nurse.OPERATING ROOMROLE:Ensures preparation of trauma operating room.Coordinates with anesthesia and ancillary departments.Assigns staffing.HOW NOTIFIED:Trauma pagerWHO RESPONDS:OR Nurse Manager or designeeRESPONSIBLE FUNCTIONS:1. Upon trauma alert notification, begins preparing designated room2. Responds to the Trauma Center after receiving the “10 minute” page on a RedTrauma Alert.3. Only the attending Trauma Surgeon (or surgical resident as designee) may “cancel”the OR before leaving the ED.TR-V – 12

BLOOD BANKROLE:Ensures availability and immediate preparation of emergency blood as requested for thetrauma patient.HOW NOTIFIED:Trauma PagerWHO RESPONDS:Blood Bank Technologist when requested.RESPONSIBLE FUNCTIONS:1. Maintain blood bank refrigerator QA in Trauma 4 u of 0+ and 2 u of O- blood as perpolicy. If blood administration is anticipated for Trauma Alert patients, the HUC callthe Blood Bank with the following information:a. Account numberb. Patient agec. Patient sexd. Number of units needed.2. Once the Trauma Alert patient arrives a blood specimen for type and screen isobtained. If blood has not already been requested, this specimen is ‘tubed’ in a to theBlood Bank with blood request slip. The type and screen specimen men must belabeled appropriately. blood. The PCT/HUC will go to the Blood Bank and receivethe type and cross-matched3. When blood is ready the Blood Bank notifies the ED and a PCT is sent to receive thetype of cross-match blood.4. When the trauma alert patient leaves the ED to the OR:a. The Trauma Surgeon should be asked whether to take any remainingblood to the OR or return to Blood Bankb. The HUC will notify the OR of the number of units coming with patient.6. When the trauma alert patient leaves the ED to other units, all unused blood will bereturned to the Blood Bank.7. EMERGENCY ISSUE BLOOD:,a. Must have Trauma Surgeon/Medical Doctor signature.b. The R.N. checks, initials, and documents vital signs q 15 minutes startingand before completion.c. The R.N. notes time finished and places slip on lab mount in chart.d. The PCT/HUC sends other slips to Blood Bank.8. REGULAR ISSUE BLOOD:a. R.N. checks, initial, and documents vital signs q 5 minutes for the first 15minutes than q 15 minutes.b. R.N. notes time finished and places slip on lab mount in chart.c. Blood big is disposed of property.NOTE: Please see policy and procedure Blood Bank for specifics on Emergency IssueBlood for the Trauma Alert patient.TR-V – 13

LABORATORY SERVICESLaboratory Services is notified of the Trauma Alert patient by Trauma Group Pagingand priority is given to the requested laboratory studies. Trauma team personnel ratherthan laboratory personnel draw blood, and, therefore, a physical response to the traumaresuscitation room is not necessary. Please note Laboratory Protocol for Trauma AlertPatients.TR-V – 14

Title: Disaster Event or Emergency DepartmentOverload PlanApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-V-BOrigin: 1/99Reviewed: 8/02Page: 1 of 5I. OBJECTIVE:To provide an outline for patient management in the event of an internal orexternal disaster. Examples of disasters are when the volume of patientsexceeds the physical space and resources or the arrival of multiple patientswithin a short period of time.II. POLICY:To provide a process for the efficient management of patient flow andprovision of safe care during a disaster event or emergency situation.III. PROCEDUREA. DISASTER EVENT1) Pre-Event:CommunicationWhen the charge nurse is notified of multiple patients arriving due todisaster/emergency event, he/she will:- contact the ES Management on-call and Administrative and MedicalDirectors. The Administrative Director will notify the Vice President ofProfessional Services. The Administrative Director or designee will discusswith the Vice President or designee if the Hospital Command Center needs tobe activated.- inform all Emergency Department (ED) staff and physicians and leadRegistration of the situation/scenario and tentative plan of action- evaluate staffing in all (ED) areas and determine if more staff need to becalled in- discuss with ED physician(s) working if the coverage is sufficient to meet thevolume of patients and determine if the on-call physician needs to be called inThe Patient Representative will:- inform the patients and families that the ED is going to be receiving victimsfrom a disaster or emergency event. Consequently, there may be delays inreceiving medical care- contact the social worker on call to inform him/her of the anticipated patientvolume into the ED and support needed.TR-V – 15

Triage- The Charge Nurse and ED physician will review patients in the ED treatmentarea and in the waiting room. The following will be determined:- which patients need to be admitted quickly,- which patients need to be discharged- which patients need to be moved to another section of the ED to includethe patients that can be moved to the waiting room- what needs to happen with the patients in the waiting room- The Charge Nurse will instruct the Health Unit Coordinator to contact BedControl with a request for “urgent” bed assignmentOperations- The ED Management or designee will ensure the following are done:- designate a second Triage Area at the ambulance entrance- designate a second triage nurse to work in this area- designate a PCT or Paramedic to assist the second triage nurse- request ED physician to work with second Triage Nurse to evaluatepatient’s condition- designate Registration staff to work with the second triage team- supply cart will be brought to the secondary triage area- the “Disaster Box” is brought to the Nurses Station so the various suppliescan be set up – standing orders, armbands, etc- Management will man the “Command Center Disaster Phone” and supportthe charge nurse- if additional staff and/or physicians are needed someone will be assignedto contact them at this time2) During the EventCommunicationThe Management person or designee will be the primary communicator andresponsible to update all ED staff and physicians regarding the event and the plan.The highest-ranking Management person will function as a liaison between theED charge nurse, the ED and the Hospital Command Center. Additionally, thisperson will take the lead in all decisions made working with the ED MedicalDirector or designee.The patient representative will check in with the charge nurse every hour toupdate her list of victims from the event and their status.TriageThe charge nurse will coordinate the placement of all patients after they aretriaged. If support is needed in this role, the Management person will assist.Primary and secondary triage will keep a log of all victims from the event withthe identifier (name, number, etc). The charge nurse will obtain a copy of thisevery thirty minutes to be have an accurate list of victims. On an hourly bases thelist of victims will be delivered to the Command Center.TR-V – 16

On an hourly, bases the Charge Nurse, management and ED Physician will reviewthe status of all ED patients to determine who can be discharged moved to anotherED location and admitted.The primary triage nurse will direct the ED Technician to obtain repeat vital signson each patient in the waiting room every hour during the Disaster Event. Thisinformation and any changes in patient condition will need to be communicated tothe primary triage nurse. The primary triage nurse will inform the charge nurse ifa patient’s condition in the waiting room has changed and needs to be brought tothe treatment area.OperationsDepending on the additional support needed, staffing, supplies, radiology help,social work help, the Management person will communicate these needs to theCommand CenterThe Management person will re-evaluate department and physician staffing,ancillary resources, supplies, etc hourly and work with department and hospitalresources to deliver safe and efficient care during the event.3) Post EventCommunicationThe Management person or designees will inform all of the ED staff andphysicians that the victims have all been received. Collaboratively, theAdministrative and Medical Directors or designees will determine when the EDwill return to normal patient flow operation and communicate this to all staff andphysicians. This information also needs to be informed to the support serviceswithin the department i.e. Registration, Radiology, etc. Additionally, thisinformation needs to be communicated to the Command Center.TriageED patients triaged to the waiting room and or other areas of the department needto be re-evaluated if they need to be brought back to the original department orleft in the ED area they are in (Minor Care, Clinical Decision Unit, etc).OperationED assignments and patient flow will need to be transition back to normaloperations. Staffing will need to be evaluated and additional staffing will need tobe released when appropriate.TR-V – 17

B. EMERGENCY DEPARTMENT VOLUME OVERLOADCommunication and OperationsThe charge nurse will notify the ED Management person on call when any of thefollowing occurs:- When the number of patients in the waiting room is fifteen or greater and theyhave been waiting two or more hours.- When six or more patients have been waiting two or more hours for a hospitalbeen to be assigned with no possible bed assignment from potentialdischarges.The management person on call will:- Evaluate with the charge nurse the staffing for the department and theindividual patient conditions so decisions can be made to modify the operationuntil the volume can be unloaded. The activation of a quick assessment andtreatment area is one option depending on the condition of the patients thatneed treatment or the overflow of less complex Main Room patients to MinorCare is an option.- Contact the Vice President of Professional Services or hospital administratoron call to inform them of the ED overload problem and discuss possiblesolutions.- Assist the charge nurse in handling the volume overload.- Collaborate with the ED physicians to determine if alternative operations i.e.modification of patient flow and/or assignment of patients is an option.- Check in with the charge nurse every hour to determine if the ED status isimproving or deteriorating. Depending on the status, modifications need to bemade to ensure safe care is provided. The hospital leadership needs to be keptinformed of the status so they can assist the ED staff to provide safe care tothe ED patients.The charge nurse will communicate to the hospital administrative supervisor:- To obtain additional staffing for patients waiting bed assignments. Thestaffing office will also need to be notified.- Every hour the supervisor needs to be notified to re-evaluate the status of theED and hospital bed availability.The charge nurse will:- Communicate the triage nurse to re-evaluate patient vital signs in the waitingroom a minimal of every two hours. Any change in patient condition needs tobe communicated to the charge nurse from triage so patients can be placed inthe treatment area- Remind the ED staff that any patient waiting greater than two hours for a bedassignment needs to have their admission orders activated, MARS initiated,and vital signs and other care needs delivered.TR-V – 18

EvaluationAfter each emergency event or overload situation, the ED Leadership Team willdebrief the situation and use each occurrence as a learning situation to maintain orrevise the ED operation. This information will be reviewed with the ED MedicalDirector to obtain physician input.The staff will also be included in the debriefings. This will either be immediatelyafter the occurrence or in an upcoming staff meeting.Any issues need to examine and a plan of action determined. The results of anychanges will be evaluated after another occurrence to see if the change waseffective.TR-V – 19

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Title: Hurricane PlanApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-V-COrigin: 1/99Reviewed: 8/02Page: 1 of 4OBJECTIVE:To ensure that all Health First patients’ needs and the needs of the communityare met, while allowing associates to meet family responsibilities during timesof hurricane/severe weather. Preplanning alternative options and preparationare critical for Health First to be ready to meet a severe weather challengewithout compromising the needs of the patients we serve. Associates areexpected to plan and prepare to meet their obligations as healthcare providers.DEFINITIONS:A. Associates - for the purposes of a disaster, defined as full time, part time, perdiem, and float personnel.B. Exempt Associates - associates with approved exemption forms that will beexcused from working during a storm.C. Pre-Storm Period – the period of time extending from notification of a stormuntil eight hours prior to landfall.D. During Storm Period – the period of time extending from eight hours beforelandfall until an all clear has been issued by the Office of EmergencyManagement in Brevard County.E. Post Storm/Relief – the period of time that begins when an all clear has beenissued by the Office of Emergency Management in Brevard County.F. Child Care Enrollment Form – the form provided to associates who aresingle parents with children age two to 21 who are required to work during orpost-storm to enroll for childcare services. This form is completed upon hireand annually in May.G. Exemption Form – the form utilized by Health First to document approvedexemptions. This form is completed upon hire and annually in May.H. Level I (72-48 Hours) – According to the Brevard County EmergencyOperations Center Level I is defined as a warning in which danger is possible.I. Level II (36-30 Hours) – Level II begins when the National Weather Servicedeclares a tropical storm watch or Hurricane Watch.J. Level III (24-12 Hours) – The NWS has announced a hurricane warning withestimated time of landfall. According to the Brevard Center EmergencyOperations Center danger probable within 12-24 hours.K. Level IV (Six Hours before Landfall) – Danger is imminent and estimatedtime of landfall is being tracked.L. Level V ( Landfall)TR-V – 21

M. Level VI (+12 Hours After Landfall) – Goes into effect when the threat of aHurricane and weather related conditions have passed according to theBrevard County Emergency Operations Center.POLICY:A. Hire and orientationAn educational program will be provided to all associates during the hiringprocess, at the Health First orientation during the Environment of Carelecture, in individual department/unit orientation, and before hurricane season(June 1) annually.B. Exemption formsAny associate unable to meet his or her requirement to work during the stormmust complete an exemption form upon hire and annually in May.To be eligible for exemption, an associate must meet at least one of thesecriteria:1. When both parents, one of which works for another employer (i.e. nursing,other hospital, law enforcement, fire/rescue, and city employee), arerequired to work and have simultaneous roles during or post-storm,associate is exempt.2. The associate provides elder care that cannot otherwise be delivered.3. The associate provides care to someone who is handicapped, or has achronic illness, that cannot otherwise be delivered.4. The associate is a single parent with a child less than two years of age.5. When both parents work at Health First and normally would havesimultaneous roles during or post-storm, one is exempt.Please note: While an approved exemption form excuses anassociate from working during a storm, the associate may berequired to work pre- or post-storm.Child care enrollment formsHealth First provides on-site child care for single parent associates withchildren between two and 21 years of age who are required to work during orpost-storm. A child care enrollment form must be completed each yearbefore June 1 (the same requirements for the exemption form.) Olderchildren (over age 16) may be permitted as appropriate to volunteer in otherareas of the hospital.D. Education/communicationAnnually, at the beginning of hurricane season, the Health First DisasterHotline (434-8989) will provide storm information and preparedness tips.Associates can call the hotline 24 hours a day/seven days a week; it will beupdated with specific instructions for individual facilities/entities as needed:TR-V – 22

Option #1—Cape Canaveral HospitalOption #2—Holmes Regional Medical Center/Palm Bay CommunityHospitalOption #3—all other Health First entitiesThe Hotline is not meant to replace communication with your director,manager, or supervisor. Please discuss your role in our hurricane/severeweather plan with your supervisor before the designated storm season, whichbegins June 1. Knowing your specific role in the event of storm is yourresponsibility.E. Staffing planEvery associate employed by Health First is considered to be a necessarymember of the staff for pre-storm, during storm, or post-storm periods.Associates are required to wear their identification badges while on the job,and will be asked to show them when entering or exiting a Health Firstfacility.Staffing plans for associates are developed in their individualdepartments/units and signed by the Director of Report. Eachdepartment/unit plan will then be given to the responsible Vice President andto the Safety & Security Department. Associates will be notified of theirresponsibilities listed in the plan before hurricane season.Employee Relations will coordinate the non-clinical associate pool anddevelop a roster of associates available to support entity or department needs.Employee Relations will be the key department to request additional nonclinicalassociates’ 48-72 hours before anticipated landfall of the storm.Employee Relations will provide assignments to associates as requested forpre-storm, during storm, and post-storm needs. Annually, in May, nonclinicaldepartment directors should evaluate their staffing needs andcomplete either a Pre-season department needs list and/or Pre-seasondepartment resources list and send to Safety and Security before June 1.Employee Relations will update the roster of non-clinical associates annuallyin May, and directors should send changes to the staffing roster as they occurthroughout the storm season to assure that adequate resources are available.During a storm situation, directors can request additional resources by calling434-7110.The Staffing Office will coordinate the clinical associate pool and develop aroster of clinical or licensed associates available to support entity ordepartment needs. The Staffing Office will be the key department to requestadditional clinical associates’ 48-72 hours before anticipated landfall of thestorm. The Staffing Office will provide assignment to associates asrequested for pre-storm, during storm, and post-storm needs. Annually, inMay, clinical department directors should evaluate their staffing needs andTR-V – 23

complete a Pre-season department needs list and/or Pre-seasondepartment resources list and sends to Safety and Security before June 1.Staffing Office will update the roster of clinical associates annually in May,and directors should send changes to the staffing roster as they occurthroughout the storm season to assure that adequate resources are available.During a storm situation, directors can request additional resources by calling434-7284.Health First volunteers and Auxiliary members will not report to the hospital,and should evacuate the area or to a designated public shelter when sodirected by the Office of Emergency Management in Brevard County.PROCEDURE / DEPARTMENT RESPONSIBILITIESLevel I (72-48 Hours)1. The Trauma Center manager or designee will notify all Trauma Center personnel ofthe weather situation. Each staff member’s commitment to staffing the Trauma Centerfor the pre/during storm, or post-storm periods will be reinforced.2. The manager will update the list of personnel and their assigned teams.3. The manager will review the needs and resource list.Level II (36-30 Hours )1. All Trauma Center nursing personnel will be contacted by the Trauma CenterManager or designee and updated on the weather situation and their familyresponsibilities.2. Each nurse will be assigned specific 12-hour shifts for staffing the trauma center.3. The Trauma Center Manager will ensure appropriate stocking of supplies in thePyxis.Level III (24-12 Hours )1. The Trauma Center Manager or designee will inform all personnel of the weathersituation.2. All Trauma Center personnel will sign in and wear name badges at all times.3. All personnel assigned to the pre/during-storm phase will report to the trauma center8-12 hours before landfall.Level IV (Six Hours before Landfall)1. All assigned personnel will assemble in the Trauma Center for strategic planningaccording to the patient census.Level V (Landfall)1. All pre/during-storm Trauma Center personnel will remain in the Trauma Center orshall be available in-house according to patient census.2. The manager or designee will communicate with the Command Center and staffevery hour.3. The staff shall be provided rest periods as the patient census allows.Level VI (+12 Hours After Landfall )1. The staff members assigned to the post-storm team will relieve the pre-during stormteam as soon as possible.2. The manager or designee will assess the staffing needs of the trauma center andtransition back to the normal staffing pattern as soon as possible.TR-V – 24

Title: Multidiciplinary Rounds for Patients on the TraumaServiceApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-V-DOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. OBJECTIVE:To ensure patients on the Trauma Service needs are identifiedthrough a multidisciplinary team approach to optimize the patient’s plan ofcare.II.III.IV.DEFINITION:Multidisciplinary Rounds are a clinical, service based approach whichpromote positive patient outcomes, continuity and consistency of care byintegrating various disciplines (including but not limited to: RehabilitationServices, Case Management, Social Services, Pharmacy, Dietary, RespiratoryTherapy, Infeciton Control, Nursing, Physician Extenders, and TraumaSurgeons) in a planned meeting format.POLICYPatient’s on the Trauma Service will be reviewed during MultidisciplinaryRounds which take place on Wednesdays beginning at 8:30 am respectively,in the SICU with continuation to 6W, 7W, and 8W if trauma patients areadmitted there.PROCEDUREA. During designated times the following services will be in attendance duringMultidisciplinary Rounds: Rehabilitation Services, Case Management, SocialServices, Pharmacy, Respiratory Therapy, Dietary, Infection Control,Nursing, Physician Extenders, and Trauma Surgeons.B. Each representative will sign the attendance book.C. Each representative will document on the comprehensive rehabilitation planD. The Trauma Case Manager will ensure that a completed rehabilitation plan ison each Trauma patient’s chart within 7 days of his/her arrival.E. The Trauma Surgeon will review and sign the rehabilitation plan within 48hours.TR-V – 25

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Title: Multidiciplinary Trauma ConferenceApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-V-EOrigin: 1/99Reviewed: 8/02Page: 1 of 2POLICY:There will be a monthly multidisciplinary trauma conference to educate thoseinvolved in trauma patient care, to review trauma cases, and to critiqueindividual system components. It will offer continuing education credits forphysicians, nursing, and prehospital personnel.PROCEDURE:I. Each month an educational trauma conference will be conducted atHolmes Regional Medical Center. Members of the trauma service willcoordinate the conference.II. After a topic is chosen for a given month, a guest speaker willbe solicited. When possible, a coordinating case will be chosen forreview.III.The Trauma Conference may also include the following components:A. The EMS SystemB. The Trauma CenterC. Individual Case ManagementD. Specific isolated issuesE. Current trauma educationIV.Notices will be extended (but not limited) to:A. Emergency department personnelB. NeurosurgeryC. OrthopedicsD. RadiologyE. AnesthesiologyF. NursingG. Ancillary departmentsH. Social ServicesI. Rehabilitation MedicineJ. EMS personnelK. Trauma Management AgencyTR-V – 27

V. CMEs and CEUs will be provided at each conference.VI. Minutes will be taken at this conference and shall be maintained forleast three- (3) years. A 50% attendance will be encouraged from theabove listed departments.TR-V – 28

Title: Protective Equipment in the Trauma RoomApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-V-FOrigin: 1/99Reviewed: 8/02Page: 1 of 3I. OBJECTIVE:To protect associates, through individual responsibility and work place safety,from health hazards connected with bloodborne pathogens.To ensure compliance with HRMC’s Infection Control policy entitledBloodbourne Pathogens Exposure Control Plan (IC-4-01)II.DEFINITION:The Bloodborne Pathogen standard, if followed, is designed to protect associatesfrom exposure to bloodborne diseases such as Syphilis, Hepatitis C, Malaria,Hepatitis B, and Human Immunodeficiency Virus (HIV) and to provideguidelines for post exposure follow-up.All Health First associates are classified into categories that define occupationalor potential occupational exposure to bloodborne pathogens. The three categoriesare listed below:Category 1:Category II:Category III:Associates perform tasks that involve exposure tobloodborne pathogens.Associates perform tasks that involve no exposure tobloodborne pathogens, but work in clinical area whereexposure to bloodborne pathogens may occur.Associates do not perform tasks that involve exposure tobloodborne pathogens and do not work in a clinical areawhere exposure may occur.III.POLICY:A. Education:All category I and II associates will receive Bloodborne Pathogen ExposureControl education before starting clinical practice, during orientation andyearly thereafter. New associates are required to read this policy during theirorientation period. This plan is located in the Infection Control Manual andmade accessible to all associates.TR-V – 29

B. Compliance:All associates are expected to promote the following principles:1. Protection of associates from health hazards connected with bloodbornepathogens must occur through individual responsibility and workplacesafety.2. Any associate who enters the trauma room when the arrival of a traumapatient is imminent or during resuscitation will wear the appropriatepersonal protective equipment. This includes, but is not limited to mask,gown, gloves, and eye protection. Personal Protection supplies are easilyaccessible in a cabinet outside the Trauma Room doors.3. Lead aprons will be worn by any associate in the trauma room whileradiographic films are being completed on a trauma patient.4. Removal of personal protective equipment will be governed by thefollowing standard precaution guidelines.C. Standard Precautions:1. Standard Precautions are designed to reduce the risk of transmission ofbloodborne pathogens and those present in other moist body substances.This applies to all patients receiving care, regardless of their diagnosis orpresumed infection status. Standard Precautions apply to (1) blood; (2) allbody fluids, secretions, and excretions except sweat, regardless of whetheror not they contain visible blood; (3) non-intact skin; and, (4) mucousmembranes.2. Standard Precautions include using these barrier precautions on allpatients:a. Gloves must be worn when:‹ direct contact with blood or other potentially infectious body fluidsis expected to occur‹ examining abraded or non-intact skin‹ during invasive procedures‹ during instrumental examination of the oropharynx, GI or GU tract‹ working directly with contaminated instruments‹ during phlebotomyb. Masks and protective eyewear must be used when:‹ engaged in procedures likely to generate droplets of blood, otherbody fluids or bone chips‹ Protective eyewear must incorporate the use of solid side shields.TR-V – 30

c. Gowns/Aprons or other protective clothing is required when:‹ spraying or spattering of blood or other body fluids is anticipated‹ Gowns and aprons must be appropriate for the procedureinvolved. The type and characteristics depend upon the task anddegree of exposure anticipated.d. Surgical caps and shoe covers must be worn when engaged inprocedures likely to involve gross contamination such as autopsy andorthopedic surgery.ALL ITEMS OF PERSONAL PROTECTIVE EQUIPMENTMUST BE REMOVED PRIOR TO LEAVING THE WORK AREA.3. Personal Protective Equipment (PPE) includes the following, but may not belimited to:a. Gowns and/or apronsb. Gloves (Hypoallergenic, vinyl, latex, and powder-free are available)c. Laboratory coatsd. Face shields and maskse. Safety glasses and gogglesf. Mouthpiecesg. Resuscitation bagsh. Pocket masksI. Hoodsj. Shoe/boot coversReusable PPE’s are cleaned, laundered, and decontaminated by HealthFirst, Inc. Disposable PPE’s are disposed of in appropriate containers.TR-V – 31

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Title: Trauma Room DesignationApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-V-GOrigin: 1/99Reviewed: 8/02Page: 1 of 1POLICY:There will be a designated area for resuscitation of the Trauma Alert patient. Thedesignated area will be in close proximity to the Emergency Department (ED)ambulance entrance, and is easily accessed by both air and ground transports.PROCEDURE:1. The Trauma Resuscitation Room (TRR) has been designated as Treatment Room1 and Treatment Room 2.2. The TRR can accommodate the full resuscitation team and two resuscitations canbe performed simultaneously.3. In situations of multiple trauma alerts, another ED room will serve as the secondresuscitation room. Adequate personnel and equipment will be available formultiple resuscitation in such situations by the ED charge nurse.TR-V – 33

Staff Distribution for One PatientTrauma ResuscitationMD 1VentRTPAUltrasoundTraumaNurse2PatientMedic/TechUSTechFirstFlightMD 2RadiologyTechTraumaNurse 1(scribe)TR-V – 34

Staff Distribution for Two PatientTrauma ResuscitationRTMD 1VentVentMD 2UltrasoundPAMedic/TechTraumaNurse 2TechUSTechPatientPatientTraumaNurse 1FirstFlightScribeScribeRadiologyTechTR-V – 35

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Title: University of Florida Physicians OfficeTrauma, General Surgery, OrthopaedicApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR:-V-HOrigin: 1/00Reviewed: 8/02Page: 1 of 2I. OBJECTIVE:The physicians office is utilized for outpatient follow-up for patients seenon the UF Physicians Service.II.III.POLICY:The physicians office shall be used as a hospital based outpatient settingfor follow up post discharge from the UF Service.PROCEDURE:A. Scheduling1. Upon discharge from the floor, Trauma Center, or E.D. the patient’s aregiven the telephone number for the physicians office with instructions tocall and schedule a follow-up appointment if applicable.2. Upon receiving a call from a patient who wants to schedule a follow-upappointment, the Registration Specialist and nurse will schedule thepatient in the Logician appointment book entering the full name andtelephone number of the patient.B. Registration1. Upon arrival to the Outpatient Registration area, the patients will beregistered as an HOC in the HBOC system.2. Information will be updated in Logician.C. Staffing1. The clinic nurse and physician on office call will be responsible forstaffing the physician’s office.2. The Trauma Center Nurses will serve as backup staff to physician’s office.3. The registrar/secretary will be responsible for registration/insuranceauthorizations/collecting co-pays.D. Documentation1. The nurse will complete the Trauma visit record. It is to include vital signsas well as the nursing assessment and any procedures performed.2. The paper chart will be transition into electronic documentation usingLogician.3. Parallel paper and electronic charts will be maintained and evaluatedweekly.4. The Trauma Clinic Nurse will enter the charges for the visit into HBOC.5. The attending Trauma Surgeon will sign the treatment record.6. The physician will either enter his note into logician or will dictate hisnote into the soft med.TR-V – 37

E. Policy Manual1. A manual with detailed policies will be maintained in the physician’soffice.TR-V – 38

Title: Collection/Labeling Acceptance of Blood Bank SamplesPolicyApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-V-IOrigin: 1/99Reviewed: 8/02Page: 1 of 7I. OBJECTIVE:All Blood Bank crossmatch samples must be drawn using a system thatguarantees positive identification of the patient, the blood sample and thecrossmatched blood unit. The Typenex bracelet system allows the patient, sampleand crossmatch request to use an identical code as positive identification betweenthe patient and the blood product. This code is verified at bedside at the time oftransfusion. All variations to this system, such as incorrectly submitted samplesare to be documented. Aseptic phlebotomy techniques are used for blood samplecollection.II. POLICY:I. BLOOD BANK CROSSMATCH SAMPLE COLLECTION.The following Typenex system must be adhered to in banding and collecting specimensdrawn for crossmatching purposes.1. Establish positive patient identification by comparing the name on the following:• The patient’s hospital ID bracelet - A green Typenex armband must be attached tothe patient at the time of collection.• The Blood Bank accession label (if available) or verbal/computer message.• Verbal identification from the patient (if patient is able.)2. Print the following information on the long blank label of a Typenex armband. (Use aball point pen)• Name Name should be copied from the hospital ID bracelet. Patient’s last name,first name. Do not abbreviate names (Wm. - incorrect; William - correct). *If thecomputer has cut the name short due to a lengthy spelling, use the same spelling ason the hospital ID bracelet.• MR # should be copied from the hospital ID Bracelet.• Collection Date (day, month, year)• Collection Time• Phlebotomist computer ID# or initials.Compare all data and correct any inconsistencies prior to banding and collectingsample.3. At the bedside, remove the top green Typenex label with the printed information andpress it onto a 7ml red top tube. The carbon copy of the label data remains on thepatient Typenex armband.TR-V – 39

4. Wrap the armband around the patient’s wrist or ankle, number side out. Firmly closethe clip.5. Tear off extra code stickers (tail) from the attached armband. Remove the clearprotective backing from the opposite end of the tail, exposing the adhesive surface.Press this surface to the tube after blood collection.6. Draw the blood sample using aseptic technique.7. The Typenex armband should remain on the patient for the entire hospital admission,unless it becomes illegible or incorrect and the Blood Bank requests that it beremoved.• The surgical units may need to remove a Typenex armband and thereby acceptresponsibility for accurate patient identification and transfusion.8. The Blood Bank armband will be used at the time of transfusion as a double check onproper patient identification. No transfusion is to be started unless the name, MR#and Typenex code are identical on the patient’s Typenex armband, Hospital IDbracelet and the data on the crossmatch tag.• Refer to Emergency Release procedure in this manual and Trauma Center sectionbelow for emergency exceptions.• "23 hour admit" nursing staff may transfuse using name and typenex only, whensamples were collected at outpatient facilities.9. It is not necessary to reband the patient when additional Blood Bank samples arerequested.• Make a biologics label from the hospital ID plate attached to the patient, using alabel gun. Apply the label to the tube. Data may also be written on the tubelabel by hand.• Remove one of the Typenex code stickers from the armband and place it on thetube.• If there are no more stickers left, copy the letters and numbers of the code andwrite them on the tube label.• Add current date, time of collection, and Phlebotomist’s ID.• Call Blood Bank for directions if the existing band is illegible or if anyinconsistencies in identification are found.TR-V – 40

II. TRAUMA CENTER CROSSMATCH SAMPLE COLLECTION1. All and only Trauma Center specimens collected for Blood Bank will use the redTypenex armband system. The red Typenex system will serve as another flag forSTAT priority and identification of the Trauma Center specimen.2. Identification of the patient is based on an “alias registration system”. A pre assignedname using the military alphabet for the first name and middle initial will be used.The last name will be “Trauma” (example: Trauma, Alpha 1). A specific preassigned patient account number dedicated for the trauma patient will be used as theidentification number. This is a 10 digit account number that starts with “7”. A redTypenex armband with this pre assigned information is included in the “traumapacket”. Refer to Trauma Center Blood Protocol.3. The following information will be added to the red Typenex label at the time ofspecimen collection:• Collection Date• Collection Time• Phlebotomist/RN computer ID# or initials.4. At the bedside, remove the top red Typenex label with the printed information andpress it onto a 7ml red top tube. The carbon copy of the label data remains on thepatient Typenex armband.5. Wrap the armband around the patient's wrist or ankle. Firmly close the clip.6. Tear off extra code stickers (tail) from the attached armband. Remove the clearprotective backing from the opposite end of the tail, exposing the adhesive surface.7. Draw the blood sample using aseptic technique. Attach to the tube after bloodcollection.8. The Typenex armband should remain on the patient for the entire hospital admission,unless it becomes illegible or the Blood Bank requests that it be removed. Once thepatient has left the Trauma Center, if a new Typenex armband is needed the standardgreen Typenex system will be used.• The surgical units may need to remove a Typenex armband and thereby acceptresponsibility for accurate patient identification and transfusion.9. The Blood Bank Typenex armband will be used at the time of transfusion as a doublecheck on proper patient identification. No transfusion is to be started unless thename, identification number and Typenex code are identical on the patient's Typenexarmband, Trauma Center ID bracelet and the data on the crossmatch tag.TR-V – 41

ACCEPTED LABEL VARIATIONS FOR CROSSMATCH SAMPLESCOLLECTED FOR TRANSFUSION OUTSIDE THE HOSPITALMelbourne Internal Medicine Associates (MIMA), MKC, IHS & other Dr.’s offices.• All facilities use the Typenex armband system.• The Typenex code and the patient’s name are used as the means of patientidentification.• Collection date, collection time and Phlebotomist’s ID should be included on theTypenex label.• Draw a line through the MR# on the Product Chart Copy (crossmatch tag). Addthe Typenex number to the "Sign Out Record" when issuing the blood. If thecomputer name sticker is used on the "Sign Out Record", cross out the MR#.LABELING OF EMERGENCY DEPARTMENT SAMPLES1. If time allows, the Emergency Department (ED) will follow standard labelingpractices. Prior to collection of properly labeled sample use Emergency ReleaseProtocol. Refer to Emergency Release Protocol.2. The ED admitting department has pre stamped emergency numbers. These numberswith any other available information will be entered into the computer on any EDpatient or during computer downtime.• If a name is not available, Doe, John or Jane will be used.• The computer will generate a MR#.3. If patient’s actual name becomes available and the ED requests blood using correctedname, the original specimen may still be used.• Check the "Doe" patient in HBOC computer (MPI Inquiry) to determine ifanother name or MR# has been assigned to the patient.If data agrees, the original "Doe" sample can be used for the request ticketsprinted with the corrected name.• Cross out the corrected name or MR # number on the crossmatch ticket andwrite in the original name/number from the sample. Example: using Doe, Johnspecimen when crossmatch tag states Cooper, Thomas.4. Within 24 hours and when convenient, the patient should be redrawn and bandedusing the corrected name/number. Leave the original band on the patient as long ascrossmatched blood tested from the original sample is available. Re crossmatch anyoriginal units using new sample. Enter crossmatches as XMNC in the blood bankcomputer and print a new crossmatch tag.5. When a trauma sample has been used, write a note in the passdown log indicating thata new sample needs to be drawn when situation allows. Each shift can investigatepatient status and write, "redrawn" when this is accomplished.TR-V – 42

LABELING SAMPLES DURING COMPUTER DOWNTIMENew MR numbers may not available when the HBOC computer system is down. ConsultComputer Downtime SOP for directions.LABELING INSTRUCTIONS FOR NON-CROSSMATCHED BLOODBANK SAMPLESCord Blood Sample1. Cord blood samples are labeled with the mother’s biologic label.2. "Cord blood" is hand written on the label.3. The mother’s blood type may be written on the label.4. A Computer label with the baby's ID information is also placed on the tube.5. The date and time should be on either label. No phlebotomist ID is required.Type and Screen, Miscellaneous Blood Bank Test Samples.1. Extra samples from ED and from L&D use the green Typenex system. Extra samplesfrom the Trauma Center use the red Typenex system. Other type and screen samplesare not required to use any Typenex system.2. The following information should be on the label.• Patients name• MR# (If in-house)• Collection date• Collection time• Phlebotomist ID3. Pedi crossmatch requests require a small purple top sample for Type and Screen.Typenex system not required.COLLECTION OF PRE-OP CROSSMATCH SAMPLES.Pre-op patients drawn by HRMC Out Patient Lab, Holding Room, PSE, CRU, andHickory Street Diagnostic Lab should fall into one of the following categories:1. Crossmatch ordered and patient has donated their own blood for surgery (autologousdonor).Patients with autologous donations must be labeled using Typenex system when theircrossmatch sample is collected. There are no time limits placed on collection of thesample, however the armband must be left on and legible when the patient is admittedfor surgery. For this reason these patients should not routinely be drawn sooner thanseven (7) days before surgery. The armband must be left on during this time.2. Crossmatch ordered and patient has not donated autologous blood forsurgery and surgery date is within two (2) days.TR-V – 43

These patients should be drawn for the crossmatch and. labeled using Typenexsystem when their crossmatch sample is collected. The armband must be left on theentire time prior to surgery. (Example - OR scheduled for the 10th, sample can bedrawn on the 8th.)3. Crossmatch ordered and patient has not donated autologous blood for surgery andsurgery date is more than 2 days away.These patients should have a sample drawn but they should not be labeled usingTypenex system. A type and screen will be ordered on the patient. On the day ofadmission, the OR Holding Room will redraw the patient, collecting a sample usingTypenex and order the crossmatch. Inform the patient that because the sample isbeing collected greater than 2 days prior to surgery they will need to be redrawn andbanded prior to admission.4. Type and Screen orderedIt is acceptable to draw these patients up to seven (7) days prior to surgery. Use ofTypenex system is not required.ACCEPTANCE/REJECTION OF INCORRECTLY LABELED SAMPLES.1. Evaluate incorrectly labeled sample and refer to "Acceptance/Rejection Guideline"chart for appropriate action.2. In surgery, the MD/CRNA will accept responsibility in a situation where time delaysfor redraw asterisk.3. Document all incorrectly labeled samples on the "Sample Acceptance/RejectionLog". Write reason for rejection.4. Discard rejected samples unless a sample mix-up is suspected. These situationsshould be immediately brought to the attention of the supervisor.5. If the sample is determined to be acceptable, correct the label and draw a circlearound the corrected/added data. Drawing a line through the incorrect data andwriting the correct data above should make the correction. (Initials are documentedon the log and do not need to be written on the tube correction.)• If the correction involves the name or MR #, the crossmatch tag must match theoriginal incorrect sample information. Cross out the data on the crossmatch tagand write in the same uncorrected data as on the sample. Notify the transfusingstaff of the correction.• The circled correction will be clear to other persons using the clot that adocumented acceptable correction has been made.TR-V – 44

6. These criteria are meant to be used as guidelines. Consult supervisor for unusualsituations.7. In emergency situations, when a sample is rejected, issue uncrossmatched type OEmergency Release blood per SOP.8. If a MR# correction has taken place, complete a “Merge Request” form. Place in theEvening Coordinator’s box and indicate which number/name is correct and if thepatient is still "in house."SAMPLE COLLECTION1. Blood samples are drawn using aseptic techniques.2. When the Blood Bank has determined that a sample (extra, redraw ect.) is needed ona patient, call the staff ordering the test to request a new sample.3. Blood Samples can be collected by the following groups:• Clinical Services• Patient Care Technicians• IV Team• Nursing Staff• CRNA (Surgery)• Laboratory Staff.• Outside Facilities Phlebotomy/Nursing StaffSUPPLEMENTAL MATERIALSSample Acceptance/Rejection Log.Blood Bank Sample Acceptance/ Rejection Guidelines ChartREFERENCES:Vengelen-Tyler V MBA MT(ASCP)SBB, AABB Technical Manual Committee,AABB Technical Manual 12th ed., AABB Bethesda MD, Chapter 16, pg(s)331, 332, 1996.TR-V – 45

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Title: Documentation of Lab Times and ResultsApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-V-JOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. POLICY:This policy is established to ensure proper recording of laboratory resultsand response times.II.III.PROCESS:In an effort to optimize the care of the trauma patient, documentation oflaboratory results and response times will be performed.PROCEEDURE:1. The time laboratory tests are drawn and sent to the lab will be documentedon the Trauma Flow Sheet.2. Laboratory results and the time laboratory results are received for theEmergency Department (ED) nurse in the narrative section of the TraumaFlow Sheet will document reporting to the physician.3. The Laboratory will keep a log of Trauma Alert patients and any tests thatare ordered the time received, and the time laboratory results are reportedto the Trauma Resuscitation Room.4. The documentation of the above items will be reviewed weekly, and asummary will be presented at the Trauma Quality Improvement Meetingon a quarterly basis.TR-V – 47

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Title: Emergency Blood Bank Supply and Maintenance ofTrauma Center Blood Bank RefrigeratorApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-V-KOrigin: 1/99Reviewed: 8/02Page: 1 of 6I. OBJECTIVE:In order to provide blood for immediate patient use, the Trauma Center will storeO Negative and O Positive emergency red blood cells in a temperature monitoredrefrigerator.II.POLICY:The Trauma Center emergency blood supply consists of O Negative and OPositive red blood cell units. All units are tagged with an Emergency Release tag,labeled with an Uncrossmatched Blood sticker. Units for the Trauma Center arestored in a temperature-monitored refrigerator in the Trauma Center room. The Opositive units will be used for men and older women over childbearing age. TheO negative units should be used for all other women or if the age of the woman isunknown. As soon as ABO Rh testing is performed on a properly labeled bloodsample, ABO Rh type specific units should be issued from the Blood Bank.Trauma Center Beeper:The Blood Bank is part of the HRMC “Trauma alert system”. The Trauma Centerhas supplied the Blood Bank with a “trauma beeper”. The trauma beeper will bepassed from shift to shift and be worn at all times by a Blood Bank technologist.The Groupwise pager system is used to alert the blood bank technologist of thearrival time of the trauma.Refer to Notes: Trauma Alert Paging Interpretation for clarification of the variousalerts issued.DIRECTIONS FOR BEEPER USE• To read message press the green “ – “ button• To scroll through the message you can use “up and down” arrow buttons• To delete message use the “< >” buttons on the bottom until you find thefunction to “delete message”. Then press the red button to delete the message.• DO NOT change any other functionsTR-V – 49

Trauma Center Packet:The trauma packet will include embosser plate; pre stamped labels; blood bankred Typenex armband; patient bracelet; downtime requisitions including lab andblood bank; and other patient care forms.Patient Identification/ Alias Registration:1. The hospital downtime system will be utilized. Trauma packets are created inadvance using a specific account numbering system dedicated for TraumaCenter patients. A specific numbering system is used. It is 10 digits long andstarts with 7. This number will be entered as the patient account numberwhen the patient is registered in the hospital computer. This number willserve as the patient identification number.2. A pre assigned name will be used. The last name will be “Trauma” (example:Trauma, Alpha 1). The number used as the middle initial corresponds tonumerical order of the alphabetical letter used in the first name (example“Alpha” - A is the 1st. letter of the alphabet).3. The patient type will be HET (HRMC Emergency Trauma). The pre assignedpatient account number will serve as the patient identification number. Allinformation in the Trauma Packet will use this pre assigned identification.• Note: If the patient is identified within 15 minutes they will be registered inHBOC computer using their real name. However, the downtime order youfirst received will have the “alias registration” name. You will have toidentify the patient in HBOC computer by using the patient account number.At the computer screen where you usually enter the MR#, read the prompt atthe bottom for instructions on how to use the account number to access thepatient. (enter “ * “ and then the patient account number)4. On occasion, patients are designated as trauma after admission as a nontraumapatient. In the event that the ED registers trauma patients using thepatient’s real name and standard admission number instead of the traumanumbering system prior to the patient being changed to trauma status, we canstill use the sample by connecting the sample to the name in HBO under MPI.5. ED registration staff must do the following:• Access the Patient Administration side of HBO.• Select MPI• Enter patient name• Select miscellaneous page• Enter Trauma admission number in “other surnames” location.6. Blood Bank can then access this information in the same manner, match thetrauma name to the collected sample preventing transfusion delays and patientredraws.TR-V – 50

Labeling of Blood Bank Specimens from the Trauma Center1. All and only Trauma Center specimens collected for Blood Bank will use thered Typenex armband system. The red Typenex system will serve as anotherflag for STAT priority and identification of the Trauma Center specimen.2. Identification of the patient is based on the “alias registration system”.3. The following information will be added to the red Typenex label at the timeof specimen collection:• Patient name or Trauma name• Trauma ID number or MR number• Collection Date• Collection Time• Phlebotomist/RN computer ID# or initials.* Refer to Collection/Labeling/Acceptance of Blood Bank SamplesPolicy.Testing of Trauma Center specimens and Entry of Results:1. The Trauma Center physician will order any blood bank tests and bloodproducts needed. If no tests or blood products are ordered, the Trauma Centerspecimens (red Typenex) will be saved for future use, as are other “extraclots”.2. Tests and blood products ordered on downtime slips will later be ordered inHBOC computer by blood bank staff.• Refer to “Release of Emergency Blood Protocol” (3.VI.4), section“Crossmatching Emergency Release Blood”• Follow routine STAT technical procedures. Trauma patientsshould receive priority status over routine tests.• Refer to sample of downtime request order.• Refer to Notes: Verbal Orders3. Lab results should be reported in the computer if the patient has beenregistered in the computer already or via downtime slips if this has not beendone. Laboratory / Blood Bank personnel should attempt to identify patientsin the HBOC computer via the account number (see Patient Identification -Note).TR-V – 51

Trauma Center Refrigerator Blood Supply:1. The Blood Bank is responsible to maintain and replace the blood units storedin the Trauma Center refrigerator. Units will be tagged with EmergencyRelease tag and have a temperature monitor sticker attached. Refer toEmergency Release Protocol for instructions on completion of EmergencyRelease tag and use of temperature monitor sticker. Enter the unit numbers tobe placed in the Trauma Center refrigerator on the Trauma Center BloodInventory Log. Refer to Special QC Instructions for the Trauma Center BloodRefrigerator for further instructions on restocking the refrigerator.2. The Trauma Center will notify the Blood Bank when the units from theirrefrigerator are used so that they may readily be replaced. Extra units may bekept in the Blood Bank Emergency Release blood storage area in thecrossmatch refrigerator for this purpose.3. Emergency Release blood from the Trauma Center refrigerator will be usedfor patients in the Trauma Center only. It is not to be released to any otherdepartment.4. Whenever units of blood are released from the Blood Bank to the TraumaCenter for a specific patient (type specific blood after ABO/Rh has beenperformed) the blood will be issued in a cooler on ice. This blood mustNEVER be placed in the Trauma Center refrigerator under any circumstance.5. The Trauma Center refrigerator will be kept locked. ED Staff has access intheir department to keys for the Trauma Center blood refrigerator. BloodBank will also have a key. It will be kept in the drawer where the key to ourfront door and beeper are located.Maintenance of Trauma Center Refrigerator:1. All refrigerator QC will be performed by Blood Bank staff. This will includedaily temperature and blood unit inspection. Refer to Special QC Instructionsfor the Trauma Center Blood Refrigerator.2. The Blood Bank will report any repair problems to Plant Operations andassure that the refrigerator is functioning properly after repairs andadjustments have been made.3. In the event of an alarm sounding, the Trauma Center staff will immediatelynotify the Blood Bank. Blood Bank staff will assess the problem and moveblood units, using an ice filled cooler, to another temperature monitoredrefrigerator within the Blood Bank. Blood Bank staff will notify PlantOperations if needed.TR-V – 52

Trauma Center Documentation of Blood Transfused1. Trauma Center nurses will record all transfusions on the “Trauma CenterBlood Transfusion Log” as well as in the patient’s chart. The log will be kepton the Trauma Center refrigerator.2. This log will be used by Blood Bank staff to verify the disposition of theblood transfused in the Trauma Center.3. The Emergency Release tag, which is attached to the blood unit, will becompleted and signed. The Blood Bank File copy of this tag will be returnedto the Blood Bank.NOTES:1. Trauma Alert Paging Interpretation• Between 0700-0800 each morning, you will receive a page that will read“test call-47296”. At that time you should call 47296 to verify that youreceived the page.• “Trauma Alert-Prehospital” means that the dispatch center has launchedthe helicopter or a ground unit is in route to the scene. You may receivethis same page that also states X2 or X3. This indicates that there are 2 or3 patient’s involved.• “Trauma Alert-Interfacility” means that the helicopter has departed to pickup a patient at another hospital to bring back to HRMC. This could alsomeans that a patient has been accepted from another hospital and a groundunit is bringing the patient in.• “Trauma Alert-ETA 10 minutes” means that the patient is 10 minutes outfrom the facility.• “Trauma Alert-Respond Immediately” means that the patient is expectedhere in less than 10 minutes or is already here. This happens at timeswhen the incident is close to the hospital or a patient is brought in by aprivate car.• “Trauma Alert Canceled” means that upon arriving on the scene, it wasdetermined that the patient was not a trauma alert patient.• Other than the morning test page, do not call the Trauma Room to respondto any of the pages.2. Verbal OrdersIn any emergency situation, computer orders for blood products may notbe able to be placed in the HBOC computer. It is acceptable to take averbal order.The “Verbal Orders Received” form will be used to document all verbalorders. Complete the form as indicated. It is important to record thecomplete name (first & last) and title of the person placing the verbalorder. The blood bank tech will record the MR# either by checking theoriginal order (as in the case of an add on) or by checking in HBOC. DoTR-V – 53

not ask the person calling a verbal order for the MR# as they do not havethis information readily available.Physician’s order should be documented on the patient’s chart.SUPPLEMENTAL MATERIALS:Trauma Center Blood Inventory LogTrauma Center Blood Transfusion LogVerbal Orders Received FormREFERENCES:Vengelen-Tyler V MBA MT (ASCP) SBB, AABB Technical Manual Committee,AABB Technical Manual 13 th ed., AABB Bethesda, MD Chapter 18,pg.376, 386-7, 1999Menitove JE MD, AABB Standards Committee, Standards for Blood Banks andTransfusion Services 20 th ed., AABB Bethesda, MD, 2000First Flight Dispatch, Trauma Alert Paging System, Janice Willette, 2/17/99TR-V – 54

Title: Laboratory Protocol for a Trauma AlertApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-V-LOrigin: 1/99Reviewed: 6/02Page: 1 of 1I. OBJECTIVE:This policy is established to provide consistent and expeditious service tothe critically injured trauma patient from the Department of LaboratoryServicesII.III.POLICY:The use of the Laboratory for a trauma alert patient and the lab studies toinitially be done will follow pre-established guidelines in an effort toensure an optimal level of patient care.PROCEEDURE:1. The laboratory department will be notified via trauma beeper,but will not physically respond unless requested.2. Upon notification of a Trauma Alert, designated Laboratorypersonnel end current laboratory testing, and give priority tolaboratory test orders for the trauma alert patient.3. The instruments in the Laboratory will be prepared for theappropriate laboratory studies4. The trauma team leader may order one of the followingTrauma Lab Panels during the initial trauma resuscitation:Extended Trauma Lab Panel: H/H, Type and Screen,PT/PTT, and Chem 8.Basic Trauma Lab Panel: H/H, Type and ScreenAdd as Ordered: ABG, CMP, Troponin, Lactic Acid,Amylase, Lipase, CPK with MB, HCG, BAL, Tox, U/A, andother laboratory diagnostic tests as appropriate.5. Blood samples will be drawn by the Trauma Team and taken tothe Laboratory. When requested, the Laboratory Technologistwill respond to the trauma room to receive the blood samples.6. Laboratory results will be reported via the computer. If thelaboratory value is a “critical value,” the Technologist will callthe results to the Trauma Resuscitation Room.TR-V – 55

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Title: Radiology – CAT Scan / Trauma ServiceApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-V-MOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. POLICY:The use of CT scanner for a trauma alert patient will follow preestablishedguidelines in an effort to ensure an optimal level of patientcare.II.III.PURPOSE:The critically injured patient necessitates a multidisciplinary teamapproach and requires the services offered by a variety of team members.This policy is established to provide consistent and expeditious assistanceto the critically injured trauma patient in regard to CT scans.PROCEDURE:1. CT Scanner is located in the Radiology Department in close proximityto the Trauma Room. There is a Registered Technologist on staff 24hours a day with an additional back-up call technologist available ifnecessary.2. When a trauma patient arrives, the CT department is notified via grouppage. The CT scanner will be cleared of existing patients. The CTroom will be kept available until the attending trauma surgeon makes adecision regarding whether a CT scan of the patient needs to becompleted.3. In the event that the first Scanner is not functioning, a second CTscanner is available in the radiology department.TR-V – 57

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Title: Radiology – Reading of Studies for Trauma PatientsApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-V-NOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. OBJECTIVE:In order to ensure optimal care for the trauma patient, the following policy hasbeen established to provide a minimum guideline for the reading of radiologicfilms associated with the Trauma Alert patient.II.PROCEDURE:1. Stat reading by a Radiologist of chest, pelvis and spine x-rays and any otherplain films that the Trauma Surgeon on call deems necessary.2. Stat reading by a Radiologist of all abdominal ultrasounds on Trauma Alertspatients will be performed.3. Stat reading by a Radiologist of all CT scans of the brain, chest, abdomen,pelvis, and spine on Trauma Alert patients will be performed unless thetrauma surgeon on call or his designee writes an order that a wet reading is notnecessary.4. Stat reading by a Radiologist of all MR spine scans on trauma patients.5. Any films, ultrasound, or CT scans on non-trauma alert patients that theindividual trauma surgeon, neurosurgeon, orthopedic surgeon, or emergencyroom physician need read emergently will be read in a timely fashion.6. If there is a discrepancy between the preliminary reading and the final readingof a study, the radiologist who completes the final interpretation will contactthe Trauma Surgeon making rounds via the transfer center at extension 47296TR-V – 59

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Title: Radiology – Reading of Studies for Trauma Patientsin MRIApproved By: Emran Imami, MDTrauma Medical DirectorNo: TR-V-OOrigin: 4/99Reviewed: 8/02Page: 1 of 2I. OBJECTIVE:To insure a safe environment in which all Trauma patients, no matter whatcondition they are in, can be brought to the MRI department for diagnosticprocedures.II. DEFINITION:Providing for the safety of the patient and medical staff while in the MRIdepartment. Certain devices are contraindicated for MRI procedures. Thispolicy will provide documentation so that the safety of the patient andstaff is provided.III. POLICY:1. All potential MRI cases are to be discussed by the ordering physicianand the Radiologist before ordering a MRI exam.2. Nursing staff pages the ED radiologic technologist, who gets theTrauma Surgeon and radiologist on call in contact with each other todiscuss the appropriateness of the test.3. If MRI is determined to be the exam of choice, Trauma surgeon ordersMRI scan. HUC enters the order into HBOC system; the1041 MRIsafety form automatically prints at the nursing station.4. Nursing staff gets the 1041 safety from filled out by the patient or thepatient’s family members.5. If the 1041 safety form cannot be cleared, the patient should have askull, chest, and abdominal x-ray done for safety clearance.6. X-rays will be digitalized to radiologist for interpretation and safetyclearance.7. After the safety of the patient has been determined, the ED x-raytechnologist or the control tech will notify the MRI technologist that ison call for the study.TR-V – 61

*****MRI technicians are on call Monday-Friday 2230-0630, Sat-Sun1730-0730.8. MRI technologists will respond within the 30-minute time frame toperform the study.9. Once the MRI technologist is on site, the ED/Trauma Center will benotified when the exam can be performed.10. The ED/Trauma Center patient will have to be prepped to enter theMRI magnet room to ensure all equipment is MRI compatible. NOFerro-magnet support equipment, oxygen tanks, IV infusion pumps,and monitors etc. Are allowed.11. MRI safety questions will have to be answered by the ED/TraumaCenter staff who may need to remain with the patient.With patients on backboard clearance of the cervical spine MUST beobtained through the Trauma surgeon prior to transport to the MRIdepartment. (Note: Patients can not be scanned if they are on abackboard.)IV. PROCEDURE:Routine 1041 safety forms are obtained on the computer system andshould be filled out completely by the patient and patient’s RN. If thepatient is unconscious or unable to verify history, a close family memberwith adequate information may give history.If no 1041 form can be adequately completed step #3 of the policy shouldbe followed. After step #2 & #3 are completed, the ER diagnostictechnologist is to call the on call MRI technologist with the followinginformation: patient name, type of exam, patient location, & diagnosis.*****Reminder all trauma cases where the patient is on a backboard, thecervical spine clearance is a must. A soft Philadelphia collar is acceptablefor scanning. **********Trauma staff that is required to go into the MRI suite during theprocedure will be required to fill out a MRI safety questionnaire and alsobe briefed by the MRI technologist prior to entering the room**********Calling 37454 will carry out Notification of the MRI technician. It isthe radiology technician or the radiologist that will alert the MRItechnician of the study. *****TR-V – 62

Title: Radiology Technologist Response to a Trauma AlertApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-V-POrigin: 1/99Reviewed: 8/02Page: 1 of 1I. OBJECTIVE:To provide a consistent and expeditious response to the radiographic needsof the trauma patient from the Department of Radiology.II. POLICY:The response of the radiologic technologist to a trauma alert patient willfollow pre-established guidelines.III. PROCEDURE:1. Immediately and without delay upon notification via trauma beeper,the designated radiologic technologist reports to the traumaresuscitation room (TRR).2. After obtaining pertinent information such as age, type of injury, andestimated time of arrival, the technologist takes appropriate film to theTRR.3. X-rays that have been ordered by the trauma team leader areperformed. Technologist should be prepared for x-rays of the cervicalspine, chest, and pelvis.4. Films are processed and provided to the Trauma team leader forinterpretation. If needed, the trauma team leader will requestinterpretation of the films by the radiologist. During times when theradiologist is not in-house, films may be reviewed by teleradiography.5. The radiologist will respond to the trauma center when requested bythe trauma surgeon.6. The technologist remains available for the trauma patient untildismissed by the trauma surgeon or his/her designee.TR-V – 63

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Title: Acceptance and Transfer of Interfacility TraumaPatientsApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-AOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. OBJECTIVE:To establish guidelines for the acceptance and transfer of interfacility traumapatients.II.III.DEFINITION:Interfacility- is the transfer from one hospital to another.POLICY:A. All calls received in the Communication Center from a referring emergencydepartment for a trauma patient transfer, Trauma Medical Director, or hisdesignee, is to be called for acceptance.B. All request must be accompanied by:1. Medical records2. EMS run sheet3. History and physical4. Nurses notes5. Physician notes6. Face SheetC. After receiving the above information, the communication specialist will thennotify The Trauma Medical Director, or his designee, for acceptance.IV.PROCEDURE:A. When the call is received from the referring facility the communicationspecialist will complete part B under policy.B. After receiving all of the information, they will then call The Trauma MedicalDirector, or his designee.C. If the patient is refused, the communication specialist will document as such.D. If the patient is accepted, the communication specialist will ask how they wantthe patient to be transported. If by First Flight they will be launchedimmediately. If by ground, the Communication specialist will work with thereferring facility to set up the transfer in a timely manner.E. The communication Specialist will also ask the accepting trauma surgeon if hewants a trauma alert paged and will follow the appropriate procedure.TR-VI – 1

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Title: Admission, Transfer, DischargeApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-BOrigin: 1/99Reviewed: 8/02Page: 1 of 15I. OBJECTIVE:To provide an integrated, coordinated, quality and patient driven process fromhospital admission through hospital discharge in a manner that ensures patientchoice, the continuity of high quality patient care, the availability of the hospitals’resources for patients requiring admission and appropriate utilization of resourcesin the hospital and in the community.II.DEFINITION:A. ADMISSION:Patients have a right to access and receive treatment. Patients, who havea medical emergency, or are in labor, have the right to receive, within thecapabilities of this hospital’s staff and facilities, an appropriate medicalscreening examination, necessary stabilizing treatment includingtreatment for an unborn child, and if necessary, an appropriate transfer toanother facility regardless of ability to pay or availability of medicalinsurance. This hospital does participate in Medicare, Medicaid, andChampus programs for entitled members. People arriving to theEmergency Department who require psychiatric or substance abuseintervention only, will be transferred to an appropriate facility byphysician order and patient consent as appropriate.Patients can be admitted as Inpatient or Observation status with aphysician’s order.1) Observation Status: Admission as 23-Hour Observations is definedas:Those that need to be evaluated for a suspected condition or whomust be observed to determine the possible need for inpatientadmission which require hospital services. A patient admittedfor Observation may not remain as an Observation patient formore than 23 hours [physicians may extend Observation Statuswith appropriate documentation for extension up to 48 hours. Atthe end of the 48 hour window, the patient must be admitted ordischarged appropriately.]TR-VI – 3

2) Inpatient Status:B. TRANSFER:Those who the physician intends to require hospital service,which cannot be done as an outpatient because of the severity ofthe patient’s illness and or the intensity of required services.Patient transfers are those which occur within the various hospital settings.C. DISCHARGE:III.Routine discharge is the release of the patient from hospital care to homeor another entity of care.1) Home2) Skilled Nursing Facility (SNF)3) Long Term Care Facility4) Other FacilityPOLICYA. ADMISSION:1) After evaluation and stabilization of the patient and once theEmergency Department physician determines that the patient’scondition warrants admission to the hospital, the EmergencyDepartment physician will contact the patient’s primary physicianor the appropriate on-call physician if the patient does not have aphysician. The Emergency Department physician will remainresponsible for the patient until the admitting physician iscontacted and gives admission orders or physically sees the patient.2) The “on call” physician is assigned based on the list provided byeach department of the Medical Staff for physicians on call. Theresponsibilities of these physicians are outlined in the medical staffbylaws, rules and regulations.3) During the transfer the patient will be given O2 therapy ifindicated and kept on a cardiac monitor as indicated. A nurse willaccompany all patients transferred from Emergency Department toassigned unit when monitors, 02 (high flow/mask device), or IV’sare required. Paramedics may transfer stable PCU patients. Whenventilators are required a Respiratory Therapist will alsoaccompany the nurse. Emergency Advanced Cardiac Life Supportdrugs and a defibrillator will accompany the patient if indicated.4) When the functional capacity of ICU beds has exceeded its limits.The ICU, Medical and Nursing Director/designee will triageTR-VI – 4

existing ICU patients and requests for ICU admissions using thepatient priority grid (Table 2).5) The Medical Director, ICU Director, and AdministrativeSupervisor to determine best use of resources (beds) will utilize thepatient priority grid. Patient wishes whether through advanceddirectives or their desires known to forego life-sustaining therapy,will be honored.6) Pediatric ICU patients will go to MICU or receive care from aMICU skilled nurse.7) Cardiac Surgical patients will go to CVICU or receive care from aCVICU nurse.8) Trauma patients requiring ICU care will go to SICU. Traumapatients will be considered as a priority admission for triagepurposes. Bed assignments will be made such that an SICU bedwill always be available to receive a trauma patient. A traumaqualifiednurse in SICU will care for trauma patients; there shall bea minimum nurse patient ratio of 1:2 per shift.B. DIRECT ADMISSION1) Patients requiring acute care can be admitted directly by thephysician via notification of the admitting department.2) Bed assignments will be made based upon established criteria.(Table 1)C. PRE-SURGICAL ADMIT/POST-PROCEDURAL ADMIT1) Patients requiring surgery/procedures can be admitted by thephysician requesting this care after scheduling has been completed.2) Bed assignment will be made based upon established criteria.D. TRANSFER(Table 1 – 4)1) Patients will be transferred based upon level of care and servicesneeded, with physician order and patient/family acceptance.2) The medical and nursing director/designee will assist in triage.TR-VI – 5

E. DISCHARGE1) Release of patient from HRMC/PBCH will be by physician orderor by patient/guardian signing out Against Medical Advice.2) Discharge preparation is an interdisciplinary process requiringcoordination of all disciplines beginning upon patient admission.3) Discharge planning and patient education assessments are to beinitiated during the admission process. This assessment willinclude physiological, psychosocial, environmental, and socialculturalfactors.4) Using a multidisciplinary integrated approach, the nursing staffwill document the educational needs of the patient and family, andprogress of the patient’s current illness towards the anticipateddischarge plan. The patient/significant other will be allowedparticipation in the planning and achievement of the patient’sdischarge goals. Education interventions and the discharge planwill be revised as the needs of the patient change.5) The nurse will document the patient’s/significant other’s ability todemonstrate and/or verbalize the skills necessary to meet thepatient’s ongoing post hospital care needs. If for any reason thedischarging nurse suspects discharge needs are unmet, thephysician will be notified to assure a safe and appropriatedischarge.6) A Case Management/Social Work referral will be initiated if it isanticipated that the patient/family cannot meet the ongoing carerequirements, if additional home supervision or intervention isrequired, or if patient will return to, or potentially will require,admission to a nursing center.7) Written documentation of ongoing post hospital care needs for thepatient and/or other individual responsible for care giving will beprovided.8) Information will be provided in understandable language in thefollowing areas: safe, effective use of medicines, safe, effective useof equipment, specific procedures/skills to be performed, potentialdrug/food interactions, nutrition or modified diets, rehabilitationtechniques, as indicated, community resources and how and whento obtain additional treatment.9) When a home care or skilled nursing facility referral is made, ormedical equipment is needed, selection is determined according tothe following protocol:TR-VI – 6

a) Patient/family requestb) All Medicare patients requiring home health care will begiven a list of Medicare Certified Home Health agencieswho have requested to be listedc) Inform patient of physician preference, if notedd) Inform patients that other agencies are listed in the phonebook and that one will be made available upon request.e) If known, the preferred provider for the patient’s insurancewill be communicated to the patient.f) A list of Skilled Nursing Facilities/Long Term CareFacilities is available: families are encouraged to visit thosefacilities prior to their selection.g) Selection will be documented in patient chart, as requestedby patient.IV.PROCEDUREA. ADMISSION1) Physician writes order for admission to appropriate level of careand bed control is notified by computer message.2) Bed assignment is made based upon level of care/services needed.3) Unit is notified requesting bed availability and room # is given tobed control with bed status (ie: clean and ready, please dischargeand transfer, etc.)4) Requesting unit is notified of bed assignment and status.5) When bed is not clean, environmental is notified by bed control orby computer upon patient discharge; once bed is cleanenvironmental notifies bed control and bed control notifiestransferring unit that patient may be transferred.6) Once bed is ready, patient status report/diagnosis is given tonursing unit.7) Patient is directed/transferred to accepting nursing unit.DISCHARGE1) Discharge Home/Self Care/Assisted Living FacilityTR-VI – 7

a) The nurse initiates discharge planning during the initialassessment. The nurse will work with all disciplinesinvolved to ensure that the needs are appropriatelyidentified and addressed. The physician will be keptapprised of progress in the discharge planning process.b) Physician writes orders for discharge.c) If patient is a DNR or patient and/or family wishes towithhold all emergency medical services outside the acutecare settings, one original HRS form 1896 (available fromthe case manager) is completed. HRS Form 1896 is givento the patient/caregiver.d) The Health Unit Coordinator copies HRS Form 1896 forhospital records.e) The nurse completes the “Patient Discharge Instructions &Medication Schedule” form, transcribing the physicianorders into an easily understandable and legible format.f) After review of instructions with the patient and/orcaregiver and the patient/ caregiver signs form confirmingunderstanding of discharge instructions, a copy of theinstructions is given to the patient and a complete copy ofthe instructions is placed on the chart.g) The discharge nurse makes certain the patient has all ofhis/her belongings, valuables, prescriptions and medicalequipment.h) The date, time, means of discharge, final dischargeassessment and education interactions are documented inthe integrated progress notes.i) The patient must be discharged via the computer within 15minutes of the actual time of discharge.j) On the day of discharge nursing staff will:1. Have patient ready for transfer by the appointedtime of transportation2. Confirm that all paperwork is completed3. Document the date, time, method of discharge,destination, and discharge assessment on theIntegrated Progress Notes and document in nursesTR-VI – 8

notes: 3008 form complete and sent with patient,along with copy of current chart, per policy.2) Discharge to home with home health care, home medicalequipmenta) Case Management will contact the identified equipmentagency and provide the agency with demographic andappropriate medical information on the patient and theanticipated discharge date.b) The identified agency will coordinate with thefamily/significant other/patient the delivery of equipment tohome or hospital.c) The Case Manager completes Home Health Worksheet.The white copy is placed in front of the current PhysicianProgress Note. Case Management keeps the yellow copy.d) If any questions or special needs arise, the Case Managerwill communicate with the patient, family, or physician forclarification.e) If patient has no insurance or lacks funds for neededservices Case Management will work with Social Services.Social Services/Case Management will initiate financialassessment and make appropriate payers contact.f) Case Management completes transfer form with diagnosisand any special physician/nursing plans of careinstructions. Physician medication orders will be identifiedon nurses discharge instructions if unavailable at time ofreferral. Enteral/IV therapy will be confirmed on day ofdischarge. Call physician as necessary to clarify orders.1. Information regarding enteral IV therapymedications should be obtained as early as possibleprior to discharge to allow adequate time forappropriate/safe arrangements to be made.2. Consult Pharmacy as indicated.g) Case Management will fax the form to the identifiedagency documenting date and time in the right hand corner.1. Call agency to notify of incoming fax.TR-VI – 9

2. Home Medical Equipment for Home Care requiredsame day, after hours (6:00PM-8: 30AM) will becoordinated by nursing unit, or by on-call SocialWorker.h) Notify agency as soon as possible if patient needs to beseen on the day of discharge for such care as tube feedings,TPN, dressing changes, etc., so they have sufficient time toarrange staff.i) If patient is satisfied with previous services and requests toreturn to a facility care will be resumed by that agency andpatient will be transferred there.j) Case Management will monitor charts concurrently fordischarge date and update transfer form if additional needsare identified.k) Check daily discharges for Case Management referralsmade day of discharge.l) Health Unit Coordinator will call home health agency theday of patient discharge notifying of hospital discharge asappropriate.4). Discharge to Subacute and Long Term Care Facilitya) When a patient will be discharged to a nursing center, theCase Manager will notify the patient’s family/S.O. of theanticipated transfer date and arrangements. The casemanager will obtain acceptance and initiate the HRS form3008.b) The Case Manager will document patient/family/ S.O.acceptance and understanding of discharge plans in theprogress notes.c) The HRS Form 3008 will be completed by all disciplineswith input into the patient’s ongoing needs.d) The Physician will complete “Physician Information”portion of the HRS form 3008 to include:1. Diagnosis2. Medications3. Treatment orders4. SignatureTR-VI – 10

e) The Case Manager will communicate with all disciplinesregarding the need for their involvement in the completionof the HRS 3008 form.e) The Case Manager will complete the following information on theform:1. Physician’s name2. Physicians phone number3. if physician will follow patient at the nursing center4. history of mental illness or mental retardation5. insurance information6. advanced directives7. medical/mental history, laboratory findings andphysical exam8. signature, printed name, agency and phone numberf) Nursing will complete the following information: Sections D,G, H, J1. types of specialty care2. functional assessment3. signatureh) Rehabilitation Therapy completes the following:1. Physical Therapy section K, L (as appropriate)2. signature and titlei) All additional therapies such as dietary, ostomy care,respiratory therapy, diabetic care will document in the“Additional Therapies” section, and sign with professionalsignature and title.j) Upon notification of an impending discharge to the nursingcenter, the case manager or staff nurse will notify theHRMC Transfer Center or Holmes to Home to maketransportation arrangements.TR-VI – 11

k) When the physician writes the discharge orders, the nursewill complete the patient discharge record and the HealthUnit Coordinator will fax discharge medications to thereceiving nursing center.l) The Health Unit Coordinator will copy and assemble thefollowing chart documents for transfer to the nursingcenter.1. facesheet2. history and physical3. physician consultations4. operative reports5. last chest x-ray report6. last EKG7. last CBC, Chem 7, Comprehensive MetabolicProfile8. echo/cardiovascular testing reports9. reports of Special Radiology tests such as CATscans, MRIs10. DNR order from HRMC chart11. Therapy evaluations [OT, PT, ST]12. last rehabilitation note[s] from IPN13. discharge medication orders14. original DNR document15. discharge record16. Health Assessment/History formThe Health Unit Coordinator will copy the completed HRS form3008 and place it in the patient record. The original Form 3008will be provided to the receiving nursing center, with the transferpaperwork.4. Other Facility: Refer to Interfacility transfer policies in theOperations Manual.TR-VI – 12

TABLE 1: LEVEL OF CARE/UNIT CRITERIA FOR BED ASSIGNMENT AT HRMCUNITADMISSIONMEDICALAccepts Neuro/Medical/renal adult patients, cardiac patients. (Accepts no cardiac7 WESTdrips, antiarrhythmic or vasopressor drips). Eight telemetry beds.7 EAST Accepts chronic ventilator patients (past a minimum of twelve (12) hours in ICU),respiratory, medical and GI patients. (Does not accept drips-vasopressors orantiarrhythmic.) Does accept renal dose dopamine.ONCOLOGY6 EASTAccepts medical oncology patients, radioactive implant patients, oncologyoutpatients, patients receiving chemotherapy agents, neutropenic patients, patientswho are terminal and dying, oncological emergencies and chronic pain managementpatients.ORTHOAccepts adult trauma, orthopaedic and/or medical/surgical patients.8 WEST8 EAST Admits children under 18 years, adult GYN & medical-surgical overflow.L & D (Labor Birth andSCMU)MOTHER/BABYNICU -TRANSITIONNICUINTERMEDIATE CARENURSERYHigh Risk Pregnancy Conditions, Labor Patients, Cesarean SectionPregnancy Induced HypertensionPreterm LaborAntepartum BleedingHigh Risk Post PartumFull Term PregnancyFirst Trimester Pregnancy - StableStable post-partum MomsStable newbornsA. Infants with more than one of the following risk factors are to transition inNICU:1. Infant of Insulin Dependent Diabetic Mother (IDDM)2. Initial chemstrip< 20 when jittery or chemstrip of zero.3. Apgars < 5 at 1 min or < 7 at 5 min.4. Tachypnea (RR > 70)5. Increased work of breathing, flaring, grunting, or retracting.6. Periodic breathing (RR< 25)7. Apnea8. Heart rate < 100 or Tachycardia > 180 at rest9. Multiple gestation < 37 weeks10. Infants < 36 weeks gestation11. Any congenital anomaly or occurrenceB. All infants of mothers with any type of diabetes whose initial heel stick bloodglucose is less than 50 are to transition in NICUC. All infants of mothers who received MgSO4 prior to delivery are to transitionin NICUD. All transition infants are admitted under Intermediate Status for a minimum oftwo hours1. Infants requiring IV therapy2. Gavage fed infants3. NPO infants4. Significant feeding intolerance5. Infants requiring monitoring, (E.G. C/R monitor or pulse oximeter)6. Direct admissions of infants who may require close observation or non-invasivemonitoring7. Stable infant requiring transfusion of WPRBCTR-VI – 13

TABLE 1: LEVEL OF CARE/UNIT CRITERIA FOR BED ASSIGNMENT AT HRMCNICUPCU4 WEST5 EAST5 WEST6 WESTUNITINTENSIVE CARECCUMICUSICUCVICUADMISSION1. Infants born at 34 weeks or less gestation may be admitted to the NICU forevaluation2. Infants weighing less than 1500 grams regardless of gestation3. Infant with uncontrolled apnea, bradycardia, and/or seizure activity4. Infants requiring invasive monitoring5. Infants on oxygen therapy via hood or mechanical ventilation6. Infants requiring transfusion or whole blood or other blood products7. Infant manifesting evidence of septic shock or other life threatening conditions8. Infants with congenital anomalies9. All post-op neonates will return to NICU10. Infants requiring exchange transfusionSPECIALTIES: Monitored. Accepts vasoactive and dysrhythmic drips4 West accepts post CABG and vascular patients, thoracic surgical, CABGreadmits, and overflow from PCU.5 East accepts Cardiac plus (5E & 5W),PTCA patients & Radiation Implants &STENTS5 West accepts peritoneal dialysis patients6 West accepts Trauma patients, pre and post surgical patients as well asMedical/Cardiac/Surgical.PCUTelemetry monitoring, Trauma step-down (6 West Only) Post surgical analgesia,Unstable angina, dysrhythmias, cardiomyopathy, congestive heart failure, Acutemyocardial infarction - definite or reasonably suspected.Pulmonary edema needing acute nursing careSyncopePacemaker insertions or failuresPatients requiring Dopamine or Inocor at less than 5 mcg/kg/min may be admittedto the PCU.However, PCU management may use discretion and accept higher rates afterevaluating the patient.Nitroglycerin drips for stable patients (Also see Policy NM: III-03-01).Patients who are admitted are unstable and critically ill, in need of intensivemedical and nursing care.CCU accepts Cardiac/ Medical Patients (overflow ICU)MICU accepts Medical/Pediatric Patients (overflow ICU)SICU accepts Trauma Patients (first priority: SICU Only) / Surgical (overflowICU)CVICU accepts Open Heart/Thoracic Surgery Patients (overflow ICU)TR-VI – 14

TABLE 2: HRMC PATIENT PRIORITY GRID FOR CRITICAL CAREHRMCPriority 1Trauma patient in need of critical care, critically ill, unstable patients in need ofintensive treatment and monitoring that cannot be provided outside the ICU.Treatments include ventilator support, continuous vasoactive drug infusions, IAPBsupport, ect. These patients generally have not limits placed on the extent oftherapy and interventions they receive.Examples of these patients may be post-operative or acute respiratory failurepatients requiring mechanical ventilatory support, shock or hemodynamicinstability requiring invasive monitoring and/or titration of vasoactive drugs.Priority 2These are patients that require the intensive monitoring services of the ICU andare at risk to need immediate treatment. Generally, no limits are placed on theextent of therapy these patients are to receive.Examples of these patients include those with underlying heart, lung or renaldisease that have an acute severe medical illness or have undergone major surgery,or those requiring invasive hemodynamic monitoring.Priority 3Priority 4These are critically ill, unstable patients who previous state of health, underlyingdisease, or acute illness reduces the likelihood of recovery and therefore benefitfrom ICU treatment. These patients may receive intensive treatment to relieveacute illness, but therapeutic efforts may stop short of measures such as intubationor CPR.Examples include patients with metastatic malignancy complicated by infection,pericardial tamponade or airway obstruction, or patients with end-stage heart orlung disease complicated by a severe acute illness.These are patients who are generally not appropriate for ICU admissions.Admission of these patients should be on an individual basis, under unusualcircumstances and at the discretion of the ICU Medical Director. These patientscan be placed in the following categories:1. Little or not anticipated benefit from ICU care based on low risk of activeintervention that could not safely be administered in a non-ICU setting. Theseinclude patients with peripheral vascular surgery, hemodynamically stable,diabetic ketoacidosis, conscious drug overdose, mild CHF, etc.2. Terminal, irreversible illness who face imminent death (too sick to benefitfrom ICU care).a) Maybe excluded: severe, irreversible brain damage, irreversible multiorgansystem failure, and metastatic cancer unresponsive tochemotherapy and/or radiation therapy (unless patient is on a specificprotocol.)b) Should be excluded: patients with decision making capacity who declineintensive care and/or invasive monitoring or therapy and receive comfortcare only, brain dead non-organ donors, patients in persistent negativestate, patients who are permanently unconscious, etc.TR-VI – 15

TABLE 3: LEVEL OF CARE/UNIT CRITERIA FOR BED ASSIGNMENT AT PBCHPalm Bay PCU (16 Beds)TelemetryPBCH Med-SurgPBCHPCU patients eligible for admission to the Telemetry Medical/ Surgical Unit arethose suffering from chronic medical or cardiac conditions or postoperativepatients whose treatment requires frequent nursing care and/or constant cardiacmonitoring. Patients eligible for admission include: Adults (18 years old andabove), post operative patients that require close observation and/or cardiacmonitoring including:Multiple trauma, hypovolemia, or extensive surgical procedure or complicationsTelemetry monitoringPost surgical analgesiaUnstable angina, dysrhythmias, cardiomyopathy, congestive heart failureAcute myocardial infarction - definite or reasonably suspected.Pulmonary edema needing acute nursing careSyncopePacemaker insertions or failuresPatients requiring Dopamine or Inocor at less than 5 mcg/kg/min may be admittedto the PCU.However, PCU management may use discretion and accept higher rates afterevaluating the patient.Nitroglycerin drips for stable patients.Palm Bay Intensive Care Unit will be the overflow unit for the PCU patients, andthese policies/procedures/standards will apply in that setting.Patients eligible for admission to the Medical-Surgical Unit are those patientssuffering from medical or cardiac conditions, postoperative patients or short termobservation patients.Pediatric Patients: Pediatric admissions are appropriately triaged to the Med-Surgunit at the request of the family and appropriate assessment by physician, ages 4and up for Surgical, ages 12 and up for Medical. Others not meeting this agecriterion must have administrative approval.a) Patients eligible for placement as an outpatient include the following:Any medical/surgical patient whose stay is expected to be less than 24hours.b) Any outpatient who requires preparation for a procedure and/or shorttermobservation beyond the procedural period.c) Any patient whose admission status and/or need is questionable.Palm Bay ICUPBCH Emergency Dept.This unit provided care for patients from acute or chronic illnesses, extensivesurgery, the treatment of which requires constant, intensive nursing and highlytechnical monitoring. The eligibility of ICU admissions is based upon thereversibility of the clinical problem as well as the likely benefits of ICU treatmentand the expectation of recovery.PBCH is required by law to make its services available to all people. PBCH EDprovides emergency care to all who present with emergent, urgent, or non urgentproblems regardless of income status, insurance, or employment 24 hours/day,7 days/week.TR-VI – 16

TABLE 4: PBCH PATIENT PRIORITY GRID FOR CRITICAL CAREPBCH Patient Priority Grid 1Priority 1 PatientsPriority II PatientsPriority III PatientsPriority IV PatientsPriority V PatientsCritically ill, unstable patients in need of intensive treatment such as ventilatorsupport or continuous vasoactive drug therapy. (Example: Septic shock,streptokinase for acute MI’s or congestive heart failure)Patients who at the time of admission are critically ill, but stable and whosecondition requires intensive surveillance and/or monitoring. These patients are atrisk for needing immediate intensive therapy. (Example: Major surgery withmulti-system failure, acute MI’s who do not meet streptokinase criteria)Critically ill patients whose underlying disease process or illness severely reducesthe likelihood of recovery. These patients receive intensive therapy to relieveacute complications, but may stop short of intubation and/or CPR. (Example:metastatic disease with complications or end stage multi-system failure)Overflow PCU patients from the med-surg unit.Overflow med-surg patients from the med-surg unit.TR-VI – 17

TRAUMA BED ASSIGNMENTALGORITHMOutside Request toAccept a TransferTrauma PatientTrauma Patient fromSceneRefer Call to Dispatchfor Evaluation perProtocolPt. Not AcceptedPt. AcceptedContactTraumaMedicalDirectorPATIENT ARRIVESINTRAUMA CENTERADMITDISCHARGENeeds ICUBedNeeds Floor Bed(6W, 7W or 8W)Trauma CenterNurse to CallICU ChargeNurse for BedTrauma CenterNurse to CallFloor ChargeNurse for BedBed AvailableNo BedAvailableBed AvailableNo BedAvailableNotify BedControl ofAssignmentand TransferPatient toRoomTraumaSurgeonEvaluates BedOptions inConjuntion withthe ChargeNurse and BedControlNotify BedControl ofAssignmentand TransferPatient toRoomTraumaSurgeonEvaluates BedOptions inConjuntion withthe ChargeNurse and BedControlTR-VI – 18

Title: Alias RegistrationApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-COrigin: 1/99Reviewed: 8/02Page: 1 of 2I. OBJECTIVE:Provide fast, accurate and professional Emergency Department Traumaregistration to all incoming trauma patients.II.DEFINITION:ED: Emergency DepartmentIII.POLICY:It is the policy of Holmes Regional Trauma Center to register trauma patients in aprompt, courteous and professional manner.IV.PROCEDURE:A. The trauma nurse notifies registration of the impending trauma patient(s)arrival.B. Upon arrival, nursing pulls a Trauma Packet and procedures are started ona downtime basis.C. The registration counselor has a fifteen minute time standard in obtainingthe identification of the patient.i. If the patient is identified within this time standard, then theinformation is registered in the computer system using a Traumaaccount number.ii.If the patient is not identified within the time standard, then analias name is registered in the computer system using a Traumaaccount number. The alias name will remain in the system untilthe correct identity is found and can be corrected.D. Once identification is obtained (i.e., current drivers license or some otherform of picture identification), the registration counselor determines if thepatient has existing records in the hospital data banks. Existing records arechecked for accuracy.TR-VI – 19

E. Claims/Billing information is obtained if no record exists. The registrationstaff will make a copy of the patient’s insurance provider card. A medicalrecord number will be system generated for the patient. The patient’smedical record number remains the same with each registration. Only theadmission number will differ each time.F. Appropriate paperwork is printed and distributed accordingly.TR-VI – 20

Title: Case Manager / Social Worker ProtocolNo.: TR-VI-DApproved By: Emran Imami, MDTrauma Medical DirectorOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. OBJECTIVE:The Case Manager/Social Worker is a necessary member of the traumateam. It is essential that the trauma alert patient and his family have anindividual who can assist them early in the hospitalization withthe psychosocial support needed, identify special needs/resources, andmake appropriate arrangements toward discharge. The social worker willfollow pre-established guidelines in an effort to ensure a holistic approachto patient care.II.POLICY:1. Social Worker on call is available by pager and will respond immediatelyto the Trauma Center if needed. When a Trauma Alert is issued the oncall Social Worker will immediately call Ext. 47155 to determine if theirpresence is necessary in the Trauma Center.2. All trauma alerts will have a social work consult unless determined that itis not needed.3. Referral will be made to the in-patient Social Worker for assessment,assistance, and referral.4. PsychoSocial assessments will be initiated following admission to thehospital.5. Supportive counseling will be provided to the patient, family and/or S.O.in conjunction with the Clergy.6. Reports will be made to agencies and Law Enforcement as required byFlorida Statutes.7. The Social Worker will participate in multidisciplinary case conferences.9. Social Workers involved in the care of trauma patients will have 4 hourscontinuing education in trauma related areas each year.TR-VI – 21

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Title: Direct Admission of Trauma Patients from theOperating Room to ICUApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-EOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. POLICY:Trauma patients who have had operative intervention may be directly admitted tothe Intensive Care Unit (ICU). The ICU should be prepared to receive these patientsif circumstances warrant direct admission from the 0.R.II.PROCEDURE:The following protocol will be followed:1. The attending surgeon and the anesthesiologist will make thedecision for direct admission of trauma patients from theO.R. to the ICU.2. Once this decision has been made, the receiving unit will becalled and the charge nurse of that unit will be notified.3. Report must be called prior to patient transport to the unit.4. The anesthesiologist, a registered nurse, and other designatedpersonnel must accompany the patient to the ICU withappropriate monitoring equipment.TR-VI – 23

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Title: Documentation on the Trauma Flow SheetNo.: TR-VI-FApproved By: Emran Imami, MDTrauma Medical DirectorOrigin: 1/99Reviewed: 8/02Page: 1 of 6I. OBJECTIVE:To provide concise Trauma Center documentation.GENERAL INFORMATIONTrauma Center Medical Record contains the trauma center treatment record,trauma flow sheet, computerized demographic sheet, continuation sheets, flowsheets, and laboratory results.II. DEFINITION:All patients presenting to the Trauma Center will have a facility medical recordgenerated. Only hospital-approved abbreviations will be used on the TraumaCenter medical record.A. The initial triage note will include the following:1. Date and time of triage2. Patient name, age, sex, and date of birth3. Mode of arrival4. Documentation of prehospital care5. Chief complaint6. History and Assessment7. Relevant medical history8. Allergies9. Current medications, doses, and schedule10. Name of primary physician11. Date of last Tetanus shot and immunization history12. Temperature, pulse, respirations, and blood pressure on all patients13. Weight of all pediatric patients in kg14. Height on all pediatric patients15. Diabetic and smoking history16. Menstrual history if relevant17. Documentation of any protocols initiated18. Triage nurse signature19. Time to treatment area20. Nurse initiated actions documented with time and nurses signature21. Notification of police or animal control22. Pain Scale23. Domestic Violence ScreenTR-VI – 25

24. Infection Control ScreenB. Consent for treatment obtained (Refer to Consent Policy).If patient is a minor and parents or legal guardian are not present, allattempts to locate parents or legal guardian are to be documented on thefront of the Emergency Department Treatment RecordC. General charting requirements:1. Charting is in EMSTAT for medical patients and completed on thetrauma flow sheet for trauma patientsa. An entry is to be made on all medical patients at least everytwo hours and at least every hour for trauma patients.b. More frequent entries are to be made when indicated by changein status, condition, or intervention.2. Vital signs will be obtained and documented at least every twohours on medical patients and at least hourly on trauma patients.a. More frequent vital signs when a change in status, condition,or intervention applies.b. Temperatures will be rechecked at least every two hours andprior to discharge on all patients presenting with fevers.3. All patients presenting to the Emergency Department/TraumaCenter who are equal or greater than 3 months pregnant, shall havefetal heart tones documented.a. Documentation shall include maternal heart rate, location offetal heart tones, and fetal heart rate. (For example, fetal heartrate of 152, maternal HR 88).4. All patients’ 20 weeks pregnant or greater who require anevaluation in the Emergency Department/Trauma Center shallhave a Labor and Delivery consult documented.5. Department/Trauma Center with a complaint of shortness ofbreath.a. 02 saturation will be measured more frequently whenindicated bychange in status, condition, or intervention.6. Documentation of cardiac monitoring will include the following:a. Monitor box checked on the Emergency DepartmentTreatment Record.b. Monitor strip attached to progress note.TR-VI – 26

c. Cardiac rhythm noted on Emergency DepartmentTreatment Record.d. Cardiac rhythm and strip will be documented at least every2 hours. More frequently when indicated by change instatus, condition, or intervention.7. Continuation sheets will be initiated on all patients who require more thanone nursing intervention, length of stay is greater than 2 hours or the patientis admitted or transferred.a. When a continuation sheet is used, the top and bottomchecklist is to be completed.b. When a continuation sheet is used, "see continuationsheet", is documented on front of ED Treatment Record.D. Medication orders:1. All medication orders are to be signed off as: given, time, route, site, andnurses’ signature.a. When using a continuation sheet, the medication order is signedoff as "Done" nurse’s initials. The medication administration isthen documented on the continuation sheet.b. When using the trauma flow sheet, the medication order is signedoff as “Done”. The medication administration is then document onpage 3 of the trauma flow sheet in the medication administrationsection.2. All medications are to be evaluated for effectiveness when indicated andthis information is to be documented on the continuation sheet or the traumaflow sheet documented.E. Intravenous Therapy:1. All IVs started enroute to the Emergency Department/Trauma Center byprehospital personnel will be documented with the following:a. Type of fluid, volume, rate and gauge of catheter.b. IV site appearance/location.c. Example: Prehospital IV - 1000 cc NS L AC #18 gauge wide-open –Good flow - No redness or swelling.2. Prehospital IV will be restarted within 24 hours if patient requiresadmission.3. Documentation of all IVs started in the Emergency Department/TraumaCenter will include the following:a. Time, type of fluid, volume, and rate of infusion.b. Gauge of needle and site.c. Positive flashback, good flow, and nurse's signature.4. Evaluation of IV site will be documented every 2 hours and prior totransfer.TR-VI – 27

5. Each IV and additional bags will be numbered.a. When an IV is changed to a second bag, amount infused will becharted.b. Example: 1030 IV #1, 1000 cc NS at 125 cc/hour started with #18gauge R hand with positive flashback, good flow - N. Nurse, RN.1400 IV #1 1000 cc infused1400 IV #2 1000 cc NS at 200 cc/hour - N. Nurse, RN6. Total IV input will be documented prior to admission, transfer ordischarge.7. When IVs are discontinued, documentation will include:a. Timeb. Catheter intactc. Evaluation of sited. Sterile dressing appliede. SignatureF. Treatments, Interventions, & Procedures:1. All treatments, interventions, and procedures will be documented with timeinitiated, equipment used, and nurse or techs initials.2. Each treatment, intervention, or procedure will be evaluated for patient’stolerance and effectiveness. This information will be documented.G. Admissions and Transfers:1. Documentation on admissions will include the following:a. Reassessment of patients condition.b. Complete set of vital signs.c. I & O when indicated.d. Time report called and accepting nurse.e. First page of admission form & valuables list completed.f. Time patient transferred and who accompanied patient.g. Equipment used.2. The following should be documented on Trauma Flow sheet under sectiontitled “disposition:a. Room numberb. Admitting MD and diagnosisc. Treatment record timed and signed offH. Discharges:1. Prior to discharge documentation will include:TR-VI – 28

I. Flow Sheets:a. Involvement of any ancillary departments in discharge planning (suchas social services and/or case management).b. Reassessment of patient’s condition including repeat vital signs,temperature or 0 2 saturation, if indicated.c. The "discharge summary" section of the EmergencyDepartment/Trauma Center Treatment Record is to be completed.This includes:1) Review of discharge instructions with patient and family and theirlevel of understanding.2) Mode of transport.3) Who accompanied patient4) Time of discharge and nurses signature.e. Patients who have received any medications which could causedrowsiness or affect judgment (i.e., sedation or pain medications)should be instructed that they are not to drive and should beaccompanied by a responsible adult.f. Patients who have received injectable medications shall be observed andreassessed 20-30 minutes prior to discharge.1. Flow sheets will be initiated when indicated. Use of a flow sheet will bedocumented on the Trauma Center Treatment Record.2. Trauma Flow Sheet:a. Trauma flow sheet will be initiated on all patients who meettrauma alert criteria or those who present with or who havepotential for multiple system trauma.b. Documentation on the trauma flowsheet shall include:1. Pre-hospital and hospital reason for trauma alert2. Pre-hospital vital signs, medications, IV’s if applicable3. Time of injury4. Time of patient admission/arrival5. Time of arrival of each trauma team member6. Time of notification and response time of consultants7. All procedures8. Laboratory examination results9. X-ray results10. Patient disposition11. Total time in the Trauma Center3. Neuro Check Sheeta. Neuro check sheet will be initiated on all patients with or who havepotential for neurological deficits. Examples include the following:1) Head injury with change in level of consciousness.2) Patients presenting with suspected intracranialbleeding.TR-VI – 29

3) Cerebral vascular accidents4) Patients with suspected spinal cord injuries4. Restraint Flow Sheet:a. All patients requiring restraint will have a restraint flow sheet initiated.TR-VI – 30

Title: Emergency Department Representative ProtocolApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-GOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. POLICY:The Emergency Department (ED) Patient Relations Representative is a Necessarymember of the trauma team. It is essential that the trauma alert patient and his/herfamily have an individual who can assist them with the psychosocial supportneeded and other non-medical needs. It is also important that the ED staff andTrauma Services personnel have a liaison to assist them with locating andinteracting with family. This individual’s role will follow pre-establishedguidelines in an effort to ensure holistic approach to patient care.II.PROCEDURE:1. The Emergency Department Patient Relations Representative is immediatelyavailable to the ED upon the arrival of the trauma alert patient for familysupport and crisis intervention.2. Contacts family members if necessary and assess and prioritizes the emotionaland other non-medical needs of the trauma patient and their family.3. Provides privacy for the family member of the trauma patient.4. Acts as a resource/liaison person for physicians, nursing, and ancillary staff withthe patients family:a) Expedites rejoining family member and patientb) Maintains communication with other family membersc) Recognizes the family’s inability to reach decisions and provides them withinstructions or assists with problem-solving efforts as appropriate5. Acts as a patient advocate to provide families with community servicesinformation and /or social work intervention6. Provides for pastoral support as requested and/or deemed necessary.7. Provides clear direction of patient location to the family members as necessary.Escorts individuals personally when necessary to appropriate waiting area.Remains with the trauma patient and/or family until such time supportintervention is turned over to other personnel, i.e. Social Services, Pastoral Care,Case Management, Nursing, etc.TR-VI – 31

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Title: Field Trauma Alert PatientsApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-HOrigin: 1/99Reviewed: 8/02Page: 1 of 3I. OBJECTIVES:To rapidly identify patients meeting TRAUMA ALERT criteria for the purpose ofinstituting life saving treatment.II.III.POLICY:Patients meeting pre-established criteria are considered TRAUMA ALERTpatients. These patients are identified as those that have a greater potential forsignificant injury and can benefit from early trauma team intervention. When theTrauma Center is notified by EMS that a patient meets at least one of the criteria,as defined in the Department of Health Trauma Center Verification Standardsand/or Chapter 10D-64E of the Florida Administrative Code, or if a patient whomeets the stated criteria arrives by means other than EMS (e.g. private vehicle), atrauma alert is called and the trauma team is mobilized.PROCEDURE:I. Adult Trauma Alert, Any one of the following:ADULT (Age 16 or greater)• Active airway assistance required beyondadministration of oxygen• HR > 120 without radial pulses• Systolic BP < 90• Best Motor Response < 4 or total GCS < 12• 2 nd or 3 rd degree burns on > 15% of the body• GCS < 12• Amputation proximal to wrist or ankle• Penetrating injury to head, neck, torso, (chest,abdomen, back, spine, groin).• Paralysis, loss of sensation, or suspected spinal cordinjuryOr any two or more of the following:• RR > 30• Sustained HR > 120 beats/minute• GCS Best Motor Response = 5• Major degloving injury or flap avulsion > 5 inches• Gunshot wound to extremityTR-VI – 33

• Age > 55• Ejected/thrown from any vehicle (including ATV,motorcycle, moped, or truck bed)• Steering wheel deformityOr judgment of EMT, paramedic, or other healthcareprofessional.PEDIATRIC (Age 15 or less)*II.The following are considered automatic Pediatric Trauma Alerts:(Any one of the following)• Active airway assistance required beyondadministration or oxygen• Any airway adjunct including manual jaw thrust,suctioning, or others to assist ventilation• Altered mental status• Paralysis, loss of sensation, or suspected spinal cordinjury• Faint or nonpalpable radial or femoral pulse• Systolic BP < 50• Open long-bone fracture, multiple fractures ordislocation sites• Major degloving or flap avulsions• 2 nd and 3 rd degree burns on > 10% of body• Amputation proximal to wrist or ankle• Penetrating injury to head, neck, or torsoOr any two or more of the following:• Suspected amnesia, or LOC• Systolic BP < 90• Palpable carotid or femoral pulse but no radial or pedalpulse• Suspected closed long-bone fracture• Patient weighs < 11kg, or body length is < 33 inchesOr judgment of EMT, paramedic, or other healthcareprofessional.*Pediatric Trauma Alerts will be transferred to a PediatricTrauma Referral Center once stabilized as per policy. Thismay occur under three conditions:1. Mistriage by EMS2. Patient presents to HRMC on own.3. Patient in need of stabilization prior to transport.TR-VI – 34

III.IV.When the prehospital care providers of the impending arrival ofpatient meeting give notification by telemetry/radio/telephone tothe trauma center trauma alert criteria, the nurse or physician willcall a TRAUMA ALERT.If the assessment of an injured patient who has arrived in theemergency department (triage or patient room) reveals that thepatient meets TRAUMA ALERT criteria, the nurse will notify theemergency department physician, and a TRAUMA ALERT will becalled. This may occur when prehospital has not called a traumaalert, the patient has deteriorated, or the patient has arrived bymeans other than EMS.V. If a patient meeting trauma alert criteria presents greater than onehour after the time of injury, and there are no signs ofhemodynamic instability or neurologic deterioration, a TRAUMACONSULT will be called rather than a Trauma Alert.VI.VII.VIII.A TRAUMA ALERT may be initiated at any time if after a periodof ED evaluation, the patient has physiological deterioration orneurological deterioration.In the event a TRAUMA ALERT arrives that is in traumaticcardiac arrest, the trauma surgeon must respond to the traumaresuscitation room if any resuscitative efforts are attempted. It isnot necessary for the trauma surgeon to respond if the patient ispronounced dead on arrival (DOA) and no resuscitative attemptsare made.When there are more than two trauma alerts simultaneously, theDirector of Trauma Services is to be notified.TR-VI – 35

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Title: Continuing EducationApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-IOrigin: 1/99Reviewed: 8/02Page: 1 of 4I. POLICY:For the delivery of efficient and effective care for the trauma patient, physicians,physicain extenders, nursing staff, and paramedics will meet the defined criteria.II.PROCEDURE:Requirements for employment as a physician in the Trauma Center include thefollowing:Trauma SurgeonCurrent ATLS provider verification as well as documentation of at least tencategory 1 CME credits every year in trauma related topics.Emergency PhysicianCurrent ATLS provider verification as well as documentation of at least fivecategory one CME credits every year in trauma related topics.Requirements for employment as a registered nurse in the Trauma Center includethe following:1. Registered Nurse Licensure in the State of Florida2. Preferably two years of experience in emergency or critical care nursing3. BLS4. ACLS within 6 months of employment5. Certification in TNCC within 6 months of employment6. Certification of PALS is preferredThe minimum required staffing for the Trauma Center is two RN’s per shift at alltime. The Emergency Department nurses may respond for initial resuscitation of apatient. If there are multiple critical care patients, at the discretion of the RN’s onduty; additional staff may be called in to provide patient care. If there are no offduty staff available to come in, the charge nurse will be called and advised of thesituation.TR-VI – 37

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Title:Education Documentation (Continued)No.: TR-VI-IOrigin:1/99Reviewed: 11/01, 07/02Approved By: Michele Ziglar, RN, MSN Page 2 of 4I. PURPOSERegistered nurses, licensed practical nurses, physician extenders andparamedics caring or trauma patients are required trauma related CE hoursevery 2 years.II.III.DEFINITIONTopics related to trauma include any lectures, inservices, courses andconferences content that can be applied to the care of a trauma patient. Forexample, an inservice on hemodynamic monitoring, patient assessment,intravenous therapy, etc., may not focus on trauma specifically but certainlythese topics are relevant to the care of a trauma patient.PROCEDUREA. Categories of Trauma TopicsClass I- Topics that have primary application to trauma and are absolutelyrelated to trauma. (i.e. Trauma Nurse Core Course Provider (TNCCP), MayDay Trauma Conference, Trauma Tracks, Multidisciplinary TraumaConference, Assessment of the Multiple Trauma Patient, Head and SpinalCord Injury, Trauma Case Presentation, etc.).Class II- Topics that have general application to trauma. (i.e. nursing care ofchest tubes, patient assessment, pain management, wound care, ACLS, etc.)B. Continuing Education Hours for CoursesTNCCP16 hoursTNCCI8 hoursCATN Course15.6 hoursPALS Recertification4 hoursPALS Provider Course 8 hoursACLS Certification8 hoursACLS Recertification4 hoursBTLS16 hoursMay Day Trauma Conference 8 hoursCNORDesignated number of hoursCCRNDesignated number of hoursTR-VI – 39

Any courses/conferences (i.e. Critical Care Course, outside conferences)outside Health-First not included in the aforementioned list need to beapproved by the Trauma Program Manager.C. Amount of CE Hours RequiredRegistered nurses, licensed practical nurses, physician extenders and paramedicscaring for trauma patients are required trauma related CE hours every 2 years.16 hours/2-year cycle required for RNs: Trauma Center and Aeromedical8 hours/2-year cycle required for RNs: ED, ICU, 6 West, 7 West, 8 West, OR,PACU16 hours/2-year cycle required for physician extenders in all areas.8 hours/2-year cycle required for licensed practical nurses in all areas.4 hours/2-year cycle required for paramedics in all areas.D. Submission of documents for CE HoursDocuments (i.e. certificates, course rosters, summary sheet, etc.) detailing theassociates attendance, date and amount of hours shall be submitted to the TraumaProgram Manager (TPM) on a quarterly basis. Information will be inputted intothe Trauma Continuing Education Central Database.Special Note: Please keep binders on the unit with dividers for each associateand proof of current licenses, certifications, and certificates.Following is the schedule for submission:1. Interim CE Documents Supporting Attendance (Documents aredue every 3 months):• 1 st Quarter-- January 1 - March 30 report due to TPM on April 15• 2 nd Quarter-- April 1 - June 30 report due to TPM on July 15• 3 rd Quarter-- July 1 - September 30 report due to TPM on October 15• 4 th Quarter-- October 1 - December 31 report due to TPM on January 152. Return Reports from Central DatabaseReports from Central Database will be disseminated to nurse managers within twoweeks of receipt of documentation.3. Full 2-year report due for the following cycles:CyclesDue in Trauma Program Office1999 & 2000 January 15, 20012001 & 2002 January 15, 20032003 & 2004 January 15, 20052005 & 2006 January 15, 20072007 & 2008 January 15, 2009TR-VI – 40

Title: Operating Room AvailabilityApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-JOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. OBJECTIVE:The Department of Surgical Services will respond to the needs of the traumaalert patient when operative intervention are necessary in a consistent andexpeditious manner. They will follow pre-established guidelines in an effort toensure an optimal level of patient care.II.PROCEDURE:1. Trauma Alert patients requiring surgery will be given immediate priority.2. When a Trauma Alert page is initiated, Surgical Services is made aware viaa pager located in the control area and the scrub tech assigned to traumaresponds to the Trauma Resuscitation Room.3. The designated trauma room is setup for the patient. If multiple traumaalerts are paged during any given time period, the OR is immediatelyassessed for availability of additional rooms, and elective surgeries are helduntil clearance is given by the attending surgeon or his/her designee. Asecond operating room will be available within 30 minutes after the initialroom is occupied by a trauma patient.4. The Trauma Surgeon or his/her designee will notify the control desk once itis determined that the trauma alert patient will need operative intervention,and the set up of the room will be completed according to the type of case.5. The patient will be transported to the OR without delay.TR-VI – 41

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Title: Patient Classification System /Urgency CategoriesApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-KOrigin: 1/99Reviewed: 8/02Page: 1 of 2I. OBJECTIVE:An acuity system to identify staffing needs is vital for patient transition from theEmergency Department to the Trauma Center. Therefore, the ED at HolmesRegional Medical Center will be implementing a patient classification system,based on the patients’ clinical presentation that determines the urgency ofinterventions and treatments.II.III.POLICY:According to the Emergency Department policy (EM –3-01 Triage Policy), uponarrival to the Emergency Department patients are immediately classified asTrauma Alert, Emergent, Urgent, and Non Urgent as part of the triage process.These patient categories are then tracked within the department to determineresource availability to administer care, see table below. When the volume in acertain category exceeds the standards, then additional resources areimplemented. These categories are for all patients registered in the EmergencyDepartment main room or the trauma service, which are trauma alert patients andmoderately complex trauma patients.PROCEDURE:Upon initial triage, the patient is assigned a category; the category is documentedon the Emergency Department Treatment Record.The charge nurse, prior to every shift change and more frequently as needed,documents the number of patients in each category.Urgency Categories are documented on the ED Acuity Shift Staffing Form.Category volume results, in conjunction with staffing guidelines, are used todetermine nursing assignments. (See policy EM2-02 Emergency DepartmentStaffing Plan).Volume numbers are evaluated for the need for additional resources.Staffing needs are resolved by the addition or subtraction of nursing personnel ie:calling in available staff, consulting with administrative director and/or staffingoffice, or by following EM 6-02 ED Policy for Patient Holding/OverloadSituations.TR-VI – 43

Urgency Category Grid for Registered NurseUrgency Category Emergent Urgent Non-Urgent*See EM3-01 TriagePolicyReassessmentContinuous Every 1-2 hrs Every 2-4 hours*Is classified as anydocumented patientinteraction includingprocedures.See Assessment PolicyGeneral examples* These are examples, notstandards for each class.Rating of the patient mustbe based on clinicalpresentation.Trauma alertModerately complextraumaCardiopulmonary arrestMajor burnsSevere resp. distressAcute hemorrhageAnaphylaxisNeurovascularcompromiseStatus epilepticusComaAbdominal painNon cardiac chest painMultiple fracturesLacerations/no bleedAsthma /no resp distressRenal calculiModerate burnsOpen fractureVaginal bleedingRashSprainCold symptomsChronic headacheRhinitisConstipationVaginal dischargeCystitisStaffing assignments(Main room Only)Trauma Room , B1, A211 bedsA1, B2,8 bedsPeds/Gyn6 bedsAcuity Total# of patients per cat( Main room only)Expected Staff on duty* See EM2-02 StaffingPlanTriageCharge>3>5>7>9 Disaster Plan7a-7p –4 RN7p-7a –4 RN7a-7p 1 RN7p-7a 1 RN7a-7p 1 RN7p-7a 1 RN>8>12>16>20 Disaster Plan7a-7p-2 RN7p-7a-2 RN7a-7p 1 RN7p-7a 1 RN7a-7p 1 RN7p-7a 1 RN>6>10>14>18 Disaster Plan7a-7p-1 RN7p-7a 1 RN7a-7p 1 RN7p-7a 1 RN7a-7p 1 RN7p-7a 1 RNTR-VI – 44

Title: Patient Name Change for SecurityApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-LOrigin: 1/99Reviewed: 8/02Page: 1 of 2I. OBJECTIVE:To provide a method to provide maximum security for at risk trauma patientsadmitted to the Division of Trauma through the designation of an alias.II.DEFINITION:Alias - assumed name for the duration of hospital stay or while presenting fortreatment.III.POLICY:The Trauma Surgeon on call, Safety & Security Department, and/or the HouseSupervisor shall be authorized to allow the trauma patient at risk to remainregistered as the alias trauma registry name that they are given upon entrance tothe facility (see Trauma Policy and Procedure II A) in order to safeguard thepatient from further publicity, threat, actual, or potential harm.IV.PROCEDURE:A. The Trauma surgeon on call, the Safety & Security Department Officers orthe Administrative Supervisor either jointly or separately shall deem thatthe patient should remain registered under their alias registration name toassure the safety of the patient. There are three (3) circumstances whereasan alias may be given to the patient: (1) At the request of the patient orsomeone acting upon the legal behalf (parent if minor) and approved bythe Senior Safety & Security Officers after consultation with theAdministrative Supervisor; (2) At the request of a law enforcement agencyand upon approval by the Senior Safety & Security Officer on-duty andafter consultation with the Administrative Supervisor; and (3) At therequest of Safety and Security or Nursing.B. Upon declaring the necessity of such a change the Safety & SecurityDepartment Officer shall write a report detailing the circumstances for thischange including any comments from the Administrative Supervisorand/or the Trauma Surgeon on call.C. The Safety & Security Department Officer shall communicate this changeto (1) Patient Business Services, (2) Medical Records, (3) Bed Control;TR-VI – 45

Administrative Supervisor shall also make the appropriate notations intheir respective continuity book.D. If a patient family requests such a change in identity, the AdministrativeSupervisor and Safety & Security shall collaborate regarding the decisionto grant such a request and provide an explanation to the family regardingthe approval of their request or denial of the request and reasons for same.The family shall be informed that this information should not be discussedwith others.E. The trauma alias name shall also be communicated to the clinicaldepartment rendering care to the patient and a summary of informationpertaining to the reason for such a change.F. Information related to this name change is considered confidential andshall not be discussed except on a need to know basis. Registration willplace an @ sign in front of the trauma alias name in HBOC to identify thatthe patient has remained registered as their trauma alias name for thesecurity of the patient and the staff caring for the patient.G. The Administrative Supervisor or clinical department charge person shallcommunicate this change to any family members and request theirassistance in maintaining the confidentiality of the change for the patient’ssafety.H. Upon inquiry, any associate shall respond that the person or patient is notat CCH, HRMC, or PBCH. Any other response may provide a need tovisit the hospital or other attempts at obtaining information.I. Any unit that has a person who remains registered, as their trauma aliaswill post their name as “T. Halo,” for example. “T” representing traumaand the last name to correspond with the last name from the trauma alias.This is to discourage any name being identified as an alias name. Thepatient’s account number will remain applicable to them for the durationof their stay.TR-VI – 46

Title: Priority Status of Trauma Alert PatientApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-MOrigin: 1/99Reviewed: 8/02Page: 1 of 2I. OBJECTIVE:To give priority to patients meeting TRAUMA ALERT criteria.II.POLICY:Trauma Alert patients will be given priority status in an effort to facilitateoptimal care.III.PROCEDURE1. Trauma Alert patients will be given priority admissionstatus.a. Patients are preregistered by assigning anappropriate identifying number as described in thepolicy, “Alias Registration.”b. Patients arriving by means other than EMS will alsobe assigned a number utilizing this methodimmediately upon arrival to the EDc. The pre-assigned number promotes priorityadmission of the trauma patient and expedites allrequests for laboratory/radiographic studies.2. Radiology and laboratory (including blood bank) servicesare in-house 24 hours a day and there is immediate accessto clinical laboratory services for all trauma patients in allareas to include ED, OR/PACU, ICU and Med/Surg areas.a. See policy, “Delineation of Roles of Trauma TeamMembers,” for response to the Trauma Alert.b. Prearranged numbers will expedite the requests oflaboratory/radiographic studies.c. The laboratory specimens which are collected onthe Trauma Alert patient or the critically ill/injuredtrauma patient will be taken to the appropriateTR-VI – 47

laboratory and will be given priority status overroutine laboratory tests. This includes all traumapatients requiring stat labs.d. Radiographic studies will be immediatelyprocessed, returned to the trauma room or otherpatient location, and given to the physician teamleader.TR-VI – 48

Title: Rehabilitative Availability on Saturdays and SundaysApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-NOrigin: 1/99Reviewed: 8/02Page: 1 of 2I. OBJECTIVE:To describe services available on Saturdays and Sundays.II. DEFINITION:Therapy staff will provide services on Saturdays and Sundays to prioritypatients in the hospital.Saturday Priority patients are defined as:A. All wound care patientsB. All patients being discharged within the following week and inneed of a home programC. All patients who will lose function without treatmentD. Patients requiring a swallowing evaluationE. All trauma patientsPhysical Therapy, Occupational Therapy and Speech Pathology staff willprovide services on Saturdays once per day to residents in the Continuing CareCenter.III. PROCEDURE:Staffing is scheduled on a rotation basis to include, but not be limited tophysical therapists, occupational therapy, speech-language pathologist, physicaltherapy assistant and aide (tech).Sunday service will include:A. Appropriately identified wound care patientsB. Orthopedic patients who underwent surgery the prior Friday orSaturdayC. New evaluationsD. Trauma patientsE. Wound Care / WhirlpoolF. All UE wound care patients will have a dual (PT/OT) referral toenable Saturday/Sunday coverage by the available therapistIf a single service referral presents on a weekend, it is the responsibility of theassigned therapist to contact the physician for a dual referral. Weekday coveragewill resume with the patient being assigned to the appropriate service.TR-VI – 49

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Title: Rehabilitative Services Outpatient CareApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-OOrigin: 1/99Reviewed: 8/02Page: 1 of 1HEALTH FIRSTDepartment of Rehabilitative ServicesPolicy:I. OBJECTIVE:To describe staffing availability in the HRMC Rehabilitative ServicesDepartment.II.III.DEFINITION:Rehabilitative Services includes Physical, Occupational and Speech Therapies.PROCEDURE:Staffing is maintained at the following levels daily Monday through Friday inHRMC Acute Care:80 hours of Physical Therapy12 hours of Occupational Therapy16 hours of Speech TherapySaturday and Sunday in HRMC Acute Care:36 hours of Physical Therapyup to 8 hours of Occupational Therapyup to 8 hours of Speech TherapyIf it is determined a greater number of hours is required, per diem staff arecalled in to assist.TR-VI – 51

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Title: Scheduling Procedure for RNs in Trauma CenterApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-POrigin: 02/02Reviewed: 8/02Page 1 of 2I. OBJECTIVE:To promote proficient coverage of the trauma center and equitable schedulingamong the trauma center RNs.II.III.POLICY:The scheduling policy for the trauma center RN staff serves as a guideline forexpectations in self-scheduling.PROCEDURE:1. The schedule will be posted no more than 2 months in advance of the currentschedule.2. Any request for personal leave time and workshop time must have priorapproval before posting. Appropriate paper work must be accompanied byrequest.3. Any request for PL time must be approved by the Trauma Program Managerwith the appropriate paper work completed and signed.4. A draft will be posted for self-scheduling no more than two months inadvance of the current schedule cycle.5. Priorities in RN scheduling:• FTEs (3 shifts per week or 6 shifts per two week pay period)• Split position (2 shifts one week and 1 shift the next week (vice versa) or 3shifts per two week pay period)• Perdiem (requirements for Health-First Associates)• Floats (as needed)6. All shifts by FTEs and Split Positions shall be completed on the draft beforeperdiem and float associates schedule.7. Shifts that are open and need to be filled to complete the schedule will beavailable first to RNs not creating overtime unless all resources are exhausted.TR-VI – 53

8. Once the draft is completed and reviewed, the Trauma Program Manager willsign and date the final schedule and post.9. The Trauma Program Manager must approve any changes to the scheduleonce posted.TR-VI – 54

Title: Staffing PolicyApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-QOrigin: 1/99Reviewed: 8/02Page: 1 of 2I. OBJECTIVETo deliver quality, efficient, effective, safe patient care for patient requiringTrauma Center services.II.POLICYPhysical StructureTwenty-two (32) beds occupy the main Emergency Department treatment area.Two (2) beds occupy Trauma Resuscitation Room.Twelve (12) beds occupy Minor Care.Seven (7) beds occupy Holding BedsStaff MixLicensed RN charge is calculated at 100% indirect care.Licensed RN Triage is calculated at 100% direct care of patients.Certified EMT Triage is calculated at 100% direct patient care under supervisionof RN.Licensed RN’s are calculated at 100% direct care of patients.Certified and/or skilled PCT’s and licensed paramedics are calculated at 100%direct.Certified and/or skilled EDT’s are calculated at 100% direct.AssignmentsThe assignments for the combined Emergency Services beds of 53 (Main-32,Trauma-2, Minor Care-12, Holding-7) are as follows:Overall Staffing for Emergency ServicesOne Charge RN ensures effective coordination and operation of all ES segmentsfor the shift.The following report directly to charge RN and primarily support Main EDTreatment Area.Two Triage RN’sOne ED Tech for Triage from 7a-7aOne Central EKG PCT/PM – receives direction from charge RN to perform EKGsor is assigned to Trauma Resuscitation Room when Trauma Alert is calledOne Transporter – 11a-11p transports patients and suppliesMain ED Treatment Area (24 hour operation)“A” Team – Beds 1, 2, 12, 14Minimum * one RN and one PCT/PMTR-VI – 55

“B” Team – Beds 3, 4, 5, 6, 7, 8, 9, 10, 11Minimum * two RNs and one PCT/PMFrom 11a-11p – three RNs and one PCT/PM“C” Team – Beds 15, 16, 17, 18, 19, 20, 21, 22, 23Two RNs and one PCT/PMTrauma Resuscitation Room (24 hour operation)T1 – Primary Trauma NurseT2 – Secondary Trauma NurseMinor Care (12 hour 10a-10p operation)Two RNs and one PCTObservation/Holding Unit (open PRN)One RN and one PM/PCTThe Emergency Services is led by one (1) director, two (2) managers, and six (6)supervisors. Twenty-four hours a day, seven days a week, one of the aboveleaders in on call for any issues. This schedule is posted at the ED nurse’s station.TR-VI – 56

Title: Trauma Center Admission Bed AssignmentApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-ROrigin: 2/99Reviewed: 8/02Page: 1 of 2I. OBJECTIVE:To define the process for obtaining and assigning an inpatient bed for a traumapatient and ensure timely admission and transfer of trauma patients.II.DEFINITION:The process by which the staff communicates the need and physician order for atrauma inpatient bed and assigns the unit and room number.III.POLICY:A. Bed assignments will be made based on the physician order which isdetermined by the patient assessment and need.B. Bed assignments will be made via communications amongst the TraumaCenter in the ED, SICU, 6 West and 8 West, 7 West based on the level ofcare required as indicated by the physician order.C. Inpatient Admissions1. The ED Trauma Center will contact the nursing unit directly.2. The nursing unit will assign a bed at that time.3. The ED Trauma Center will send a message to bed control(between the hours of 0600-2300) containing the physician order,i.e. SICU, 6 West PCU, and the bed assignment given by thenursing unit. After hours (2300-0600) the AdministrativeSupervisor must be notified of the bed assignment.D. Inpatient Transfers1. The transferring unit will contact the receiving unit to request abed as per the physician order, i.e. 6 West PCU.2. The receiving unit will assign a bed.3. The receiving unit will send a message to bed control (between thehours of 0600-2300) containing the physician order and the bedassignment. After hours (2300-0600) the AdministrativeSupervisor must be notified of the bed assignment.E. Bed assignments will be made such that an SICU bed will always beavailable to receive a trauma patient.F. Any immediate issues with bed assignments will be communicated to theTrauma Medical Director and the Director / Manager of the receiving unit.TR-VI – 57

IV.PROCEDURE:A. Inpatient admissions:1. See process flowB. Inpatient transfers:1. Physician writes order for transfer, i.e. 6 West PCU.2. The Charge Nurse / designee contacts the receiving unit ChargeNurse and requests ordered bed assignment.3. The receiving Charge Nurse assigns the bed and communicatesthis to the sending unit Charge Nurse / designee.The receiving unit sends a message to bed control (between the hours of 0600-2300) to contain the physician order and the bed assignment. After hours (2300-0600) the Administrative Supervisor is notified of the bed assignment.TR-VI – 58

Title: Trauma Unit Procedure for Acuity Level ShiftStaffingApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-SOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. OBJECTIVE:To determine patient staffing requirements based on patient acuityII.DEFINITION:Patient acuity level staffing takes into account the degree of illness of the patientand the work requirements to provide the necessary level of care.III.POLICY:This procedure will be used every shift and as necessary to make patient careassignments.This will be used in conjunction with the staffing plan for each unit.This will be reviewed and revised by the Department Director/Designee at leaston an annual basis.IV.PROCEDURE:Charge Nurses and nursing staff, prior to shift change, will determine acuitylevels of patients according to established patient attributes.Patient rankings are documented on Acuity Staffing Guideline form.Patient acuity level results, in conjunction with staffing guidelines, are used todetermine nursing assignments.Discrepancies are resolved by the addition or subtractions of nursing personnelthrough procedures designated in policy i.e. maintain on call list of staff available.Re-evaluation performed in an on-going basis as needed with formal reporting toStaffing Office at designated times.TR-VI – 59

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Title: Triage of Emergency Room Patients to the TraumaCenterApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VI-TOrigin: 1/99Reviewed: 8/02Page: 1 of 5I. OBJECTIVE:A. To ensure prompt evaluation and assessment of all patients presenting tothe Trauma Center regardless of their ability to pay.B. To prioritize patients based on their condition to ensure that the mostseriously ill or injured patients are treated first.C. To assign patients to the appropriate treatment area based on patient acuityand special needs.D. To implement departmental protocols when indicated.E. To initiate the Trauma Center Flow Sheet.F. To document patient’s chief complaint, assessment, and pertinent medicalhistory. PLEASE REFER TO DOCUMENTATION POLICY.II.DEFINITIONS:A. Triage - A term which means to "sort".B. Class I (Emergent) - Patients whose condition is critical and life, limb orvision is threatened. These patients are to be sent to the main treatmentarea immediately and assigned to a bed with close monitoring capabilities.The Trauma Center flow sheet will be initiated at the bedside. TheEmergency Department Physician will be notified and appropriatedepartmental treatment protocols will be implemented as indicated.C. Class II (Urgent) - Patients whose conditions are stable, but should beevaluated as soon as possible. These patients will be brought to atreatment room once triage is completed, and as soon as a room isavailable. Stable Class II patients may be sent to the waiting area toregister while awaiting bed availability. The triage nurse may elect tokeep the patient in the triage bed to observe while awaiting bedavailability.TR-VI – 61

D. Class III (Non-urgent) - Patients whose conditions are stable and are in noacute distress. These patients may be sent to the waiting area andregistered while awaiting bed availability.III.POLICY:A. Holmes Regional Trauma Center provides emergency services, care, andtreatment to all individuals who present with emergent, urgent, and nonurgentconditions regardless of their ability to pay.B. All patients presenting to the Trauma Center will be evaluated by anEmergency Registered Nurse based on criteria established by the MedicalDirector of the Emergency Department, and a Trauma Center flow sheetwill be initiated. The initial triage notes will include the following:(Please refer to Documentation Policy).1. Date and time of triage.2. Patient name, age, sex, and date of birth.3. Mode of arrival.4. Documentation of prehospital care.5. Chief complaint.6. Nursing History and Assessment.7. Past medical history.8. Allergies.9. Current medications, doses, and schedule.10. Name of primary physician.11. Date of last Tetanus shot and immunization history.12. Temperature, pulse, respirations, and blood pressure on all patientssee Triage Fastercare criteria.13. Weight of all pediatric patients in kg.14. Head circumference of all infants.15. Height on all pediatric patients.16. Diabetic and smoking history.17. Menstrual history.18. Documentation of any protocols initiated.19. Triage nurse signature.20. Time to treatment area.C. The triage nurse is to ensure prompt evaluation of all patients presenting totriage. This may mean a brief interruption during a patient interview toevaluate a newly arriving patient. The triage nurse is to notify the chargenurse immediately when the number of patients waiting to be triagedrequires an additional nurse or staff member.TR-VI – 62

D. The following patients will be brought to the main room immediatelyupon arrival: (be aware this is not an exhausted list)1. Trauma Alert Patients2. All Class I patients.3. Legal exams.4. Chest pain of suspected cardiac origin.5. Hemodynamically comprised patients.6. Possible cervical spine injury < 48 hours post injury.7. Severe burn.8. Severe pain.9. Severe allergic reactions.10. Poisonous snake and spider bites.11. Toxic inhalation injuries.12. Gunshot wounds, stab wounds, and chest wounds.13. Overdoses.14. Seizures.15. Acute asthma, shortness of breath.16. Suicidal patients, psychotic patients.17. Violent patients.18. Patients with suspected contagious disease.19. Altered level of consciousness.20. Infants’ 3 months or less with elevated temperature.21. Syncope or dizziness.22. Injuries to the eye, foreign bodies, or substance of fresh origin.23. Head injuries.24. Pregnant women in active labor.E. Class II patients will be brought to a treatment room as soon as a treatmentroom is available. The charge nurse will be aware of the number andcomplaint of all patients awaiting room assignment.F. Class III patients will be brought to a treatment room as soon as all Class Iand Class II patients have been assigned a treatment area. This will ensurethat the most ill or seriously injured patients will be treated first.G. The patient representatives will assist the triage nurse and the charge nursewith keeping patients and families informed.H. Patients will be placed in the appropriate Trauma Center bed based on thepatient’s classification and special needs.1. Patients meeting Trauma Alert Criteria will be placed in the TraumaRoom in T1 or T2 and a trauma alert will be issued via group page ifone had not been issued prior to patient arrival.TR-VI – 63

IV. PROCEDURE :2. Patients who require cardiac monitoring will be placed in a bed with amonitor or placed on portable telemetry monitors.3. Patients who are unstable or who require close observation will beplaced in a bed easily observed from the nurse’s station. (These bedsare 4, 5, 6, 7, 8, 9, 10, 11, 18, 19, 24, 25, and 26).4. The most critical patients are best managed in beds 3 through 11, or inthe trauma room.5. Patients requiring isolation may be placed in room 17.6. Stable pediatric patients can be placed in any ED room.7. Women with lower abdominal pain or OB/GYN complaints will beplaced in the GYN rooms.8. Pregnant women who are 20 weeks gestation or greater with apregnancy related complaint are to be sent to Labor and Delivery forevaluation.9. If a pregnant woman (20 weeks of gestation or greater) presents to theEmergency Department with a medical condition or a traumatic injury,the patient will be evaluated in the Emergency Department and aLabor and Delivery nurse will come to the department to documentfetal heart tones and record a monitor strip.A. When a patient presents to triage, a primary triage is done to determinechief complaint and patient classification.B. Those patients who need to be brought to the main room immediatelywill be placed in the appropriate treatment room. The charge nurse orthe patient’s primary nurse will take over the care of the patient and thetreatment record will be initiated at the bedside. The registration slipwill be taken to the registration clerks with the patient’s room numberwritten on the top. Registration will be completed at the bedside.Prompt registration is important to generate a patient bracelet and entryinto the computer system to allow for ordering of tests and procedures.C. Class II and Class III patients will be assessed by the triage nurse in thetriage area. During that time the Emergency Department treatmentRecord is initiated and triage documentation is completed in accordancewith the Documentation Policy. Departmental protocols will beimplemented when indicated.D. Once triage assessment is completed the charge nurse will bring Class IIpatients to the main room and place them in appropriate treatment room.The primary nurse will be notified of the patients’ arrival and the chartwill be placed in the E D physician stack with highest priority chartsplaced on top. The registration slip with the room number will be takento the registration clerks to ensure prompt bedside registration.TR-VI – 64

E. Stable Class II and Class III patients may be sent to the E D waiting areato await bed availability. After triage assessment and documentation iscomplete the nurse will then place the chart in the box located on thewall outside of triage. The triage nurse will explain to the patient thatthey are being sent to the waiting area for a treatment room. Theregistration slip is given to the clerks with the patients’ location writtenon top.F. The charge nurse is notified of any patients waiting to be brought back.The charge nurse will bring patients back to the treatment area as soonas a bed is available.G. The triage nurse will assess Fastercare patients and an EmergencyDepartment Treatment Record will be initiated. The entire chart will begiven to the registration clerks who will place the completed chart in theFastercare area after registration is completed. The registration clerkswill notify the Fastercare staff of any newly arriving patients.TR-VI – 65

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Title: Trauma Patient Follow-upApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VII-AOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. OBJECTIVE:To identify those patients seen in the Division of Trauma that may need furtherfollow up or further patient education.II. POLICY:The Division of Trauma patients will receive a call from a Trauma Center Nursewithin a 48-72 hour period after being discharged to inquire on how the patient isdoing.III. PROCEDURE:A. The Trauma Center nurse will receive a list of discharged patients on a dailybasis from I/T.B. The Trauma Center Nurse will call the patient back and question the patientbased on their discharge summary information to determine:1. If the patient has a follow-up appointment and/or direct the patients call tothe scheduling secretary to set up a follow-up appointment.2. If the patient has had sufficient discharge planning to meet his/her needs.C. If the patient needs additional discharge planning beyond follow-up in theTrauma Clinic, the Trauma Center nurse will refer the patient for follow-up tothe Case Manager assigned to the Division of Trauma.The Trauma Center Nurse will document pertinent information from the followupphone call into Logician.TR-VII – 1

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Title: Trauma Quality Management CommitteeApproved By: Emran Imami, MDTrauma Medical Director1R759,,%2ULJLQ5HYLHZHGPage: 1 of 3I. OBJECTIVE:To monitor trauma care prospectively and retrospectively to assure theoptimal performance of all individuals and/or departments involved intrauma patient care.II.POLICY:A Trauma Quality Management (TQM) committee will review traumacare on an ongoing basis at monthly meetings; the provision of traumacare will be monitored, evaluated, and compared to predeterminedstandards of practice and outcome criteria.III. PROCEDUREI. The TQM Committee will meet monthly to review trauma cases.II. Committee members include:• Trauma Services Medical Director• Trauma Surgeon (other than Director)• Surgical Subspecialist• Neurosurgeon• Orthopedic surgeon• ED Physician• Anesthesiologist• Radiologist• Vice President of Medical Affairs• Trauma Nurse Coordinator• Vice President, Professional Services• OR Nursing Director or designee• ED Nursing Director or designee• ICU Nursing Director or designeeOther specialists are invited and encouraged to attend as deemednecessary by the Trauma Medical Director and the TraumaCoordinator.III.All trauma alert patients treated at Holmes Regional MedicalCenter, all trauma critical care admissions, all trauma operatingroom admissions, all trauma transters, and all trauma deaths areTR-VII – 3

eviewed by the trauma service (excluding same day discharges, orisolated, non-life threatening orthopedic and soft tissue injuries.)IV.The trauma audit filters are applied to this population (see attachedfilters) by he Trauma Services Medical Director (TSMD), theTrauma Coordinator (TC) or designee.V. The population of trauma patients that are identified as not meetingidentified standards are reviewed to determine a clear andappropriate reason for the situation to have occurred.VI.VII.VIII.IX.If a clear and appropriate reason for the identified situation cannotbe found, then the case will be referred to the TQM Committee forfurther evaluation. The case will be then be referred to appropriateindividuals, services, or departments for action.In addition to the evaluation of the patient’s medical record withthe audit filters, a concurrent review of trauma patient care is doneto determine any ongoing problems or concerns. Documentationfrom the Trauma Flow Sheet, to include the Trauma TeamResponse Form, all policies and procedures, etc. are utilized toevaluate the system of trauma patient care.The response times of trauma team members as defined in thestandards will be documented on the Trauma Team ResponseForm. The elapsed time for laboratory results will also bedocumented on the Trauma Flow Sheet. Please see policy,"Documentation of Laboratory Results and Response Times."All trauma deaths and any cases, which are determined to havemorbidity or require in-depth review, will be taken to the TQMCommittee. The same process for review and corrective actionwill be followed. All physician specialties involved will beencouraged to attend for a peer review. The Medical Examinerwill also be invited to attend. Appropriate personnel will beinvited to attend if any nursing or departmental issues areidentifiedX. Appropriate action on quality improvement issues generated fromthe discussion at the meeting and by ongoing review is approvedby the TSMD. The TC and the TSMD will obtain responses to anyaction recommended by the department and/or the committee.Documentation of any action/resolution is performed. Whenappropriate, policies and procedures will be instituted or updatedsecondary to the identified concern.TR-VII – 4

XI.XII.The TSMD will be responsible for reporting resolutions back to theTQM for each case needing action.A summary of reviewed cases not requiring additional follow up aswell as those requiring further evaluation will be provided.XIII.Minutes of the meetings will be submitted to the Department ofSurgery Quality Improvement Committee and the Quality CareCouncil, which reports to the Executive Committee. Minutes willbe maintained at Holmes Regional Medical Center for a minimumof three (3) years. These minutes will be maintained asconfidential.XIV. The Trauma Service will prepare a quarterly report. The reportwill list every case selected for corrective action by the committeeand will describe the questionable care and the corrective actiontaken. This report will be submitted to The Department of Healthand to the Medicare Staff Office.XV.Committee members shall attend at least 75% of the TQMCommittee Meetings.XVI. A log will be maintained of all cases to which the audit filters wereapplied. The In-hospital Trauma Registry, having all elements asdescribed in the standards, will be utilized as this internal log.XVII. Monthly statistics (number of cases notified to respond andresponse time) for each trauma surgeon will be maintained in theTrauma Services office.XVIII. A Trauma Conference for the purposes of education will be heldmonthly. Please see policy and procedure.TR-VII – 5

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Title: Performance Improvement Trauma ResuscitationVideotaping PolicyApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VII-COrigin: 1/99Reviewed: 8/02Page: 1 of 2I. PURPOSE:Videotaping of the initial resuscitation of Trauma Alert patients with subsequentreview affords performance improvement opportunity for the trauma teammembers to enhance organizational skills used to care for trauma patients.II.DEFINITION:Video recording allows analysis of:1. Priorities during resuscitation.2. Cognitive and physical integration of the plan of care and interventions bythe trauma team members.3. Team member adherence to assigned responsibilities, response time, andprocedural technique.Goals: To promote optimal care of trauma patients by critiquing theinitial resuscitation.III.PROCEDURE:1. The primary nurse as part of the preadmission duties prior to patientarrival turns on the camera and recorder. The videotape should bestopped after the patient leaves the resuscitation area.2. The tape shall be labeled with the following information:a. MR# and Trauma Nameb. Datec. Start# and End#3. The videotapes will be secured by the trauma nurse in a locked cabinetand will be collected by the Trauma Program Manager.4. Selected videotapes may be presented at the weekly TraumaDebriefing with the Physician Extenders and trauma nurses presentinga synopsis of the patient’s course of care.5. Team members for peer review of the videotape will use a videotaperesuscitation critique form as an assessment tool.6. Immediately following the conference the videotape will be erased.7. All videotapes will be erased within 10 days of the initial taping.Except, if an incident occurs during the procedure that would typicallyresult in the generation of a Risk Management Incident Report, anincident report is to be completed and Risk Management is to beconsulted before the tape is destroyed.TR-VII – 7

8. Problems identified will be reported through the Trauma TQMprocess. The Trauma Medical Director and/or Trauma ProgramManager will determine appropriate action.9. During the review the trauma team members will use the critique formto assess the plan of care.10. Areas that will be evaluated and discussed include:a. Forward progression of the resuscitation (defined as totalresuscitation time)b. Systematic attention to primary assessment and initialmanagement priorities:• Airway establishment• Breathing• Circulation• Disabilityc. Appropriate procedures performedd. Radiographic studies appropriate.11. Universal precautions adhered to.12. Nursing care.13. Ancillary services care (Ultrasound, Respiratory Therapy, andRadiology Technician).TR-VII – 8

Title: Reporting of Brain and Spinal CordInjuriesApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VII-DOrigin: 1/99Reviewed: 8/02Page: 1 of 2I. OBJECTIVE:Effective July 1, 1994, Florida Statutes require that every public and privatehealth agency as well as every private and public social agency, attendingphysician report persons who have sustained a moderate-to-severe brain or spinalcord injury.II.POLICY:A. Upon admission to Holmes Regional Medical Center/Palm BayCommunity Hospital Emergency Department or upon admission toHRMC/PBCH as an inpatient, or to HRMC/PBCH from another facility:Individuals who meet the following definitions must be reported to theCentral Registry within five (5) days after identification or diagnosis.Traumatic Injury1. Spinal CordA lesion to the spinal cord or caua equina with evidence ofsignificant involvement of two of the following deficits ordysfunctions:a. Motor deficitb. Sensory deficitc. Bowel and bladder dysfunction2. BrainAn insult to the skull, brain, or its covering, resulting from externaltrauma which produces an altered state of consciousness oranatomic motor, sensory, cognitive, or behavioral deficits.(Glasgow Coma score of twelve {12} or below).B. Facilities will no longer be required to report the following conditions tothe BSCI Central Registry:1. Spinal cord disease resulting in permanent and total disability.2. Amputations of extremities that require a prosthesis.TR-VII – 9

3. Visual acuity of 20/200 or worse in the better eye with the bestcorrection.4. A peripheral field so constricted that the widest diameter of suchfield subtends an angular distance no greater than 20 degrees.5. A serious visual limitation in any infant sufficient to warrantspecial assistance to parents in matters of child rearing anddevelopment.III.PROCEDURE:A. All individuals reported to the Central Registry will be contacted by arepresentative of the BSCI Program. This data will be used to monitor theincidence of moderate-to-severe brain and spinal cord injury within thestate and to develop prevention programs.B. It is required to report the information on a BSCI Central Registry ReferralForm. See attached form A.1. A toll free line is available for reporting purposes; 24 hours a day,7 days a week; 1-800-342-0778.2. A telefax number is available for faxing referral forms; 1-904-922-0998.C. Holmes Regional Medical Center/Palm Bay Community Hospital isrequired to report persons who have sustained a moderate-to-severe brainor spinal cord injury to the Division of Vocational Rehabilitation (DVR)Brain and Spinal Cord Injury Program (BSCIP) Central Registry, and thiswill be done by the Case Management Department at HRMC/PBCH.1. Individuals who meet the definitions must be reported to theCentral Registry within five (5) days after the identification ordiagnosis.2. Upon admission to HRMC/PBCH Emergency Department or as aninpatient, any individual meeting the definition of moderate-toseverebrain or spinal cord injury will have a Social Work Consulton the admission orders by the admitting physician.3. The Social Worker and/or the Clinical Nurse Specialist, and/or theattending physician will initiate a “Brain and Spinal Cord CentralRegistry Reporting Form”.TR-VII – 10

4. A copy of the "Brain and Spinal Cord Central Registry ReportForm" will be kept with the chart and made part of the medicalrecord.D. Holmes Regional Medical Center/PBCH will also maintain its responsibilityfor reporting individuals who sustain brain and spinal cord injuries to the StateTrauma Registry on the HRS Trauma Registry Form.TR-VII – 11

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Title: Sentinel Event and ReportingApproved By: Emran Imami, MDTrauma Medical DirectorNo. TR-VII-EOrigin: 6/01Reviewed: 8/02Page 1 of 1I. POLICY:Sentinel events are an unexpected death or serious physical injury including lossof limb or function. The following are also considered sentinel events and toprovide a consistent method of reporting sentinel events from the Trauma Center.♦ Suicide♦ Infant abduction♦ Infant discharged to the wrong family♦ Rape of a patient♦ Hemolytic transfusion reaction♦ Surgery on the wrong patient or wrong body partSentinel events should be reviewed on a case by case basis and discussedpromptly so that causative factors can be identified and the problem addressedimmediately.II.PROCEDURE:1. The sentinel event shall be reported within 48 hours to the TraumaProgram Manager (TPM) or the Trauma Center Medical Director(TCMD).2. The TPM will record the event on the Trauma Problem Log.3. The TPM and/or the TCMD will perform an investigation. Initialcommunication will include contact with the appropriate department headsto appraise them of the sentinel event. The personnel involved will becontacted to gather information surrounding the event and to discuss thecircumstances.4. Following discussion, the TPM and TCMD (with input from theappropriatepersonnel) will develop the action plan. Corrective action shall be takenthrough one of the following mechanisms:a) change of existing or development of new policies/procedures thatgovern or define the standard of careb) professional education (Multidisciplinary Trauma Conference,Morbidity/Mortality Conference, inservice educational program, etc.)c) personnel counselingd) other action as deemed appropriate by the TPM and TCMD ordepartment headTR-VII – 13

5. A summary of the event, corrective action(s), follow-up, reevaluation ofthe corrective action and outcomes will be documented by the TPM and/orTCMD and kept on file in the Trauma Program Department and reportedto the Risk Management Department.TR-VII – 14

Title: Procedure DocumentsApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VIIIOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. POLICY:All procedures performed by the physician should be clearly documented on thepatient’s chart by means of a separate procedure note.This should include:1. Patient's name2. Procedure name and date3. Physician Extender4. Attending surgeon5. Anesthesia6. EBL7. Complication8. Outcome9. SignatureII. PROCEDURE:A. See the following approved procedure documents:1. Central line placement2. Cricothyroidotomy3. Cutdowns4. Pericardiocentesis5. Thoracotomy (Open)6. Tube ThoracostomyTR-VIII – 1

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Title: Central Line PlacementApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR:-VIII-AOrigin: 1/99Reviewed: 8/02Page: 1 of 2A. Indications:1. Monitoring central venous pressures (CVP).2. Central administration of drugs.3. Placement of transvenous pacemaker.4. Unable to initiate peripheral IVs. (In these patients, a large cordis introducer orsterile IV tubing should be placed in the vein.)5. *Avoid internal jugular and subclavian in majority of resuscitations. Femoralline safer.B. Technique:Internal Jugular1. Place patient in supine position in 15 o of Trendelenburg, if possible, todistend neck veins and prevent air embolism. Turn patient’s head away fromvenipuncture side.2. Cleanse the skin around the site with Betadine and drape the area. (Sterilegloves should always be worn when performing this procedure.)3. Introduce a large bore needle (16-18 gauge) attached to a 10cc syringe in thecenter of a triangle formed by the two heads of the sternocleidomastoidmuscle and the clavicle.4. After the skin has been punctured, with the bevel of the needle upward, expelthe skin plug that may occlude the needle.5. Direct the needle caudally, parallel to the sagittal plane, at a 30 o posteriorangle with the frontal plane, aiming at the ipsilateral nipple.6. Slowly advance needle while gently drawing back on plunger of syringe.7. When free flow of blood appears in the syringe, remove the syringe from theneedle and occlude the needle with a finger to prevent air embolism.8. Pass a wire through the needle9. Thread the catheter over the wire.10. Affix catheter in place (with suture), apply dressing and attach IV tubing to hecatheter.11. Tape IV tubing in place.12. Obtain chest x-ray to ascertain position of catheter.TR-VIII – 1

Subclavian1. Place patient in supine position, 15 o of Trendelenburg, if possible, to distendneck veins and revent air embolism. Turn patient’s head away fromvenipuncture side.2. Cleanse the skin around site with Betadine and drape the area. (Sterile glovesshould always be worn when performing this procedure.)3. Introduce a large bore needle (16-18 gauge) attached to a 10cc syringe, 1 cmbelow the junction of the middle and medial thirds of the clavicle.4. After the skin has been punctured, with the bevel of the needle upward, expelthe skin plug that may occlude the needle.5. Hold the needle and syringe parallel to the frontal plane.6. Direct the needle toward finger placed in suprasternal notch.7. Slowly advance needle while gently withdrawing on plunger of syringe.8. When free flow of blood appears in syringe, rotate the bevel of the needlecaudally; remove the syringe from the needle and occlude the catheter with afinger to prevent air embolism.9. Pass a wire through the needle.10. Thread the catheter over the wire.11. Affix catheter in place (with suture), and apply dressing and attach IV tubingto the catheter.12. Tape IV tubing in place.13. Order chest x-ray to ascertain position of line and to rule out pneumothorax.TR-VIII – 2

Title: CricothyroidotomyApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR:-VIII-BOrigin: 1/99Reviewed: 8/02Page: 1 of 1I. PROCEDURE:A. Indications: Inability to intubate the trachea due to:1. Edema2. Fracture of larynx3. Severe oropharyngeal hemorrhage4. Cervical spine injury5. Severe maxillofacial fracturesB. Technique:1. Position patient in supine position with slight hypertension of the neck.(Palpate thyroid, thyroid notch, cricothyroid interval and sternal notch.)2. Prep area with Betadine (use mask and gloves).3. Use local anesthesia.4. Stabilize thyroid cartilage with one hand.5. Make a transverse skin incision approximately 2.5 cm in length over thelower one half of the cricothyroid membrane.6. Incise through membrane.7. Insert knife handle into incision and rotate 90 o to open the airway.8. Insert cuffed ET tube or Tracheostomy tube into cricothyroid membraneincision (tube size 6).9. Inflate the cuff and ventilate the patient.10. Ausculate chest for adequate ventilation.11. Secure tube.12. Order chest x-ray to ascertain tube position.TR-VIII – 3

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Title: CutdownsApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR:-VIII-COrigin: 1/99Reviewed: 8/02Page: 1 of 2Arterial CutdownA. Indications: Inability to place percutaneous arterial line in:1. Patients with continued instability that requires other diagnostic tests (e.g., CTscan, arteriogram) prior to admission.2. Patients on IV pressors or Nipride.3. Patients with continued hypotension (BP

3. Upper extremity cutdowns should be avoided in penetrating chest trauma andlower extremity approaches should be avoided in penetrating abdominal trauma.C. Technique:1. Prep the area with Betadine and drape sterilely (use mask and gloves).2. Anesthetize the area locally.3. Make a transverse skin incision with following landmarks:a. Medial antecubital vein - 2 fingerbreadths superior and 2 fingerbreadthsmedial to the medial epicondyle of the humerus;b. Saphenous vein - 2 fingerbreadths superior and 2 fingerbreadths medial to themedial malleolus.4. Spread the subcutaneous tissue to identify the vein (in the arm, stay above thefascia to avoid damage to brachial artery and median nerve).5. Encircle the vein proximally and distally with 3-0 silk.6. Ligate the vein distally and make a transverse venorrhapy proximal to this.7. Dilate the vein with a clamp and insert either cut-off IV tubing or a 10 Frenchpediatric feeding tube.8. Advance the catheter to the desired length. In the arm catheters should beadvanced to the CVP position.9. Attach the catheter to the IV tubing and tie down with proximal tie.10. Close the skin with running 4-0 nylon and suture the catheter in place.11. Place a sterile dressing and tape the catheter securely.TR-VIII – 6

Title: PericardiocentesisApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR:-VIII-DOrigin: 1/99Reviewed: 8/02Page: 1 of 1A. Indications:1. Cardiac tamponade2. HemopericardiumB. Technique:1. Monitor vital signs, CVP, EKG during procedure.2. Prep xiphoid and subxiphoid areas with Betadine.3. Anesthetize puncture site (if necessary) locally.4. Attach a 16 or 18 gauge catheter to a 50-cc syringe.5. Assess patient for any mediastinal shift that may have caused the heart to shiftsignificantly.6. Puncture skin 1 to 2-cm inferior and to the left of the xiphocostal junction,holding the needle at a 45 angle to the skin.7. Connect chest lead from EKG machine to the metal needle hub with an alligatorclamp.8. Carefully advance the needle cephalad, aiming toward the tip of the left scapula.9. If needle is advanced too far (into ventricular muscle) an injury pattern willappear on EKG. If this happens, withdraw the needle until previous baseline EKGtracing appears.10. Withdraw as much non-clotting blood as possible from the pericardial sac.11. Aspiration should result in a rapid drop in CVP and gradual improvement inblood pressure.12. During aspiration an injury pattern may appear on EKG. If this occurs, withdrawthe needle slightly. If patter persists, withdraw needle completely.13. Reassess vital signs and CVP. Orders 12 lead EKG.TR-VIII – 7

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Title: Thoracotomy (Open)Approved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-VIII-EOrigin: 1/99Reviewed: 8/02Page: 1 of 1A. Indications: Traumatic cardiac arrest due to:1. Pericardial tamponade2. Hypovolemic shock3. Air embolismB. Contraindications:1. Cardiac arrest in field > 10 minutes2. Absence of EKG activity3. Cardiac arrest due to penetrating cerebral traumaC. Technique:1. Airway and IV access should be obtained prior to this procedure.2. Prep chest by having assistant pour Betadine over left anterior chest (wear maskand gloves at all times).3. Rapidly incise the skin and subcutaneous tissue in the left fifth intercostal space(below the nipple in men and below the breast in women).4. Incise the intercostal muscles and costal cartilages superiorly (2-cm lateral tosternum to avoid the internal mammary artery).5. Insert the Finochietto retractor and spread the ribs.6. Incise the pericardium anterior to the phrenic nerve and open it longitudinally in asharp fashion.7. Evacuate clot and suture laceration with 0 silk if applicable.8. Compress the heart between both hands or between the right hand and sternum.9. If blood pressure does not return, compress the thoracic aorta against the spinewith the left hand. Do not try to clamp the thoracic aorta in the EmergencyDepartment.10. If blood pressure returns, transport the patient to the Operating Room.TR-VIII – 9

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Title: Tube ThoracostomyApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR:-VIII-FOrigin: 1/99Reviewed: 8/02Page: 1 of 1A. Technique:1. Determine insertion site:4th or 5th intercostal space, mid-axillary line2. Prep with Betadine and drape chest at insertion site (use mask and gloves).3. Locally anesthetize the skin and rib periosteum.4. Make a 2 - 3-cm transverse incision and bluntly dissect through subcutaneoustissues just over top at the rib.5. Puncture parietal pleural cavity to clear any adhesions, clots, etc.6. Clamp proximal end of thoracostomy tube (size 28 - 32 Fr.) and insert tube intothe pleural space to desired length.7. Listen for air movement, look for "fogging" of tube with inspiration, and checkfor drainage.8. Connect end of tube to pleuravac.9. Suture tube in place with 0 silk using U stitch.10. Apply dressing with Xeroform and gauze.11. Tape chest tube securely.12. Obtain a chest x-ray.TR-VIII – 11

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Title: Standing OrdersApproved By: Emran Imami, MDTrauma Medical DirectorNo.: TR-IXOrigin: 1/99Reviewed: 8/02Page: 1 of 7I. OBJECTIVE:To provide approved predetermined sets of orders to be carried outsystematically.II.POLICY:It is the purpose of the standing orders to provide efficient, consistent qualitycare to Holmes Regional Trauma Center patients.III.PROCEDURE:See the following approved standing orders.TR-IX

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ABBREVIATED TRAUMA EVALUATIONHISTORY & PHYSICALDATE:TIME:AGE: SEX: RACE:MECH OF INJURY: [ ] MVC [ ] MCC [ ] PED VS AUTO [ ] GSW [ ] FALL ft.OTHER:I. HISTORY: [ ] LOC [ ] AMNESTIC [ ] RESTRAINED [ ] UNRESTRAINED [ ] ETOHC.C.ALLERGIES: [ ] NKDA OTHER: SOCIAL: [ ] TOBACCO [ ] H/O ETOH [ ] IV Drug AbuseLAST MEAL:[ ] H/O BLOOD TRANSFUSIONMEDS: [ ] ASA [ ] COUMADIN [ ] STEROIDS OTHERPMHPSH:II. PHYSICAL EXAM: VS:B/P Pulse Temp_____ RR_____NEURO: E M V [ ] NO DEFICITS [ ] OTHERHEENT(include pupil size): PUPILS: L R [ ] PERRLA TM’SOTHER:NECK (C-spine). [ ] NT [ ]TENDER OTHER:CHEST/LUNGS: [ ] CTA OTHER:CV: [ ] RRR⎺S M OTHER:ABD: [ ] SOFT NT/ND + BS [ ] REBOUND [ ] GUARDING [ ]TENDEROTHER:PELVIS: [ ] STABLE/NON TENDER [ ]UNSTABLE [ ]TENDER OTHER:BACK: [ ] NT [ ]TENDER OTHER:RECTAL: [ ] NORMAL TONE [ ] DECREASED TONE [ ] NO TONE[ ] GUAIAC NEGATIVE [ ] GUAIAC POSITIVE PROSTATE: [ ] NML OTHER:GU: [ ] NML [ ] BLOOD @ MEATUSEXTREMITIES: [ ] NML [ ] ABRASION [ ] FX[ ] DECREASED PULSE [ ] NML MOTOR [ ] NML SENSORYOTHER:III. Studies: [ ] C-Spine LAT [ ] NML to T1 OTHER: C-Spine 3 view [ ] negative[ ] CXR [ ] Neg. [ ] Ptx [ ] Htx [ ] Rib fx [ ] Mediastinum[ ] Abd U/S [ ] Neg. 4 view [ ] + ABD [ ] + Pericardium[ ] Pelvis [ ]Neg. [ ] Pubic Rami Fx [ ] Sacral fx Other:[ ] CT Head [ ] Neg Other:[ ] [ ] Neg. [ ][ ] [ ] Neg. [ ][ ] [ ] Neg. [ ]Labs: [ ] T & S [ ] T & C Units [ ] H/HIMPRESSION/PLAN:TR-IX - 1

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Holmes Regional Medical CenterDivision of Trauma(Addressograph)Trauma Service Discharge InstructionsDiet Regular, no restrictions.Special instructions .Activity As tolerated.No strenuous exercise fordays/ weeks.No lifting more than pounds for days/ weeks.Weight-bearing status .No driving fordays/ weeks.Return to work indays/ weeks.Special Wear cervical collar at all times until follow up in trauma clinic.InstructionsWear soft collar for comfort.Wear sling for comfort.Do not change chest tube dressing for 48 hours.Use Incentive Spirometer as instructed.Do not shower fordays._ Call for increased pain, fever, nausea or vomiting, shortness of breath, mental statuschanges, or any other problems.Do not drink alcohol or operate a car or heavy equipment while taking pain medication._Wound care Wet to dry dressing change every 8 hours.Apply triple antibiotic ointment to wound once daily.Call for increased redness, swelling, drainage, pus, or pain.Head InjuryInstructionsCall for the following symptoms: nausea, vomiting, increased headache,GLIILFXOW\ZLWKYLVLRQFRQIXVLRQRUFKDQJHLQSHUVRQDOLW\You will need someone to stay with you for the next 24 to 48 hours. You may go to sleep, butsomeone should wake you up several times during the night to make sure you know who andwhere you are, and that you are able to talk and move around normally.Follow-up appointments: The Trauma Clinic is located at the Outpatient Entrance of the hospital. The phone number is (321) 434-1401. Patients will be seen by appointment only. You will be seen by a Trauma Physician Assistant or Nurse Practitioner under thesupervision of the trauma surgeon. Please report to the registration desk approximately 15 minutes before your scheduled appointment.Patients arriving late will be required to reschedule. Cancellations require 24-hour advance notification. Failure to do so will result in a$30 physician clinic charge. Items to bring with you include your driver’s license, insurance information, and social security card.Patients with emergent needs should either report to the Emergency Room or call 911 for assistance.If you need insurance forms completed, please sign them and send the forms to Holmes Regional Medical Center, Division of Trauma,1350 S. Hickory Street, Melbourne, Florida, 32901. After completion, the forms will be forwarded to the insurance company.Your Trauma Clinic appointment will be:Other follow-up instructions:indays/ weeks. Call (321) 434-1401 for an appointment.Medications:Patient/ Guardian:Date/ time:Nurse:Physician:TR-IX - 5For further information regarding the Division of Trauma please visit our website at:http://www.health-first.org/affiliates/hrmc/trauma/

Holmes Regional Medical CenterDivision of Trauma(Addressograph)THIS PAGE INTENTIONALLY LEFT BLANKTR-IX - 6For further information regarding the Division of Trauma please visit our website at:http://www.health-first.org/affiliates/hrmc/trauma/

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